The 2011 session of the Texas Legislature convened Jan. 11 and, as expected, the state's dire budget situation became lawmakers' immediate focus. Even before committees were appointed, House and Senate budget writers laid out proposed budget bills that slashed tens of billions of dollars from current state spending levels. Health and human services programs and medical education were hit hard by the proposed cuts.
Meanwhile, the scope of practice and physician employment wars also heated up with the filing of several bills to give nurse practitioners authority to practice independently and to allow individual county hospital districts to directly employ physicians.
Finally, lawmakers also began the debate on implementing at least one major provision of the national health system reform law.
Doctors and patients couldn't have asked for much more when it came to placing members of the Family of Medicine on key Texas House and Senate Committees. Three TMA member-legislators and one TMA Alliance member were appointed to the Texas House Appropriations and Public Health committees by House Speaker Joe Straus (R-San Antonio). These two powerful committees make critical budget and public health decisions. The new members are Reps. Susan King (R-Abilene); Charles Schwertner, MD (R-Georgetown); Mark Shelton, MD (R-Fort Worth); and John Zerwas, MD (R-Simonton). Representative Zerwas, the only one of the four not serving on the Public Health Committee, will also chair the House Appropriations Subcommittee, writing health and human services portions of the budget.
Across the rotunda, Sen. Bob Deuell, MD (R-Greenville), the only physician and the only TMA member in the Senate, already has spent weeks examining the budget on the Senate Finance Committee. Dr. Deuell also is vice chair of the Senate Health and Human Services Committee.
Budget Battle Begins
Just days into the new legislative session, House Appropriations Committee Chair Jim Pitts (R-Waxahachie) unveiled a proposed budget bill for the 2012-13 biennium that whacked more than $31 billion from the current two-year budget. Senate Finance Committee Chair Steve Ogden (R-Bryan) followed a few days later with his own budget proposal, which was only slightly less draconian, cutting spending by $28.8 billion.
The proposed cuts were in response to State Comptroller Susan Combs' revenue estimate that showed projected tax and other revenues for the biennium could fall as much as $27 billion short of meeting current spending levels or covering caseload growth in Medicaid and the Children's Health Insurance Program (CHIP) or enrollment growth in the state's public schools.
Health and human services and medical education would see major cuts under both appropriations bills. House Bill 1 would slash Medicaid payments to physicians, hospitals, and other providers by 10 percent. The bill also makes deep cuts in CHIP, trauma funding, the Children with Special Health Care Needs program, children's mental health services, and tobacco cessation programs.
On the medical education front, the bill cuts medical school formula funding by 23 percent and graduate medical education (GME) formula funding by 33 percent. It also eliminates two physician education loan repayment programs and cuts funding for primary care residencies and preceptorships administered by the Texas Higher Education Coordinating Board.
Senator Ogden's bill makes similar cuts to Medicaid and CHIP but provides about $3 million more for GME and about $2,000 more per student per year for medical school formula funding than was included in HB 1. Like the House bill, Senate Bill 1 eliminates the Medicaid physician loan repayment programs set up under the Frew v. Hawkins lawsuit settlement. But, unlike the House bill, the Senate bill maintains $17 million for the Physician Education Loan Repayment Program, which was expanded just two years ago.
The Senate Finance Committee began hearings on SB 1 in early February. In written testimony to the committee, Texas Medical Association urged the panel to reconsider proposed cuts in medical education, saying they would devastate the state's efforts to produce more homegrown doctors to combat existing physician shortages across the state.
Fighting Over Scope
While the budget is getting most of the attention among lawmakers and legislative observers, several other key health care issues already have lit up TMA's radar scope, including scope of practice and direct physician employment by hospitals.
At least three bills that would allow independent practice by advanced practice nurses have been filed. Those bills – HB 708 by Rep. Kelley Hancock (R-North Richland Hills), HB 915 by Wayne Christian (R-Center), and HB 1266 by Rep. Garnet Coleman (D-Houston) – include diagnosing, prescribing, ordering tests, and making referrals without physician supervision within nurse practitioners' scope of practice.
In addition, HB 637 by Rep. Craig Eiland (D-Galveston) authorizes physical therapists to treat patients without a physician referral. TMA officials expect the filing of legislation to expand the scope of practice of optometrists, chiropractors, and possibly other allied health professionals.
While TMA opposes the nurse practitioner bills, TMA leaders say there have been preliminary discussions about potential compromises between representatives of orthopedists and the physical therapists over the direct patient access issue.
Meanwhile, Gov. Rick Perry raised the idea of creating a super regulatory agency that would assume authority for licensure and regulation of all health professions in his State of the State address. TMA officials say the association is unlikely to support that idea, unless it utilizes a model in which the Texas Medical Board has oversight over the other health professions.
While the scope battles heated up, so too did the fights over direct employment of physicians by hospitals. At least two bills that would give individual county hospital districts authority to hire physicians, among them the El Paso County Hospital District, have been filed. Several other bills likely will be filed, including one to grant the Harris County Hospital District authority to hire doctors.
TMA officials say several other bills have been filed dealing with county hospital district boards of directors that easily could be amended to include employment authority.
TMA is watching all of those bills closely.
In 2009, Sen. Robert Duncan (R-Lubbock) sponsored a bill that would have given certain critical access hospitals across the state authority to employ physicians, but Governor Perry vetoed it at TMA's request because of a last-minute amendment that would have weakened the state's 2003 medical liability reforms. Senator Duncan is expected to file a similar measure again this year.
Creating An Exchange
On another front, TMA and an unusual coalition of other groups support a measure by Representative Zerwas to create a state health insurance exchange required under the Affordable Care Act (ACA).
While Representative Zerwas acknowledges that he is a vocal opponent of the reform law, he and the groups supporting HB 636 say the state cannot afford to wait to see if the courts will declare ACA unconstitutional before creating an exchange.
Under the reform law, states must have their health insurance exchanges operating by Jan. 1, 2014, or the federal government will create one for them. Representative Zerwas says he filed HB 636 to ensure that Texas maintains control over its own health insurance marketplace.
As envisioned by ACA, the exchange would allow individuals and small employers to shop for affordable health coverage. Health plans in the exchange would have to offer a standard set of benefits, and the exchange would give consumers information allowing them to easily compare price and coverage options between the plans.
In addition to TMA, groups supporting the bill include the Texas Association of Business, the Texas Hospital Association, and the Texas Association of Health Plans
Kicking Off First Tuesdays
Finally, TMA held its initial First Tuesdays at the Capitol event on Feb. 1. Despite ice and snow in many parts of the state, the event drew more than 150 physicians, medical students, and TMA Alliance members who fanned out around the capitol to discuss Medicaid, medical education funding, and other issues with their representatives and senators.
Future First Tuesdays events will be held March 1, April 5, and May 3.
Ken Ortolon, senior editor of Texas Medicine, prepared this special supplement to Action.
Action, Feb. 15, 2011