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TMA sort of endorses Medicaid expansion

Hard to say what this means.

It’s constitutional – deal with it

Trustees of the Texas Medical Association passed a resolution urging state leaders to snare all federal Medicaid matching dollars that are on the table.

The group hinged its support, though, on simultaneous actions by state officials to make doctors’ participation in Medicaid more palatable and federal dispensations of flexibility “to change the program as our needs and circumstances change.”

The association, which held its winter meeting in Austin, didn’t specify what kind of discretion Texas ought to seek. The group’s endorsement of state acceptance of a huge windfall of federal Medicaid dollars comes months after another major provider group, the Texas Hospital Association, came out unconditionally in support.

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Texas has one of the least generous Medicaid programs in the country. Because of the state’s high poverty rate, though, Texas Medicaid looms larger in the state’s overall health care system than its counterparts in some states. State GOP leaders frequently complain about its cost.

Doctors complain, not just of low reimbursement, but about what they see as hassles and scary threats made against them by overzealous fraud investigators who work for the commission’s inspector general. In the Saturday session on Medicaid, several doctors complained about what they see as a lack of due process and a rush to paint doctors as greedy.

Rep. Garnet Coleman, a Houston Democrat who is the Legislature’s most vocal proponent of the Medicaid expansion, downplayed the importance of the Texas Medical Association’s resolution.

He said the group is dominated by specialists, many of whom don’t see Medicaid patients.

“This is about money,” Coleman said, referring to Texas’ low Medicaid reimbursement rates. “It isn’t about anything else.”

I couldn’t find the TMA’s statement on this, if they have one, and their 2013 legislative agenda wasn’t much help. Mostly the impression I get is that they don’t want to rock the boat with the state leadership, but there were enough cranky do-gooders in their ranks that they had to throw them a bone. Rep. Garnet Coleman put out a statement regarding the TMA’s announcement that I think addresses the issue perfectly:

As someone who has advocated for Medicaid expansion from the very beginning, I applaud TMA’s statement that we need to find a way to implement the expansion here in Texas. It’s a great start, and I agree with their position that denying care to over 1 million disabled and low-income Texans is ‘unconscionable.’

However, the devil is in the details. TMA’s proposal that Texas should have more ‘flexibility’ in the Medicaid program is worrisome because of its vagueness. ‘Flexibility’ has long been a code word used by those who only want the ‘flexibility’ to reduce Medicaid services, beneficiaries, or both. Further, it’s unclear whether TMA wants more flexibility in the entire Medicaid program or just the expanded portion. Finally, the federal government already allows for Medicaid flexibility through the 1115 Waiver process, most recently seen in the 1115 Transformation Waiver that allows Texas health providers to continue to receive federal UPL funds after the switch from fee-for-service to managed care.

TMA correctly points out that the low reimbursement rate of Medicaid in Texas has resulted in only 30% of Texas physicians accepting new Medicaid patients, but I want to remind everyone that Medicaid reimbursement rates are set by the Texas State Legislature and the Governor through the appropriations process, not by Washington. We could simply pass a budget that raises them. I’d vote for it. Also, physicians are not the only providers who see Medicaid patients. Advanced practice nurses, physician assistants, and entities such as Federally Qualified Health Centers, county hospital districts, and Accountable Care Organizations will all help fill the gap. Our primary goal should be to ensure that all Texas have access to care, and this is something we can do.

Finally, Texas, not Washington, will decide whether or not we expand Medicaid in this state. Governors across the country of each party are realizing that expanding Medicaid is important and the best policy for their populations; we need to do the same. The bipartisan solution that TMA calls for is already on the table. We just need to take it.

As with the case of the business lobby and immigration reform, if the TMA wants something different from the Legislature they really ought to consider supporting different candidates for the Legislature. Supporting the same people but hoping for different results, we all know what the diagnosis is for that. The Trib has more.

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