The League of Women Voters of Texas supports a basic level of health care for the medically indigent.
The League believes that all persons whose incomes fall below the federal poverty guidelines are most at risk of medical indigence and should be eligible for basic health care services. Special attention should be given to children of low-income families and to persons of low income who are elderly, pregnant, or mentally ill.
It is the responsibility of individuals to pay for their own health care to the best of their ability. For those unable to pay, health care services and programs for the medically indigent are the responsibility of various levels of government.
The League of Women Voters believes the following services constitute the basic level of health care for the medically indigent:
Support programs and policies that will ensure availability of a basic level of quality health care at an affordable cost to all U.S. residents, equitable distribution of services, efficient and economical delivery of care, advancement of medical research and technology, and a reasonable total national expenditure level for health care.
The HCMI position was reviewed during the 1993-1995 Periodic Program Review process. The PPR Committee recommended an editorial change and a substantive change in wording; the recommended substantive change was deletion of a phrase which listed several government levels as being responsible for indigent health care services. The committee's rationale was that the listing was not all-inclusive and that the phrase, "various levels of government," without specifying which levels, would give Leagues more options for local advocacy efforts. The PPR Committee's recommendations were approved, and the updated position is printed above.
Important gains for expansion of Medicaid were realized during the 71st Legislature in 1989. Because Medicaid for pregnant women was no longer tied to AFDC guidelines, perhaps up to 22,000 pregnant women and 50,000 more children became eligible for health care benefits under Medicaid. Income eligibility for this special population was set at 130% of the federal poverty guideline. The income eligibility cap for nursing home care was raised to the maximum federal level, allowing Medicaid benefits that increase access to care for a greater number of elderly, disabled persons.
1990-1992: The League monitored the Governor's Health Care Policy Task Force and presented written testimony in support of major portions of the draft recommendations. The final report was released in January 1993, calling for universal access to health care and, as a first step toward that goal, creation of health care coverage for all children and pregnant women.
1993: Please refer to the end of Program Perspectives under LWVUS Social Policy for the LWVUS Health Care position and the LWV-TX HCMI position during the 1993 legislative session.
1995: LWV-TX published an Advocacy Paper, Medicaid Reform: To Solve a Crisis, which was circulated to legislators and other interested officials, groups, and individuals. The paper called for implementation of the following cost-saving steps to ensure the availability of health services for the indigent: streamlining of administrative processes; emphasis on preventative and primary care; expansion of managed care options for Medicaid recipients; and creation of incentives for expansion of community services by public and private providers.
The 74th Legislature enacted legislation that dramatically alters how the state delivers and funds medical care to the indigent. In effect, the Medicaid program has been converted into a managed health care system which places new emphasis on prevention. The legislation also mandates pooling local and state health care monies used to provide indigent health care in order to maximize access to federal matching funds.
1997: Five League-supported bills on health care were signed into law. The Texas Healthy Kids Corporation will provide low-cost health insurance for children of parents who cannot afford insurance but make too much money to qualify for Medicaid. Another bill directs the Texas Department of Health to provide rules for lead abatement, a serious health hazard faced disproportionately by children in the lower socio-economic level, while an omnibus nursing home act establishes procedures and penalties for noncompliance of existing laws and regulations. Legislation was enacted requiring health plans that provide maternity benefits to also include coverage of inpatient care for a mother and her newborn in a health care facility for a minimum of 48 hours, and, consistent with the League's position on Medicaid reform, a new law provides increased penalties for Medicaid fraud.
1997-1999: In the fall of 1997, following passage of enabling federal legislation, LWV-TX became actively involved in a coalition of child health advocacy groups calling for a Children's Health Insurance Program (CHIP) for Texas. Throughout the legislative interim, the coalition, including LWV-TX representatives, worked with agency staff to help shape the legislation which was ultimately introduced. Named one of the priority issues for LWV-TX, CHIP received grass- roots advocacy from local Leagues, including travel to the capitol for CHIP Advocacy Day. We achieved passage of all our goals: a health insurance plan which will provide primary and preventive care to low-income, uninsured children who are not eligible for Medicaid. The plan will maximize the use of federal matching dollars, provide family-friendly enrollment, provide appropriate benefits for children, and support working parents.
In addition to CHIP, health care in general was an active issue for LWV-TX. Nine League- supported bills on health care became effective September 1, 1999. School districts may establish school-based student health centers. Legislation was enacted that sets forth the standards and procedures for the delivery of indigent health care. Another bill provides for state assistance to counties that spend at least 10% of county general revenue to provide health care services to residents through a hospital. Permanent funds were established for certain public health items. The elderly should benefit from a bill that provides for required immunizations for nursing home residents. Consistent with the League's position on Medicaid reform and cost containment, a bill streamlines the administration and delivery of federally funded Medicaid programs supporting long-term care while another stipulates that contracts must be in effect for insurers to reimburse providers. Legislation directs state agencies to study and make strategic plans concerning the delivery of long-term care and other health services. While female genital mutilation was prohibited, the 75th Legislature did not add the budget line item for Women's Health for which the League had actively lobbied. The Campaign for Women's Health will regroup during the interim and work for a more favorable outcome in 2001.
2001: During the 77th session LWV-TX continued its active participation in the CHIP Coalition working towards simplification of the Medicaid application and recertification procedures to become comparable to those of the CHIP program. We were largely successful in obtaining more simplified forms and processes, phased-in continuous eligibility, age six to age 19, by 2002, and one-year continuous eligibility no later than June, 2003. We were unable to obtain elimination of the assets test for Medicaid, although the extensive documentation formerly required has been dropped. In addition, the governor signed a bill requiring a pilot study and, if successful, a pilot project to allow portability of Medicaid benefits for migrant children. The governor vetoed a bill that would have allowed Texas to exercise its option under federal law to provide Medicaid benefits to otherwise-eligible legal immigrants after they have been in the U.S. for five years. It is not clear that there is adequate funding for either Medicaid or the CHIP program. Since Medicaid is an entitlement program, the legislature must fund any shortfalls. However, CHIP is not an entitlement program and is already exploring options for restricting or reducing services if a budgetary shortfall materializes. The League was also active in the area of women's health care. Medicaid can now cover uninsured women under the age of 65 who have breast cancer. However, the governor vetoed a bill for a Medicaid waiver for women's health and family planning. The waver would have saved the state $300 million over the next four years and provided family planning services and preventive health care to an additional one million uninsured Texas woman. The legislature did not pass legislation that would have allowed application for a Medicaid waiver to provide for comprehensive health care for women.
2003: During the 78th session the Medicaid Waiver failed again. A bill, which would have called for the state to apply for the Medicaid Waiver for Women's Health, was heard in House Human Services Committee and died in Committee. The bill would have established a demonstration project through the application of an 1115 Medicaid Waiver to expand women's health care services for women 18 years and older with an income at or below 185 percent of the federal poverty level. During the appropriations process prenatal health care services were also reduced.
2007: Due to lots of hard work by members of the Children's Health Insurance Program (CHIP) coalition and by a number of committed legislators, HB109 passed restoring much of what had been lost in 2003. The bill is to be to fully implemented by September 1, 2008.
Provisions of the bill are:
2011: Children's Health Insurance Program (CHIP). Much of the legislation impacting health care for the children of Texas was contained within the budget and a massive health efficiency bill. These measures changed and expanded multiple times during the regular and special sessions. As finally passed and signed, they included beneficial provisions and provisions that could undermine the well-being of those qualifying for either Children's Medicaid or CHIP. Budget discussions focused on proposed provider rate cuts of 10% to those delivering health care to Medicaid and CHIP patients, in spite of Texas' already low reimbursement rates and recent cuts. In the end, payments to children's hospitals and primary care physicians treating children were spared the large cuts made to other hospitals and providers. Multiple proposals targeting greater health care efficiency evolved into SB 7 (Nelson), which passed during the special session. On the positive side, SB 7 included strategies for improved quality of care provided to CHIP and Medicaid recipients. It also called for shifting from the traditional system of payment for services to payment rewarding better health outcomes. Negatively, the final bill carried provisions designed to give the State of Texas more control over health care programs. A health care compact, if ultimately approved by the US Congress, would turn all federal health funding coming to Texas for Medicaid and Chip, as well as Medicare and other programs, into a single large block grant to the state. A waiver of federal law would radically restructure Medicaid in the state. If either the block grant or the waiver were to take effect, children and other vulnerable populations would lose much in the way of protection currently guaranteed under federal law. Most individual bills designed to either improve or restrict Children's Medicaid and CHIP died in the regular session. Unfortunately, an attempt to extend Children's Medicaid eligibility to a 12-month continuous period, thus allowing many qualified children to retain access to health insurance, made little headway. Other Issues: With a $27 billion shortfall, Medicaid and education were big targets for cuts in the 82nd State Legislative Session. Maintaining existing reimbursement rates was a priority for many groups including the League. Because of strong advocacy, Medicaid reimbursement rates for nursing homes and community based alternative care were maintained at 2010 rates. Hospice got a 2% cut. Everyone on a Medicaid waiver got their funding cut 10%. Direct health care will not be cut as it is deemed non-negotiable. Negotiable expenses such as home modifications will make up the 10%. Providers got cuts in administration costs. During the Special Session, "Secession Legislation" passed seeking a health care compact, a partnership with other states to take control of Medicaid & Medicare, and legislation asking the Obama administration for a waiver to operate Medicaid as Texas sees fit. Both are unlikely to happen under the Obama administration. Legislation passed to protect patient advocacy activities by nurses and certain other persons, providing an administrative penalty for denying right to advocate. 2013: The most significant health care considerations for the 83rd Legislature were related to implementation of the Patient Protection and Affordable Care Act (ACA). Other measures concerning Children's Medicaid and Children's Health Insurance Program (CHIP) were focused mainly in three areas: expansion, efficiency and funding. Legislators filed only a few bills designed to expand access to publicly funded insurance for deserving children. Proposed measures called for opening CHIP to families with somewhat greater assets or increasing the time to a full year before families must reapply for Children's Medicaid. Expansion efforts all died without consideration by the full legislative body. Massive bills intended to make health care delivery more efficient did become law. Some features of the bills could ultimately benefit children, such as extending managed care to a wider range of medical situations and providing incentives for quality care. Other features could have a negative impact, such as limitations on the criteria for expanding Medicaid eligibility. Lawmakers rectified some of the deliberate underfunding of Medicaid and CHIP from the previous session just in time to meet current needs. The budget for 2014 to 2015 provided for an 11% increase in the number of children in Medicaid, but it projected a drop in the number of children in CHIP due to ACA implementation. When adjusted for inflation and population growth, overall health related funding (including immunizations, Children with Special Health Care Needs, education on tobacco and abstinence, and a number of other programs, in addition to Children's Medicaid and CHIP) saw a per-child decrease.
2015: The most significant health care issue, Medicaid expansion, was completely ignored by the 84th Legislature. There was no consideration or deliberation on any Medicaid expansion laws in Texas.
The Appropriations committee did have one meeting to consider the possible loss of the federal 1115 Waiver money. No actions were taken. The cost of uncompensated care in Texas is partially paid for by the Affordable Care Act's (ACA) 1115 Waiver. The 1115 Waiver was meant to be a temporary solution to uncompensated care while the ACA was ramping up. Now the federal government' Center for Medicare and Medicaid Services (CMS) is threatening to cut the 1115 waiver to encourage Texas to participate fully in the ACA and allow more citizens access to health insurance.
Meanwhile the Children's Health Insurance Program (CHIP) continues to be an available insurance program for Texas. With the Affordable Care Act more children qualified for Medicaid. Rider 50 to the Texas budget was added at the last minute which removed 350 million dollars for therapy services for children with special health care needs.