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Expect to hear more about Perry vetos and no-bid contracts

Bring it on.

Corndogs make bad news go down easier

Corndogs make bad news go down easier

Democratic lawmakers and government watchdog groups on Saturday called for the reopening of an investigation into no-bid state contracts that ended in 2013 after Gov. Rick Perry vetoed funding for the team conducting it.

The critics decried the millions of dollars in Department of Public Safety contracts and another set of similar deals given by the state health commission under Perry, who will step down Tuesday after 14 years in office and is considering a 2016 presidential run. They said a thorough evaluation of contracting is needed to assure taxpayers that their money is being spent responsibly.

“Hell, yes, we need to review everything,” said state Sen. John Whitmire, a Houston Democrat who has served in the upper chamber longer than any other member. “There seems to be an awful lot of no-bid this and no-bid that, and I just think we need to look at it all so we can tell where the problems are and what needs to be changed.”

[…]

Democratic state Reps. Garnet Coleman and Armando Walle of Houston were among those calling Saturday for the investigation of no-bid contracts to be reopened.

“Using state resources to bolster a political career by fomenting a non-existent border crisis, then giving no-bid contracts to a company that has limited experience in border security seems like an issue the Public Integrity Unit should be investigating,” Walle said.

Craig McDonald, director of Texans for Public Justice, an Austin-based government watchdog group whose complaint initiated the investigation that led to Perry’s indictment, agreed. He added that if the investigation had continued, it may have prevented some of the issues now surfacing with state health contracts.

Four high-ranking Texas Health and Human Services Commission officials have so far resigned as a result of those issues, stemming from no-bid Medicaid fraud detection contracts with Austin technology company 21CT that got tentative approval to balloon to $110 million before being canceled.

The deal is now being investigated by the Public Integrity Unit.

Unit director Gregg Cox on Saturday cited that investigation as a reason why it was unlikely that his office could reopen the probe into DPS contracts.

“I just don’t have the horsepower right now to open new investigations, with everything else we have going,” said Cox, who added that he would review the option next week. He added that for now, he “would prefer to see other agencies investigate this, and then we can work with them.”

See here for the background. If nothing else, one hopes this is the fulcrum by which the Public integrity Unit gets its funding restored, which is something the House budget would do but not what Dan Patrick wants. Regardless, this is a giant turd that Rick Perry is leaving in Greg Abbott’s punch bowl, and I plan to enjoy watching the fallout.

Texas Obamacare enrollments top 850K

And counting.

It's constitutional - deal with it

It’s constitutional – deal with it

Officials at the Department of Health and Human Services Wednesday announced nearly 860,000 Texans so far have enrolled in health insurance marketplace coverage with a month left still left to go until the 2015 open enrollment period ends.

It’s unclear how many of those signups are new marketplace customers. Last year, nearly 734,000 Texans, many of whom had never been insured, signed up for coverage. About 198,000 of them were in the Houston area.

“As of Jan. 9, 859,377 Texans have access to quality, affordable health coverage for 2015 through the Health Insurance Marketplace,” said Health and Human Services Secretary Sylvia Burwell in a written statement.

Good to hear. National enrollments have been strong as well. It seems eminently reasonable to me that Texas could top one million signups by February 15, given the likelihood (as was the case last year) of some number of people waiting till the last minute to get it done.

There’s also an intensified focus on the Latino community.

Officials plan more than 600 enrollment events nationwide, including a few in the Houston area, that target Hispanics in an effort to get more signed up for coverage under the Affordable Care Act. In the meantime, grass-roots organizations and the Department of Health and Human Services are spreading the word about the marketplace by using webinars, Twitter, advertising and Spanish television telethons.

“We’re doubling down,” Health and Human Services Secretary Sylvia Burwell told reporters Wednesday, noting that the agency has dedicated a third of its advertising budget to Spanish speakers. “The Latino community is one of the fastest growing communities in the country. We’re specifically focused on this community because of the health disparities that exist for them and we think having insurance will help.”

[…]

Researchers have found Texas Latinos were more than twice as likely as Anglos to enroll in marketplace coverage. They also discovered Hispanic adults in Texas have more difficulty affording health care and are three times as likely to be uninsured.

Burwell repeatedly has said Spanish speakers would be targeted for more outreach this enrollment period. Insurers and enrollment organization trained more application assisters to accommodate Latino applicants and marketplace officials simplified the insurance application process, expanded the number of documents people could use to verify their identities and income and made it easier for applicants to use hyphenated names, which are common in Latino communities.

“We’re working to meet Latino consumers where they are, whether that’s online, over the phone or in person,” Burwell said.

There’s a lot of potential there, and one thing we learned from the first round of enrollments was precisely that these customers needed more engagement to get signed up. I hope this has the desired effect, and that we can learn more for the next time.

What would happen to all these people if SCOTUS takes the opportunity to gut subsidies for the national exchange? My guess is that as are the million or so folks that would qualify for Medicaid under a normal expansion plan, they’d be SOL. Oh, I’m sure that Rep. John Zerwas will put forth a bill to create a Texas state exchange, as he has done before. He’ll have the support of all the Dems, a few honorable Republicans, every non-crazy local official, and the business establishment, but it won’t be enough. Nothing will change till we start to win more elections. I wish I had a sunnier outlook than that, but I don’t. Sorry.

The veto that keeps on giving

I haven’t closely followed the burgeoning scandal at the Texas Health and Human Services Commission, which involves no-bid contracts, up front tuition reimbursements for top level staffers, and rampant cronyism. It’s already cost three people their jobs and will likely eventually result in the HHSC Commissioner, Kyle Janek, either falling on his sword or getting defenestrated. If nothing else, it’s been a nice little stink bomb for Greg Abbott and a timely reminder as Rick Perry exits the main stage that there’s a damn good reason why everyone should be glad to see him go. And since this is a scandal that happened on Rick Perry’s watch, there is as always more to it than meets the eye.

Corndogs make bad news go down easier

Corndogs make bad news go down easier

A year and a half before a no-bid state contract collapsed in scandal last month, a criminal investigation into tens of millions of dollars worth of deals awarded through the same process by Rick Perry’s administration was derailed by the funding veto that got the governor indicted, according to the prosecutor who led the probe.

The earlier inquiry, which concerned Texas Department of Public Safety contracts for Perry’s highly touted and controversial border-security program, lasted more than a year before abruptly shuttering, said Gregg Cox, director of the Public Integrity Unit at the Travis County District Attorney’s office.

“We lacked the resources to continue that investigation,” Cox said. “Because the staff was cut when our budget was vetoed.”

[…]

The news also raises questions about whether a continuation of the inquiry could have alerted officials much earlier to vulnerabilities in the so-called “Cooperative Contracts” process.

The process, which allows state agencies to bypass competitive-bidding, but was designed for smaller purchases, was used for both the Department of Public Safety contract and the scandal-ridden Medicaid fraud detection deal given by the Texas Health and Human Services Commission to Austin technology company 21CT.

That contract, which eventually was set to cost $110 million before abruptly being canceled last month, already has led to the resignations of four high-ranking state health officials, led some lawmakers to call for Executive Commissioner Kyle Janek to step down and triggered investigations by Cox’s Public Integrity Unit, Gov.-elect Greg Abbott and the State Auditor’s Office.

Officials said the earlier Public Integrity Unit investigation focused on more than $20 million in no-bid contracts given to Virginia defense contractor Abrams Learning and Information Systems, Inc., to help Texas develop its border security strategies.

The Virginia firm, founded by retired Army Gen. John Abrams, initially got a $471,800 contract in March 2006 to help the state establish a Border Security Operations Center in Austin, according to a state documents. The deal went through the no-bid process because officials said it was in response to “an emergency.”

An internal memo that later surfaced in news reports showed that the declaration of an emergency was based on public statements by Perry, who at the time was in a tough re-election campaign in which border security was a big issue.

Three months after its first contract, Abrams received a second emergency deal, for $679,600, that greatly expanded the company’s responsibilities.

Over time, state records show, officials quietly added more and more responsibilities to the contracts until they grew to more than $20 million and covered work in most segments of the state’s growing border-security programs.

See, that’s the sort of thing that happens when the one law enforcement authority over state government gets declawed. At the time that the threat and the veto were happening, the conspiracy theory was that Perry wanted to cut any investigations into the scandal-plagued Cancer Prevention and Research Institute of Texas (CPRIT). I don’t think there was any specific intent like that – though if some evidence turned up to suggest there was, I would hardly be shocked – I think Perry just didn’t care about any collateral effects of his actions. He had his own objective, and that was all that mattered. And stuff like this is the result. Thanks for interminable years of service, Rick.

Even Rick Perry appointees back Medicaid expansion

It’s just the right thing to do.

It's constitutional - deal with it

It’s constitutional – deal with it

A board of medical professionals appointed by Gov. Rick Perry said Wednesday that the state should provide health coverage to low-income Texans under the Affordable Care Act — a move the Republican-led Legislature has opposed.

The 15-member Texas Institute of Health Care Quality and Efficiency recommended that the state’s health commissioner be authorized to negotiate a Texas-specific agreement with the federal government to expand health coverage to the poor, “using available federal funds.”

“We’re trying to look at actions whereby more Texans can be covered,” said board chair Steve Berkowitz, the president and founder 0f SMB Health Consulting. “We’re trying to take the politics out of it.”

[…]

Members of the Institute of Health Care Quality and Efficiency — which was established by lawmakers in the 2011 legislative session to identify evidence-based approaches to improving health care and cutting costs — said Wednesday that Texas’ rate of uninsured was “unacceptable,” and that state leaders should look for an alternative way to expand health coverage. The board’s recommendations are not binding and any such decision is up to the Legislature.

“We should be maximizing available federal funds through the Medicaid program to improve health care for all Texans,” said Joel Allison, a board member who is chief executive of the Baylor Scott & White Health System.

I don’t remember anything about the legislation that created the Institute of Health Care Quality and Efficiency and I don’t have anything in my archives about them, but seeing this was a pleasant surprise. If only the 2015 Legislature will listen to them.

Just don’t call it “Medicaid expansion”

It’s the public policy that dare not have its name spoken, at least by Republican legislators.

It's constitutional - deal with it

It’s constitutional – deal with it

State lawmakers renewed efforts Thursday to find a “Texas solution” to expand health-insurance coverage for low-income residents without accepting the Medicaid expansion in President Barack Obama’s signature health care law.

Social-services advocates and local officials are among those pushing for a compromise measure that gives the state more flexibility than in the law to spend the money available from the federal government to cover more residents.

On Thursday, the state Senate Health and Human Services Committee met to “start a conversation that will give us an accurate picture of who the uninsured are, what services are available to them and what we can do to help them,” said chairman Charles Schwertner, R-Georgetown.

Katrina Daniel of the Texas Department of Insurance said about 6.5 million state residents do not have health insurance, although some of those can afford insurance and have chosen not to purchase it. An estimated 1.3 million uninsured Texans earn less than the federal poverty level, leaving them in the so-called “coverage gap.” The president’s law assumed all states would expand Medicaid, so it left those eligible for Medicaid out of its subsidies to help poor residents buy insurance.

Caring for those and other uninsured residents is costing counties billions of dollars a year, according to a letter sent to Schwertner on Wednesday by the judges in Harris, Bexar, Dallas, Tarrant, Travis and El Paso counties.

“We write not to complain about this fiscal burden or duty, but to urge your committee to use this interim to find a Texas way forward to fund and increase access to healthcare coverage for low-wage working Texans,” the judges wrote.

Two of those county judges are Republicans, of course, and frankly I think they have every right to complain. The cost of health care for those uninsured people comes out of their budgets, not the state’s. A lot of that cost includes treatment for folks with mental illness, who generally get that treatment in county jails. Medicaid expansion solves a whole world of problems, we just have to be smart enough to take it. If that means calling it something else, or coming up with something that’s almost but not quite exactly Medicaid expansion so we can claim it’s a “Texas solution”, then so be it. Either is better than what we’re doing now.

From the files of privatization failures

A story from last week.

State officials have decided to slow the rollout of a controversial overhaul of the foster-care system after the private contractor running a pilot program abruptly pulled out Friday.

Judge John Specia, commissioner of the state Department of Family and Protective Services, said a second pilot of the overhaul will continue but other planned expansions will not move forward until his agency studies what went wrong.

“It would be foolish of us to not look at this situation, look at the contract being terminated, talk to the legislative leadership, talk to the providers and advocates and then fully make a decision about moving forward,” said Specia, hours after receiving notice that Providence Service Corp. intended to opt out of a five-year contract after just 18 months. “That’s necessary at this point.”

Lawmakers said the cancellation of the contract would force them to take a closer look at the overhaul, called “Foster Care Redesign.” There will be no disruption of services for the children, as the state will take over the work after a transition period of at least 30 days.

But the development marked a setback for the “redesign” program, which was approved in 2011 as a way to improve the system without increasing costs.

[…]

“As we move forward, the Legislature should carefully examine whether Foster Care Redesign still represents the best solution to the challenges facing our state’s foster care system,” said state Sen. Charles Schwertner, a Georgetown Republican who chairs the Senate Health and Human Services Committee.

Providence, based in Tucson, Ariz., had been failing to meet some of its performance metrics and recently unsuccessfully sought more money from the state, officials said.

Mike Fidgeon, the company’s chief operating officer, said it had proved impossible to provide services for roughly 1,100 children in the pilot’s 60 West Texas and North Texas counties without spending more than the state had spent in previous years, as the contract required.

“The contract guiding us doesn’t adequately address the needs of the children and families,” Fidgeon said. “The most responsible way forward is to conclude the current arrangement and work to help the Legislature more adequately fund the state’s foster care system.”

Providence started work last February after winning its $30 million annual contract. ACH Child and Family Services of Fort Worth was tapped for a second pilot, in Tarrant and six nearby counties. More contracts were expected to be put out to bid soon.

But Providence struggled from the start to produce better outcomes or even stay afloat financially.

Emphasis mine. Funny how these things work, isn’t it? The free market can always do it better and more cheaply than the government, and spending must always be cut. It would be funny if there weren’t real people – children, to be specific – on the business end of it. The Legislature created this mess as part of its orgy of budget slashing in 2011, the Legislature can figure out how to fix it. See this Observer story from May for more.

Expanding Medicaid the hard way

A lot smaller than it should have been, but it’s still something.

It's constitutional - deal with it

It’s constitutional – deal with it

More than 80,000 additional Texans have enrolled in Medicaid or the Children’s Health Insurance Program since the rollout of the Affordable Care Act last fall despite Republican state leaders’ decision not to expand eligibility to poor adults, according to federal figures.

The 80,435 new enrollees as of May — mostly Texans who already qualified for coverage but did not previously seek it — represent a 1.8 percent increase over pre-Obamacare figures. That places Texas, which has the nation’s highest uninsured rate, in the middle of the pack among states that chose not to expand access to those programs to everyone under 138 percent of the federal poverty line under the president’s signature health law. The expansion, a key tenet of Obamacare, was deemed optional by the U.S. Supreme Court.

This “woodwork effect” or “welcome mat effect” — in which people hear about Medicaid expansions around the country and learn they qualify in Texas — has not been huge. Roughly 874,000 Texans eligible for Medicaid or CHIP have still not enrolled, according to Kaiser Family Foundation estimates. That includes more than 700,000 children, said Christine Sinatra, state communications director for Enroll America, a group seeking to get the uninsured covered under the federal health law.

Stephanie Goodman, spokeswoman for the Texas Health and Human Services Commission, said her agency started seeing enrollment rates rise a couple of years ago, when the conversation on Obamacare was heating up. After the act took effect, and parents took to the federal marketplace to purchase private insurance plans, many discovered that their children were eligible for Medicaid, Goodman added.

[…]

Get Covered America and Enroll America, which are leading the charge to bring more people into the coverage fold across the country, also cited the Affordable Care Act’s simplification of the sign-up process as a driver of Texas’ recent enrollment growth, which took off in the spring.

And though Texas leaders did not expand Medicaid, the criteria for eligibility here and elsewhere did broaden slightly: The act raised from 21 to 26 the age at which people formerly in the foster care system have to give up their Medicaid coverage.

Absent the Medicaid expansion that Texas chose not to join, Medicaid and CHIP eligibility in the state is generally limited to members of several vulnerable groups, including children under 200 percent of the federal poverty line and some low-income seniors, pregnant women and parents, Sinatra said.

Texas has historically put up a lot of obstacles to enrollment in Medicaid and CHIP. In addition to the exceedingly stingy income requirements, there has been a six-month enrollment period at times, meaning you have to sign up twice a year. The state, and in particular the Republican leadership, does all this in a deliberate effort to keep enrollment down, since that allows for less spending. By the state, anyway – sucks to be you, counties and hospital districts. I for one would consider it justice if every currently eligible person managed to get themselves enrolled, however much it wound up costing the state. We’d be far better off overall regardless of the price. Texas Leftist has more.

We really should have expanded Medicaid

We know it would have done a lot of good, at a very reasonable cost. Turns out that cost was even less than what we had been told.

It's constitutional - deal with it

It’s constitutional – deal with it

News reports and state officials have commonly stated that expanding the Medicaid program in this fashion would cost the state about $15 billion over 10 years. Except, that figure, provided by the state Health and Human Services Commission, is actually an estimated total cost for all aspects of the Affordable Care Act, many of which the state is going to have to pay for even though state leaders have remained steadfastly opposed to almost all aspects of the law.

“What?!?,” you say?

In a presentation given to lawmakers in March 2013, state Health and Human Services Executive Commissioner Kyle Janek estimated that because of the publicity and outreach involved with the Affordable Care Act, more people who are eligible for Medicaid but not currently part of the program would likely enroll. The estimated price tag? About $6 billion over 10 years, or approximately 40 percent of the total Affordable Care Act implementation cost.

According to that presentation, the estimated cost for expanding Medicaid eligibility to all adults who make less than the 138 percent of the poverty level was about $8.8 billion over 10 years. However, the Legislative Budget Board, the Legislature’s budget arm, came up with a far lower cost estimate of about $4 billion over 10 years. The differences can be attributed to two factors, HHSC spokeswoman Stephanie Goodman said. First, HHSC projects that more people will join the Medicaid program than the LBB does; and second, HHSC projected it would cost more to provide the coverage than the LBB does.

Secondly, assume that $1.5 billion figure is correct and that adding it to the state budget would cause taxes to skyrocket and the state’s economy to crumble. However, it begs the question why that hasn’t already happened. Taxpayers in the five major urban counties in Texas — Harris (Houston), Dallas, Tarrant (Fort Worth), Bexar (San Antonio) and Travis (Austin) — already shell out more than $1.5 billion a year in hospital district taxes to provide care and facilities for their largely indigent populations. A study commissioned by Methodist Healthcare Ministries and Texas Impact estimated total local government spending on providing health care at roughly $2.5 billion a year.

Thirdly, expanding Medicaid would produce additional revenue for hospital districts, potentially allowing county governments to cut their tax rate. In Bexar County, hospital district officials estimate that expanding Medicaid would save them $52 million a year, roughly 20 percent of the amount of revenue they get from the hospital district tax, and County Judge Nelson Wolff said he would cut property taxes to pass on the savings if it were approved. In Harris County, hospital district officials say the expansion of Medicaid would mean they would receive an additional $77.5 million in reimbursements, or roughly 15 percent of their tax revenue, based on 2013 financials.

Sure would have been nice to get that extra revenue to help pay for what we’re already paying for, wouldn’t it? We can still take advantage of it if we want to. All it takes is a different set of leaders in our state government.

On a side note, remember that the 7.1 million figure you’ve been hearing for Obamacare signups is just for people going through the healthcare.gov webpage. It doesn’t count state exchanges, Medicaid enrollments, or people who got ACA-compliant policies outside of the exchange. Those first two numbers would surely have been a lot higher nationally had it not been for the cruel and mulish refusal by governors like Rick Perry to create state exchanges and expand Medicaid. There was an increase in Medicaid enrollments across the country, as people who had been eligible all along but didn’t know it or hadn’t gone through it did so thanks to the publicity push from Obamacare. Of course, the total enrollment count was much higher in states that expanded Medicaid, but Texas saw new enrollments as well. That 7.1 million number will likely be higher as well when all is said and done, thanks to some lag in the system. I’ll say it again – just imagine how many more people this law could have helped if only everyone agreed that providing coverage to as many people as possible was a worthy goal and not something to fight against. EoW has more.

The coverage gap

As you may know, the intent of the Affordable Care Act was to get people below a certain income level onto Medicaid, with people at or above that income level receiving subsidized health insurance via the exchanges. Unfortunately, when the Supreme Court ruled that the Medicaid expansion mandate was unconstitutional, it meant that in states that refused to expand Medicaid people who fell below that income level but above the income level for Medicaid eligibility as things were would be left out of coverage – too poor to receive insurance subsidies, not poor enough for Medicaid. More than one million Texas adults fall into that coverage gap. Here’s a story about one of them.

It's constitutional - deal with it

It’s constitutional – deal with it

Damaged discs in Irma Aguilar’s neck make it hard to raise her arms, something she must do repeatedly when stacking boxes at the pizza restaurant where she earns $9 an hour as an assistant manager.

Sometimes, her untreated high blood pressure makes her so dizzy she has to grab onto something to prevent a fall.

And she struggles with anxiety, a heart-pounding fear that can strike at any time, but especially at night, when she lies in bed and wonders how she’s going to make ends meet.

Without insurance, she worries about how she will find the money to treat her health problems, which threaten her livelihood and the well-being of her family.

[…]

Aguilar’s four children are covered by Medicaid, which provides free or reduced-cost health care. But Aguilar makes too much money – $19,200 a year – to qualify. Texas’ Medicaid eligibility requirements are among the tightest in the nation, and Aguilar has to be nearly destitute to meet them – making no more than $4,200 a year as head of a family of five.

Emphasis mine. What that means is that if you make more than two dollars an hour working fulltime, you make too much money as the head of a family of five to qualify for Medicaid in Texas. Think about that for a minute.

Still left out of Medicaid, Aguilar hoped to get insurance under the ACA, but to qualify for a tax credit to help her pay for it, she would need to earn more than she does – at least $27,570 a year. Only those earning between 100 percent and 400 percent of the poverty level are eligible for the subsidies. Aguilar is at 70 percent.

This puts her in the gap, with neither Medicaid nor affordable health insurance.

If she could get a subsidy, Aguilar would have shelled out about $46 a month for a midlevel health plan. Without one, the cost would have zoomed to more than $200 a month, a price that puts health insurance out of her reach.

“I have to scrape by as it is,” Aguilar said. “By the time I pay rent, lights and water, there’s not much left over. Sometimes, I don’t eat so my kids can eat.”

[…]

As Texas rejected the extra Medicaid money, state lawmakers committed more resources to health care in the past session, said Stephanie Goodman, a spokeswoman with the Texas Health and Human Services Commission.

The Legislature set aside $100 million in added money for primary care services for women and an additional $332 million for mental health services, she wrote in an email.

“We’ve also developed a strong network of health centers across the state that provides low-income citizens with access to both preventive care and treatment for medical issues,” she said.

Such clinics depend on a mix of revenue – Medicaid, private insurance and patient fees – to enable them to provide care to those who lack insurance.

But those front-line providers don’t have enough money and resources to care for all the uninsured, including those in the coverage gap, said José Camacho, head of the Texas Association of Community Health Centers.

Nor can health centers provide a broad range of services, making them a too-porous safety net, others say.

“They’re no substitute for not having coverage,” said Anne Dunkelberg, a policy analyst at the Center for Public Policy Priorities, which advocates for low-income Texans. “They can’t provide specialty treatment or trauma care. If you’ve been hurt in a car wreck or have a broken bone or cancer, if you need a CT scan, you’re going to be out of luck. Health centers are wonderful for primary care, but they’re not a substitute for comprehensive care.”

Ms. Aguilar has chronic conditions, as noted above, so these health centers likely wouldn’t be of much good to her anyway, assuming she could afford their fees. Even if she could, she wouldn’t be able to afford any medications they might prescribe. So she’s pretty much SOL. I personally think that Rick Perry, David Dewhurst, Greg Abbott, Dan Patrick, Ted Cruz, and everyone else responsible for Texas’ horrible lack of health insurance for so many of its residents should be made to personally explain to Ms. Aguilar and her kids why they don’t want her to be able to get health care. Not that I think it would have any effect on them, but maybe if they had to explain it to all one million plus Texans that they have excluded from coverage it might eventually wear them down.

I do know one way that Ms. Aguilar and the million others like her could get helped, and that’s by electing Wendy Davis and Leticia Van de Putte this November. No guarantee that they’d be able to overcome legislative resistance, of course, but there was some sentiment for expansion in 2011, and at least they wouldn’t be adding to that resistance. And if the Lege still can’t stand the idea of expanding Medicaid, there’s another way they could help Ms. Aguilar and many others like her: Raise the minimum wage. If Ms. Aguilar earned a bit more than $13 an hour, then her fulltime salary would make it to that magic $27,500 level – which is to say, exactly at the federally defined poverty line – and she’d qualify for insurance subsidies on the exchange. Either way would be fine by me.

Rick Perry doesn’t want people to get health insurance

There’s really no other viable explanation.

It's constitutional - deal with it

It’s constitutional – deal with it

On a White House conference call on Monday, Texas Democrats criticized Gov. Rick Perry and other Republican state leaders for “getting in the way” of implementing federal health care reform.

During the call, which was organized by the White House to tout the impact of the Affordable Care Act in Texas, state Rep. Trey Martinez Fischer, D-San Antonio, and Dallas County Judge Clay Jenkins accused state leadership of creating obstacles to keep Texans from obtaining health insurance, as required by the health care law, also known as Obamacare. The two Democrats cited Texas’ decision not to expand Medicaid, the lack of a state-based insurance marketplace and proposed additional rules for federal navigators.

Martinez Fischer called Texas the “poster child” for the uninsured, adding that the state’s rate of residents without health insurance — the highest in the nation at about 25 percent — had received “no relief from state leadership.”

“I wish we would use our energy and momentum in Texas with our statewide elected officials to actually embrace and work cooperatively with the administration to expand ACA opportunities in Texas rather than the trail of roadblocks,” Martinez Fischer said.

Jenkins questioned Perry’s request for additional regulations on federal navigators, who are charged with helping individuals sign up for health insurance.

“If they won’t help citizens gain access to coverage, they ought to stand down and stay out of the way for those of us who are willing to work to do the job for Texas,” Jenkins said.

Perry first requested the rules in September, citing consumer privacy concerns. Other Republican state leaders, including Lt. Gov. David Dewhurst and Attorney General Greg Abbott, followed suit.

Perry spokeswoman Lucy Nashed called the conference call an attempt to distract from the Affordable Care Act’s “continued failures.” She cited the technical problems of the federal online insurance marketplace, concerns surrounding the training of navigators and delayed enrollment deadlines.

“Texas families and businesses don’t need more empty rhetoric from the Obama administration to know that Obamacare is a failure,” Nashed said.

It takes a certain level of sociopathy to say something like that when you are the Governor of the state with by far the highest number of uninsured people, and you’ve been Governor for thirteen years without doing a single thing about it. Except for all the things you’ve done to deny health insurance to people, such as the CHIP cuts and our famously stingy Medicaid eligibility requirements and onerous enrollment processes. Hey, remember when we spent a couple hundred million dollars outsourcing our Health and Human Services Commission and gave the money to a private firm that didn’t know its ass from a pencil eraser? Those were the days, my friend.

The antipathy towards health insurance comes through in everything Rick Perry – and David Dewhurst and Greg Abbott and the rest of the sorry lot – does, from imposing needless burdens on navigators to refusing to expand Medicaid to refusing to implement an exchange, and on and on. If there were some honest ongoing effort over the past decade-plus to do something about the millions of uninsured in Texas, that would be one thing. But the record, and the inactivity, speak for themselves. There’s really no other way to characterize it. Millions of people have become insured around the country, but all we get here is rage and denial.

Oh, and bad journalism, no doubt influenced by the lying and obfuscation. Do make sure you click those two links and read the stories, which have now coaxed an apology for the half-assed job they did from the Star-Telegram. Senators Sylvia Garcia and Rodney Ellis have more.

HHSC publishes rules relating to HB2

HHSC is all in on the omnibus anti-abortion bill passed during the special session this summer.

Texas health officials have a message for the more than 19,000 folks who wrote in to oppose new abortion regulations: Each individual commenter failed to show that clinics will close or that women will face an undue burden under the rules.

In what amounts to a robust defense of Texas’ sweeping new abortion law, the state Health and Human Services Commission is set to publish responses to the crush of public comments it received while wrapping up the last set of regulations for House Bill 2.

Final rules go live Friday in the Texas Register to spell out how the state will implement a portion of the law that requires clinics to meet the standards of ambulatory surgical centers. That document will contain a 16-page preamble to directly address the 19,000-plus commenters who asked regulators to amend the rules to prevent potential widespread clinic closures by carving out waivers for existing facilities

As expected, however, the commission earlier this month gave its blessing to a set of final rules that ignored those requests and instead adhered strictly to legislative intent.

In the document, state health officials argue the new standards will improve patient safety and said the rules are not intended to punish abortion clinics and do not “pose a substantial obstacle to a woman who seeks an abortion in Texas.”

The agency also pointed a finger back at the people who wrote in, saying individual commenters failed to produce even a shred of evidence proving the new rules would cause an undue burden for women seeking an abortion.

“The department is aware of no comments that explain how particular abortion-seeking patients will face unconstitutionally long travel distances, unconstitutionally long wait times, or unconstitutionally high costs for abortion services in any particular part of the state,” according to a copy of the final rules obtained by the Express-News.

The rules are here. It takes a special kind of willfulness to refuse to see any harmful effects of this dangerous and unnecessary legislation, but then these people are Rick Perry appointees, so they’re just doing their jobs. This story only reports on what HHSC was doing, so we go to this Trib story to hear from the folks on the sharp end of HHSC’s antics.

Amy Hagstrom Miller, executive director of Whole Woman’s Health, which operates five abortion clinics in Texas, called the department’s claim that it doesn’t know of any abortion clinics that have closed or will close “preposterous.” She emphasized that the new restrictions have already caused abortion facilities in the Rio Grande Valley, Killeen and Waco to stop performing abortions, leaving thousands of women without access to care.

“Women can still decide to terminate a pregnancy, but thousands of them can no longer actually access safe, professional medical care to receive that termination,” Miller said in an email to the Tribune. “A right is meaningless if you cannot act on it. Without providers, the right to an abortion is an abstraction that does not exist for thousands of Texan women.”

Abortion providers in Texas have challenged the constitutionality of two laws that took effect in November: the admitting-privileges rule and another requiring doctors to follow federal guidelines — rather than a common, evidence-based protocol — when administering drug-induced abortions. The rules finalized on Friday also require abortion facilities to meet the same standards as ambulatory surgical centers starting in September.

Although six abortion facilities already qualify as ambulatory surgical centers, only three of them currently have a physician on staff with hospital admitting privileges. The department wrote in the rules that it’s aware of three ambulatory surgical facilities that abortion providers plan to open in Dallas, San Antonio and Houston by September.

[…]

As the case moves through the courts, roughly a third of abortion providers operating in Texas have discontinued abortion services because they do not have a physician with hospital admitting privileges. Some facilities that discontinued services when the law first took effect now have physicians who have obtained hospital admitting privileges, such as the Whole Woman’s Health facility in Fort Worth.

Planned Parenthood was forced to stop performing abortions at four facilities in Texas when the new law took effect in November because those facilities do not have physicians with such privileges. Planned Parenthood facilities that offered abortions in Bryan, Midland and San Angelo have also recently closed.

Although the finalization of the new rules are a “deeply troubling development,” said Sarah Wheat, vice president of community affairs for Planned Parenthood of Greater Texas, the organization would continue to evaluate its options and take steps to secure women’s access to health services.

“These restrictions will do nothing to protect women’s health and safety, which is why doctors and leading medical groups — as well as thousands of Texans — opposed them,” Wheat said in a statement. “By cutting off access to safe, high-quality medical care, these restrictions will endanger women’s health and safety.”

I suppose one could claim there’s a difference between closing down a clinic that provided abortion services and simply forcing that clinic to stop providing those services, but I daresay it’s a distinction that would be lost on the women who no longer have access to those services. It also rather egregiously ignores the stated intent of Rick Perry, Dan Patrick, and a huge swath of other Republican elected officials, which is to outlaw abortion in Texas, if not in the actual statutes then in the effect of them. If HB2 doesn’t fulfill that goal, then I guarantee you they’ll be back with another bill next session. There’s no end game here – if they succeed at making abortion illegal or impossible, they’ll move on to closing down Planned Parenthood or restricting access to birth control or something else. There will always be something next on their list.

The one thing that won’t be on their list is working to improve health care for women. They claim that that was that goal of HB2, but an amicus brief filed by the American Medical Association and the American College of Gynecologists on behalf of the plaintiffs in the federal lawsuit against HB2 puts the lie to that. From the brief these medical groups filed:

H.B. 2 does not serve the health of women in Texas, but instead jeopardizes women’s health by restricting access to abortion providers and denying women well-researched, safe, evidence-based, and proven protocols for the provision of medical abortion.

[…]

The privileges requirement imposed by H.B. 2 does nothing to enhance the safety of, or healthcare provided to, women in Texas. There is no medically sound reason for Texas to impose a more stringent requirement on facilities in which abortions are performed than it does on facilities that perform other procedures that carry similar, or even greater, risks. Therefore, there is no medically sound basis for H.B. 2’s privileges requirement.

You can see the full brief here (PDF), or click the BOR link above for the highlights. The full appeal of HB2 before the Fifth Circuit is one of many high-profile lawsuits that will be heard beginning next week. There’s still a lot of this story to be told.

Once again, the cost of not expanding Medicaid

We are paying for Medicaid expansion, regardless of what our “leaders” want. The only question is whether we get a benefit from it, or if it all goes to other states.

It's constitutional - deal with it

It’s constitutional – deal with it

If Texas keeps refusing to enlarge Medicaid under the Affordable Care Act, the state will pass up a heap of money, a new study has found.

In 2022, the state would pass up federal money for Medicaid expansion equal to more than twice its haul that year in federal highway aid, according to researchers Sherry Glied and Stephanie Ma of New York University.

Texas would forfeit $9.6 billion of federal Medicaid matching funds in 2022. That’s one-fourth of what the federal government expects to spend on defense contracts in the state that year, the study said.

“No state that declines to expand the program is going to be fiscally better off because of it,” said Glied, a former Obama administration health planning official who is dean of NYU’s Robert F. Wagner Graduate School of Public Service.

Texas Republican leaders have resisted Medicaid expansion, saying federal rules are too rigid and state costs in future years would soar. GOP leaders predict that federal budget cuts and the Affordable Care Act’s rollout problems will force a rollback of the generous pledge of federal funding.

Last year, Texas took $17 billion in federal money for its $28 billion Medicaid program. It currently covers 3.6 million children, pregnant women, seniors and disabled Texans.

More than 1 million poor adults of working age would be added to the program by 2016 if Texas changed course and embraced expansion, according to the state Health and Human Services Commission.

You can see the study here. The usual suspect at the corporate-owned “think tank” TPPF make their usual blatherings about Medicaid being something they don’t like, but they never address two key facts. One is as noted above, that we’re paying for this one way or another, and it’s up to us whether we reap any benefit from it or if we just give it away to New York and California and so on. Two, we’re still paying for the health care of these folks one way or another, too. We pay for it in local taxes when they visit the ER for things that could have been treated more easily and efficiently if they could have done a routine doctor’s visit, and we pay for it in lost productivity and economic potential, especially for the children. Not that the sociopaths at the TPPF care, of course. But we are paying for it. We’re wasting a ton of money doing it the way we are now. We do it differently and get a huge benefit for not much more, and possibly even save a few bucks if we really do it right. Not as long as people listen to the TPPF, though.

Perry keeps asking for the same Medicaid waiver he hasn’t gotten in the past

Same as it ever was.

Corndogs make bad news go down easier

Free corndogs with every approved treatment!

Gov. Rick Perry is preparing for yet another battle in his war against Obamacare.

In a letter to the state’s health agency on Monday, the governor laid out his plan to request a federal waiver to reform Medicaid as Texas sees fit — without expanding eligibility.

“Seemingly, the president and his administration are content to simply throw money at a problem and hope that any problems will resolve themselves,” Perry wrote in a Monday letter to Kyle Janek, the executive commissioner of Texas’ Health and Human Services Commission. “My response, and the response of the Texas Legislature, has been crystal clear: Texas will not expand Medicaid under Obamacare.”

Instead, Perry has asked that the agency request flexibility in the form of a block grant — a fixed amount of money, rather than matching dollars for Medicaid services — from the federal government to fundamentally reform Medicaid. Specifically, Perry requested that the agency seek a waiver that allows the state to make changes to the program without receiving federal approval, continue asset and resource testing to determine eligibility, and initiate cost-sharing initiatives, such as co-payments, premiums and deductibles, among other reforms.

The waiver “should give Texas the flexibility to transform our program into one that encourages personal responsibility, reduces dependence on the government, reins in program cost growth and efficiently improves coordination of care,” Perry wrote.

[…]

In a second letter sent to HHSC on Monday, Perry requested that the agency develop a mechanism to continue collecting and analyzing income, asset and resource information on Texans who apply for Medicaid benefits. That’s despite a provision in the Affordable Care Act — one that takes effect on Jan. 1 — that requires the state to stop asset testing to determine Medicaid eligibility.

A copy of the letter requesting the block grant is here, and a copy of the letter on asset testing is here. Texas has been asking for a Medicaid block grant since at least 2008, when the Bush administration rejected the request. Perry knows full well what the answer will be, he’s just going through the motions out of spite and the continued delusion that he’ll be appealing to Iowa voters in 2016. If the CMS assigned me the task of writing the response, I’d start out by noting that in any negotiation, there must be good faith and a willingness to give something to get something. As the primary purpose of block granting Medicaid is the limit services, and the primary purpose of the Affordable Care Act is to enroll more people in health insurance plans, Perry’s proposal demonstrates neither of those things. Just this week, we’ve seen two examples of other Republican governors agreeing to expand Medicaid. They both wrung some concessions out of the feds in doing so, but the end result will be more people getting access to health care. And Lord knows, we need a commitment to providing access to health care in Texas.

Texas continued to have the highest rate of people without health insurance in 2012 at 24.6 percent, according to the Current Population Survey estimates released by the U.S. Census Bureau on Tuesday.

“Texas has often had the highest uninsured rate throughout the country,” said David Johnson, chief of the Census Bureau’s Social, Economic and Housing Statistics Division. He added that additional data from the American Community Survey that the Census Bureau plans to release later this week would provide more specific information on health insurance rates in states and metropolitan areas.

The Current Population Survey estimates revealed that the national uninsured rate declined in 2012, to 15.4 percent from 15.7 percent in 2011. The national real median income and official poverty rate were not statistically different in 2011 and 2012, according to the estimates.

Thanks to the insurance exchanges and the ACA subsidies, Texas’ unacceptably high level of uninsured people will decline, though as always Perry is doing everything he can to keep as many Texans as possible sick and unable to do anything about it. Perry and his fellow Republicans just don’t give a damn about the problem. Until they do, I see no reason for the feds to waste any time on these pointless requests.

A reduction in funding for women’s health leads to fewer women getting health care

Shocking, I know.

Right there with them

Right there with them

The number of claims filed for medical and family planning services in the new state-run Texas Women’s Health Program has dropped since the state ousted Planned Parenthood from it and set up its own program without federal financing, according to figures from the Health and Human Services Commission.

Stephanie Goodman, a spokeswoman for the commission, wrote in an email that the program is “running at about 77 percent of the number of claims this year compared to last year.” She added that the agency expects to “see a similar trend with the number of women served,” though those numbers are more difficult to calculate.

“We expected to see a drop-off in the number of claims when we moved to the state program because we knew some women wouldn’t want to change doctors,” Goodman said. “We’ve been able to find new doctors for women who call us, and we’ve got the capacity to increase the number of women we’re serving in the state program.”

[…]

While Planned Parenthood continues to provide services with community donations and other revenue, Danielle Wells, a spokeswoman with Planned Parenthood of Greater Texas, said many patients have expressed frustration “that politicians are telling them where they should and should not go for their health care.”

“We’re still hearing from patients who were in the program and were unable to locate a provider or schedule services in a timely manner,” she said. The exclusion of Planned Parenthood requires many women to travel farther to find an available provider, she said, and to make “tough decisions about paying out of pocket for care or simply putting off vital care that could potentially save lives.”

Amanda Stevenson, a research associate at the University of Texas at Austin’s Texas Policy Evaluation Project, a three-year study evaluating the impact of the 2011 women’s health policy changes, said determining whether women still have adequate access to care is complicated. While the health commission is working hard to enroll new providers to replace Planned Parenthood, she said women may delay care because they do not know which providers are available or end up paying out of pocket costs by continuing to seek services at a Planned Parenthood clinic.

“We’re seeing obviously that access is diminishing in places, particularly [those] that rely heavily on Planned Parenthood providers,” she said. But other areas of the state have not been as affected by the policy changes, she added, referencing a data application created by the researchers that shows how the 2011 policy changes and funding cuts have affected women’s health services regionally.

She also noted that more data is necessary to determine whether the percent reduction in claims represents a persistent trend.

“If things were getting better then we would expect consistent reduction in that proportion, but it’s not happening,” Stevenson said. “There might be a trend, and we might see it, but it’s not enough here to say that it is.”

To be as fair as I can to something that doesn’t deserve fair treatment, Planned Parenthood had previously served forty percent of the Women’s Health Program clients, but the decline in participation is now only about 23% of the pre-cutoff total, which means that at least some of the women who were directly affected by this bit of ideological bloodletting have since found an acceptable alternative. Hooray for small victories. Of course, they were all still forced to change doctors, and we have no way of knowing how much less convenient or more expensive these new arrangements are for them. And Lord knows the people that brought you this little catastrophe aren’t interested in finding out the answer to that. But again, as I said before, even if you could reasonably claim that access to health care is no worse than it was before, hundreds of thousands of women had their access to health care disrupted, for no good reason. And a lot of legislators plus our state leaders count that as a victory.

In related news, that ballyhooed restoration of family planning funds this session is less than meets the eye.

The Texas Women’s Healthcare Coalition has raised concerns that a bipartisan effort to restore access to family planning services by expanding a state-run primary care program isn’t shaping up as planned.

During hearings in the regular legislative session, David Lakey, the commissioner of the Department of State Health Services, told lawmakers that 60 percent of the $100 million allotted to expand the primary care program for women’s health care in the 2014-15 biennium would be used to provide family planning services and contraception. But the forms created by DSHS for health providers to apply to take part in the program do not explicitly state that 60 percent of providers’ services must go toward family planning.

In a letter sent Monday to DSHS and lawmakers, the coalition — which counts the Texas Medical Association, Texas Academy of Family Physicians and Texas Association of Community Health Centers among its 39 members — argued that the proposed rules don’t ensure that the program will achieve lawmakers’ intent of restoring access to family planning services.

“We’re concerned that this was really like a bait and switch,” Dr. Janet Realini, chairwoman of the coalition, said in an interview. Although she does not believe DSHS has intentionally disregarded the legislative intent to increase family planning services, she said, “the system to do that is missing an essential piece of direction for the contractors.”

Carrie Williams, a spokeswoman for DSHS, said the department received the coalition’s letter and is working to clear up misunderstandings about the program.

“We’ve been very open in developing and talking about this program, so it was disappointing to see these inaccuracies being promoted as fact,” Williams said in an email to the Tribune.

She added that family planning services are emphasized throughout the department’s materials on the program, but that the program does not exclusively provide family planning services.

“The 60 percent target for family planning was what we have been proposing all along. While that threshold is not explicitly stated in the materials, it has long been the plan and we have never indicated otherwise,” said Williams.

In its letter, the coalition recommended that the department explicitly prioritize family planning services by setting specific targets and performance measures for contractors. The state could save money and avert unintended pregnancies, the coalition argues, by setting performance targets for family planning services and giving funding priority to contractors that have demonstrated the ability to provide these types of services.

“I think putting it in the materials to let contractors know what you’re looking for is important,” said Realini.

In the private sector, we call that setting metrics. Metrics reflect goals and values. You can draw your own conclusions.

If Medicaid is broken, who broke it?

Patricia Kilday Hart asks an excellent question.

It's constitutional - deal with it

It’s constitutional – deal with it

[Rep. Garnet] Coleman’s observation provides part of the answer: Just last session, the Legislature trimmed $486 million in state money paid to Medicaid providers, and ended a student loan-forgiveness program for new doctors exclusively serving Medicaid patients.

The federal government, which has established some rules that restrict the state’s ability to rein in costs, also bears some responsibility.

For example, the federal government will not allow states to charge even small co-pays, which could discourage overuse of services.

In 2009, the Texas Medicaid program paid $467 million for almost 2.5 million emergency room visits – but half of those visits were not emergencies, according to Stephanie Goodman, communications director for the Health and Human Services Commission.

“Private insurance plans typically charge a higher co-pay for an emergency room visit than for going to a doctor’s office because they want to create an incentive to choose the right level of care for the situation,” she said. “Medicaid should do the same.”

[…]

Medicaid has kept its costs down better than other sectors of the health care system. On a per-beneficiary basis, the program’s costs grew only 4.6 percent between 2000 and 2009, compared with a 5.1 percent increase in Medicare and a 7.2 percent increase in costs for patients covered by private insurance, according to the national Center for Budget and Policy Priorities, which focuses on policies affecting low-income families.

“Medicaid is the victim of Swift-boating,” said Anne Dunkelberg, analyst for the Austin-based Center for Public Policy Priorities, referring to the political ad campaign that torpedoed Sen. John Kerry’s 2004 presidential bid. “It is the power of the talking point that is repeated so often that people believe it.”

Medicaid is spending less per recipient today than in 2001, Dunkelberg says. The program’s bigger footprint can be traced to demographics, not overuse, she argued. Texas accounts for half the increase in children in the U.S., says the census, and most of them are poor.

The point about the reimbursement rates being set by the Legislature has been made before, but can’t be made often enough. If you don’t maintain your car, you have no business complaining when it craps out on you. Given the flexibility that the federal government has already shown Florida and Arkansas, there’s no question that co-pays will be allowed – Rep. Coleman has been talking about that, and some other items on Texas’ wish list, all along. The rest is up to us. And please note, if we really cared about controlling costs we’d be all over the Medicaid option. There’s no reason at all to believe that the private insurance way – the Arkansas option – will be less expensive. At the end of the day, if we don’t expand access to health care, via Medicaid or some convoluted not-Medicaid process, it will be because the Republicans chose not to, not because it didn’t make sense not to do so. Burka has more.

Medicaid “expansion” bill passes out of House committee

Forgive me for tempering my excitement about this, but it’s not that much to be excited about.

It's constitutional - deal with it

It’s constitutional – deal with it

Despite opposition from conservative Republicans, the House Appropriations Committee on Tuesday advanced a proposal that would reform Medicaid by allowing the state to request a block grant from the federal government and expand coverage to low-income Texans.

“This is not an expansion of Medicaid — this is the creation of a new program that leverages our private sector,” said Rep. John Zerwas, R-Simonton, the author of House Bill 3791. Members of Appropriations voted 15 to 9 to move the legislation out of committee and continue debate on the House floor.

[…]

The revised bill has four parts: It outlines what the block grant would look like; identifies Medicaid reforms that Texas could implement already, such as cost-sharing requirements and co-payments; sets up a separate program to potentially draw down federal financing to help individuals at or below 133 percent of the poverty level find private market coverage; and sets up an oversight committee for both programs.

Trail Blazers fills in some details.

[HB 3791] would, among other things, attempt to appease hospital leaders and urban county judges and commissioners who are irate over state GOP leaders’ apparent determination to walk away from about $100 billion in additional federal funds that Texas could draw down over the next decade. The money would flow to Texas if it expands Medicaid to more adults — a move that would pull forward to government coverage more than 400,000 poor children who are already eligible but haven’t enrolled. Texas would have to put up just more than $15 billion of its money through 2023.

[…]

The bill by Zerwas, though, would at least force Team Perry to go through the motions [of negotiating with the Obama administration]. Governors in other states have reached some deals with federal Medicaid czars, some involving private insurance subsidies as an alternative to traditional Medicaid.

Zerwas’ measure says any Texas-specific premium assistance plan must include features near and dear to conservative lawmakers’ hearts. The deal must include outcomes-based provider reimbursements, “meaningful cost sharing requirements and wellness initiatives,” tailored benefits, nudges for existing Medicaid recipients to take the premium subsidies and for people to accept employer-offered coverage — and of course, health savings accounts, which allow patients to spend from a pool of dollars that rolls over at the end of the year and they keep.

“I understand the kind of political radioactivity around this particular bill,” Zerwas told colleagues. “But I … am hearing and many of us are hearing especially from our county and local governments that this would have a profound effect not only on the provision of care [but] some of the collateral effects are its potential to reduce property tax rates” charged by county hospital districts, such as one in Dallas County that supports Parkland Memorial Hospital, he said.

Rep. Stefani Carter, R-Dallas, praised Zerwas’ hard work but said she had to vote no because his bill needs more vetting. Carter questioned how many of her constituents would benefit.

Democrats weren’t thrilled by the laundry list of conservative “health care reforms” in the bill but went along.

“Cautiously, yes,” said Rep. Helen Giddings, D-Dallas, announcing her vote.

What Rep. Giddings says. As with the Arkansas option, this is a Rube Goldberg monster whose complexity is a direct result of Republican intransigence to the obvious solution. It’s a kluge on top of a kluge that starts out by wishing for a pony – block grants – then resigns itself to coming up with something that won’t require the state to give up on billions in funding. It’s still better than nothing, which once again gives you an idea of how awful the status quo is. Better Texas has more.

On a side note, the House also instructed conference committee members to not expand Medicaid in the budget reconciliation negotiations. Which they couldn’t do anyway, since you can’t use the budget to make new law, but never mind that. The Republicans in the Legislature are wise to Barack Obama and his sneaky tricks, yes they are. Whatever happens from this point, it needs to happen quickly because time is running short in the session. The issue could be picked up again in a special session, but only if Rick Perry wants that to happen. Getting it done now is the best bet by far.

The limits of the Arkansas option

I’ve mentioned the Arkansas option for expanding Medicaid several times, under which the state uses Medicaid money to buy private health insurance for those who would be eligible for Medicaid under the Affordable Care Act. It’s not my preferred solution, but it has some merits and would certainly be better than doing nothing. However, while the federal government has shown a great deal of flexibility in allowing an arrangement like this and like what is on the table in Florida if their legislature doesn’t deep-six it, that flexibility has its limits, as the state of Tennessee found out.

It’s constitutional – deal with it

Tennessee wanted to pursue a plan like that of Arkansas, one where it would use the Medicaid expansion dollars to buy private insurance coverage. And while Arkansas received a preliminary go-ahead from HHS, Gov. Bill Haslam had a quite different experience: He says that Health and Human Services would not support his plan to expand Medicaid and, as a result, he will not move forward.

“As a result of the lack of clarity from HHS,” his office said in a late Wednesday statement, “the governor will not ask the General Assembly for approval to accept the Medicaid expansion federal funds as he continues to work for the flexibility needed to implement his plan.”

Haslam told local reporters that the Obama administration didn’t reject the entire proposal. “Of our request to Medicaid,” he said, “we got one or two yes’s, one or two no’s, and a whole lot of I don’t knows.”

[…]

But some of the other points in the Tennessee proposal might have raised eyebrows in the Hubert Humphrey Building. The governor proposed “co-pays for those who can afford to pay something.” As for what that would mean in practice, Andy Sher at the Chattanoga Times Free Press reports that the governor wanted Medicaid beneficiaries to pay the same cost-sharing as other exchange enrollees.

Medicaid experts I’ve spoken with have made it clear that such an approach wouldn’t fly: Even if they receive private coverage, the Medicaid agency would need to ensure they aren’t spending more out of pocket than they would in the public plan.

Officials in Arkansas agree with this interpretation, too. “Medicaid definitely has strict rules for people below the poverty line and then they issued some new rules this year, for people above the poverty line,” Arkansas Medicaid spokeswoman Amy Webb told me last month. “We still believe those apply, and we intend to follow those.”

I bring this up because while there has been some talk about the “Arkansas solution” among Texas Republicans, what they’re really talking about is more akin to the Tennessee proposal. Specifically, “copays, deductibles and premium payments on a sliding scale for poor patients, using asset testing to ensure services are going to people who truly need them” are among the items Rick Perry and his ideological cohorts are demanding. The shell bill filed by Rep. John Zerwas that would direct HHSC to negotiate with the Obama administration over a “Texas solution” includes this language, though it’s not clear to me if it’s an option or a requirement. If it’s the latter, I think we now know how these negotiations are going to go.

The point I’m trying to make here is that we need to pay attention to the contents of HB 3791 and listen carefully to what people like Rep. Garnet Coleman have to say about it. If the final bill includes demands for things that the feds have already categorically rejected, then we need to be aware of that up front. Because if it does contain such a requirement, then we need to be prepared for when Rick Perry claims that he “tried” to negotiate with the Obama administration but they were too inflexible and unwilling to compromise so we can call it out for the BS that it is. If Texas negotiates in good faith, the feds have shown that they can be very accommodating. If not, we shouldn’t be surprised when the negotiations fail, and we shouldn’t let the state claim that they made a legitimate effort. Perry and his cronies have made it abundantly clear that they really, really don’t want to expand Medicaid. We should take them at their word and not be distracted by side issues.

Feds bypass the state on Title X funds

Very interesting.

The federal government announced [Monday] that it would no longer award a large slice of federal family-planning funds to the state of Texas. Instead, the feds will award the $6.5 million grant to the Women’s Health and Family Planning Association of Texas, a coalition of providers led by Fran Hagerty, to distribute to clinics for birth control, wellness exams, STD screenings and other family planning services.

The Observer reported in November that the coalition would apply directly to the federal government for the grant—called Title X (Title 10).

Before today, the sole grantee for Texas’ Title X funds had been the Texas Department of State Health Services. The health department had in turn distributed the grant money to family planning providers statewide. In 2011, the Title X grant had been part of $111.5 million available to the state for family-planning services.

But the 2011 Legislature slashed family planning funding by two thirds, causing more than 60 clinics to close and cutting in half the number of Texans receiving services through Title X, according to an annual review by the Texas Department of State Health Services.

The collateral damage wrought by this decision has been widespread. Many of the providers in Hagerty’s coalition had lost state family-planning funds and are struggling to stay open. Though they still received other government health funding, the loss of Title X grant money had been keenly felt. Unlike other state funding streams, the Title X grant had allowed providers to cast privacy protection over all of their clients. This is especially important for teens that would otherwise need parental consent to access birth control. The Title X grant also allowed clinics to buy pharmaceutical drugs at a steep discount, and gave them the flexibility to invest in staff and infrastructure. Losing the Title X money and the flexibility that came with it had seriously destabilized the family planning safety net across Texas and reduced low-income women’s access to birth control and preventive care.

The federal government in turn decided that Hagerty’s group would be a better steward of Title X.

The Texas Department of State Health Services had sponsored 40 providers that operated a total of 122 clinics. Hagerty’s coalition will distribute the Title X money to 34 contractors operating 121 clinics across the state, beginning next month. Hagerty said in an email that she doesn’t yet know how much the three-year budget will be due to uncertainty over federal budget cuts.

“WHFPT and [the Department of State Health Services] must work together to improve the health status of all Texans,” Hagerty wrote. “We are all ready and eager for this opportunity to provide family planning care for Texas families.”

Trail Blazers, the Trib, and the AusChron also reported on this, with the latter recapping some more of the history of this coalition and noting that Planned Parenthood is a member of it. I blogged about the Observer’s reporting in November as well. Not surprisingly, the powers that be in Texas didn’t take this well.

Gov. Rick Perry on Tuesday called a decision by the Obama administration to send a $6.5 million federal family planning grant to a Texas coalition of women’s clinics, rather than a state agency, “a clear attempt to circumvent the will of the Texas taxpayers and impose their own values on the people of Texas.”

His criticism of the White House at a Texas Faith and Family Day rally at the state Capitol was echoed by Lt. Gov. David Dewhurst, who claimed the decision would “line the pockets of Planned Parenthood.”

[…]

egarding the grant announced this week, Fran Hagerty, CEO of the Women’s Health and Family Planning Association of Texas, said she believes her group won the competition because it demonstrated it could serve more women than the state agency’s program. The association promised to serve some 160,000 women next year, while the state’s program reached only 65,000 last year because of rules limiting what kinds of health entities could access the funds. She also said that only two of the 34 clinics in her association are affiliated with Planned Parenthood.

“Nobody is making money off of anything,” Hagerty said. “It’s not possible. People do this work because they care.”

Hagerty noted that in 2011, the Texas Legislature cut $73 million from the budget’s family planning programs, forcing some 50 women’s health clinics across the state to close. Health and Human Services Commission analysts have estimated the family planning cuts would result in 24,000 more births to low-income mothers, at a cost of as much as $273 million more in spending by the state, mostly in Medicaid expenses, over the next budget cycle.

“We are hoping to go back and reopen clinics,” she said. None of the 34 clinics that will get the grant money provide abortions. “They provide high-quality family planning.”

Blake Rocap, legislative counsel for NARAL Pro-Choice Texas, praised the decision by the Obama administration and argued that rules adopted by the Legislature should not apply because “it’s not Texas’ money.”

“They submitted a more competitive bid than the state agency,” he said. “Is the state afraid of a little free-market competition?”

Ouch. As I said back then, this is good news for the coalition since it will not have to put up with the state’s BS for these funds. Lord knows, with the way the Lege continues to screw with Planned Parenthood and women’s health in general, any degree of freedom is good. I wouldn’t count on it long-term, since there’s no guarantee the federal government won’t someday be as reactionary and anti-woman as the 2011 Lege was, but it’ll do for now. The hysterical reaction from Perry et al is strong evidence that this was the right call.

Straus wants someone to do something on Medicaid

Don’t we all, Joe. Don’t we all.

Rep. Joe Straus

Seeking to light a fire under fellow Republicans to provide health care to more uninsured Texans, House Speaker Joe Straus said Wednesday that it is time to “get our heads out of the sand” and find an alternative to Medicaid expansion that would bring billions of federal dollars to the state.

Straus said he and other Republicans have made it clear that they oppose expansion of Medicaid as the program now stands.

“But I think it’s time that we said more than that,” he said. “It’s time that we put forth a good-faith effort to find a Texas solution. We need to move beyond the word ‘no’ to something that the administration might entertain. There are no winners if nothing is agreed to. We have a very large state, a significant population of uninsured people … and I think it could be an opportune time to put some proposals on the table that could be supported by Texas leadership.”

Straus, R-San Antonio, said elements to focus on include subsidies to allow people to obtain private coverage, promoting personal responsibility and cost-sharing, such as co-pays and deductibles.

Straus said there may be a way to tie a plan to a reduction in local taxes, since a key argument for expansion is that it would relieve local taxpayers of some of the burden they now bear to cover the cost of treating uninsured people in public hospitals.

[…]

It is unclear exactly how the conversation will move forward, but Straus said it is important to gear up talks with the aim of building consensus behind a Texas solution.

“We need to make the right business decision for Texas taxpayers,” Straus said. “Local governments have to carry a very heavy burden and look, poor people are going to get sick. They’re going to be treated. And somebody’s going to pay for it.”

Nice talk, if plenty vague. But let’s keep these things in mind:

– Medicaid is going to be cheaper than private insurance. If there’s a problem with doctors not accepting Medicaid, that’s entirely within the Lege’s discretion to fix, since the Lege sets the amount that doctors get paid from Medicaid. But even with more generous reimbursements, Medicaid is going to be less expensive than insurance provided by a profit-seeking enterprise.

– The single biggest obstacle in all this is Rick Perry, with Greg Abbott right behind him. These guys just don’t care about this issue. I can’t state it any more plainly than that.

– Of course, after ten years of complete Republican control of Texas government, the only reason people like Joe Straus are even talking about this is because they have to, thanks to the efforts of President Obama and Congressional Democrats. Texas leads the nation in uninsured people, a situation that has only gotten worse under the Republicans. What little progress there has been has been in spite of the Republicans. It didn’t have to be that way, but it was and is. I’m glad that Straus wants to do something, but I don’t take it as a change of mind, just as a recognition of the lay of the land. He hasn’t exactly been powerless to effect change before now, after all.

Be that as it may, there was a hearing in the House on Friday to talk about just what Texas might do to expand health care access, whether Medicaid or something else.

There are thousands of scenarios that the state could take to expand and reform Medicaid, Kyle Janek, executive commissioner of the Texas Health and Human Services Commission, told the committee. But “we don’t have something on paper,” he said. Janek said he is awaiting further direction from the Legislature to craft a specific plan.

Rep. Sylvester Turner, D-Houston, referenced a compromise Arkansas’ Republican-led Legislature reached with the federal government, and said if “the people in Arkansas are much more capable of designing a system than the people in the state of Texas, that has taken us to a different level.” He called on his colleagues to stop being critical of the Medicaid expansion presented by the Affordable Care Act and to ask themselves “whether or not Texas has the ability to design something that works for Texas.”

Requiring Medicaid patients to make co-payments for their care — an option that has received support from Perry, Straus and other GOP members — is allowed under the Affordable Care Act, Janek said. He said if Texas took a different route and attempted to subsidize private health plans through an Orbitz-style health insurance exchange like Arkansas, the state would need to set up policies to ensure benefits offered by Medicaid that weren’t covered by private plans didn’t disappear.

“I think the public has a misconception that Medicaid expansion will get us the greatest bang for our buck,” said Rep. Lois Kolkhorst, R-Brenham, who chairs the House Public Health Committee. “For Texas, the bang for our buck is really in the exchange, the subsidy [for] people going into private insurance.”

Kolkhorst said without expanding Medicaid, other tenets of the Affordable Care Act would reduce Texas’ uninsured rate from 24 percent — the highest in the nation — to 16 percent. Including the Medicaid expansion would drop the uninsured rate slightly more, down to 12 percent.

As noted above it’s actually almost 29 percent. But who’s counting?

In total, unreimbursed charity care creates a $4.3 billion annual tax burden on local government entities and public hospitals, Billy Hamilton, the state’s former chief budget estimator, told the committee. Overall, he said, there is enough local and state spending in the current system to cover the state’s share of Medicaid expansion costs.

“I know this is a controversial issue… but I don’t really think you’re going to see a more overwhelming fiscal opportunity during your service here,” said Hamilton. “I served this Legislature for 30 years and I’ve never seen anything like it.”

The committee also heard testimony from judges from Harris and Dallas counties who spoke in favor of expanding Medicaid, and from John Davidson, a policy analyst from the conservative Texas Public Policy Foundation, who spoke against Medicaid expansion.

Rep. John Zerwas, R-Simonton and an anesthesiologist, said Texas needs to ensure that any expansion of reform of Medicaid include ways to incentivize more health care providers to accept those patients. If it doesn’t, those patients will end up in the highest-cost environments, emergency rooms. Zerwas pointed out that only 32 percent of doctors are willing to take Medicaid patients in the existing program, under current reimbursement rates.

Rep. Donna Howard, D-Austin, said the Legislature should be held responsible for this lack of Medicaid providers, because lawmakers set those reimbursement rates. “The provider capacity is a real issue for this system, whether we expand or not,” she said.

So that’s Ed Emmett and Clay Jenkins, two guys who live in the real world and have to deal with the real world consequences of having thousands of uninsured people needing medical services their counties provide, versus some pampered, well-paid shill from a right-wing think tank. In a just world, that would be no contest. I’m glad to see Rep. Turner address the Arkansas plan, as that’s the first comment I’ve seen from a Democratic official about it. Again, it’s not my preference but if it’s that or nothing I’ll grab it with both hands.

In the end, as the updated story from the Trib notes, the Lege punted to the HHSC for now.

Rep. Zerwas filed legislation Friday that would grant the Health and Human Services Commission authority to craft “a Texas solution” to Medicaid reform and negotiate with the Obama administration to draw down billions in federal financing to expand Medicaid services.

As debate in the House Appropriations Committee on Medicaid expansion revealed Friday morning, the House remains divided on how Medicaid should be reformed and whether the program should be expanded. Currently, House Bill 3791 is a shell bill that will be altered as state legislators continue to negotiate how Medicaid should be reformed.

“We felt like it was time to start to get the ball moving on this. We’ve made it pretty clear that we’re not for current Medicaid expansion, but we do need to be for something else,” said Zerwas on Saturday, “because I think its very important for the state that we determine a way to cover this group of people that are currently uninsured.”

HB 3791 directs the HHSC to negotiate with the Obama Administration, so that Texas can draw down Medicaid expansion financing while implementing Medicaid reforms that enhance “personal responsibility” of Medicaid recipients, such as copayments or deductibles. It also includes a severability clause to end the agreement if the federal government reduces it share of Medicaid expansion financing.

As it stands, the HHSC does not “have a legislative directive or mandate to go forward on this, and that’s what this is intended to be,” said Zerwas, explaining the bill gives state lawmakers the opportunity to weigh in on how Texas should tailor a Medicaid expansion agreement with the federal government. The bill prompts the HHSC “to move forward on something that the Legislature, the [state] leadership is comfortable with that is in the best interest of Texans and allows us to pull down those dollars, which ultimately are our dollars,” he said.

In other words, they still don’t know what they want, but some of them at least have decided that doing nothing isn’t the best idea. I’m confident the Obama administration will be flexible in the negotiations given what we’ve seen them allow so far. It remains to be seen how flexible the state of Texas will be.

Finally, Sara Kliff provides some useful information about what the Arkansas plan really means, via an interview with George Washington University’s Sara Rosenbaum, an expert on Medicaid policy.

Sarah Kliff: Right now, you have a number of governors looking at the idea of using Medicaid expansion funding to buy private health insurance for enrollees. How novel of an idea is that?

Sara Rosenbaum: It’s been treated as this brand, new thing, but I don’t actually think it’s completely revolutionary. Keep in mind that states have been using Medicaid to buy managed care plans since the beginning of Medicaid. The whole notion of this as a conceptual breakthrough for Medicaid feels a bit off for me.

It does happen though that this is in Arkansas, which traditionally has not been a buyer of managed care, not a place like Arkansas, and not somewhere like Texas which has been buying managed care.

One of the good things about it, from my perspective, is that it gives you more stability of coverage, or gives you the chance at stability. You’re brought into a plan to stay.

SK: So the idea is, if your Medicaid expansion population is in private insurance, they won’t have to bounce back and forth between private and public plans.

SR: It does address a problem of churn. Four years ago I raised this and put this forward to House and Senate committees as a model. It was met with a lot of opposition from Medicaid advocates, which I didn’t totally understand having worked in Medicaid for almost four years now.

The need for stability of coverage is so great. These are the youngest, healthiest and lowest-income workers. All they have to do is churn from different insurance plans two or three times, and they’re going to say I’m through with this. And these are the exact people we want to enroll.

There’s more about the costs and other aspects of this that are worth your time to read. I still don’t believe the Republicans care enough to actually do something about this – note Kyle Janek’s remark about not having something on paper – but I will be happy to be proven wrong. EoW has more.

Harris Health System plans to serve more patients via Medicaid waiver

The story about what they’re going to do leaves a few details out, however.

Harris Health System leaders plan to serve 100,000 new patients in the next three years. That is a 37 percent increase from today, and is particularly ambitious when you consider how many patients the system added in the last year: about 500.

To bridge the enormous gap by the end of 2016, the county hospital district is counting on state and federal approval of a $1.2 billion plan that represents the ambitions of health care providers throughout the region. The plan grows out of the federal government’s decision to grant Texas a waiver from Medicaid rules, allowing it to reimburse providers for charity care and for delivering care in new ways.

The plan, awaiting approval in May, envisions unprecedented cooperation between the district and local private and nonprofit providers.

“That’s a major undertaking. We’re very committed to it. We feel it’s very doable,” Harris Health CEO David Lopez said. “We cannot do it all by ourselves. We need partners with us to help us address the needs of our community.”

[…]

Among the district’s proposals awaiting approval: Build nine new primary care clinics during the next three years, build “quick” clinics next to its emergency rooms where patients who are not in crisis can be seen, outsource more primary care visits to private clinics, and leverage federal funds to support Memorial Hermann and Texas Children’s Hospital’s expansion of primary care services.

Members of Harris County Commissioners Court, which appoints the hospital district’s board, say the waiver plans are too slow in cutting the backlog of patients who cannot get primary care appointments. That waiting list, first identified in fall 2011, is estimated between 91,000 and 104,000 a year.

Commissioner El Franco Lee last week issued a memo with the phrases “reduce waiting lists” and “get patients moving through the system” underlined, calling on Lopez to cut the backlog by outsourcing more doctor visits.

I had a few questions about this after I read the story, so I sent some inquiries to the Harris Health System’s media relations email address. Here are the questions I sent, along with the answers I got:

1. The article says that “the county hospital district is counting on state and federal approval of a $1.2 billion plan”. Where is the money for this coming from? Are there new funding sources being sought, or is this a repurposing of existing funds?

Answer: The $1.2 billion plan in the article refers to the Delivery System Reform Incentive Payments (DSRIP) projects available under the 1115 Medicaid Transformational Waiver Program. Harris Health System serves as the anchor entity for the regional planning for several counties in SE Texas. The Waiver primarily does two things: 1) expands Medicaid managed care to the entire state 2) replaces the Upper Payment Limit (UPL) program with two new pools of funding, The Uncompensated Care Pool and the DSRIP Pool. Detailed information about the proposed local regional health plan may be found at www.SETexasRHP.com.

2. What entities are being asked to approve this plan? What exactly are they being asked to approve? What happens if they reject some or all of it?

Answer: The state of Texas and U.S. Centers for Medicare and Medicaid Services (CMS) will approve all plans.

3. The story says that this plan is unrelated to the Affordable Care Act. How will the plan be affected if the state changes course and decides to pursue Medicaid expansion, or a law is passed that grants counties the authority to pursue it on their own?

Answer: The 1115 Medicaid Transformational Waiver Program should not be affected by Medicaid expansion since it is unrelated. Detailed information about the 1115 Medicaid Transformational Waiver at-large, may also be found at the state’s Web site.

4. Are details of this plan available on the HHS website? If not, is there a document you could send to me with plan details?

Answer: Detailed information about the proposed local regional health plan may be found at www.SETexasRHP.com.

In other words, if you want to know more, you’re going to need to get your wonk on. State Rep. Garnet Coleman has discussed the 1115 waiver before – see here and here for two examples – and there’s some further discussion here. Basically, this is about delivering health care services via public hospitals and their partners more effectively and efficiently, with some extra federal funds available. It’s not fully clear how this will all work out, and there won’t be a decision on the waiver request until May, but this is what’s coming. Let’s hope it lives up to its promise.

Smaller WHP provider list back up

Maybe they got it right this time.

Right there with them

A revised list of Texas Women’s Health Program providers — with 965 fewer doctors and clinics — has returned to the state’s website.

[…]

The HHSC had previously stated that the Texas WHP had 3,500 participating providers, roughly 1,000 more than the number of providers that participated in the former Medicaid WHP. That list has shrunk to 2,448 doctors and clinics, as 965 providers said they would not accept WHP patients, despite being certified for the program. The contact information for 700 other providers has also been updated on the state’s website.

“HHSC added the provider search back to the Texas Women’s Health Program website late Friday after thousands of calls were made to verify the information,” Linda Edwards-Gockel said in an email. “The search is now set up to display first those health care providers who can serve the greatest number of clients.”

State Rep. Jessica Farrar, D-Houston, said in an email that she remains skeptical of the list’s accuracy. Farrar requested a list of all WHP providers and the number of patients they can serve from the HHSC under the Public Information Act, but the agency is still processing her request. “After briefly going through part of the list for Houston providers, my staff already found numerous duplicates.”

Going from 3,500 providers to 2,448 is a reduction of thirty percent. If I’m reading this correctly, there are now as many providers in the replacement WHP as there were in the original, except that the single largest provider by far is no longer allowed in. Would someone please remind me how it is that this program could possibly be an adequate alternative to the perfectly functional one we used to have? Assuming that this “corrected” list of doctors and clinics is now in fact complete and accurate, which is not a sure bet. We’ve had our fun error-checking the HHSC’s work, but the real issue is still how many of the women who depend on this program will actually be able to receive adequate health care through it? We can’t lose sight of that. Trail Blazers has more.

The state begins preparing its excuses for its WHP screwup

The fail is strong in this one.

Right there with them

State health officials continue to insist that they have signed up more than enough providers to replace Planned Parenthood across most of Texas. Areas of limited coverage — including San Angelo, Corsicana and Paris — are being scoured to find health care providers willing to join the Women’s Health Project, they said.

In the meantime, the provider information that was pulled from the Health and Human Services Commission’s website is undergoing a belated check for accuracy to remove doctors and clinics that were mistakenly listed as participants in the Women’s Health Program or that provided only limited services, such as surgical contraception.

New information will not be posted online until a state contractor verifies that every listed health care provider is a participant in the Women’s Health Program — and state health agency employees double-check the revised list, said Stephanie Goodman, a spokeswoman for the state Health and Human Services Commission.

What went wrong?

Originally, the list was generated by the contractor, the Texas Medicaid and Healthcare Partnership, by using provider numbers for practices that had joined the health program, Goodman said. That shortcut, however, captured all locations of a provider group, even those that were not participating — including pediatric clinics, labs and surgeons.

“Obviously, on something this high-profile, that’s going to be this scrutinized, this is an area where we should have done a better job,” she said.

“Our mistake, honestly, was not calling on our own” to verify the contractor’s work, Goodman said. “On paper, picking up all those providers that could legitimately bill under the program made sense. We should have realized that pulling from billing records would make it difficult for women to use” the list.

Goodman said she expects the revised list to be published online this week.

That’s what you said last week, Stephanie. I guess one of these weeks you’ll be correct about that.

The mistakes were unfortunate, Goodman said, because they overshadowed a lot of hard work that has been done to launch the state program, particularly in signing up enough new providers to meet the need left by Planned Parenthood’s ouster.

“That’s one of the sad parts of this. I’d hate for women to see these stories and think, ‘There’s no help for me,’ ” she said. “There are clinics all over the state that said they have the ability to serve more women.”

The real mistake, of course, was believing that in Rick Perry’s Texas, where the 2011 Legislature slashed spending on family planning by two-thirds, there would be any incentive for this to be done right. Forget the scapegoating of the contractor, whose work was apparently never supervised or verified by anyone at the HHSC – we don’t need no stinkin’ project management! – and focus for a minute on the statement above on how “areas of limited coverage” – that is, places where only Planned Parenthood had done this kind of work before – are still “being scoured” to find providers more than three weeks after the state WHP was supposed to go live. No one could have seen this coming, because the Perry administration has such an admirable record of caring about women and children, especially poor women and children. If these women have received a message that there’s no help for them, there’s a good reason for it.

Where are the doctors?

The Morning News tries to verify that the Dallas-area providers listed for the new Texas Women’s Health Program are in fact providing health care services to the women in this program as advertised. It goes about as well as you’d expect.

Right there with them

A Dallas Morning News survey of 336 contacts listed online for the program showed that 18 percent of the 55 unrepeated physicians and offices surveyed knew they were a part of the program and are accepting new patients. Two listings point people to businesses with no connection to the program — a sports medicine clinic and a title company.

A spokeswoman for the Health and Human Services Commission, which operates the new program, acknowledged that the list has problems.

“It’s not that it’s a list that they shouldn’t be using, it’s that there are addresses on that list that shouldn’t be there, so we’re going to have to do some work to clean that list up,” said Linda Edwards Gockel.

Gockel said the list, which has been available on the program website for more than three months, is not the same list of 3,500 approved providers the state has touted. It represents all the locations a potential provider billed from in the past.

She said the commission hopes to have the list corrected by next week. Gockel could not say why it was not removed sooner, but that women can always call the 1-800 number listed on the website. After The News pointed out the list’s failings, subsequent press releases from the commission avoided mention of the website.

In fact, if you go to the Texas Women’s Health Program website now and click the Find A Doctor link, you will not see any providers listed at all:

According to Trail Blazers, the site “will be fixed sometime this week”, though it looks now like that has been pushed out a few more days. Reps. Donna Howard and Lon Burnam had previously found the same problems that the DMN reports on here in Austin and Fort Worth. Now other Democrats are getting in on the action.

“It is unacceptable that thousands of Texas women may be cut off from access to the program due to the program’s inability to meet demand,” said Rep. Jessica Farrar, D-Houston, the House Democratic Caucus chairwoman, in a prepared statement. “My main concern is to ensure that women may be given the opportunity to affordable and accessible health care.”

Using the Texas Public Information Act, Farrar requested that the agency release a list of the available providers enrolled in the Texas Women’s Health Program along with the number of patients they anticipate serving, the number of patients served by the former Medicaid Women’s Health Program and the geographical areas in the state where provider enrollment does not meet demand.

Good on you, Rep. Farrar. What all this says to me is that the list that had been given on the website was complete and unadulterated junk and that they have taken it down in a desperate attempt to fix it. Remember that the state has been bragging for months about how they’re all fired up and ready to go without Planned Parenthood and with a list of 3,000 providers all set to step in. Is there any reason now to believe that was anything but a lie? Further, given the obvious problems and the complete disconnect between what the state has been saying and what everyone who has bothered to check has discovered, is there any reason to think the state will get this fixed any time soon? I say no and no.

I also say it’s time to get the people primarily responsible for this mess on the record about it. That includes State Sen. Bob Deuell, who requested the AG opinion that declared the state could sever ties with Planned Parenthood while still receiving federal money for the WHP (and how has that turned out so far?); Kyle Janek, the chair of the Health and Human Services Commission; and of course Rick Perry himself. Good on the DMN and Reps. Howard, Burnam, and Farrar for uncovering this lie, but it’s time for everyone else to get in the game as well. Rick Perry isn’t going to care about this until he’s forced to care about it.

Substitute WHP has problems: Film at 11

No one could have seen this coming.

Right there with them

State Rep. Donna Howard, D-Austin, has been worried about the Women’s Health Program since the state said it would create its own version of the program. That came after the state moved to exclude clinics affiliated with abortion providers, like Planned Parenthood, from participating — which led the federal government to pull all funding.

Howard was worried when she wrote a letter to the Health and Human Services Commission, or HHSC, asking for information about new providers.

“I was told immediately upon sending this letter, by HHSC, that they were in the process of doing a study on this and would get back with me,” Howard said.

The state-run program’s new website prominently shows how to search for local providers, so Howard had one of her staff members visit the program website to see what might be available.

“One of my staff members actually typed in the ZIP code for 78701 and contacted the first 30 providers on that list,” Howard said, “and only found five of the 30 who actually serve women in the Women’s Health Program.”

KUT called a few of the doctors on that list. Of the first three, two said they were not providers in the program.

I really want this program to work, because if it doesn’t then thousands of women will be denied the health care they need, and that’s a problem for all of us. On the other hand, I fully expect this to be a miserable failure, because what does Rick Perry care about women’s health? What’s in it for him? In any event, the Texas WHP website is here. If you have some time on your hands and a sense of mischief, feel free to look up the providers listed in your area and call them to see if they’re aware that they’re listed as such.

State fails to get injunction against terminating Womens Health Program funds

As you know, last year the Lege passed a law that forbade Planned Parenthood from participating in the Women’s Health Program on the grounds that PP does abortions even though none of the PP clinics that participate in the Women’s Health Program perform abortions – they’re in a separate organization all together. The federal government then told Texas it would cut off funds for the WHP, since denying PP’s participation meant denying women their choice of provider, which is against Medicaid regulations. The state then announced it would create its own Women’s Health Program with its own money, but they still wanted those federal funds anyway, and sought an injunction barring the feds from cutting off the funds. They lost.

Right there with them

Texas’ request to force the U.S. Health and Human Services to continue funding its Women’s Health Program was denied Friday, as a judge sided with federal authorities who say the state’s exclusion of Planned Parenthood violates HHS guidelines.

U.S. District Judge Walter Smith’s ruling won’t affect the state’s decision to move forward next year with an entirely state-funded program, even though the state was also seeking to keep its federal funding, said Stephanie Goodman, a spokeswoman for the Texas Health and Human Services Commission. But Planned Parenthood, which serves more than 40 percent of the low-income women in Texas’ program, questioned whether the state’s efforts would be effective without federal funding or its clinics.

[…]

Texas officials say they have created an entirely state-funded program, which, starting Jan. 1, will provide the same services but exclude Planned Parenthood, Goodman said. The program is estimated to cost $40 million a year.

Goodman said the commission had found “pockets of money” in its budget to fund the Women’s Health Program through the end of the current fiscal year, which ends in August. The Legislature will have to pass funding to continue the program from September on, she said.

[…]

Joseph Mead, an attorney from the U.S. Department of Justice, said federal law gave Sebelius discretion to approve or deny state funding requests. Medicaid rules also guaranteed patients the chance to choose their provider, Mead said.

“The state wants to have its cake and eat it too,” Mead said.

Smith did not detail why he declined to grant an injunction.

Goodman said the state has signed up more than 1,000 new providers to replace Planned Parenthood, and that its surveys indicated there were enough providers for major metropolitan areas. Officials are still evaluating some smaller and rural areas, she said.

But Planned Parenthood and its supporters question whether participants in the state-funded program will have access to care if the reproductive care provider is excluded. It has sued in state court to be included in the new program.

I agree with Attorney Mead, and I consider this move on Texas’ part to be another admission that they’re not ready to replace Planned Parenthood in the WHP despite their bluster and braggadocio. It would be funny in a pathetic sort of way if the Lege is unable to get that money it needs to keep their WHP program afloat appropriated. Don’t think for a minute there isn’t someone in the Lege who’s misogynistic and zealous enough to want to torpedo the whole thing for some bizarrely sexist reason. Whether such a person is able to make such an attempt is a different question, but I have no doubt there will be someone whose first thought is “why do we even need this at all”.

Planned Parenthood files another lawsuit

Keeping the heat on the state.

Right there with them

As a tumultuous year in women’s health draws to a close, Planned Parenthood is turning up the heat on Texas, today filing a new lawsuit that challenge the state’s move to ban the nonprofit from participation in a state-run and funded Texas Women’s Health Program.

While previous lawsuits have focused on the state’s move to ban Planned Parenthood from the Medicaid-waiver Women’s Health Program, the suit filed this week focuses on the state’s efforts to ban the provider from a proposed state-run Texas WHP – meant to replace the successful and federally-funded program that the state has voluntarily sought to end solely to exclude Planned Parenthood from participation.

[Tuesday] in state court Marcela “Marcy” Balquinta joined Planned Parenthood family-planning providers from across the state to sue Texas in Travis County district court, arguing that she will effectively be left without access to health care if the state goes through with excluding Planned Parenthood from providing women’s health care in the revamped TWHP. “Without the affordable care I receive through Planned Parenthood and WHP, I would have to make tough decisions between paying for my cancer screenings and birth control, or buying groceries or gas for my car,” Balquinta said in a statement. “If I couldn’t go to Planned Parenthood, I don’t know where I’d turn. And there are tens of thousands of Texas women like me.”

Indeed, Balquinta lives in the Valley, one of the areas of the state that will be hardest hit if state officials make good on a promise to ban Planned Parenthood from participation in the new TWHP. Balquinta, a 26-year-old graduate student at University of Texas–Pan American who works part-time teaching students about preventing sexual violence, will continue to try to pay for services at Planned Parenthood, because that is her “trusted provider where she feels comfortable seeking reproductive health services,” though “because of her limited means, she believes it would be highly unlikely that she could pay for the same range of services that has been covered by WHP and would be covered by TWHP,” reads the lawsuit.

See Trail Blazers and POstcards for more on this story, and here and here for more on the other state lawsuit, which is on hold as Texas appeals the temporary injunction that halts it from keeping Planned Parenthood out of its replacement Women’s Health Program. As this story notes, it is far from clear that the state really has a functioning replacement program ready to go when the federal funds are scheduled to cease, given its inability to meet its own deadline in rolling it out. A hearing on this new suit will happen sometime before the end of the year. A statement from Planned Parenthood Gulf Coast about this is here.

Planned Parenthood gains a stay in state lawsuit

If you’re confused by where the Women’s Health Program stands in Texas, I don’t blame you.

Right there with them

Planned Parenthood will continue participating in the Women’s Health Program — for now. Travis County District Judge Stephen Yelenosky on Thursday approved a temporary injunction to delay the state’s implementation of the “Affiliate Ban Rule,” which would bar the nonprofit from participating in the program, until a full trial can be held in December.

Planned Parenthood is “likely to prevail on their claim that the rule is inconsistent with the instructions of the Texas
Legislature,” wrote Yelenosky in a letter authorizing the temporary injunction.

“This is another victory for the women of Texas that Planned Parenthood is proud to serve,” said Pete Schenkkan, the lawyer representing the group.

Multiple court proceedings have delayed and complicated the implementation of the Affiliate Ban Rule and the Texas Women’s Health Program, which the state previously planned to start on Nov. 1. In October, a three-judge panel of the 5th Circuit Court of Appeals shot down Planned Parenthood’s claim that the Affiliate Ban Rule is unconstitutional and set the stage for the state to move forward with its plan. But a few days after that ruling, another Travis County district court judge issued a temporary restraining order requiring the state to continue the program until it could be determined whether state law made the rule inoperative, because it caused the state to lose federal funding for the program.

[…]

“We’ve got the state program ready to stand up at any time, and that transition would be seamless for patients and their doctors,” Kyle Janek, Texas’ executive commissioner of health and human services, said in an earlier statement announcing that Texas would continue the federally funded Women’s Health Program until funding stops or a state court decision is made.

TM Daily Post has a primer on how we got here, which will bring you up to speed. See here for background on the lawsuit, and here for my opinion on Janek’s claim of readiness. The state will of course appeal this ruling, so I’m going to save myself the ride on the emotional roller coaster and wait to see how that shakes out.

No, they can’t

You just need to ask yourself one simple question about this.

Right there with them

Planned Parenthood will remain part of the Women’s Health Program for now, state officials said Wednesday, putting off the organization’s ouster as critics questioned whether enough health-care providers would exist without it.

Gov. Rick Perry and Texas Health and Human Services Executive Commissioner Kyle Janek cited court action and a desire to hold on to federal funding in putting off Thursday’s anticipated start of a new Texas Women’s Health Program, which would be run only with state dollars and without Planned Parenthood.

Perry on Wednesday said Texas remains committed to barring the clinics from the program, saying state law excludes those affiliated with abortion providers. He also said the remaining health-care providers will have the capacity to serve women in the program, saying 3,000 providers have signed up.

[…]

Mara Posada of the Planned Parenthood Trust of South Texas said the delay in launching the state program suggests “they are not ready to start this program, which by all accounts has been deemed a disaster. There are simply not enough providers with the capacity to see the same number of patients as Planned Parenthood.”

The Wednesday announcement is “an important victory for every woman who relies on the Women’s Health Program for basic, preventive health care,” said Melaney A. Linton, president and CEO of Planned Parenthood Gulf Coast.

Texas officials on Wednesday said that the state-funded program is ready, but it is unclear when they will abandon the federal program. They said federal officials have suggested they can’t provide funding past Dec. 31.

Janek said the state will continue to operate the program with Medicaid funds until that federal funding is stopped or a final court decision requires the state to include Planned Parenthood, violating state law.

Is it even remotely likely that Rick Perry would wait one minute longer than necessary to tell the feds to take their filthy Medicaid money and stick it where the sun don’t shine if the state’s replacement Women’s Health Program were ready to go? Not only would it be a giant middle finger to Planned Parenthood and all of the naysayers who have been predicting – correctly, it would seem – that the state would not be able to pull this off, it would be a nice little base rallier to wrap up early voting. Would Rick Perry turn down that opportunity? The question answers itself. They’re not ready and they don’t want to admit it. Now the question is whether they’ll be ready by January. I wouldn’t bet on it.

No Planned Parenthood, no women’s health care

It’s a simple enough concept.

Right there with them

Women’s access to affordable health care will be reduced if the state follows through with its plan to eschew federal funding for the Women’s Health Program and create a state program instead, according to a new study from George Washington University.

The study, a follow-up to a May report from the university on Texas women’s health, examines the impact of excluding Planned Parenthood from the state Women’s Health Program in Bexar, Dallas, Hidalgo, Lubbock and Midland counties.

[…]

“While other clinics may be able to care for some of the displaced patients if Planned Parenthood is excluded, there is no evidence that they are prepared to sustain the very large caseload increases that would be required to fill the gaps left after Planned Parenthood clinics are excluded,” the study says.

Planned Parenthood served between 51 and 84 percent of the program’s patients in the counties the study examined. Across the state, almost half of the more than 100,000 women in the program received care at Planned Parenthood, according to a recent study from the University of Texas Population Research Center.

Here’s the study in question. I blogged about the other study referenced in this story here. HHSC continues to claim that they’ve rounded up enough replacement providers to fill the gap that Planned Parenthood’s exclusion will create, while duplicitous legislators like Rep. Sarah Davis try to obfuscate the fact that they voted for this to happen. We’ll know for sure soon enough what the effect will be. Democrats need to pound on this every damn day between now and the 2014 election.

Psych hospital privatization rejected

Good.

The Department of State Health Services has rejected a bid by Geo Care to privatize Kerrville State Hospital.

Last year, legislators told State Health Services it had to solicit proposals from mental health providers that wanted to run one of the state-run psychiatric hospitals. Those proposals had to show that the bidder could run the hospital for 10 percent less then its current budget.

Boca Raton-based Geo Care was the only company to submit a proposal. Its bid was to run Kerrville State Hospital.

But the state has rejected Geo Care’s bid, according to an email sent to hospital employees today by Kerrville State Hospital Superintendent Jay Norwood.

“I have just learned that Commissioner (David) Lakey has rejected the proposal submitted to privatize one of our state hospitals. HHSC Executive Commissioner (Kyle) Janek is in agreement with this decision and the proposal will not be moving forward,” Norwood wrote. “Therefore, at this time, there is no plan to privatize Kerrville State Hospital or any other state hospital in Texas.”

See here and here for the background. This was a bad idea from the get-go, and I’m glad it’s been canned. And to think, the decision was made before this happened. Good call, folks.

This is what a government takeover of health care looks like

It’s happening right here in Texas.

Right there with them

Texas officials express confidence that thousands of low-income women will be able to find new providers should Planned Parenthood be excluded from the state’s Women’s Health Program, but Xelena Gonzalez does not think woman should have to make that search.

“They are playing politics,” the 33-year-old San Antonio librarian and single mother said. The men dominating the policy decisions “have no idea what it’s like to be in the body of a woman and to make the decisions that we have to make.”

Gonzalez said she is happy with Planned Parenthood and angry that Texas is losing federal money for the program because of state leaders’ determination to exclude the group from a program. She said its free annual exam has been important to her tight budget.

“It’s difficult to pay for things. Your health is almost a luxury,” Gonzalez said.

Health screenings and contraceptives for about 50,000 low-income women who rely on Planned Parenthood are on the line after a federal appeals court said Texas can cut Women’s Health Program funding to the group’s health centers. Planned Parenthood served 43 percent of the program’s clients in fiscal 2011.

If the ruling stands, Planned Parenthood clients’ access to free services through the program will depend on whether patients can find new providers.

[…]

[Stephanie Goodman, spokeswoman for the Texas Health and Human Services Commission] said the state has 2,971 providers, aside from Planned Parenthood clinics, in the program, an increase since the policy change.

“Our analysis indicates that the vast majority of women won’t have to travel any farther to find a qualified WHP provider, and no clients will need to travel more than 2½ miles more to get services,” she said.

A George Washington University School of Public Health and Health Services study questioned the state’s assumptions. It looked at fiscal year 2010 figures, when Planned Parenthood served nearly 52,000 clients, or 49 percent of the total, while community health centers served just over 10,000.

The study said that of 1,469 providers that billed the program that year, 908 of them served 10 or fewer patients; 368 served just one patient.

Community health centers would have to expand their Women’s Health Program capacity fivefold to close that gap, the study said.

Thousands of women may wind up with no access to health care at all as a result of this disastrous policy. But let’s pretend that Goodman is correct and that there will be plenty of providers available for all these women, at no greater distance, no greater cost, and no less convenience for them. Even with that impossibly optimistic assumption, it remains the case that thousands of women will be forced to find new health care providers. If that’s not the government coming between you and your doctor, what is? Note that this will affect some women who see private physicians as well. As Rep. Garnet Coleman pointed out when I interviewed him, if a WHP patient sees a private physician and that physician does abortion referrals – not actual abortions, because that would already be barred, just referrals – that patient can no longer use WHP funds to pay for her visits. Rick Perry and the Lege are telling women what doctors they can and cannot see. It’s as simple, as as ironic, as that.

Fifth Circuit strikes again

Dammit.

Right there with them

A federal appeals court ruled Tuesday that Texas did not act unconstitutionally when it moved to expel Planned Parenthood from a health and contraceptive care program for low-income women.

The ruling overturned a preliminary injunction, issued in April by U.S. District Judge Lee Yeakel of Austin, that banned Texas from enforcing rules designed to exclude Planned Parenthood from the Women’s Health Program. Yeakel found that the regulations violated the organization’s rights of free speech and association.

The 5th Circuit Court of Appeals, however, sided with Texas late Tuesday — ruling that the state had the authority to prohibit Women’s Health Program money from going to health care providers that promote abortion or affiliate with organizations that perform or promote abortions.

Officials said Texas will act promptly to drop Planned Parenthood from the program.

“We appreciate the court’s ruling and will move to enforce state law banning abortion providers and affiliates from the Women’s Health Program as quickly as possible,” said Stephanie Goodman with the state Health and Human Services Commission.

Here’s a copy of the ruling, via TM Daily Post and The Trib. First there was injunction, then the injunction was stayed, then the stay was lifted, and now it’s back. The Fifth Circuit has been quite hostile to women’s health advocates this year.

But this isn’t about women’s health, is it? I mean, the state of Texas pinky-swears that it will have a super-duper Planned Parenthood-free replacement for the Women’s Health Program up and running any day now, assuming there are any clinics left to handle it. Rick Perry and Greg Abbott say this is about abortion, so let’s take their word for it. What do Rick Perry and Greg Abbott and all the rest of them think about abortion?

Mere hours after U.S. Rep. Todd Akin, R-Mo., and an ardent opponent of abortion in almost all cases, made comments on Sunday suggesting that women’s bodies would naturally reject pregnancy in cases of “legitimate rape,” Mitt Romney and Paul Ryan released a statement distancing themselves from him. They said their administration “would not oppose abortion in instances of rape.”

Elected officials from Texas widely condemned Akin’s comments: U.S. Sen. John Cornyn released a statement that seemed to suggest Akin should drop his Senate bid; Gov. Rick Perry’s office called Akin’s words “off-base, insensitive and a distraction from the important issue of protecting life.” Akin, for his part, quickly backtracked, saying he “misspoke” in his “off-the-cuff remarks,” and adding that he understands “that rape can result in pregnancy.”

Yet Akin’s broader opposition to abortion in cases of rape is shared by many top Texas leaders. Perry, Attorney General Greg Abbott, Lt. Gov. David Dewhurst and GOP Senate hopeful Ted Cruz only support abortion when the mother’s life is in jeopardy. The position isn’t uncommon among Republicans; CNN reported on Monday night that a rape exemption is likely not part of the GOP abortion platform set to be adopted at next week’s Republican Convention in Tampa.

Perry’s stance is a relatively new one for him; he revised his position to oppose abortion in cases of rape and incest late last year on the presidential campaign trail, saying the issue had troubled him for a long time.

The difference between Todd Akin and other such troglodytes and the likes of Perry, Dewhurst, and other “pro-life heroes” is simply this: Akin et al are too insulated from reality to believe that rape of any kind can and does lead to pregnancy, and thus he is free to oppose a rape and incest exception for abortion since it won’t make any practical difference as far as he’s concerned. Perry, Dewhurst, Abbott, Cornyn, Ted Cruz, and all of the other tut-tutters who are shocked, shocked that Todd Akin would say such an impolitic thing, oppose rape and incest exceptions because they are perfectly happy to force the victims of rape and incest to carry their assailants’ pregnancies to term. They’re too slick to say it out loud, of course, but give them an opening and you can be sure they’ll take it. Paul Ryan agrees with Todd Akin. The GOP platform agrees with Todd Akin. What kind of Supreme Court justices – and Fifth Circuit Court of Appeals justices, for that matter – do you think Mitt Romney and Paul Ryan would appoint? If you want more like this, vote for them and find out.

Anyway. For now, Planned Parenthood remains in the WHP, at least until the state figures out what it’s going to do with it. Given how little they care about women’s health, that could still take awhile. A statement from Rep. Carol Alvarado is here, a statement from Melaney Linton, the CEO of Planned Parenthood Gulf Coast, is here, and a statement from Ann Johnson is beneath the fold.

(more…)

The first rule of women’s health

Is don’t talk about things that make certain Republicans queasy.

A proposed state rule that would prohibit doctors in Texas’ Women’s Health Program from discussing the option of abortion with their patients — even if the patient asks about it — has drawn the opposition of Texas medical groups.

The groups take issue specifically with a clause that states the provider must not “promote elective abortions.” The word “promote” as defined by the proposed rule includes counseling and referrals to abortion providers, as well as the display of any materials from abortion providers.

In a letter to the Department of State Health Services on Friday, the Texas Medical Association, along with four other groups representing a combined 47,000 physicians and medical students, wrote that the rule would jeopardize medical ethics and doctors’ relationships with their patients. They argued that doctors might leave the program as a result of the rule, putting the already embattled program at risk.

You can see the TMA’s letter here. Note that they mention First Amendment concerns, which was the basis of the lawsuit against the horrible sonogram bill, for which an injunction was granted by the federal district court, then tossed by the activist appeals court. If the state of Texas yields on this point, I guess that means some people’s First Amendment rights are greater than some other people’s First Amendment rights. Remember also that this is for the replacement Women’s Health Program that the state is paying for with its own money after its fit of pique against Planned Parenthood. They pretty much have to come to some arrangement with the doctors or else there won’t be anyone to actually provide the services that the state insists it can provide. I don’t know if that will have any practical effect on the sonogram litigation, but it will highlight once again how ludicrous that Fifth Circuit ruling was.

Medicaid expansion: Not as expensive as the state claimed it would be

Remember last year when the state Health and Human Services Commission claimed that Medicaid expansion would cost the state of Texas $27 billion over ten years, causing every Republican in the state to have a fainting spell and a hissy fit about how that would bankrupt us all? Turns out that estimate was a wee bit too high.

On the heels of Gov. Rick Perry’s declaration that Texas will not expand Medicaid because it is too costly, his health and human services commissioner said Thursday that fully implementing health care reform would cost the state about $11 billion less over 10 years than previously estimated.

Executive Commissioner Thomas Suehs told a Texas House subcommittee that the new estimate is between $15 billion and $16 billion in state costs over a decade, compared to the previous estimate of $26 billion to $27 billion.

The state would get an additional $100.1 billion in federal money over that time, according to the Texas Health and Human Services Commission – money that Suehs acknowledged would be attractive to local entities grappling with the cost of caring for the quarter of the state’s population that currently is uninsured.

“If I was a county hospital district, I would be knocking on your door saying we need to re-debate” Medicaid expansion, perhaps with a push for a local option, Suehs said. That idea, in which a local agency would deal directly with the federal government to expand Medicaid in its area, has been cited by Bexar County Judge Nelson Wolff.

I’ll get back to that “local option” in a minute, but for now take a look at the reasons why HHSC says they overshot the mark. The interesting thing is that in an ideal world that original HHSC esitmate would be closer to the mark because more people who would be eligible for Medicaid under the Affordable Care Act would be getting it in a more timely fashion. Of course, the dirty secret is that under those same assumptions Texas would be paying a lot more for Medicaid now. A lot of people who are eligible today for Medicaid don’t get it, in large part because of policy decisions made by Texas such as means testing and six month enrollment periods. The same is true for CHIP, whose enrollment levels have never returned to those before the 2003 cuts. Our stringent enrollment requirements and stingy benefits, both of which are big contributors to the large number of uninsured people in Texas, are matters of policy and priority, just as Medicaid expansion is. Rick Perry and legislative Republicans don’t want to spend any money on that. It’s just not something they care about. For all their carping and whining about the federal government making them do something about this, they themselves have never proposed a solution to deal with the problem. Well, they are proposing something now, but I’ll get to that in a minute as well.

What does that “local option” mean?

“It (the federal portion) is a huge amount of money. You just can’t leave that on the table, particularly when the burden falls on public hospitals that are funded by local taxpayers,” said Wolff. He is head of the commissioner’s court, which approves the budget for University Health System, a main provider of health care to low-income Bexar County residents.

Harris County Hospital District president and CEO David Lopez said he wants to talk with Perry’s office about possible funding alternatives.

The local option would have to be discussed by all the area’s health care providers, Lopez said.”It’s more than just a public hospital issue. All providers in our community are impacted by this, so they should all be part of the discussion.”

Sen. Leticia Van de Putte, D-San Antonio, said she does not think a local option is available in the law as written, but she is making inquiries about what is possible. “This is real money, and it means real health care for Texans,” she said.

I’ll have to do some research, because this is the first I’ve heard of this, but I gather that a “local option” means that local entities such as counties or hospital districts would apply to the federal government for some amount of money to cover the needs that the state has abdicated by opting out of Medicaid expansion. I have no idea how this would work, whether we’re talking about a restoration of funds to covered uninsured patients who show up at emergency rooms – which, you will recall, is the most expensive and least efficient way to deliver health care – or if these local entities would somehow be administering their own mini-Medicaid programs, or something else entirely. How this is a better idea and a less burdensome regulatory context than simply expanding Medicaid is a question I can’t answer. (The same could be said about having fifty individual statewide Medicaid programs instead of one federal program, but that’s beyond the scope of this discussion.) Whatever this is, I’d call it better than nothing, which is what the state wants to do right now, but in the absence of any details I can’t say how much better than nothing it is.

On the matter of funding to cover uninsured patients, some hospitals are in for more hurt than others if nothing happens.

Bruce Siegel is the chief executive of the National Association of Public Hospitals, which represents the nation’s safety-net hospitals. His members include more than 60 hospital systems, largely in urban areas. As public institutions, they tend to see a greater share of Medicaid and uninsured patients, and also provide more medical services that ultimately do not prove profitable.

That all made the Supreme Court ruling of the Medicaid expansion as optional a huge deal for Siegel and his members. “It’s a pretty grim menu of choices,” he says. We spoke Thursday afternoon about why he’s taking governors’ threats to opt-out seriously, what that would mean for public hospitals and how his group will push the White House for a fix.

[…]

SK: I was writing about DSH payments last week and I was hoping you could explain why they’re so important. They amounted to $11.5 billion last year, which isn’t nothing, but is a pretty small part of Medicaid’s $393 billion budget.

BS: It’s important to keep in mind these payments don’t go to every hospital. They are designed to target those who serve lots of uninsured people. So DSH payments are very important for public hospitals in places like Mississippi, Alabama and Texas, really a lot of Southern states. They’re not going to most hospitals. They’re targeted to a very specific purpose.

SK: Let’s say a big state like Texas, which got nearly $1 billion in DSH payments last year, doesn’t participate. Game out what happens to the public hospitals in that state.

BS: The average American hospital has an operating margin of 7 percent. The average among our members is 2 percent.

We project that if you took away DSH, the margin drops to negative 6 percent. If that happens, you can’t keep up a negative 6 percent margin for more than short time. After a year or two, you have to think about what happens next. You’re having to think about what you shut down after a year or so.

We think there are essentially three options. One is you start cutting back on services. You start figuring out what isn’t bringing in much revenue. And that could be things like community clinics or trauma services. You make some hard decisions.

You may be forced to go to local taxpayers. You find yourself basically putting this in the lap of taxpayers and tacking on the bill for your uninsured to their bills.

In the worst circumstance, you simply decide you can’t go on in that situation and close your doors. It’s a pretty grim menu of choices.

SK: How do you fight this at the state level?

BS: We’re working in state capitals, trying to give our members facts to work with about what this does and doesn’t mean, so they can have an intelligent discussion. There are different strategies for each state. We’re raising awareness that you can’t have it both ways. You can’t say no to the coverage program and cut the DSH program in half, and have this work. We need to get to a consensus that is a huge problem.

Again, the point is to reduce the number of people who rely on emergency rooms – the most expensive and least efficient way to deliver health care – by getting people onto insurance so that they can have access to non-emergency health services. Maybe expanding Medicaid isn’t the best way to do that, but any program to expand health care access is going to involve some up front cost. Some part of that is mitigated by reducing costs elsewhere such as this, which is why the Affordable Care Act cut the subsidy for uninsured patient care to hospitals. Without the expansion of Medicaid, however, you get the worst of all worlds. What does the state’s Republican leadership plan to do about this? Going by the rhetoric of retiring Medicaid director Billy Millwee, speaking to a bunch of zealots at the TPPF, it’s mostly slogans.

Despite Perry’s announcement that Texas will not expand Medicaid, the state will likely see a jump in those enrolling in the current program, Millwee said. Because the individual mandate — which requires all citizens to purchase health insurance — was ruled constitutional, those who were “eligible but not enrolled” in Medicaid will now join the program, he said.

“Medicaid is crowding out other programs,” Millwee said. “In my mind, it is starting to enable poverty.”

Millwee called the current Medicaid system “antiquated” and suggested the state instead receive block grants — federal funds with relatively few restrictions — to expand its health care system.

Expanding Medicaid would “add a lot of people” to the program without increasing their actual access to coverage, Millwee said, because of the scarcity of doctors accepting new Medicaid patients.

Last year 31 percent of doctors accepted Medicaid patients, The Texas Tribune reported earlier this week. Millwee attributed this number to the complexity of Medicaid, saying doctors are not paid as well under the current system as they could be under a block grant system.

That remark about poverty is the sort of thing that could only be said by someone who doesn’t worry about where his next meal is coming from to a bunch of people who think poor people have no one to blame but themselves for their situation. I’m sure they all congratulate themselves for their rectitude every Sunday at church. Having said that, there is some truth to what Millwee says, in the sense that as people move up the income ladder from the very bottom to a step or two above the very bottom, they suffer the equivalent of extremely steep marginal tax rates as they lose eligibility for various programs, including Medicaid. There’s no reason why Congress and the State Lege can’t address this in a fashion that makes more sense, but what with all the wailing and gnashing of teeth by the TPPF types about millionaires paying slightly higher marginal tax rates, which as we know will cause them to stop creating jobs, that seems to get lost in the shuffle.

Then there’s the talk of block grants, for which five GOP legislators shilled on the Chron’s op-ed pages on Saturday. This is a GOP wish list item, and the SCOTUS ruling that invalidates the ACA provision penalizing states for rejecting Medicaid expansion has given them fresh hope of getting it. The thing to remember is that a block grant is a single lump sum of money, with the lure for states being that it has few restrictions on how it can be spent. But the thing about a block grant is that if you run out, either because the amount you were given was insufficient to meet your need or because you spent it foolishly, that’s all there is. If you’ve been paying any attention to the budget ideas of the Congressional GOP – the Ryan plan, in particular – you know that the strategy for controlling future costs is to ensure that block grants remain static or grow at a fixed rate that’s sure to be less than the rate of growth of the actual expenses. To be blunt, this is all about controlling expenses by cutting them. How it would expand coverage, as Millwee claims, is not explained, but look at it this way: You would be putting your faith in the people who have kept Texas at the bottom of the national list for health care access to do something about it once we’ve given them what they want. If that sounds like a winning scenario to you, I’ve got some beachfront property in Midland you might be interested in.

Finally, as far as the lack of doctors is concerned – what, you mean tort “reform” hasn’t solved all of our problems yet? – who says we have to have doctors accepting Medicaid? Why not seek out ways to encourage more nurse practitioners to do the kind of checkup and maintenance work they’re perfectly capable of doing? Maybe there are some burdensome regulations holding them back that the Lege could address. All I know is that going on a dozen years of Republican control of state government we’re no closer to solving this problem on our own, and we’re resisting a comprehensive solution that’s been presented to us. It’s all a matter of priorities.