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“Fetal remains” rule goes into effect

Cue up that next lawsuit.

Texas’ proposed rules requiring the cremation or burial of fetal remains will take effect Dec. 19, according to state health officials.

Despite intense outcry from the medical community and reproductive rights advocates, the state will prohibit hospitals, abortion clinics and other health care facilities from disposing of fetal remains in sanitary landfills, instead allowing only cremation or interment of all remains — regardless of the period of gestation.


Proposed at the direction of Republican Gov. Greg Abbott, the health commission had argued the rules would result in “enhanced protection of the health and safety of the public.” Abbott said in a fundraising email that the rules were proposed because he doesn’t believe fetal remains should be “treated like medical waste and disposed of in landfills.”

But the new requirement prompted outrage from the reproductive rights community, which accused state leaders of pushing unnecessary regulations. Women who experienced miscarriages or lost children in utero questioned why the state would make their situations more difficult by enacting the requirements. And medical providers — including the Texas Medical Association and the Texas Hospital Association — had also raised concerns about who would bear the costs associated with cremation or burial — a figure that can reach several thousand dollars in each case.

In response to those concerns, health officials indicated that health care facilities — and not patients — will be responsible for the disposal of fetal remains and related costs. They also wrote that those costs would be “offset by the elimination of some current methods of disposition.”

See here, here, and here for the background. If you think it’s a coincidence that this was proposed within a few weeks of the SCOTUS ruling striking down HB2, I’ve got a carload of diplomas from Trump University to sell you. Let’s get that next lawsuit going so we can maybe have an injunction in place before this atrocity can take effect. (And if you want to help facilitate that, a donation to the Center for Reproductive Rights would be a fine way to do so.) The Austin Chronicle has more.

The next abortion lawsuit should be on its way

We were warned it would need to happen.

Despite intense outcry from the medical community, reproductive rights advocates and funeral directors, Texas isn’t budging on a proposed rule to require the cremation or burial of fetal remains.

Following an initial public comment period that sparked medical concerns and a legal threat, Texas health officials have re-submitted for public consideration a proposed rule change that prohibits hospitals, abortion clinics and other health care facilities from disposing of fetal remains in sanitary landfills, instead allowing only cremation or interment of all remains regardless of the period of gestation — even in instances of miscarriages.

After considering hours of public testimony at an August hearing and more than 12,000 comments submitted in writing, the state made no changes to the rules, which are set to be published in the Texas Register on Sept. 30.

The rules were re-published “after reviewing the feedback and comments we received,” health commission spokeswoman Carrie Williams said on Wednesday. This will require another 30-day public comment period before the rules can go into effect.


The proposed rule has prompted outrage from the reproductive rights community, which has accused state leaders of enacting unnecessary regulations. Medical providers — including the Texas Medical Association and the Texas Hospital Association — also questioned why the rule change does not allow an exception for miscarriages and ectopic pregnancies.

Despite making no revisions to the rules themselves, the commission has amended its analysis on the financial impact of the rule on health care organizations that must comply, saying the rules won’t increase “total costs” for health care facilities.

Medical professionals and funeral directors had raised concerns about who would bear the costs associated with cremation or burial — a figure that can reach several thousands dollars in each case — and questioned whether the new would trigger a requirement for death certificates so that fetal remains could be cremated or buried. (Under current rules, the state requires funeral directors or a “person acting as such” who take custody of a dead body or fetus to obtain an electronic report of death before transporting the body, according to the Funeral Consumers Alliance of Texas.)

The amended fiscal analysis indicates that the methods allowed in the proposed rules “may have a cost” but “that cost is expected to be offset” by costs currently incurred by facilities. Hospitals and abortion providers currently contract with third-party medical waste disposal services.

See here and here for the background. All this happened by executive order, with no legislative input or public hearings, in the immediate aftermath of the SCOTUS decision striking down the odious HB2. If the words “undue burden” have not formed in your head by now, you need to go back and read that decision again. I guarantee, once this rule is in place, a lawsuit will follow.

Feds grant 15 month Medicaid waiver extension

I sure hope they keep the pressure on to expand Medicaid during this time.

It's constitutional - deal with it

It’s constitutional – deal with it

The Obama administration has agreed to temporarily keep some federal Medicaid money flowing into Texas to help hospitals treat uninsured patients, a relief to health care providers that feared losing the funds over state leaders’ refusal to provide health insurance to low-income adults.

State health officials said Monday they have struck a deal with the federal Centers for Medicare and Medicaid Services to keep the program going for another 15 months, with hospital reimbursements remaining at their current level.

Those were the exact terms the Texas Health and Human Services Commission asked for last month. Agency leaders said the negotiations were a “big win for Texas.”

“We’re pleased these innovative programs will have the opportunity to continue,” Chris Traylor, the agency’s executive commissioner, said in a statement. “These programs are improving health care for Texas’ Medicaid clients and creating cost-savings for taxpayers.”


The 15-month extension also includes an additional $3.1 billion for DSRIP initiatives.

The Obama administration had previously signaled it was likely to stop footing the bill for at least some of Texas’ uncompensated care costs. Under the Affordable Care Act, the president’s signature health law, Texas was encouraged to expand its Medicaid program to cover nearly 1 million additional adults living in poverty — a move that would have given more poor patients a means to pay for care. The state’s Republican leadership hasvehemently opposed that option, criticizing Medicaid as an inefficient government program.

Federal health officials were unswayed by that argument, repeatedly telling state leaders they had no desire to use waiver funds to pay for costs that would otherwise be covered by a Medicaid expansion.


Texas health officials say they will continue negotiating a longer term extension of the funding over the next 15 months.

Those negotiations will likely be influenced by a study of the effectiveness of the uncompensated care pool, which the federal government asked Texas to commission. The Texas Health and Human Services Commission contracted with outside firms Health Management Associates and Deloitte to submit the study by the end of August. It will address questions such as how hospitals’ uncompensated care costs would be reduced under a Medicaid expansion.

If Texas and the federal Centers for Medicare and Medicaid Services do not reach an agreement at the end of the 15-month extension, in December 2017, the Obama administration said it “expects” that uncompensated care funding would be reduced after that.

“Specifically, the reduction will limit the size of the Uncompensated Care pool to the costs of uncompensated and charity care for low-income individuals who are uninsured and cannot be covered” under a Medicaid expansion, wrote Vikki Wachino, a senior federal health official, in a letter to the Texas Health and Human Services Commission.

Additionally, the DSRIP pool would be reduced by 25 percent in 2018 and by an additional 25 percentage points each year after that, according to federal officials.

See here, here, and here for some background, and here for a copy of the letter CMS sent to Texas. I don’t really have anything to say that I haven’t said before. Texas needs to expand Medicaid, and if the state continues to refuse to do so, the federal government should not take any steps to mitigate the consequences of that decision. It’s up to the next Legislature now. State Rep. Garnet Coleman, Trail Blazers, and the Austin Chronicle have more.

Health insurance exchange open enrollment, Year 3

The challenge, in a nutshell.

It's constitutional - deal with it

It’s constitutional – deal with it

In rural Borden County, 12 people signed up for Obamacare this year.

Livid over the government telling them they must buy something and loath to take anything that looks like a “handout,” the uninsured here are likely to stay that way. As Obamacare’s third open enrollment season began Sunday, this rock-solid conservative community of about 650 people offers a window into the challenges health law advocates face to expand coverage around the country.

“Health care is fine, if you can afford it,” said Brenda Copeland, a middle-aged woman who works at the Coyote Country Store and café, along with her two grown daughters, all of whom are uninsured. Copeland has had health insurance only once in her life, and opted to pay Obamacare’s tax penalty earlier this year rather than buy a plan.

“I hope Obamacare goes down the toilet,” she added.


Outreach workers who are supposed to educate people here and in other parts of west Texas must travel huge distances to find small pockets of the uninsured — people like Copeland and her daughters, Becky Justice and Rika Law, both married women with children. And all of them think the Affordable Care Act is anything but affordable.

Copeland said her income fluctuates but she made about $19,000 last year; she didn’t know that she would have qualified for significant subsidies to lower her monthly insurance premiums, as well as for lowered co-pays and out-of-pocket costs. A plan for the coming year in the mid-priced, most popular tier would cost about $200 a month, after subsidies are figured in.

When she did learn about the subsidies, she softened her stance slightly and said she might look into it. But she said she’s done just fine without health insurance most of her life and is still angry that the federal government can mandate she has to buy it.

“At this point, I don’t mind them penalizing me,” she said.

Law, her daughter, did take a look at the federal enrollment website, but said the plans cost too much for her family of four. She too was unaware that she might qualify for tax credits to lower her premiums.

Her family previously had job-based coverage that cost about $1,000 a month — her husband works in the oil fields, but when oil prices dropped, his hours were cut and the Laws decided they didn’t have the money to cover premiums. The plans she looked at on cost even more, about $1,350 a month.

“I understand the benefit of having it,” she says of health insurance. “When you’re trying to juggle everyday bills, that’s when it becomes a problem.”

Her sister Becky Justice, who owns this one-room store on the only road through town, said she had health insurance until mid-2014. She doesn’t agree with Obamacare and, unlike her sister, never even window-shopped for plans. If she needs to see a doctor, she says she’ll go to a community health clinic outside the county and figure out how to pay the bill.

On the one hand, it’s hard to feel sympathy for people who refuse to help themselves. On the other hand, when people’s heads get filled with poison for a long time, it’s hard to overcome that. Keep this in mind when you hear poison producers like the shills at the TPPF talk about the “failure” of Obamacare to cover as many people as it should, as if they had nothing to do with it.

But challenge or no, the work proceeds, and as we go forward I do expect the uninsured rate in Texas to continue to decline. Of course, what could make it take a huge step down remains off the table, at least for now.

The uninsured rate in Texas is 19 percent. There are multiple reasons: the number of low-wage jobs in Texas that don’t offer benefits, cultural and language barriers, and political opposition to health reform. Another reason is that Republican leaders have not expanded Medicaid to more poor people, as 30 other states have done. That part of the law is optional, but by declining the expansion, Texas loses out on billions of dollars in federal funds every year.

There is growing pressure for Texas to expand Medicaid, and supporters are now looking for the right political message that could bring the parties together.

For the moment, Republicans still consider the Affordable Care Act to be political kryptonite. Senator Ted Cruz continues to criticize it. Attorney General Ken Paxton just filed another lawsuit attacking part of it. Governor Greg Abbott has said he won’t consider the Medicaid expansion, because he considers Medicaid a dysfunctional entitlement program that should not be allowed to expand.

In Houston, local leaders want the expansion. Harris County Judge Ed Emmett, a moderate Republican, has supported it for years. The CEO of the taxpayer-supported Harris Health System, George Masi, says he needs the revenue that Medicaid expansion would bring. He’s had to lay off more than 100 employees, and cut back on charity care.

“What is even more profound is that money is going to other states that expanded Medicaid, like New York, California, Connecticut,” Masi said. “And so the taxpayer of Texas is being penalized, if you will, for not taking advantage of that option.”

By emphasizing the impact on taxpayers, Masi and others are framing the issue in terms of economics rather than humanitarian concerns.

“We call it a paradigm shift,” Masi added. “It’s a different way of thinking.”


In 2013, the Texas legislature took no action on Medicaid expansion. The same thing happened this year.

But more voices are starting to push for change, according to Ken Janda, who runs Community Health Choice, a not-for-profit insurance company in Houston.

Janda said the Texas Medical Association and the Texas Hospital Association are both being more vocal on the issue, as is the Texas Association of Business. The federal Medicaid funds would help the state budget, and inject revenue into the medical sector of the economy.

“Doctors’ offices are able to hire more people. Pharmacies are able to hire more people. That becomes an economic multiplier,” Janda said.

County budgets would benefit as well, because they support safety-net clinics and public hospitals such as Ben Taub, part of the Harris Health system.

“If Texas expanded Medicaid, we would be able to look at reducing local property taxes across the board in all counties, or use those dollars for something besides healthcare,” said Janda.

Janda says the new emphasis on economics could eventually bring the parties together.

“There is some interest now by some Republican state senators because of the potential to reduce local property taxes,” he added.

Janda isn’t naming names yet. He also says don’t expect to see any movement on this issue until after the 2016 presidential election. But he says he is “guardedly optimistic” that Republicans will be willing to discuss a possible Medicaid expansion after that.

Color me very skeptical of that. The Senate has gotten worse, from a problem-solving, get-things-done perspective, in the past couple of elections, and I’m hard-pressed to think of any Republican Senators that will be in the Lege in 2017 that I can imagine having interest in Medicaid expansion. I’d be delighted to be wrong about this, but I sure wouldn’t bet on it. I’ve said this about multiple issues, from things like equality to immigration and Medicaid expansion – things won’t change until someone loses an election over it. I’m sure Ken Janda knows that the Texas Medical Association and the Texas Hospital Association both endorsed Greg Abbott and Dan Patrick in 2014. I know why they did, and I know why the Texas Association of Business did as well, but this is as clear an example of the canonical definition of insanity you’ll ever see. Nothing will change until someone loses an election over this sort of thing. In the meantime, other states will continue to receive the money that we’re turning away in the name of ideology.

Rural hospitals

If this story was meant to evoke my sympathy, I’m afraid it failed.

It's constitutional - deal with it

It’s constitutional – deal with it

Since the hospital closed in Paducah, a town 30 miles to the north, patients in Guthrie have 60 long miles to travel to Childress for care. It’s a feeling of isolation that has crept up on other rural corners of the state following a spate of 10 hospital closures in the past two years. And financial data collected by the state and federal government shows revenue is falling for other rural hospitals, suggesting more may be on the brink.

Policymakers, operating on tight budgets, must decide whether they are willing to spend more money on small hospitals serving a limited number of patients, hospitals that in most cases could not keep their doors open without government assistance. But without them, people, inevitably, will die.

“We’ve all seen the crash that’s coming in the next five years,” said Kell Mercer, an Austin-based lawyer who has worked on hospital bankruptcy cases. “The Legislature’s more interested in cutting revenue and cutting services than providing the basic services for these rural communities. This is a perfect storm of events that’s going to hit the state, hard.”

Texas’ rural hospitals have long struggled to stay afloat, but new threats to their survival have mounted in recent years. Undelivered promises of federal health reform, payment cuts by both government programs and private insurers, falling patient volumes and a declining rural population overall have been tough on business — a phenomenon one health care executive called “death by a thousand paper cuts.” Add to that Texas’ distinction as the state with the highest percentage of people without health insurance and you get a financially hostile landscape for rural hospital operators.

“Hospital operating margins, and this is probably true of the big guys and the small guys, too, are very small, if not negative,” said John Henderson, chief executive of the Childress Regional Medical Center. “In a way, Texas rural hospitals are kind of in a worst-case scenario situation, because we lead the nation in uninsured, and we took Medicare cuts hoping that we could cover more people.”


The sum of all these changes has people like Don McBeath, who lobbies for rural hospitals, warning of a repeat of the widespread hospital closures Texas experienced three decades ago. In 1983, the federal government restructured the way Medicare made payments to hospitals, meant to reward efficient care. Those changes proved untenable for small hospitals with low patient volume, heralding decades of closures that claimed more than 200 small Texas hospitals as casualties, McBeath said.

Some counties can afford to raise taxes to keep their hospitals open; others cannot, or find that raising taxes is politically impossible.

And when a small county hospital closes, often the hospital in the next county over must shoulder a bigger burden of uninsured patients. Even patients with insurance face higher deductibles and often can’t pay their bills.

“When it closes, you’re forced to make other decisions, other plans,” said Becky Wilbanks, a judge in East Texas’ Cass County, which saw a hospital closure last year. “That’s an economic hit that we took.”

Rural hospitals are often one of the biggest and highest-paying employers in a community, Wilbanks said.

And when they close, it can have a domino effect on other local businesses, said Hall County Judge Ray Powell. When his county’s hospital closed in 2002, it prompted the local farm equipment dealership to close its doors and move to Childress.

“It was a big loss,” he said. “It was devastating.”

Across Texas, rural counties are seeing their populations dwindle. King County, home to Guthrie, is one of Texas’ 46 rural counties that are projected to lose population over the next four decades — at a time when the rest of the state’s population is expected to double.

Maybe I’m just a jerk, but my first reaction to stories like this is to check the most recent election results in the counties named.

In Cass County, Greg Abbott got 74.64% of the vote.
In Hall County, Greg Abbott got 85.09% of the vote.
In King County, Greg Abbott got 96.77% of the vote. Ninety-three people voted in total, and 90 of them went for Abbott.

In other words, the voters in these counties have gotten what they voted for. Perhaps someone should point that out to them if and when more of these rural hospitals close.

This isn’t entirely fair. Declining population in these counties is nobody’s fault. A change in Medicare payments in 2002 caused a lot of upheaval. But the problems they’re facing now are entirely the result of Republican intransigence on Obamacare and hostility to Medicaid. It’s abundantly clear by now that Medicaid expansion has been a boon for the states that have done it, while states like Texas are feeling the downside good and hard. If you want to blame Wendy Davis for not adequately communicating the issue to these voters, you have to equally blame Greg Abbott for continually lying about the need for “freedom” from the “tyranny” of Obamacare. Elections have consequences. This is one of them.

It’s still not Medicaid expansion

The Legislature may do something that could sort of be called “Medicaid expansion”, if only for lack of a better term, but we would all do well to remain deeply skeptical of what they might consider.

It's constitutional - deal with it

It’s constitutional – deal with it

The once taboo subject of expanding Medicaid in Texas has been broached in recent weeks by some Republicans and GOP-friendly organizations, as the Legislature prepares to reconvene early next year.


In 2013, state Rep. John Zerwas, R-Richmond, wanted to use federal dollars and a Medicaid waiver to create a new insurance program for poor Texans, but he was never able to build much support among his Republican colleagues.

“Last time, everybody was pretty reactionary,” said Zerwas, a physician. “We were playing defense.”

But with Perry leaving office in January and a new legislative session set to begin, Zerwas and his allies once again are pushing for a new program.

The difference this time is the dialogue is more thoughtful and the effort is more organized, he said.

Zerwas and other legislators had the chance after the 2013 session to go back to their districts and listen to their constituents. Many expressed interest in insuring people who can’t get coverage under the new law, he said, but many more have indicated that they want to see the already stressed, safety-net hospitals get some relief from being forced to care for so many uninsured people.

Gov.-elect Greg Abbott said on the campaign trail that he opposed Medicaid expansion, but spoke of seeking a block grant from the federal government to reform Medicaid in the state, echoing some other Texas Republicans.

The words “block grant” are your first clue that despite the sincere words of people like Rep. Zerwas, this is the same old song and dance with some fresh wrapping paper on it. Block grants are a shibboleth and a mirage. The Bush administration refused to grant waivers to allow for these things. President Obama will nominate Ted Cruz to be its next Attorney General before his administration will consent to block grants for Texas.

The Texas Association of Business, an influential group with close friends in the Republican Party, has come out again in support of expanding Medicaid, just as it did in 2013.

Bill Hammond, president of the organization, said it will take a “massive effort” in 2015 to increase coverage for Texans, but it’s a fight he is willing to take on.

“It just makes sense for us from the business perspective,” he said.


Dan Stultz, president and CEO of the Texas Hospital Association, said in a presentation that hospitals need meaningful coverage expansion.

Stultz told the Associated Press earlier this year that hospitals agree with Perry that the Medicaid program is “severely flawed,” but he also said that “without the Medicaid expansion, many will remain uninsured, seeking care in emergency rooms, shifting costs to the privately insured and increasing uncompensated care to health care providers.”

The Texas Medical Association, one of the most powerful lobbies in state government, also supports allowing state leaders to work with the federal Centers for Medicare and Medicaid Services to come up with a solution that fits Texas’ health care needs.

The association’s leaders are pushing the Legislature to create a concept, as it says on the group’s website, that “works for the state and helps Texans in the coverage gap get affordable and timely care.”

The “support” these organizations have for Medicaid expansion doesn’t extend to supporting candidates that support Medicaid expansion, of course. In that way, it’s like their support of immigration reform. Fill in your own definition of insanity, and go search for insurance policies that would cover that affliction.

Be all that as it may, we now have an interim report with recommendations on the subject.

Texas should pursue a waiver from the federal government for more flexibility to administer Medicaid, heighten the “visibility” of the state’s mental health programs to “ensure adequate leadership and accountability” and consolidate its three major women’s health programs, the Senate Committee on Health and Human Services said Monday.

In a lengthy report, the interim committee released its recommendations for the 2015 legislative session, addressing charges from outgoing Lt. Gov. David Dewhurst to expand access to women’s healthcare, improve the state’s mental health services, stop prescription drug abuse, and provide affordable care options for the state’s uninsured — all under the constraints of a fiscally conservative budget.


Among the report’s other recommendations:

Texas should not expand Medicaid to cover low-income adults, a key tenet of federal health law. Lawmakers should, however, seek to renew the “transformational” Medicaid waiver that, among other things, helps reimburse hospitals for the emergency care they provide to the uninsured. Notably, the report does not rule out pursuing a transformational waiver like the one the feds approved in Arkansas, which provided for a private health coverage expansion to low-income people using the Medicaid expansion dollars made available under the Affordable Care Act.

See here for some background, and here for a copy of the report. Rather than get distracted by shiny objects, read these two paragraphs from page 23:

The state’s first order of business must be to repair this broken Medicaid system and bring these costs under control. By enacting common-sense reforms such as cost sharing, health savings accounts, variable benefit packages, and high-deductible emergency care plans, Texas can reform its Medicaid program in a way which contains costs, encourages personal responsibility, and lessens the burden of providing uncompensated care.

Unfortunately, most of these innovative solutions are not able to be implemented under the strict Medicaid guidelines imposed by the federal government. By receiving a federal waiver from these restrictions, Texas can finally have the flexibility it needs to design a sustainable and cost-effective Medicaid program that is appropriate for the citizens it serves and accountable to taxpayers.

Like I said, let’s keep our eyes on the ball. The feds have been making noise about that “transformational” waiver not being a guarantee if Medicaid isn’t expanded in some acceptable form. What “acceptable” looks like is the hundred billion dollar question. The feds have been fairly accommodating to recalcitrant states, but there’s only so far they’ll go. Block grants ain’t happening, and those pet rocks masquerading as “common sense reforms” are more smoke than substance. Texas is going to have to give something to get something, and I’ll believe that will happen when I see it. A press release from Sen. Charles Schwertner, the chair of the HHS committee, is here, and Texans Together has more.

734K ACA enrollments in Texas

Pretty damn impressive, all things considered.

It's constitutional - deal with it

It’s constitutional – deal with it

New numbers out show that 734,000 Texans bought health insurance through the federal marketplace from last October to April 19, 2014, a report released by Health and Human Services shows.

Prior to March 1, an anemic 295,000 people had signed up, but in the final stretch of the Affordable Care Act first-year sign-up, another 439,000 obtained private insurance through the exchange.

Health care advocates applauded the new sign-up numbers and said the results are impressive, especially in the face of strong opposition from virtually every state Republican leader.

Texas has made more progress on affordable health insurance in the last six months than in the last decade,” said Stacey Pogue, a health care analyst at the left-leaning Center for Public Policy Priorities.

“We know that Texas could do much more,” she said. “Too many Texans are still one illness or one accident away from going bankrupt.”

Emphasis mine. Keep that in mind the next time you hear a Republican dead-ender talk about how horrible Obamacare is. After more than a decade in complete control of Texas government, they’ve not done a damn thing to try to solve this problem. Hell, in that time they’ve never even recognized it as a problem. Then the federal government – President Obama and the Democrats in Congress – stepped in and finally did something about it, and the Republican leadership in Texas resents it like crazy, because it so clearly points out their abject failure. The final enrollment surge, generated purely by tons of need for health insurance coverage, since the state did everything it could to impede signups, was impressive enough that even the TPPF’s designated hack had to admit is was remarkable. Just imagine what could have been if only Rick Perry and Greg Abbott and the rest of them gave a damn.

Some details from Texas Well and Healthy:


  • Eight-four percent of Texans who signed up also received financial assistance, lowering their monthly costs.
  • Thirty percent of Texans who selected insurance plans through the Marketplace were 18-34 years old.
  • Approximately six million Texans were uninsured in 2012. With 25 percent of the state uninsured, Texas has the worst rate in the nation.
  • About half of the state’s one million uninsured children and teens are eligible for Medicaid or CHIP.
  • More than one million Texas adults are in the Coverage Gap. Their jobs do not provide insurance, but their income is not high enough to qualify for assistance in the Marketplace. The Texas legislature can provide insurance to Texans in the Coverage Gap by accepting federal health care funds.

The overall numbers are right in line with that Baker Institute study that had pegged the figure at 746K. You can see how Texas compared to other states in the updated Kaiser numbers.

More from the Chron:

For weeks, officials have said an estimated 8 million people nationwide signed up for coverage. Until Thursday, it was unclear that a little more than 9 percent of enrollees were Texans. Before the marketplace’s Oct. 1 launch, government officials projected about 625,000 Texans would sign up for coverage.

“I’m pleasantly surprised,” said Vivian Ho, James A. Baker III Institute health economics chair at Rice University. “I thought that anyone who wanted insurance would have signed up by Dec. 31.”

Although the state surpassed enrollment expectations, Ho said millions of Texans remain uninsured. About half of Texas’ estimated 6 million uninsured residents could have applied for marketplace coverage created by the 2010 Affordable Care Act.

“We’ve only made a slight dent in the number of uninsured in Texas,” Ho said. “We need more resources down here.”

No one from the offices of U.S. Sens. John Cornyn and Ted Cruz or Gov. Rick Perry responded to requests for comment about the number of Texas enrollments. All three lawmakers oppose the health care law commonly known as Obamacare, and Cruz repeatedly has pushed for its repeal.

No comment from any of them? Not even a smart-aleck remark? Wimps.

Thursday’s report did not include Houston-area enrollment information. In April, the Associated Press reported more than 177,000 Houston residents signed up for health coverage, exceeding expectations and indicating a last-minute enrollment push just before the March 31 deadline might have helped Texas.

Texas Hospital Association officials said they were encouraged by the enrollment update but agreed with Ho that the state needs to do more to help its remaining uninsured residents. Texas has the nation’s highest rate of uninsured residents.

Perry has refused to expand Medicaid, which would extend health coverage to more than 1 million residents who earn too much to qualify for the program and too little to afford private health insurance.

“Our federal income tax dollars are going to other states because the state’s leadership said no to connecting low-wage working families with health insurance options,” hospital association president and CEO Ted Shaw said in a written statement. “Other states have proposed innovative private-market solutions to expand coverage using available federal funding, and Texas should follow their lead.”

Maybe next year, if we have a better Governor, we can exceed this year’s totals. A statement from Rep. Garnet Coleman is here, and Progress Texas and Stace have more.

More on Texas Left Me Out

The Observer reports on the launch of Texas Left Me Out.

Members of the coalition pointed to two different studies that estimate that thousands of uninsured Texans with chronic conditions are likely to die as a result of not expanding Medicaid.

A Harvard University/CUNY study released last week predicts between 1,840 to 3,035 deaths. Another study, by a University of Texas Medical Branch researcher, projected approximately 9,000 preventable deaths per year. Dr. Robert Luedecke of Doctors for America, a national coalition for healthcare reform, said the death toll associated with the uninsured is something many lawmakers won’t talk about.

“What would people do if they didn’t have health insurance?” Luedecke said of critically ill patients who put off seeing a doctor because they can’t afford it. “They would just die—that’s what they’d do.”

Linda Berman, 63, is one of those who says she’s been left out by Texas. She’s languishing in the coverage gap while dealing with diabetes and high-blood pressure. As a small business owner teaching Science, Technology, Engineering and Mathematics (STEM) skills to kids through a traveling workshop, Berman said she’s left with little to no taxable income at the end of the year. The cheapest individual private plan she’s found comes with a $450 monthly premium—out of her price range. She makes too little to qualify for subsidies on the marketplace and she’s never been eligible for Medicaid under Texas’ strict eligibility standards. Two years ago, Berman racked up $70,000 in medical debt after she was hospitalized.

“I knew I had no money to pay for [the visit] but had I not [paid out of pocket], they wouldn’t have saved my life,” Berman said.

Not long after her hospitalization, a debt counselor told her that she would never be able to pay off her medical debts. Berman soon filed for bankruptcy. The hospital was left holding the bill.

“People without insurance don’t get preventative care,” Berman said. “You don’t die of diabetes, you die of complications.”

See here and here for the background. The Trib also tells Ms. Berman’s story, and adds this extra bit of context to the situation.

State Rep. John Zerwas, R-Richmond, who led efforts to craft “a Texas solution,” said he hoped that the period between legislative sessions would give lawmakers a chance to work on a road for reform. However, he said he wasn’t sure that this particular coalition would have a significant impact, and he said a coalition of businesses concerned with health care issues would have a stronger impact. He said a business-focused coalition would “resonate especially with the conservative Legislature.”

Texas has declined billions of dollars from the federal government to assist with Medicaid expansion and will lose $100 billion in federal funds over a 10-year span, according to a report by Billy Hamilton, a tax consultant and former deputy comptroller, for Texas Impact and Methodist Healthcare Ministries of South Texas Inc. The federal government would cover 100 percent of the Medicaid expansion enrollees’ health care costs from 2014 to 2016, then gradually lower its share of the costs to 90 percent over ten years, resulting in 10 percent of financial responsibility for the state by 2020.

The Texas Association of Business, local government officials, and the state’s largest medical associations, including the Texas Hospital Association, and Texas Medical Association, pushed lawmakers to expand Medicaid during the 2013 session, but the issue still failed to gain traction among Texas’ conservative leadership.

Rep. Zerwas has been an honorable actor in this saga, but I don’t know what he’s talking about here. Look at that last paragraph and the supporters of Medicaid expansion in it. If that’s not a sufficiently business-focused coalition to resonate with the Lege, who else is there? We need a change of leadership at the top. That’s the only way this is moving forward.

TMA sort of endorses Medicaid expansion

Hard to say what this means.

It’s constitutional – deal with it

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

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

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


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

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

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

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

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

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

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

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

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

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

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

No Medicaid expansion for you!

So much for that.

Texas will not expand Medicaid or establish a health insurance exchange, two major tenets of the federal health reform that the U.S. Supreme Court upheld last month, Gov. Rick Perry said in an early morning announcement.

“I stand proudly with the growing chorus of governors who reject the Obamacare power grab,” he said in a statement. “Neither a ‘state’ exchange nor the expansion of Medicaid under this program would result in better ‘patient protection’ or in more ‘affordable care.’ They would only make Texas a mere appendage of the federal government when it comes to health care.”

Perry’s office said he’s sending a letter to U.S. Health and Human Services Secretary Kathleen Sebelius [Monday] morning asserting his opposition, both to accepting more than a hundred million federal dollars to put more poor Texas adults onto Medicaid, and to creating an Orbitz-style online insurance marketplace for consumers.

Of course, opting out of creating a state exchange means that the federal government will create one instead. It does not mean there will be no exchange in Texas. This is why some Republican legislators like Rep. John Zerwas tried to pass a bill to create an exchange, so that it would be implemented by Texas instead of the federal government. The rationale for not implementing the state-run exchange confounds me, but I have never been Rick Perry’s intended audience.

As for the refusal to expand Medicaid, just on Friday the Dallas Morning News reported that Perry was still thinking about it.

Gov. Rick Perry won’t say whether Texas should take or reject the federal largesse that could allow the state’s Medicaid program to cover more poor adults.

But a spokeswoman confirmed Friday that his aides have begun canvassing health care provider groups for their opinions about expanding Medicaid and creating a state health-insurance exchange

Though he’s a staunch opponent of President Barack Obama’s federal health care law, Perry’s reluctance to declare immediate opposition to the Medicaid expansion after the Supreme Court’s ruling last week puts him at odds with several other Republican governors. Some, such as Florida’s Rick Scott, have already vowed to keep their states on the sidelines, taking advantage of the court’s ruling that they can do so without jeopardizing the funds they already receive.

Perry spokeswoman Catherine Frazier played down the calls as routine outreach on a major issue. But several health-care lobbyists and experts said it’s shrewd for Perry to say little because the Supreme Court ruling gives him leverage to negotiate with the Obama administration for tighter Medicaid eligibility rules and leaner benefits before agreeing to the expansion, which would take place starting in 2014.

“It’s smart politics because there’s no need to make a decision at this time, and he and a lot of Republicans are playing for more flexibility within the program,” said Tom Banning, chief executive and executive vice president of the Texas Academy of Family Physicians.

Apparently, he didn’t listen very closely to what the health care providers want, because they have made their preference quite clear.

Getting the Medicaid expansion in place has already become the “number one priority” for the Texas Hospital Association, said John Hawkins, the senior vice president for advocacy and public policy at the organization. “It’s the kind of thing that hits our members right on the margin when they’re trying to digest other payment cuts,” he said.

Twenty-seven percent of working-age Texans, or more than 6.1 million people, were uninsured in 2010, according to the Kaiser Family Foundation. That’s the highest rate in the nation and the second-highest number to California’s 7 million people. Under the Medicaid expansion, 2.5 million Texans would qualify, the Urban Institute estimates.

But Texas Gov. Rick Perry (R) has been a staunch opponent of health care reform and his administration has indicated a willingness to opt out of the Medicaid expansion. For Texas hospitals, which absorbed $4.6 billion in unpaid bills and charity care in 2010, that’s a problem, Hawkins said.

I’m thinking that will provide for some interesting fundraising pitches this fall. My advice to them is to start donating to Democrats now.

So now Rick Perry will take a victory lap on Fox News and bask in the adulation of his cultish supporters. Everyone else will have to deal with the reality of this, starting with county taxpayers.

It's constitutional - deal with it

Unlike many states, Texas does not directly subsidize the cost of caring for the uninsured. Instead, taxpayers in Dallas County and elsewhere help pick up that tab through property taxes that support safety-net hospitals such as Parkland Memorial Hospital.

Last year, Parkland reported that its own cost for delivering uncompensated care was $335 million. Dallas County taxpayers funded $425 million, or 35 percent, of the hospital’s operating budget.

For the average Dallas County homeowner, that created a hospital tax bill of $370.

Some advocates of health reform say the new revenue from Medicaid payments is large enough that hospital districts — whose budgets are controlled by county commissioners — could reduce their tax rates.


Some experts expect that Texas will eventually accept the Medicaid funding. After all, the federal government would cover the entire cost of the expansion between 2014 and 2016. Hospitals that have struggled to find ways to offset charity care are certain to demand that state lawmakers take the money.

“It really depends on the political pressure they get from the counties and the hospitals that benefit from having these people covered,” said John Holahan, director of the Urban Institute’s Health Policy Center. “To leave all this federal money on the table will create an intense debate.”

The hospitals are big losers as well.

Hospitals regularly get stuck with bills that the uninsured cannot afford to pay. Every year, the American Hospital Association adds all those bills up to calculate the total amount of uncompensated care that its members provide. Every year, the number gets bigger and bigger, hitting $39.3 billion in 2010. Here’s a chart I put together with the AHA data:

Under the health reform law, hospitals will see reductions in some of their Medicare reimbursement rates. They will be forced to deliver higher quality or see financial consequences.

All of that was worth it, in hospitals’ eyes, because of the insurance expansion. That would finally put someone on the hook for the medical bills that have, for decades, gone unpaid.

If states opt-out of the Medicaid expansion, that essentially means there’s no one on the hook for some of the poorest patients. And that explains why Bruce Siegel, president of the National Association of Public Hospitals, calls states opting out a “potentially disastrous outcome” and is urging Congress to come up with a fix. For them, the status quo is the worst possible outcome: One where they have accepted cuts to Medicare, and still get stuck with billions in unpaid bills.

Remember, a part of the Affordable Care Act was a reduction in the federal subsidy for uncompensated care costs because it assumed the expansion of Medicaid would greatly reduce the number of uninsured patients. Unfortunately, no one foresaw the SCOTUS decision striking down the provision that states would lose existing Medicaid funding if they didn’t accept the subsidies to expand it, and so here we are. Just as a reminder, states like Texas that have a lot of uninsured people would have benefited greatly from it as a result. It was a simple case of red state/blue state math.

The deal the federal government is offering states on Medicaid is too good to refuse. And that’s particularly true for the red states. If Mitt Romney loses the election and Republicans lose their chance to repeal the Affordable Care Act, they’re going to end up participating in the law. They can’t afford not to.

Medicaid is jointly administered between states and the federal government, and the states are given considerable leeway to set eligibility rules. Texas covers only working adults up to 26 percent of the poverty line. The poverty line for an individual is $11,170. So, you could be a single person making $3,000 a year and you’re still not poor enough to qualify for Medicaid in Texas. That’s part of the reason Texas has the highest uninsured rate in the nation.

Massachusetts, by contrast, covers working adults up to 133 percent of the poverty line — partly due to a former governor whose name rhymes with Schmitt Schmomney. It’s a big reason it has the lowest uninsured rate in the nation.

The Affordable Care Act wants to make the whole country like Schmitt Schmomney’s Massachusetts. Everyone earning up to 133 percent of the poverty line, which is less than $15,000 for an individual, gets Medicaid. And the way it does that is by telling states the feds will cover 100 percent of the difference between wherever the state is now and where the law wants them to go for the first three years, and 90 percent after 2020.

To get a sense of what an incredibly, astonishingly, unbelievably good deal that is, consider this: The federal government currently pays 57 percent of Medicaid’s costs. States pay the rest. And every state thinks that a sufficiently good deal to participate.

But, somewhat perversely, the states that get the best deal under the law are states like Texas, which have stingy Medicaid programs right now, and where the federal government is thus going to pick up the bill for insuring millions and millions of people. In states like Massachusetts, where the Medicaid program is already generous and the state is shouldering much of the cost, there’s no difference for the federal government to pay.

So if Texas had accepted Medicaid expansion, it would have gotten a vastly better deal than states like New York, California, and Massachusetts. Now that Texas has decided to “send that money back” to Washington, we will subsidizing the Medicaid expansions of New York, California, and Massachusetts, and getting nothing in return. Does that sound like a good idea to you? BOR, Neil, EoW, Juanita, Hair Balls, Ed Kilgore, Sarah Kliff, and Rep. Garnet Coleman have more, and statements from Rep. Jessica Farrar and Sen. Rodney Ellis are beneath the fold.


Just call it “DewhurstCare”

I’m not sure what to make of this yet.

Lt. Gov. David Dewhurst and Sen. Jane Nelson, R-Grapevine, introduced two bills Wednesday they believe could save the state a significant amount of money and produce “healthy patient outcomes.” The duo repeated those words throughout a press conference in the Capitol, flanked by stakeholders from the Texas Medical Association, the Texas Hospital Association and House Public Health Committee Chairwoman Lois Kolkhorst, R-Brenham.

“We don’t have health care in America — we have sick care,” said Dewhurst, who cited studies from The Dartmouth Institute for Health Policy & Clinical Practice indicating that the state could save up to one-third of its health-related costs by incentivizing doctors and hospitals to use best practices for treating patients, as opposed to paying them for the number of procedures they perform.

Nelson, a state budget writer and chairwoman of the Senate Health & Human Services Committee, said that after weeks of sobering meetings on the state’s financial constraints, there needs to be a “paradigm shift” in the way Texas funds medical costs.

“If I’ve learned nothing else — it is unsustainable. We’ve got to do something differently,” she said.

When asked whether the bills would cost or save the state money — and how much — Dewhurst said he is working with the Legislative Budget Board to determine exact figures. However, he is convinced there will be savings for the state. Unlike President Barack Obama’s federal health care reforms, the lieutenant governor said, these two new bills do not mandate that all citizens have insurance or increase regulations for states.

I guess he mentioned that to reassure the teabagger crowd that he’s not going to force his way into their homes and shove a tongue depressor down their throats or something. I’m not entirely clear on how it is that the individual mandate went from a Republican idea to a shibboleth. The Trib provides a word cloud comparison of these bills to the Affordable Care Act, which doesn’t really tell me anything. I see now that Rep. Garnet Coleman has issued a press release that praises Dewhurst for these bills, which heartens me greatly. The main thing I have to add is that much like Rep. Zerwas’ insurance exchanges, we would not be having this conversation if it weren’t for the Affordable Care Act, which has basically forced the hand of our state leaders. If any of this had been a priority to them at any time before now, they had plenty of opportunities to take action. Still, better late than never, so good on Dewhurst, Nelson, and Kolkhorst for putting these bills forward. Patricia Kilday Hart, who suspects this is Dewhurst’s attempt to put a little sugar in the budget’s castor oil, has more.

Harris County braces for state budget cuts

More joy to look forward to.

Proposed state budget cuts could cost Harris County government nearly $50 million a year, according to a legislative analyst’s rough estimates, rolling back or eliminating state allowances for dozens of programs that include mental health services, auto theft prevention, alternatives to jail and a school for juvenile offenders.

The starting-point House budget introduced in in Austin last week would possibly take a $13 million chunk out of money the Mental Health and Mental Retardation Authority of Harris County uses to treat adults and children.


If the state cuts come to pass, the sheriff’s unit dedicated to auto theft would be halved and a camp for youth offenders would have to turn away kids who need its intensive counseling to prevent them from becoming career criminals, county officials said.

In other cases, the state cuts would transfer the burden onto a county government already contemplating hundreds of layoffs.

For example, the state mandates that the county run a school for children expelled from their neighborhood schools for weapons and serious drug offenses. But the starting-point budget would take away $3 million of the $12 million the state sends to cover the cost of busing, educating and counseling kids from all over the county at a school near Reliant Park.

Tom Brooks, the county’s juvenile probation director, said the school would be “crippled” by the proposed cut and that he would ask the state to lift the mandate if the proposed spending plan is what emerges from Austin this year.


Sheriff Adrian Garcia, County Judge Ed Emmett and MHMRA executive director Stephen Schnee have been saying for months that such drastic state cuts will transfer the bill to county agencies as people who could have benefited from treatment in community centers end up in emergency rooms and jail cells.

“Harris County will pick up the tab for them to be staying in jail and the mental health care they receive in jail, which is much more expensive than in the free world,” sheriff’s spokesman Alan Bernstein said Wednesday.

The state budget in its current form would eliminate the entire $1 million in state money spent on auto theft prevention and detection in Harris County. The Houston area accounts for about 30 percent of the state’s stolen cars, according to the sheriff’s office. Sheriff’s spokespeople were particularly puzzled by the auto theft cut, since the money comes from a surcharge in motorists’ auto insurance premiums and not from taxes.

So expect there to be more firings and more crime, not to mention higher local taxes in many places as the state sloughs its responsibilities off on cities and counties. Oh, and quite possibly your insurance rates, too.

Budget drafts call for a 10 percent reduction in payments to Medicaid providers and deep cuts in health and human services spending, including mental-health programs.


Proponents of the reductions call them necessary to control spending on the state’s Medicaid program, which cost a total of $24.7 billion in fiscal 2011. The federal government picks up $16.6 billion of that.

More than $7 billion a year in Medicaid money is paid to the state’s 500 hospitals.

Texas hospitals have protested the reductions, saying they will further strain hospitals’ resources and lead more providers to drop Medicaid. The program now covers only about 60 percent of a provider’s cost for treating a patient. Less Medicaid coverage would lead more patients to seek help in emergency rooms, where care is far more expensive, hospitals say.

An effort to shift more Medicaid patients into managed-care programs could exacerbate the financial pain for providers, according to the Texas Hospital Association.

“Reductions of this magnitude will seriously jeopardize access to healthcare and shift more healthcare costs to local governments and insured Texans,” said Dan Stultz, association president, in a statement.

Funny thing, just because the state refuses to pay for a need doesn’t make that need go away. It just means some other entity winds up paying for it. In many cases, they wind up paying more than what the state would have paid. In the end, of course, it all comes out of our pockets. But hey, at least we balanced the state budget.

You think there might be a connection there?

In the middle of this Trib story about the Driver Responsibility Program and the Lege’s efforts to reform it comes a reminder about the relationship between federal and state legislation.

Denise Rose, senior director of government relations at the Texas Hospital Association, says she doesn’t anticipate the new rules will have a large fiscal impact on the Driver Responsibility Program. “The state’s only collecting a third of the surcharges that are out there, so I don’t know that it’s going to make a huge dent,” she says. Even if the state isn’t collecting all it could, she says, the hospital trauma centers that get the money badly need it. Since 2004, Texas trauma centers have received some $380 million from driver surcharges, which helps pay for care provided to uninsured patients. “It seems like a lot of money, but hospitals have reported in the same time frame close to over $1 billion in uncompensated trauma care,” Rose says. Though hospitals acknowledge the surcharge program is not ideal, Rose says they’d rather see it fixed than eliminated. “If the state was funding uncompensated trauma care in a different way, there wouldn’t be a need for things like the Driver Responsibility Program,” she says. “But that’s a whole a different argument.”

Emphasis mine. The Affordable Care Act, which will provide insurance for those trauma victims for which these hospitals have been providing uncompensated care, will do more to close that gap than anything the Lege can or will do. You would think the state of Texas would be happier about that. Here was the federal government finally stepping up to solve a federal problem that was having an outsized impact on state and local governments. The lack of action by the federal government on a similar problem that’s theirs to solve – comprehensive immigration reform – is frequently cited these days (usually by Republicans) as justification for states taking that matter into their own hands. Yet what’s the reaction of these same Republican legislators to this great achievement by the federal government, which among many other things will solve problems like these? Why, they want to repeal it, to file lawsuits against it, to pass laws forbidding their states from recognizing it. One might think they’re not really all that concerned about the federal government solving problems. Funny how these things work, isn’t it?