Good News, Bad News:
TAFP’s recap of the 82nd Texas Lege
By Kate Alfano
For health care reform advocates, the 82nd Texas Legislature will go down as the session of what might have been. More than previous sessions, lawmakers seemed to get it, and they crafted bills that could put Texas at the forefront of innovation in high-quality, cost-effective health care delivery. Yet lawmakers simultaneously adopted a budget that slashes critical funding to educate and train vital health care professionals and could debilitate the state’s primary care infrastructure.
“The good intentions of the Texas Legislature to improve the state’s health care delivery system were thwarted by their refusal to invest in the production and support of the state’s health care workforce,” says TAFP CEO Tom Banning.
Legislators entered this session with ideas to address the three most pressing problems bedeviling health care delivery across the country: cost, quality, and access. For weeks, committees held hearings at which lawmakers decried the inadequacies of Texas’ fractured health care delivery system and championed the tenets of efficient, high-quality systems. Communities with ready access to primary care physicians in a well-coordinated delivery system experience better health outcomes for less money.
They crafted a reform bill that would employ free-market principles to encourage better coordination of care between doctors, hospitals, and other caregivers, aligning financial incentives to keep patients healthy and out of the most expensive care settings. Measures in the bill held great potential to drive down the costly variations in the care patients receive across the state, reduce medical errors resulting from miscommunication, and improve outcomes, therefore increasing the value of the state’s health care resources.
After failing to pass in the regular session, the bill was resurrected in a special session, although the chances that its provisions will succeed in practice had already been undermined by budget-writing that neglected to include projected caseload growth in health and human services programs like Medicaid and that crippled the programs that produce our primary care physician workforce.
The Bad News
The budget was the theme of the session. Fully aware of the multibillion-dollar deficit in general revenue, state leaders made it clear from the beginning that they would not seek additional state revenue or use the estimated $9.6 billion in the state’s savings account, the Rainy Day Fund, to pay for the next biennium’s budget. That meant enacting severe cuts across every area of state government, particularly the two biggest, as Sen. Steve Ogden, R-Bryan, warned in his speech on opening day in January.
“If you look at our budget with respect to education and health and human services—article II and article III—81 percent of all the general revenue that we appropriate is appropriated in article II and article III. It is impossible to balance this budget without making cuts in article II and article III.”
Before the end of the regular session, both the House and Senate approved a budget for 2012-2013 that spends $15 billion less than the budget for the current 2010-2011 biennium, a decrease of 8.1 percent. The Health and Human Services Commission says the budget underfunds Medicaid by at least $4.8 billion and that the program will run out of money by May 2013. The budget also shorts public schools by $4 billion, according to the state’s current school finance formulas. All efforts to change the formulas failed in the final days of the session, leading to the immediate call for a special session.
Overall, health and human services took the biggest hit, with almost $11.3 billion in cuts from state and federal funds. Federal funds make up the bigger loss due to the expiration of federal stimulus dollars and the associated 10-point decline in the federal Medicaid matching rate, says John Hawkins, senior vice president of advocacy and public policy for the Texas Hospital Association.
While Medicaid provider rates were not reduced for physicians, nursing homes, and mental health services, hospitals received an 8 Medicaid rate cut on top of the 2 reduction already in place for 2012-2013.
“Clearly, hospitals are financing a disproportionate share of the state shortfall,” Hawkins says. “Unfortunately the budget situation could be even worse in 2013 because lawmakers wrote an IOU for Medicaid caseload and cost growth, and were unwilling to address the structural deficit in the business margins tax, which takes in less revenue than the state pays out for property tax relief.”
“The cuts in Medicaid—coupled with a 23 reduction in trauma funding—will curtail growth in the health care sector, lead to more unemployment, increase costs to those with health insurance, require higher local taxes, and reduce access to health care services in communities statewide.”
With much of the attention directed toward public education, higher education sustained about $1.2 billion in cuts from general revenue. Medical schools will receive about $280 million less in medical student formula funds, and about $25 million less in graduate medical education formula funds. Funding administered by the Texas Higher Education Coordinating Board for primary care residency programs was slashed by almost 80 percent, leaving just $2.8 million per year for the state’s 29 family medicine residencies. Altogether, the state cut its support for graduate medical education by $47.4 million, or 39 percent.
The Good News
Despite these seemingly paradoxical budget tactics, medicine did celebrate several wins in the areas of licensure reform, scope of practice, and public health.
The IMG licensure bill, House Bill 1380 by Rep. Vicki Truitt, R-Keller, and Senate Bill 1022 by Sen. José Rodríguez, D-El Paso, passed both chambers before the end of the regular session and was signed into law on Friday, June 17. The law permits international medical graduates to receive a medical license after two years of residency instead of three, removing the barriers to licensure for these physicians and allowing them to start caring for patients as quickly as graduates of U.S. medical schools.
It removes the incentive for practice-ready, Texas-trained physicians to leave the state in search of employment and it removes related credentialing delays to allow them to be paid, keeping more Texas-trained physicians in the state and thus improving Texans’ access to care.
Featured in the last issue of Texas Family Physician, Cephas Mujuruki, M.D., an international medical graduate from Zimbabwe and current chief resident at the Texas Tech University Family Medicine Residency Program in Amarillo, said he would like to stay in the state where he trained, but had to consider the well-being of his wife and young son.
“Before this bill we had to make a difficult choice between staying in the state we love and facing financial difficulties until finishing licensing, or moving to another state and starting over but having that financial security from the beginning,” Mujuruki says. “We no longer have to face that difficult choice, and we no longer have to look outside Texas. We can simply stay here.”
Three bills aimed at granting nurse practitioners independent diagnosis and prescriptive authority failed to beat House deadlines and died in the regular session. H.B. 915 by Rep. Wayne Christian, R-Center, and H.B. 708 by Rep. Kelly Hancock, R-North Richland Hills, were never voted out of the House Public Health Committee. H.B. 1266 by Rep. Garnet Coleman, D-Houston, and Rep. Rob Orr, R-Burleson, which would have required a legislative interim study, was not scheduled for debate by the House before the deadline for bills to be heard on first reading.
The scope of practice bills were defeated thanks in part to the hard work of several TAFP members and TAFP’s partners in organized medicine. On April 21, 2011, so-called “scope day,” the House Public Health Committee heard the three bills in a marathon committee meeting that began after 7 p.m. on Wednesday and didn’t adjourn until 5 a.m. the next morning. TAFP member Tricia Elliott, M.D., of Galveston, and Texas Pediatric Society member Gary Floyd, M.D., of Fort Worth, were at the hearing into the wee hours to provide testimony on behalf of TAFP.
Elliott, director of the University of Texas Medical Branch Family Medicine Residency Program, stood before the committee just before 3 a.m. to testify against H.B. 915 and H.B. 1266.
“Twelve years ago, I completed my residency program in the Bronx in New York, in the inner-city, underserved area, and I also practiced in that community for several years,” she said, adding that during that time she worked closely with nurse practitioners. “They are a valuable part, a critical part of our health care team, but they must work with us collaboratively.”
Nurse practitioner organizations will not give up on their pursuit of independent practice in Texas. TAFP will continue to oppose such expansion during the legislative interim and when the next round of scope bills is filed in the 83rd Legislature in 2013.
In public health, S.B. 1107 by Sen. Wendy Davis, D-Fort Worth, was signed into law on May 27. The law requires students entering Texas colleges and universities to receive a bacterial meningitis vaccination, expanding existing law that requires the vaccination of students who will live in on-campus housing. Now all students must show through vaccine certificate or immunization record that they received the vaccination dose or booster within a certain period of enrollment. It excludes students enrolled in online courses or those older than 30, and parents may apply for an exemption.
Also signed into law on May 27, H.B. 3336 by Rep. Coleman, and Sen. Robert Deuell, R-Greenville, requires staff in the hospital setting to provide information about pertussis to all new parents, including the availability of the pertussis vaccination and the CDC recommendation that parents receive Tdap during the postpartum period to protect newborns from the transmission of pertussis.
A bill to require health care facilities to develop and implement vaccination policies for employees did not pass during the regular session, but did pass in the special session as part of a larger health reform bill. TAFP past president Erica Swegler, M.D., of Keller, testified in support of the regular session bill, S.B. 1177 by Sen. Jane Nelson, R-Flower Mound, at a May 18 hearing of the House Public Health Committee.
Swegler said the measure prevents health care workers from unknowingly spreading flu and other preventable diseases to patients in their care. “Numerous published medical studies show that when health care workers are immunized, patient mortality is reduced by nearly 58 percent,” she said at the hearing. “Additionally, evidence shows that preventing influenza reduces patient hospitalizations and death from heart, chronic lung, and kidney disease, and diabetes, so this is really a critical patient-safety issue.”
On the defensive front, measures to repeal school-based fitness measurements and end health education were defeated in the regular session, but reappeared in the special session. Amendments to an education bill known in the regular session as H.B. 400 by Rep. Rob Eissler, R-The Woodlands, aimed to remove or reduce Fitnessgram annual fitness testing in grades 3-12, remove coordinated school health programs, and remove or reduce physical education or health requirements as a means to cut spending in public schools. As passed in the special session, only children in PE courses must participate in the Fitnessgram assessment.
According to Carrie Kroll, chair of the Partnership for a Healthy Texas, this means that fewer Texas high school students will participate in the fitness assessment and those who do will only participate during one year. Middle school students will participate one less year than current PE requirements. “While the most devastating proposals impacting nutrition and obesity policy weren’t successful, cuts were made and the true impact of those changes may take time to feel,” Kroll says. “It is clear, however, that a good majority of the legislators in the House aren’t aware that Texas has been in the forefront among states developing nutrition and obesity public policy, to the benefit of our children and taxpayers. It’s up to the champions of these issues to provide this necessary education in the interim.”
The Late Edition
Gov. Rick Perry called the special session the evening of the last day of the regular session, directing legislators to return at 8 a.m. the next morning to work on two outstanding issues: school financing and Medicaid reform. As was the case with the first called session, special sessions can last a maximum of 30 days. They can only address legislation listed on the call, though bills’ relevancy to the call is determined by each chamber, and the governor can and did add additional issues since the original proclamation, including redistricting and immigration.
The special session presented the opportunity for many bills to be brought back for consideration. This included the state’s health reform bill, which became an omnibus health and human services efficiencies bill encompassing elements of the regular session’s S.B. 23, S.B. 7, H.B. 32, H.B. 3537, and S.B. 8, plus other provisions.
Proponents believe the bill saves money in Medicaid and the Children’s Health Insurance Program by expanding Medicaid managed care into South Texas and creating incentives for doctors and hospitals to form “health care collaboratives” that provide coordinated, more efficient care. It takes steps to improve access to after-hours medical care and reduce emergency room use for non-emergent care. The Legislative Budget Board estimates that measures in the bill could save $468 million over the next biennium.
“Every day that goes by that this is not implemented, we are losing money,” bill author Sen. Nelson told fellow members of the Senate Finance Committee in a hearing on June 2. “We keep using a word that I want to remind everybody of and that is ‘unsustainable.’ Our Medicaid cost trends are unsustainable so we need this bill, but we don’t just need it for [cost savings]. It truly does improve the quality of our system and creates a more efficient system.”
On the next-to-last day of the special session, the Legislature finally passed the bill, sending it to the governor’s desk where it’s likely to receive his approval.
Moving forward, TAFP’s Banning encourages stakeholders to stay engaged to help build the case for family medicine in preparation for the 83rd Legislature. “Texas must invest in educating, training, and producing the primary care physician workforce the state so desperately needs so that the laudable goals of the reform legislation—improved quality of care at a lower cost—can be realized,” he says.
“Over the interim we will need to redouble our efforts to show the cause and effect of the Legislature’s funding decisions. We need to methodically document the downstream cost increases and higher emergency room utilization.”