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Texas Medical Association

Doctors against bathroom bills

Good.

[Last] week, the American Medical Association (AMA), the country’s largest medical organization, took several actions to solidify their defense of transgender people. This included a resolution opposing any policy or legislation — like “bathroom bills” put forth in North Carolina and Texas — that prohibits transgender people from living according to their gender identity throughout society.

During its annual meeting in Chicago [last] week, the AMA House of Delegates approved a resolution favoring “Access to Basic Human Services for Transgender Individuals.” As drafted, the resolution notes that laws that restrict which facilities transgender people can use “place undue harm on the physical and social well-being and safety of transgender individuals.” It also highlights the way that transgender minors “are at particular risk of social, mental, and physical detriment by being forced to disregard their gender identity or to publicly identify as transgender due to these policies.”

Thus, the AMA officially opposes “policies preventing transgender individuals from accessing basic human services and public facilities in line with one’s gender identity, including, but not limited to, the use of restrooms.” The resolution also calls for the creation of additional policies that “promote social equality and safe access to basic human services and public facilities for transgender individuals according to one’s gender identity.”

I’m glad to see it. This is exactly what a responsible, caring establishment organization ought to do. I would be remiss if I did not note that this is not enough. The politicians who are pushing these bills aren’t doing so because they are misinformed or misguided. They’re doing it because they see political advantage in pushing them, and because they do not care at all for the people they hurt by doing so. The proper response to politicians of this type is to vote them out of office. Which brings me to the awkward fact that the Texas Medical Association endorsed Dan Patrick in 2014. Now, the TMA is not the AMA – I googled around and searched their respective websites, and I can’t honestly say if there’s any official relationship between the two organizations. But they do broadly share the same mission, and I have no doubt that many members of the TMA are also members of the AMA, and vice versa. It may not be the AMA’s place to tell the TMA what to do, but if the AMA wants to achieve its goals as stated above, it’s going to need organizations like the TMA to be aligned with them on it, and to take the lead in the states where it is relevant. Words are good, but action is necessary.

“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.

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 HealthCare.gov, 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 HealthCare.gov 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.

Abbott would like to restore the uninsured rate

It’s what he does.

It's constitutional - deal with it

It’s constitutional – deal with it

Greg Abbott on Monday urged his fellow Republicans not to “rescue” President Barack Obama’s signature health care law if it is torpedoed by the U.S. Supreme Court, an unusually public stance that could make the first-term Texas governor a leading voice on a national issue dividing the GOP.

Abbott’s position, announced in an opinion article published on the conservative National Review magazine’s website ahead of an expected high court decision, puts him in a group, including U.S. Sen. Ted Cruz, that hopes a ruling against the Affordable Care Act’s subsidies to help poor residents buy health insurance ultimately would undo the entire law. Others, including U.S. Sen. John Cornyn and former Texas Gov. Rick Perry, say the government should patch the problem by replacing the subsidies for the nearly 1 million Texans and 5 million other Americans now receiving them, at least temporarily and with some changes to the law.

Abbott’s piece also suggested what he intends to do if the justices throw out the subsidies and Congress fails to replace them: nothing.

“Now is not the time to throw Obamacare a lifeline,” Abbott wrote, “it is time to sound its death knell.”

Now is apparently the time to make sure that everyone who didn’t have insurance before the passage of the Affordable Care Act goes back to not having insurance if the Supreme Court strikes down the subsidies. Because that’s how we keep score in this state. Abbott’s article was typically full of the usual lies and distortions about Obamacare, which the Chron story to its credit points out. It also includes the same warmed-over Republican proposals for increasing health care access that Abbott would totally push for if only his party had any control in Texas. Oh, wait.

This is usually the place where liberal/Democratic types like me bemoan low turnout and lost opportunities and the like. I am instead going to point out that groups like the Texas Association of Business and the Texas Medical Association, both of which support the full implementation of Obamacare via Medicaid expansion and also supported Greg Abbott’s gubernatorial campaign, have a role in this as well. Yes, yes, I know – Wendy Davis was a lousy candidate, the Democratic Party in this state is feckless and impotent, there’s no point for these groups in supporting someone who can’t win, blah blah blah. These things may be true, but they’re also self-fulfilling. TAB and TMA supported Abbott for their own reasons – tax cuts and tort “reform”, to be specific – but there are plenty of other things they support that they aren’t ever going to get from him or his partymates. At some point they need to decide when doing the same thing and hoping for a different result starts to become more crazy than it’s worth to them.

UPDATE: Sorry (not sorry), Greg.

Medical marijuana gets its committee hearing

Don’t know that it will get more than just that committee hearing, however.

House Bill 892 would legalize oils containing CBD, a non-euphoric component of marijuana known to treat epilepsy and other chronic medical conditions. By 2018, the measure would allow the state to regulate and distribute the oils to epilepsy patients whose symptoms have not responded to federally approved medication. The measure was left pending by the House Committee on Public Health.

At the hearing, supporters of the proposal, also known as the Compassionate Use Act, recounted the seizures endured by children who they say could benefit from derivatives of medical marijuana. But opponents of the bill, including representatives of law enforcement agencies, expressed concerns that increased access to any component of marijuana would jeopardize public safety.

“This is a focused bill designed to give people with intractable epilepsy another option when others have failed,” the bill’s author, state Rep. Stephanie Klick, R-Fort Worth, told the committee. “[CBD oils] have no street value, and these families have no other options.”

The representative’s interest in medical marijuana came after she met constituents in her district who have children suffering from Dravet syndrome, a rare form of epilepsy that begins in infancy.

“If CBD weren’t available in the number of states it is available in, we wouldn’t be having this conversation today,” said M. Scott Perry, a pediatric neurologist with Cook Children’s in Fort Worth, testifying in favor of the bill. “The human data on CBD use is very encouraging. What is frustrating is that I can’t prescribe CBD to patients in my state, in Texas.”

[…]

Opponents of the bill expressed concerns over public safety and increased recreational use of marijuana as an unwanted consequence of increasing access to CBD oils. Others worried that the products would be hard to regulate.

“I am concerned about the other children in the household getting ahold of this medication when the parents aren’t around,” said Denton County Sheriff William Travis, speaking on behalf of the Sheriffs’ Association of Texas. “As a father, I would do anything for my child. But putting low amounts of marijuana oil in a child’s body where the brain is not fully developed is not the way.”

The Texas Medical Association has made clear that it does not support legalizing marijuana for medical use. “There is no validated science to support its use in broad treatment,” the association said in a statement earlier this year.

But some medical marijuana advocates are still reluctant to support the proposed Texas Compassionate Use Act, calling it appeasement legislation that would do little to help Texans with epilepsy — and nothing for those with other diseases, such as cancer, that can be treated with medical marijuana.

See here, here, and here for some background. I’m all about the science, but the TMA’s statement seem way too restrictive to me. Surely there are studies showing the efficacy of marijuana for some things. I favor a much broader loosening of marijuana laws than this, so I’m having a hard time understanding why this tiny baby step is so controversial. What are we really afraid of here? Unfair Park has more.

More on the Texas Compassionate Use Act

The Chron covers the legislation that has been introduced to loosen medical marijuana laws just a bit.

The twin bills, both authored by Republicans and supported by lawmakers across the aisle, await hearings in Senate and House subcommittees.

The bills are far more restrictive than those that legalized medical marijuana in 23 states, broad laws that in general green-light the marketing of “whole plant” products to a wide range of patients, such as those with cancer, multiple sclerosis, HIV and other illnesses.

The Texas bills would allow for the implementation of “compassionate use” of CBD oil by 2018, a move that would effectively bypass FDA drug trials, which can take as long as a decade.

“These are families that have run out of options,” said Rep. Stephanie Klick, R-Fort Worth, a nurse and lead author of the House bill. “Other states have legalized CBD oil with promising results. We want Texans with intractable epilepsy to have that option.”

The bills face opposition from conservative lawmakers, who fear a yes vote might cast them as champions of marijuana, and from the Texas Medical Association, which is opposing the lack of testing available on CBD oil.

Even some parents of children with intractable seizures are against it, arguing their kids need higher levels of THC to make their convulsions stop, a dose ratio the Texas law wouldn’t allow. A botanical derived from plants, CBD oil would have to be calibrated from different batches to conform to the strict, low-THC ratio the Texas law would mandate.

It’s that very ratio that has made Dean Bortell an opponent of the Texas Compassionate Use Act.

His daughter Alexis, now 9, began having seizures at age 7, convulsing wildly and foaming at the mouth. The various medications doctors gave her actually made her condition worse, he said.

Bortell moved his family from the Dallas area to Colorado, becoming “medical refugees.”

Bortell said his daughter’s epilepsy now is well-controlled on CBD oil – $150 for a 40-day supply – but one of her doses contains more THC than would be allowed under the proposed Texas law. To get the right ratio, he must add pure THC oil to the CBD oil.

“If I got caught with that in Texas, I’d go to prison,” he said. “I’ve talked to tons of parents here in Colorado, and for many of them, the ratios in the Texas bills wouldn’t help their children because they require more THC. For no other medication does the law dictate dosing levels.”

See here for the background; most of what is in this story is also in the one I blogged about there. Time is beginning to get short for any bills that have not yet been heard in committee, so unless these bills get scheduled to be heard in the next couple of weeks, they won’t be going anywhere. One bill that has already gotten a hearing is Rep. Joe Moody’s bill to change possession of less than one ounce of marijuana to a civil penalty, like a traffic ticket. That bill has picked up some Republican cosponsors, which may be a sign that it could go the distance, or at least go farther. I’d like to see more done, and I’d go a lot farther on medical marijuana than the Compassionate Use Act, but this just doesn’t look to be the session for it.

Banning e-cigarette sales to minors

You’d think this would have a decent chance of passing.

Legislators in Texas, one of just nine states that permit the sale of e-cigarettes to minors, will consider banning such sales amid concerns about growing use of the “safer” alternative to smoking among youth.

Even as the Texas Medical Association and Texas Public Health Coalition plan to lobby the 2015 Legislature to regulate e-cigarettes, three bills have been filed to forbid their sale to anyone under 18, a group now found to favor the battery-powered devices that turn liquid nicotine into a vapor the user inhales. The product isn’t considered harmless, particularly in young people.

“Why should it be OK for minors to buy one nicotine product and not another?” asked state Rep. Carol Alvarado, D-Houston, author of one of the bills. “I don’t know how you justify that. I don’t know how any responsible adult would justify that.”

Alvarado, who as a Houston City Council member spearheaded passage of the ordinance that bans smoking in restaurants and bars, said she’s optimistic the Legislature will pass a bill restricting the sale of e-cigarettes. The idea enjoys bipartisan support, she said, and she is not aware of any likely opposition. The other bills were filed by Sen. Juan Hinojosa, D-McAllen, and Rep. Ryan Guillen, D-Rio Grande City.

[…]

The planned lobbying effort by the Texas Medical Association and Texas Public Health Coalition stresses banning e-cigarette sales to minors but also includes extending state regulation of tobacco products to e-cigarettes too. Other provisions would fund research on e-cigarettes’ effects and provide for more school-based education about the effects of e-cigarettes, nicotine, tobacco, and other addictive substances.

But Dr. Eduardo Sanchez, a Texas Medical Association leader and chairman of the Texas Public Health Coalition, said prohibiting sales to minors is the most important goal.

“E-cigarettes are too easy for young people to access,” said Sanchez. “It should be just as difficult for young people to obtain and get hooked on them as combustible cigarettes.”

Rep. Alvarado’s bill is HB 170. SB 96 and SB 97, both filed by Sen. Hinojosa, would prohibit the use of vapor products on school property, and apply many of the regulations on cigarettes to vapor products, respectively. Some cities outside Texas have taken action to treat e-cigs the same as regular smokes, though cities like Houston have not done so yet. That may change depending on what the state does. None of the usual arguments against statewide smoking bans apply in a case like this, and as Rep. Alvarado notes it’s hard to imagine any lobbying being done in opposition to these bills. Doesn’t mean they’ll pass – it’s always a matter of priorities as much as anything – but if this gets on the calendar I’ll expect it to wind up on Greg Abbott’s desk for a signature.

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 healthcare.gov 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.

Expand Medicaid or else

Turns out the federal government has more leverage over Texas than you might think.

It's constitutional - deal with it

It’s constitutional – deal with it

If Texas wants to keep receiving billions of federal dollars to help hospitals care for uninsured patients, state lawmakers may have to look again at expanding Medicaid coverage for impoverished adults, some political observers say.

That’s because in 2016, Texas will have to ask the federal Centers for Medicare and Medicaid Services to renew a five-year waiver to pump $29 billion into state health care coffers.

Since landing its first such waiver in 2011, Texas leaders have defiantly refused to expand Medicaid as envisioned under the Affordable Care Act, leaving more than 1 million impoverished Texans with no health insurance.

With the waiver renewal nigh, observers said, there’s some expectation that the federal agency will hold the waiver approval hostage in exchange for Medicaid expansion.

“CMS is going to hold that over Texas’ head to say, ‘You want this money? You do the expansion,’” said Matt Salo, executive director of the National Association of Medicaid Directors. “It’s one of the points of leverage that CMS now has.”

Texas received the 2011 Medicaid waiver in part to reimburse hospitals for care provided to patients who couldn’t pay. Two years later, state leaders under Gov. Rick Perry declined to expand Medicaid, criticizing the program as inefficient.

That left a “coverage gap” of more than 1 million Texans too poor to receive federal subsidies for private health insurance but too rich to qualify for coverage under Texas’ current, restrictive Medicaid requirements.

Now, policy analysts on the left and right say, the feds are likely to be less sympathetic to Texas’ request for another waiver to help pay for uncompensated care.

A similar tug-of-war is playing out in Florida, said Joan Alker, executive director at the Center for Children and Families at Georgetown University. In May, the federal government renewed Florida’s waiver to reimburse hospitals for just one year, rather than the standard three, “which was very unusual,” Alker said.

[…]

State Rep. John Zerwas, R-Richmond, one of the lawmakers who advocated for the “Texas solution,” said the Legislature would revisit coverage expansion during the session.

“It still behooves us as a Legislature to figure out, what’s the policy going to be around these people?” he said. “I’ll be the first to say that finding a solution for these million and a half people is important.”

And the transformational waiver from 2011 is already a source of some conflict with the federal government. CMS is currently withholding $75 million in waiver money that Texas used to reimburse private hospitals while federal officials review whether any rules were broken.

Tiffany Hogue, policy director for the Texas Organizing Project, which has worked to get Texans to sign up for health coverage on the exchange, said Medicaid expansion would be a top priority for her group during the legislative session.

“It’s absolutely going to be a battle cry for us,” she said. “The sheer number of uninsured — that’s daunting.”

Still, Alker said she was skeptical that Texas would expand Medicaid anytime soon.

“I remind myself when the Children’s Health Insurance Program was passed in 1997, Texas was the last state in the country to pick up the program,” she said. “That may be instructive moving forward.”

It’s always a safe bet to assume that the Legislature will fail to do the right thing when given the chance. I for one will be rooting for the feds to apply the screws as hard as they can in pursuit of a Medicaid expansion deal that would do untold amounts of good for more than a million people, not to mention be a nice bit of stimulus for the Texas economy. Making Ted Cruz’s head explode would be the cherry on top. Against that, when the Republicans from Greg Abbott on down (with the honorable exceptions of Zerwas et al) dig their heels in, perhaps this will finally be the impetus to get the Texas Medical Association to quit trying to placate the bullies and start working to actually further their own and their patients’ best interests.

Cheerleading is now a sport in Texas

This is a real thing.

Cheerleading will finally get its tryout from the University Interscholastic League.

After a hearty debate and a failed first vote, the UIL Legislative Council approved a one-year pilot program to hold a league-sanctioned cheerleading competition for the 2015-16 school year.

Crowning state champions in each of the state’s six classifications, the “Game Day Cheer” competition will be the first cheerleading event in the league’s history.

“As big as cheerleading is in Texas, I feel like a lot of people will gravitate to this,” Highland Park cheerleading coach Jason McMahan said. “Not only because it’s new, but also because it gives them an opportunity to showcase their athletes and their abilities vs. just their home crowd seeing them on the sidelines.”

[…]

Passage of the proposal wasn’t easy.

After squeaking through the UIL’s Standing Committee on Policy on Tuesday, the concept faced similar skepticism and criticism from many on the full council on Wednesday.

Normally, the league moves at a glacial level, with a proposal waiting six months between approval from a subcommittee to a final vote. The cheerleading concept, however, was fast-tracked — with league staff asking for its approval less than a day after moving out of committee, in an attempt to get the event launched for the upcoming school year.

Many of the 32-member council didn’t like the speed of that process, with only seven members — including Duncanville ISD Superintendent Alfred Ray and Katy ISD’s Alton Frailey — initially voting in favor of the pilot program.

“The main reason that I can support this is that we can keep our kids involved and we can keep them safe,” said Frailey, the former DeSoto superintendent.

Richardson ISD Superintendent Kay Waggoner originally voted against the proposal, concerned with the readiness of districts to pay for additional expenses and provide oversight to another activity.

Only when implementation of the pilot was pushed back to the 2015-16 school year did the program gain approval.

“I think the folks around this table were concerned on how it would affect their budget on such short notice, and how it might affect their student body because of other activities that they’ve signed up for,” Breithaupt said. “To give more detail as we move forward, so that they can share it with people they represent, I think that’s fair.”

An earlier story has some of the background on this.

“It’s a controversial topic — it just is,” UIL executive director Charles Breithaupt said. “I’m just interested in doing what’s best for an activity that’s kind of been ignored, to be honest with you. Give them a state championship for all the things that they do.”

Game Day Cheer would differ from a competitive cheerleading event, Breithaupt said. The elements of the UIL contest would mimick what cheerleaders do during a pep rally or on the sidelines, without the high-flying tosses and difficult gymnastics found in competitive cheer.

In a 2012-13 National Federation of State High School Associations survey, 32 states held girls’ “competitive spirit squad” competitions, with 116,508 students participating nationwide, the ninth-most popular girls’ athletic activity.

[…]

Bringing cheerleading under the umbrella of the UIL has gained momentum over the last 18 months. In a letter to the UIL in January 2012, the Texas Medical Association asked the league for oversight of cheerleading, saying it would “be a bold move to ensure we have a state system focused on injury prevention under consistent, evidence-based safety guidelines.” As a result, the league’s medical advisory committee recommended in April 2013 that cheerleading be included in the list of activities that abide by the UIL’s safety and health regulations.

A former football coach and athletic director, Breithaupt said his opinion evolved from that point.

“If we are going to make them comply with all the other standards, to me it just makes sense,” Breithaupt said. “It’d be like, for example, if we said, ‘OK, we don’t sanction lacrosse, but we are going to require you to follow all of our rules.’”

You may be shaking your head about this, but the UIL is just following the official recommendation of the American Medical Association.

The American Medical Association adopted a policy declaring cheerleading a sport at its annual meetings Monday, weighing in on a long-lasting debate with a solid reason in mind: giving cheerleading “sport” status at high schools across the country would make it safer by increasing training and safety measures to protect its participants.

Cheerleading, according to the AMA and other independent researchers, is the leader in catastrophic injuries in female athletes, and considering it a sport would help increase training and awareness among coaches, parents, and cheerleaders themselves, the AMA said.

“These girls are flipping 10, 20 feet in the air,” Dr. Samantha Rosman said at the meeting, according to the Associated Press. “We need to stand up for what is right for our patients and demand they get the same protection as their football colleagues.”

[…]

The American Academy of Pediatrics designated cheerleading a sport two years ago, and 35 states and Washington D.C. have declared it a sport at the high school level. The AMA policy means that it will push remaining states and sports bodies to adopt the designation.

You can now add Texas to the list of adopters. As that article above noted, concussions are a big issue in cheerleading, and unlike in other sports, the risk is even higher in practice than at games. One of the effects of the UIL declaring it a sport is that practices can now be regulated in the same way as other sports. Hopefully, that will help reduce the injury risk.

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.

Four things to work on now that the omnibus anti-abortion bill is reality

1. Organize, organize, organize. Maintain the energy and sense of urgency that originated with the #StandWithWendy filibuster. This is a good way to draw people in while the iron is hot.

Progressives and Planned Parenthood took their opposition to the abortion-restricting bill winding its way through the Texas Legislature on the road to Houston Tuesday with the orange-tinged “Stand with Texas Women” tour.

Hundreds gathered in a sea of tangerine, apricot and melon at Discovery Green to welcome the motorcoach carrying state Sen. Wendy Davis, several other Democratic state legislators and Planned Parenthood Action Fund president Cecile Richards.

After a debut rally in Austin on Tuesday morning, the carrot-colored bus made an evening stop in Houston to oppose the bill’s anticipated effect on access to preventive health services and abortions. Rallies also are planned Wednesday in Dallas and Fort Worth.

[…]

“It’s time to get the Texas Legislature out of our exam rooms,” said Richards, daughter of former Democratic Gov. Ann Richards. “It’s wasn’t just that Gov. Perry and some of his allies in the Legislature ended the women’s health program and cut more than 130,000 women in Texas off of preventive care, but now the Legislature is considering a bill that would force dozens more health centers in this state to close down – close their doors – making it even harder for women to get care and ending access to safe and legal abortion.”

Don’t forget the veto of the Lilly Ledbetter bill, too. Democrats have underperformed with Anglo women in Texas compared to the country as a whole. The last two sessions have been very hard on women in Texas. These past few weeks I’ve seen a ton of stuff on Facebook from people I don’t normally think of as being politically oriented, some of whom I had no idea were on my side of this. We need to build on this. Stace, Egberto Willies, and Texas Leftist have more on the Houston event, and the Press has a photo slideshow.

2. Remind people who have aligned with the GOP in the past because of certain specific issues that they’re not dealing with the same party now. I’m thinking specifically of doctors and other medical professionals, who loved the GOP ten years ago when tort “reform” was on the agenda. BOR has an open letter from a couple of docs who’d like the Lege to stay out of their exam rooms.

While we can agree to disagree about abortion on ideological grounds, we must draw a hard line against insidious legislation that threatens women’s health like Texas HB2 (House Bill 2) and SB1 (Senate Bill 1).

That’s why we’re speaking to the false and misleading underlying assumptions of this and other legislation like it: These bills are as much about interfering with the practice of medicine and the relationship a patient has with her physician as they are about restricting women’s access to abortion. The fact is that these bills will not help protect the health of any woman in Texas. Instead, these bills will harm women’s health in very clear ways.

We’re setting the record straight, loudly and unequivocally, with these simple messages to all politicians: Get out of our Exam Rooms.

I would submit to the members of The American Congress of Obstetricians and Gynecologists, the Texas Medical Association, and other organizations that formally opposed SB1 and HB2 that if they want legislators that won’t interfere with the doctor/patient relationship, they need to vote against legislators that do interfere with the doctor/patient relationship, and that includes everyone who voted for these bills, including the handful of Dems who did so. Do it in March and do it again in November as needed. Nothing will change until the leadership changes.

3. Prepare for the inevitable litigation.

The Guttmacher Institute reported earlier this week that more new abortion restrictions were enacted in the first half of 2013 than in all of 2012; 2013 now ranks second to 2011 as a landmark year for antichoice legislation.

Now from a superficial point of view, the latest batch of state antichoice actions have focused on the relatively safe ground (politically and to a lesser extent constitutionally) of late-term abortions, where the Supreme Court has allowed some leeway in the past. But since most of the “fetal pain” laws have been accompanied by what Guttmacher calls “TRAP” measures—Targeted Regulation of Abortion Providers—they are clearly intended to restrict access to all clinical abortions at any stage of pregnancy, and certainly have that effect.

Since the current constitutional standard for abortion restrictions remains Casey v. Planned Parenthood’s ban on measures that place an “undue burden” on the right to choose, most of these new state laws are clearly in the “danger area” constitutionally. Just yesterday, a federal district court judge in Wisconsin temporarily blocked implementation of that state’s new regulations on abortion providers pending a showing that it did not violate Casey. Federal court challenges are likely in other states as well.

So the long-awaited day of a fresh SCOTUS review of the constitutional law of abortion (last visited by the Court in the 2007 Carhart v. Gonzales decision upholding a federal “partial-birth abortion” ban) may soon be upon us. It could even happen sooner that expected: at the end of the recently concluded term, SCOTUS agreed to hear an appeal of a case involving a Oklahoma restriction on the use of RU-486 that could involve a reinterpretation of Casey. And in any event, the shrewd adoption by antichoicers of the strategy of justifying restrictions as “health and safety regulations” seems designed to exploit the loophole opened up in Carhart by Justice Kennedy that invited policymakers to make their own determinations of women’s health interests.

Litigation is hardly risk-free, as there are four solid votes to overturn Roe and Casey, and who knows what bee will be in Anthony Kennedy’s bonnet by the time the appeals make their way to SCOTUS. The best thing that could happen between now and then would be for Kennedy and/or Scalia to retire, but of course we can’t count on that. But what other choice is there? Let’s bring our A games and keep our eyes open about what could happen when we go down this road.

4. Fight back with reason and with ridicule. In my post about Tuesday’s action in the House, I included a link to Baptist Standard editorial about all the things that the state of Texas and its Republican leadership is not doing for the post-born. Many Democratic legislators filed and fought for amendments to HB2 that would have tried to address some of these things, but of course the Republicans and the “no one is more pro-life than me” author of HB2 rejected them all. That needs to be a campaign issue – really, it needs to be THE campaign issue – in 2014. But it’s also time for our legislative Democrats, who have fought the good fight with honor and perseverance, to not always be so high-minded. A little snark can go a long way, as Lisa Falkenberg demonstrated.

Women will always bear the brunt of the responsibility for family planning and pregnancy, which is why the folks in Austin are back at it again this week, trying to help the little women in this endeavor by protecting their health with unnecessary regulations and restricting access to constitutionally protected medical options.

Still, I can’t help but think the men of this state are worthy of some Texas-style reproductive protection as well. The Legislature’s compelling interest in restricting the reproductive rights of Texans shouldn’t stop at lady parts.

Gentlemen of Texas, it’s with sincere concern for your health and safety – and a hat tip to legislation pioneered in Oklahoma, Georgia, Illinois, Virginia and Ohio – that I hereby propose the following pro-life omnibus bill to regulate your man parts.

The bill is already written, someone just needs to file it at the next opportunity. File it for what’s left of this session. Of course it won’t go anywhere. That’s not the point. Someone needs to do this.

UPDATE: “I want you to be angry and remember,” Wendy Davis says at the Fort Worth rally. That’s what I’m talking about.

Better late than never, I guess

Way to be ahead of the curve, y’all.

It's constitutional - deal with it

It’s constitutional – deal with it

A resolution endorsing the expansion of Medicaid was approved by Texas Medical Association delegates Saturday at the group’s annual meeting in San Antonio.

“The patients need the care and, if we pass Medicaid expansion, it will lower our taxes. How can you be against that?” said the measure’s author, Dr. Robert Luedecke, a San Antonio anesthesiologist and member of the Bexar County Medical Society.

He doubtful the group’s stance will sway Gov. Rick Perry, who last month said, “Texas will not be held hostage to the Obama administration’s attempt to force us into this fool’s errand.”

The resolution, which Luedecke said was adopted by a voice vote of the 500 delegates gathered at the Convention Center, estimates that Texas could reap $100 billion in matching federal funds over a 10-year span in return for $15 billion investment, under the provisions of the Affordable Care Act.

A separate vote to oppose Medicaid expansion was voted down before this one was done, so they have that going for them, which is nice. I think it’s safe to say that the TMA has managed to avoid having any influence over the Medicaid expansion debate for the legislative session. I do mean it when I say “better late than never”, but in this case, not by very much.

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.

Testifying about the Women’s Health Program

More hearings like this, please.

Right there with them

The Texas Department of State Health Services got an earful today from lawmakers and women’s health advocates at a public meeting in Austin to discuss proposed rules for the Texas Women’s Health Program — specifically, the state’s plan to sacrifice 90 percent of federal funding for the program in order to exclude Planned Parenthood and prevent participating physicians from discussing abortion in any capacity with patients.

“Try to get the politics out of the way and do what’s best for Texas women,” said Rep. Donna Howard, D-Austin, before an eruption of applause from the audience. She emphasized a point reiterated by others testifying at the hearing: that the Women’s Health Program provides cancer screenings, birth control and wellness exams for 130,000 low-income women but does not provide abortions.

One of the proposed rules for the program states that a participating physician could not “promote elective abortions” by providing “counseling concerning the use of abortion as a method of family planning” — even outside the scope of the Women’s Health Program. Physician groups, including the Texas Medical Association, the Texas Association of Obstetricians and Gynecologists and the Texas Academy of Family Physicians, oppose the proposed rule, arguing it will put a “gag order” on physicians that could interfere with patient-physician relationships.

“We strongly oppose any interference into a physician’s ability to use his or her medical judgment as to the information that is in the best interest of his or her patient,” the groups wrote in a letter to DSHS.

[…]

Although Planned Parenthood clinics account for less than 2 percent of the providers participating in the program, 45 percent of women participating in the program chose to receive care at Planned Parenthood.

Opponents of the state’s decision to knock Planned Parenthood and other providers out of the WHP worry the state will not be able to provide an adequate health network. But the state and proponents of the reformed Texas Women’s Health Program say that won’t be a problem, as Planned Parenthood clinics make up a small portion of the 2,500 providers enrolled in the program.

What a silly argument that is. As we have discussed, the vast majority of existing providers in the WHP served at most ten clients. Claiming that the loss of Planned Parenthood will cause no disruption in service to the WHP patients is like saying there would be no disruption in the smarphone market if Apple were to disappear because hey, they’re just one manufacturer. You can find that letter to the DSHS here, and for more see State Rep. Ana Hernandez Luna’s op-ed in the Chron, and this letter from Senate Democrats to outgoing HHSC Chair Tom Suehs.

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.

Tort “reform” is still a scam

I know, I’m as shocked as you are.

A national report released Wednesday says the 2003 Texas law that limited damage awards in malpractice suits has caused health care spending to rise and has not significantly increased the number of doctors in Texas.

[…]

The 24-page report by Public Citizen, “A Failed Experiment,” says that using Texas as a model would benefit doctors and insurers — not residents.

The report claims that Medicare spending in Texas has risen faster than the national average, and so have private health insurance premiums. It also says that, contrary to Perry’s claims, the per capita increase in the number of doctors practicing in the state has been much slower since the state passed the so-called tort reform law than it was before the law.

Organizations that support the 2003 law — the Texas Medical Association and the Texas Alliance for Patient Access — disputed the report’s assertions on the number of physicians who have come to the state. As for health care costs, “we never said consumer costs would go down,” Jon Opelt, the alliance’s executive director, said Wednesday.

You can see the Public Citizen press release here, and the full report here. I wish I had done enough blogging on the 2003 tort “reform” issue to take a crack at evaluating Opelt’s claim that no one promised this would help consumers, but I didn’t so I can’t. It sure sounds bogus to me, and I don’t believe him for a minute. I distinctly remember seeing pro-tort “reform” propaganda in the waiting room of our obstetrician around the time of the vote, and while I can’t remember exactly what it said, I’m sure it promised some benefits to the voting public. Anyway, while I can’t directly judge that claim I can say that the pro-tort “reform” side did make some outlandishly exaggerated promises about insurance rate reductions for doctors that they later tried to walk back. The Public Citizen report notes that insurance costs have eased a bit for doctors since 2003, but not that much. Anyway, check it out for yourself, and if you have any clearer memories – or better yet, evidence you can point to – about what the tort “reform” crowd said would happen if we all gave the insurance lobby a pony, leave a comment and let us know.

Spending money on medical students

I have two things to say about this story, which is about a budget rider that would concentrate the money the state spends on graduate medical residencies into the doctors’ first three years of training regardless of how long their residencies take to complete, which would have the effect of favoring general practitioners, who only need three years, over specialists. Actually, before I get into that let me say that I had no idea the state spent any money on this. The story doesn’t get into the details of who the beneficiaries are or how they qualify for it. Anyway, I have two things to say:

Proponents say the budget rider would give residency programs an incentive to produce the primary care doctors Texas desperately needs, because those slots would be fully funded. They say residents who go into specialties that take longer than three years are often paying for themselves — because they’re providing services their supervisors can bill for.

“It is the state’s obligation to use tax dollars in a fashion that best serves the citizens of Texas,” said Dr. Nancy Dickey, president of the Texas A&M Health Science Center, which has one of the state’s largest family medicine residency programs. “As we try to address a physician shortage in a state that continues to grow its population, it would be appropriate for legislators to consider selective use of graduate medical education funds.”

But opponents say it’s misleading to suggest residents in any specialty are making money for their hospitals, especially since they’re now barred from working more than 80 hours a week. They say cutting off funding for years four through seven would have a devastating effect on surgical specialties and those that lose the most residents to other states, from neurology to urology.

“Texas needs specialists and primary care physicians,” said Dr. Susan Bailey, president of the Texas Medical Association. “I would hate to see us sacrifice one for the other.”

In case you haven’t noticed, this budget is full of sacrifice, as far as the eye can see. The vast majority of that sacrifice is being placed on children, the elderly, the poor, the sick, and so forth. I trust you will forgive me if I feel somewhat less sympathy for medical students than I do for these folks. If you find this budget rider intolerable, then by all means please join with the rest of us in demanding that the state generate the revenue to pay for the things it needs to do. But if it comes down to how we allocate the insufficient funds that we now have, there are a lot of other things I’d prioritize over this.

Texas has a physician shortage across all medical fields: In 37 out of 40 major specialties, it ranks below the national average of physicians per 100,000 people. It’s particularly pronounced in primary care, where last year, just 8 percent of Texas medical students went into family practice, down from 14 percent in 2001. More than a quarter of those students left Texas for out-of-state residencies, a strong indicator that they won’t practice in Texas.

Gee, wasn’t tort “reform” supposed to solve that problem? What a shock (*snort*) to learn that it was not the case.

Two smoking stories

Rep. Myra Crownover will make her biennial attempt to pass a statewide smoking ban in Texas, which if it passes would make it harder to smoke.

Although she believes in limited government, Crownover said 53,000 people die each year in the U.S. from second-hand smoke, and that is unacceptable.

“I think this is the most important public health issue before the Legislature at this time,” she said. Banning indoor smoking, she said, would benefit both customers and employees.

The bill would also create a level playing field for business across the state with a uniform statewide policy instead of the hodgepodge of city regulations that exist now, said Crownover. And people who choose to smoke would still be able to do so outside, she said.

Dr. Joel Dunnington, speaking for the American Cancer Society, told the House Public Health Committee the smoking ban would save $440 million to the state’s economy biennually because most bar and restaurant employees don’t have health insurance. When those employees get sick, they end up going to public hospitals, where often the cost is passed on to taxpayers.

The Legislative Budget Board estimates the savings would be a bit more modest: $31 million over the next biennium.

Meanwhile, in its attempt to find loose change under every budgetary couch cushion, the Lege will also make it harder to quit smoking.

Finding ways to cut health care costs is all the rage under the Pink Dome — and curbing smoking is a proven way to do it. But both the House and Senate budget proposals slash tobacco cessation programs by more than 80 percent, or $20 million over the biennium.

Health care advocates say such cuts would devastate programs that deter children from smoking and eliminate regional efforts that have curbed tobacco use among adults. And they argue that the money, which comes from a multibillion-dollar lawsuit settled with big tobacco companies in the late 1990s, is supposed to be used for anti-smoking education.

“If you ask what the biggest health threats are to the state, tobacco is in the top three, but we’re not putting money where our mouth is,” said Troy Alexander, associate director of advocacy for the Texas Medical Association, one of several groups gathering at the Capitol this morning to oppose cuts to tobacco control and obesity reduction efforts. “If you look at how we’re taxing tobacco, we’re not hesitating to benefit from the use of tobacco, but we aren’t doing much to reduce consumption.”

Well, when cost cutting becomes an end rather than a means to an end, one should expect some contradictory policies. I don’t know what else to say.

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.

Get ready for another Medicaid lawsuit

That’s the very likely outcome if proposed cuts to Medicaid reimbursement rates go through.

“You cut rates an additional 10 percent, I’m not sure I can comply with the access provision,” Thomas Suehs, commissioner of the state Health and Human Services Commission, told the House Appropriations Committee on Thursday.

He warned that short-term savings from cutting reimbursement rates could be outweighed by a long court fight over whether the state was providing sufficient access to health care for children who are Medicaid recipients.

[…]

In 2007, the state ended a nearly 15-year dispute over whether Texas provided sufficient medical coverage to children enrolled in Medicaid. As part of the settlement, the Legislature increased funding for the program by more than $1.8 billion, using state and federal funds.

While the settlement specified only the amount of money the state had to spend on Medicaid for the 2008-09 budgeting period, Texas also agreed to maintain standards of accessibility of health care services for citizens on Medicaid.

Hospital and child advocacy groups say that the proposed reduction of reimbursement rates would result in fewer doctors seeing patients using Medicaid for insurance. That would increase the likelihood that the state violates the accessibility standards it agreed to, potentially setting the stage for another legal battle, they said.

“You’re talking about a payment rate currently, that’s before the cuts, that’s about 50 percent of commercial rates,” said John Holcombe, chairman of the Medicaid committee at the Texas Medical Association. “Now, we’re looking at a situation where we’re going to cut rates again. And if we believe what’s happened in the past will happen again, we’ll see a reduction again in the number of physicians that are willing to see Medicaid patients.”

And in the meantime, all those folks who would have had access to Medicaid will start showing up at the emergency room instead, so even the short-term savings of these cuts is largely illusory as cities and counties get stuck with the tab. People don’t stop needing medical services. It’s just a matter of how to pay for them, and whose budget it comes out of. And I’ll say again, Texas and its handling of Medicaid is a strong argument for federalizing the program and providing a single standard for reimbursements. It’s a shame that wasn’t part of the Affordable Care Act.

More pushback from the medical community on Medicaid

Doctors and medical associations had a big effect on public opinion during the fight over the Affordable Care Act. We’ll see whether that is true during the fight over Medicaid.

“Unless our state leaders can come up with a financing plan to replace the current Medicaid structure that’s even better than what we have now, I think it will ultimately end up backfiring and costing more in the long run,” said Dr. Susan Bailey, a Fort Worth allergist and president of the Texas Medical Association.

Republican Rep. Mark Shelton, a Fort Worth pediatrician, said: “I think opting out of Medicaid without a viable alternative is not a good idea. We need to make sure … the vulnerable people in our society — the poor, children and the elderly — are taken care of.”

Shelton is certainly a conservative, so seeing him take this position is notable. I don’t know how much influence he has as a legislator, but as a doctor he might get some of his colleagues to pay attention.

The state’s nearly 500 hospitals have a big stake in the issue, with Medicaid covering more than half the births in Texas. Additionally, federal law requires hospitals to provide emergency room treatment to anyone who needs it, including the indigent. More than $7 billion in Medicaid payments went to hospitals last year, including $4.5 billion in federal money.

Medicaid covers children, people with disabilities, pregnant women and the elderly. Nearly two-thirds of the state’s 90,000 nursing home residents depend on Medicaid, said Tim Graves, president and CEO of the Texas Health Care Association.

“We certainly understand the need to look at options because the state budget is in such bad shape, but I don’t understand how getting out of Medicaid would help,” Graves said.

The loss of billions of federal Medicaid dollars could have a “devastating effect” on Texas healthcare, he said.

Did you hear all that, Warren Chisum? Do children, people with disabilities, pregnant women, and the elderly meet your standard of who is worthy of receiving health care? Or will you find some reason to blame them for their lack of resources?

Perhaps we should learn from what other states have already figured out.

A Wyoming Department of Health study, released in September, on the impact of a Medicaid opt-out said: “While some that lose Medicaid coverage under an opt-out scenario may find coverage as a result of health care reform, it is clear that coverage may not be affordable nor provide the services needed by many. There would also likely remain a significant number of individuals who would not be able to obtain coverage under the current health reform bills.”

The study also said: “The strain that will ensue should Wyoming determine to opt-out of participating in Medicaid without a solid plan to replace it is truly immeasurable. Further, Wyoming residents will be paying Federal taxes for services that residents of this state will never benefit from.”

Texas Health and Human Services is conducting a similar review. Findings are expected in December.

Remember, one of the cornerstones of the Affordable Care Act was making more people eligible for Medicaid. The only way that giving them a subsidy to buy insurance from a private for-profit enterprise makes sense as an alternative to that is if the subsidies are only sufficient to purchase crappy, bare-bones plans. Everything is less expensive if you don’t care about quality or adequacy. If Republicans believe that letting more people, in particular more children, people with disabilities, pregnant women, and the elderly, get sick and die as a means to balancing the budget is an acceptable outcome, then by all means they can go ahead and figure out the best way to make that happen. It’s up to all of us Democrats to make it clear that this is what they’re doing.