2015: An agenda for health care

Photo by Alex Proimos

For 140 consecutive days starting Tuesday, health care will likely be reduced to a third- or fourth-tier concern for state lawmakers as they grapple with other issues like public education, tax cuts, roads, water and energy.

There will be plenty of remedial work to be done on health care this session, but let’s face it: The incoming members of 84th Texas Legislature didn’t run on health care, weren’t tested by health care and weren’t elected on health care.

The Legislature could make some constructive changes, as well as strategic investments, to help shape the natural market forces already transforming how medicine is being delivered and financed in Texas. But in most respects, the marketplace is already well ahead of them.

As Yogi Berra famously said, it’s tough to make predictions, especially about the future. But given the state of Texas politics, demographic trends and the recent public health scare, these predictions are a pretty safe bet.

Medicaid

If politics is the art of the possible, then Republican primary politics alone should quash any expectation that this Legislature would contemplate a Medicaid expansion deal or any other red-state-style private-market Medicaid solution.

Few, if any, politicians were elected on the promise of expanding coverage to Texas’ uninsured. Quite the opposite is true for most.

Despite overwhelming support from Texas’ health care community, leading business organizations, chambers of commerce, and local and county governments, no one I know realistically expects any parting of the Red Sea on this issue, especially in the state Senate. And House Speaker Joe Straus won’t ask his members to take a potentially career-ending vote, only to have the legislation get stuck in the upper chamber.

Transparency

All indications in the health care marketplace suggest that value-based payment — or rewarding providers for quality of care over volume — has arrived and will only become more ubiquitous among payers and across contracts in the coming years. The indefensible variation in price and outcomes has led health plans to increasingly employ the use of “high performance” or narrow physician and hospital networks. It has also provoked an outcry from employers, patients and politicians on both the left and right for greater transparency in health care cost and quality.

If we ever want to strengthen the link between the price and “value” of health care services, all players will have to show their cards. Structural and economic impediments notwithstanding, no market — especially in health care — can function with incomplete information. However, with so many competing interests trying to define transparency in a manner that benefits them, solving this problem in a fair and equitable way may be a difficult needle to thread.

Graduate medical education

Given the state’s established demographic trends, how we recruit, educate and train our future physician workforce and how we pay for that effort will be on the agenda yet again.

The Statewide Health Coordinating Council’s little-read 2011-16 report uncovered one of Texas’ worst-kept secrets: “Year after year … Texas is faced with two clear trends: (1) the population is growing faster than almost any other state in the U.S., and (2) the number of health care providers is not keeping pace with that rate of growth. In addition, there continues to be major geographic maldistributions of health care practitioners across Texas.”

Last session, led by state Sen. Jane Nelson, R-Flower Mound, the Legislature made significant strides in restoring funding cuts to the state’s residency programs and laid the foundation to create new and expanded graduate medical education, or GME, positions.

But within the next biennium, Texas will produce approximately 180 more medical school graduates than the number of first-year residency positions available, meaning Texas taxpayers will spend $168,000 educating a medical student then force him or her to leave the state to find residency training programs. Texas could lose an investment of more than $30 million in one year alone.

Thankfully, there seems to be bipartisan support to increase GME funding and grow our residency training slots.  

Public health infrastructure

Finally, if last year’s Ebola scare taught us anything, it’s that Texas’ public health infrastructure is frighteningly understaffed and fragmented. As a result of systematic underfunding over the last decade, the Dallas incident exposed public health surveillance, protocol and staffing weaknesses. The lack of a coherent set of state and local guidelines for dealing with a public health emergency is sure to be corrected. On this topic, Republicans and Democrats can agree: Microorganisms are not partisan.

Here’s hoping that another one of Berra’s famous lines — “It's like déjà vu, all over again” — is wrong. But he’s probably right.

Tom Banning

CEO of the Texas Academy of Family Physicians

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