Missed opportunities in the 84th Texas Legislature

Tags: legislature, legislative update, 84th, medicaid, banning, medicare, graduate medical education, nelson, zerwas, residency, family medicine residency program, higher education, primary care coalition, texas medical association, preceptorship, bonnen, hancock, direct primary care, schwrtner, crownover, prescription, drug abuse, substance abuse, darby, yogi

By Tom Banning

Yogi Berra famously said I hate making predictions, especially about the future. It’s particularly painful when those predictions come true as was the case for many of the predictions TAFP made at the outset of the 84th Texas Legislature on how health care issues would fare this session.

Playing to their primary voters, the House and Senate focused attention almost solely on tax cuts, border security, transportation, when and where you can carry a gun, and a host of other mostly inconsequential partisan ideas.

With a record budget surplus and money overflowing from the state’s rainy day fund, health care funding issues in the 84th Texas Legislature can best be described as a session of missed opportunities. The Legislature largely punted on coverage expansion for the uninsured, investment in our health care infrastructure, and other market reforms that could have benefited patients and physicians alike.

In a January blog post published by the Texas Tribune, I wrote that “Republican primary politics alone should quash any expectation that this Legislature would contemplate a Medicaid expansion deal or any other red-state-style private-market Medicaid solution.”

True to form, the topic was not even fleetingly considered during the session. Lawmakers said as much at a March 2 press conference, when the lieutenant governor and every Republican member of the Senate delivered the message that, “any expansion of Medicaid in Texas is simply not worth discussing.” Even when federal officials warned the state’s health agency that refusing to expand Medicaid could threaten the renewal of the 1115 waiver hospitals depend on to offset the cost of providing uncompensated care to uninsured patients, legislators refused to budge.

Worse, the Legislature failed to invest any additional resources in physician Medicaid rates, which currently pays approximately 61 percent of Medicare. The House, recognizing that woeful Medicaid rates paid to primary care doctors were threatening access to care, authorized an additional $460 million to bring primary care rates on par with Medicare payments. But the Senate objected and the budget conference committee opted not to include the primary care rate increases in the final budget. It would almost be comical, if not so sobering; physicians who provide Medicaid services probably felt a bit like Charlie Brown after Lucy pulled the football away again.

For the past several sessions, one of TAFP’s main advocacy goals has been to strengthen the state’s fragile primary care infrastructure by increasing support for primary care graduate medical education. As the session began, the Legislative Budget Board released its 2015 Government Effectiveness and Efficiency Report, which shined a light on a series of problems facing GME funding that ultimately results in an imbalance in the geographic distribution and the specialty mix of our physician workforce. The report recommended the Legislature improve funding to the state’s existing family medicine residency programs and align new GME funding with the state’s health care needs and produce more primary care physicians.

Senate Bill 18 by Sen. Jane Nelson, (R-Flower Mound), and Rep. John Zerwas, MD, (R-Simonton), provides the statutory framework to expand existing GME programs and create new GME positions. The bill establishes a permanent trust fund to support GME, prioritizes the creation of new GME positions for critical shortage specialties, and creates an independent physician workforce resource center to conduct research on medical specialties in Texas that are determined to be in critical shortage.

The Legislature put more than $53 million in the budget to fund various strategies to foster GME expansion. $32.55 million of that is designated to fund 290 new first-year residency training positions at $75,000 per resident per year. About a third of those funds, $12 million will be targeted at new primary care positions.

The budget also included a $4 million increase for the Family Medicine Residency Program, a line item in the Higher Education Coordinating Board budget that allocates direct support to existing family medicine residency training programs. Restoration of this funding has been TAFP’s top policy priority since the funds were slashed in 2011.

The Senate budget originally included a $16 million increase to the program, which would have fully restored funding to the Family Medicine Residency Program to historic levels. By the end of their deliberations, the budget conference committee with the support of the Texas Medical Association shifted $12 million from the Senate budget to fund new GME programs, leaving the FMRP appropriation with 20 percent less than it received in the 2010-2011 biennium.

With the help and support of our partners in the Primary Care Coalition, the Legislature restored funding for the Texas Statewide Primary Care Preceptorship Program, which will receive $3 million in state support over the next two years.

The Legislature did pass a few important bills to encourage direct contracting for primary care services, reduce administrative hassles for practices as well as restrict minor’s access to e-cigarettes.

House Bill 1945 by Rep. Greg Bonnen, MD, (R-Friendswood), and Sen. Kelly Hancock, (R-North Richland Hills), will improve physician’s ability to provide and patients’ receive direct primary care services. The legislation recognizes these practice arrangements, protects them, and defines them as outside the scope of state insurance regulation.

Another bill eliminates the state’s troubled Controlled Substance Registration Program. S.B. 195 by Sen. Charles Schwertner, MD, (R-Georgetown), and Rep. Myra Crownover, (R-Denton), moves the Prescription Drug Monitoring Program from the Texas Department of Public Safety to the Texas State Board of Pharmacy and broaden physicians’ authority to delegate who can access the information.

Last but certainly not least, the Legislature passed a bill by Rep. Drew Darby, (R-San Angelo), that repeals more than $300 million in fees over the next two years, including the $200 a year fees charged to physicians and other professionals. 

This session reaffirmed the time honored doctrine that politics drives the process that sets policy. The House and Senate waved the bloody red shirt of guns, gays, tax giveaways, and anti-federalism. Highways were the only infrastructure investment of any consequence, a testament to the durability and local relevance of pothole politics.

Absent an uprising by patients who are being systematically denied coverage or some crisis forcing physicians and hospitals to close their doors it will be, as Yogi said, “déjà vu all over again.”

We may be approaching a tipping point where health care politics is as important as potholes, but not this legislative session. Until then, to borrow from Yogi one last time, “the future ain’t what it used to be.”

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