1999 Legislative Compendium: Public Health Initiatives

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 Child and Adolescent Health

Children's Health Insurance Program
To give working parents an affordable option for insuring their children, the Texas Legislature overwhelmingly approved implementation of the new Children's Health Insurance Program (CHIP). CHIP is a state-federal initiative that will make health insurance available to children ages 0 through 18 whose families earn up to 200 percent of the federal poverty level. Once fully implemented, the Texas CHIP plan is expected to cover more than 460,000 children. Funding for CHIP will be shared by the state and federal governments, with federal monies covering three-fourths of program costs. Texas' share of CHIP expenditures will be funded from the state's historic tobacco lawsuit settlement.

In passing CHIP, legislators overcame some early resistance to establishing a program that will meet the needs of most working families. Early in the session, the CHIP bill set eligibility at 150 percent of poverty as legislators debated whether Texas could afford to raise eligibility higher. Numerous House members, however, crusaded to implement eligibility at 200 percent of poverty, the highest level allowed by federal law. To overcome cost concerns, the bill allows the state to establish a waiting list if CHIP enrolls more children than the state can afford.

Governor Bush signed the CHIP bill on May 28. Prior to implementing the program, Texas must receive federal approval for the state plan, which was submitted to the Health Care Financing Administration on June 22. Texas anticipates CHIP enrollment to begin in May 2000.

TMA, in partnership with the Texas Pediatric Society and Texas Academy of Family Physicians, worked tirelessly in support of CHIP. The Association will remain actively involved during the implementation process.

Key provisions of the bill:

  • Enacts a state-run program, separate from the Medicaid program. To the extent possible, the state will use private contractors to administer CHIP. HHSC must conduct readiness reviews of all contractors to ensure such entities can comply with state requirements.
  • Designates the HHSC as the state agency responsible for overseeing the program. HHSC may delegate specific functions to other state agencies, including the TDH, TDHS, and TDI.
  • Establishes a child-specific, comprehensive benefit package, developed in collaboration with TMA, TPS, TAFP, and patient advocacy organizations.
  • Requires family cost-sharing at all income levels, including nominal co-payments. Families earning above 150 percent of poverty will pay higher fees, not to exceed 5 percent of gross income.
  • Ensures choice of health plans.
  • Guarantees 12-month continuous coverage for enrolled children.
  • Encourages participating CHIP plans to include traditional Medicaid and charity care providers in their networks.
  • Directs HHSC to conduct an extensive outreach and education campaign in coordination with Medicaid and the Texas Healthy Kids Corporation (THKC). The campaign will include a toll-free hotline and the use of contracted community-based organizations, such as civic organizations, churches, and local school districts (to the extent schools wish to participate).
  • Requires children who apply for CHIP but who appear to be Medicaid-eligible be identified and referred to the TDHS. If the child is not Medicaid-eligible, then the child will be enrolled in CHIP automatically.
  • Establishes a minimum waiting period before a child can enroll in the program to discourage employers or families from dropping existing child health coverage. However, there are numerous exceptions to the waiting list for families who have involuntarily lost child health coverage or who are paying premiums that exceed 10 percent of the family's net income.
  • Directs HHSC, to the extent possible, to develop an integrated application for CHIP, Medicaid, and THKC. Applications could be submitted by mail, telephone, or the Internet.
  • Establishes a separate, CHIP-like plan for legal immigrant children through a separate program. The 1996 welfare reform act excluded these children from Medicaid coverage during their first five years in the United States. Pending federal legislation would give states the option to actually include these children in CHIP. Language within the CHIP bill allows Texas to take advantage of this legislation if adopted by Congress.
  • Establishes regional advisory committees to advise the state on implementation and administration of CHIP. The advisory committees shall include primary and specialty care physicians, providers, patient advocates, health plans, state agencies, and other child health advocates.
  • Reiterates that the THKC may be awarded the contract to administer CHIP if it can demonstrate its capability. HHSC would retain all policy making functions over CHIP if THKC or another third-party administers the program.
  • Establishes that the program is not an entitlement. If federal funds dry up, the state retains the option to discontinue the program.

State Employee Child-Health Insurance
When Congress enacted CHIP in 1997, lawmakers prohibited states from enrolling children of state employees into the program. Federal lawmakers feared states would shift these children to the new CHIP plans in an effort to control their own health care budgets. SB 1351 by Sen. Gonzalo Barrientos (D-Austin) allows children of state employees to be enrolled in the CHIP plan, but using only state dollars to finance the costs (for other CHIP eligible children, the costs are shared by the state and federal governments). Parents who work for the state, The University of Texas System, or Texas A & M University System will be offered the opportunity to enroll their children in CHIP. Eighty percent of the premium costs will be paid by the state, while the remaining amount will be paid by the parents. Under existing state law, the state pays 50 percent of health insurance premiums for children. All other CHIP eligibility and enrollment requirements apply (see above).

Coverage under SB 1351 will not be available prior to Sept. 1, 2001.

Newborn Hearing Screening
Each year more than 900 babies are born in Texas with hearing impairment or loss. Unfortunately, the vast majority of these children do not receive a hearing screen until between ages 2 and 4, substantially jeopardizing their ability to successfully acquire many social and communication skills. Texas currently requires that all newborns be screened for genetic and metabolic disorders. Yet, despite the fact that congenital hearing loss is almost three times more prevalent than the other disorders combined, Texas does not routinely screen babies for congenital hearing loss. HB 714 by Representative Naishtat addresses this disparity by implementing a newborn hearing screening, tracking, and intervention program within TDH.

The bill, actively supported by TMA:

  • Requires birthing facilities to offer parents a screening test to determine whether their newborn has hearing loss or impairment. The screening test must be performed during the child's birth admission.
  • Defines "birthing facility" as hospitals offering obstetrical care or birthing centers that are located in counties with 50,000 or more residents and that have more than 100 births per year.
  • Requires birthing facilities to share test results with the newborn's parents and physician or health care provider of record. With parental consent, test results also will be shared with TDH.
  • Specifies that a physician or health care provider should direct and coordinate appropriate and necessary follow-up care for children identified with hearing impairment or loss.
  • Requires health benefit plans (including HMOs) that provide coverage for enrollees' family members to pay for screening tests and any medically necessary diagnostic follow-up care. Coverage also is required for children participating in the state Medicaid program.
  • Directs TDH to offer intervention services for families with hearing impaired newborns. Intervention services must be made available to newborns from birth through age 2.

Hospitals or birthing facilities with more than 1,000 births have until May 2000 to implement a hearing screening program. Facilities with fewer than 1,000 births have until April 2001 to implement a program.

School-Based Health Clinic
HB 2202 by Rep. Dale Tillery (D-Dallas) allows school districts to establish school-based student health centers to meet the health-care needs of students who don't have access to health care. These centers are allowed to provide health-care services, dental health care, family and home support, health education, and preventive health strategies. Referrals for mental health services may be provided with the written consent of the parent or guardian.

Written consent from a parent or legal guardian is required for the provision of any services, and school clinic staff members and parents must jointly identify any health-related concerns. School districts can seek assistance from any public agency in the area, and school districts and public health agencies can jointly establish, operate, and fund school health centers. Districts must seek all available sources of funding for the clinics, including Medicaid and insurance.

The bill also allocates $300,000 for the biennium to TDH to award grants to school clinics. An additional amount of approximately $3.2 million was given to TDH for school health services, but not specifically for this bill. All school clinics receiving grant funds must focus on reducing student absenteeism, increasing students' ability to meet their academic potential, and stabilizing the physical well being of students. To be eligible to receive grant funds, school districts must provide matching funds. Priority will be given to school districts located in rural areas and in areas with low property wealth per student. Clinics receiving state grant dollars are prohibited from providing reproductive services.

The law makes an attempt to maintain existing doctor-patient relationships. If a school health clinic is located in a medically underserved area, it must make a good faith effort to coordinate with existing providers and preserve existing health care systems and medical relationships in the area. For children who have a primary care physician under Medicaid, a state children's health plan program, or private health insurance, the clinic must obtain authorization from the primary care physician to provide the service. The Texas commissioner of health will be required to report to the legislature on the efficacy of services delivered by school-based health clinics. The bill takes immediate effect.

This bill represents a great success to advocates for school health clinics. It not only permits the creation of school-based clinics but provides funding for their implementation. In addition, the bill successfully protects parental rights and, by striving to maintain existing relationships with health care providers and to work with other providers, helps ensure that clinic services are not duplicative. Moreover, by requiring clinics to utilize all available funds, including Medicaid and private insurance reimbursement, the clinics will be implemented in a cost-effective manner.

Child Safety Belts
Senator Moncrief and Rep. Tony Goolsby (R-Dallas) co-sponsored SB 60 requiring children between the ages of 4 and 15 to wear a safety belt whenever riding in a passenger car or light truck, provided that the child is occupying a seat that is equipped with a safety belt. In a passenger car, the law also applies to rear seats. Failure to comply is a misdemeanor punishable by fines of between $25 and $50. Certain exemptions allowed under current law also apply to this new requirement.

Treatment for Craniofacial Abnormalities
HB 969 by Representative Van de Putte and Sen. John Carona (R-Dallas) clarifies the difference between cosmetic and reconstructive surgery as related to craniofacial abnormalities in children. The bill, backed by TMA and Texas Society of Plastic Surgeons, was prompted by several prominent health plan treatment denials for children needing extensive reconstructive surgery to repair malformations from birth, injury, or disease. Specifically, the bill requires that health benefit plans that provide benefits to children younger than 18 years of age must define reconstructive surgery for craniofacial abnormalities as "surgery to improve the function of, or to attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease."

The bill affects health benefit plans issued, delivered, or renewed after Jan. 1, 2000.

Newborn Genetic Screening
House Bill 2748 by Representative Smithee clarifies that state-mandated newborn screening is a part of well baby/well child care, which is a required benefit for all group health insurance plans. This legislation also amends the insurance code to add "rotavirus" to the list of immunizations a health plan must cover.

As of March 1998, TDH began charging providers a fee for the newborn screening test kit which is used to test all newborns for certain inherited and metabolic conditions. This legislation should improve reimbursement for both newborn screening and rotavirus vaccination, which are universally recognized standards of care. The provision regarding newborn screening is effective immediately, and the rotavirus provision becomes effective Sept. 1, 1999, and applies only to coverage delivered or renewed on or after Jan. 1, 2000. For more information about newborn screening, contact Brad Therrell, PhD, Laboratory Services, TDH, (512) 458-7430. For more information about immunizations, contact Bob Krider, TDH, (512) 458-7284.

Medical Foods
The state appropriations bill includes language providing the TDH with $300,000 for a pilot to provide medical foods for children age 0 through 5 with phenylketonuria, an inherited disorder requiring a special low-protein diet. Medically formulated formulas are currently available but fall short of meeting the nutritional needs of persons with this genetic disorder. Medically formulated low-protein foods can fill the gap but are very expensive since there are only some 350 persons in the entire state with this condition. A report will be provided to the legislature regarding the efficacy of state coverage of medical foods for this and other genetic disorders.

Acanthosis Nigricans Prevention
HB 1860 by Rep. Roberto Gutierrez (D-McAllen) creates a pilot program to screen children who attend public and private schools for acanthosis nigricans, a disorder that is associated with insulin resistance and diabetes. The pilot program will be developed and overseen by the UT System Texas-Mexico Border Health Coordination Office and will run for the 1999-2000 school year in nine counties: El Paso, Hudspeth, Cameron, Hidalgo, Jim Hogg, Starr, Webb, Willacy, and Zapata.

The screenings will be performed at the same time that hearing and vision screenings are done. Parents can elect to have their children screened by another professional, or, for religious reasons, refuse to have their children screened.

SB 114 by Sen. Mario Gallegos (D-Houston) redefines "intoxicated" by reducing the level of alcohol concentration in the blood stream to 0.08 percent or more, rather than 0.10 percent or more. While this bill applies to drivers of all ages, it will certainly affect young adolescent drivers.

Body Piercing
SB 61 by Senator Madla requires individuals or facilities performing body piercing to be licensed by TDH. The bill also prohibits body piercing of persons younger than 18 without written parental consent and requires regular inspections of body piercing facilities. The Texas Board of Health is required to adopt rules to implement this bill by Jan. 1, 2000.

Children and Adolescent Health Staff Contacts
Helen Kent Davis, Governmental Affairs: (512) 370-1401
Susan Griffin, Public Health: (512) 370-1462

Tobacco Settlement Distribution

The 76 th Texas Legislature was charged with allocating the initial $1.8 billion of Texas' landmark $17.3 billion tobacco settlement. As a matter of unwavering principle, TMA worked diligently to convince the legislature that all tobacco settlement dollars be dedicated to the improvement of the health of Texans through funding of direct medical care, prevention, and research.

Laying the groundwork for TMA's efforts was the 1998 Memorandum of Understanding signed by Sen. Bill Ratliff (R-Mount Pleasant), chair of the Senate Committee on Finance; Rep. Robert Junell (D-San Angelo), chair of the House Committee on Appropriations; and the former Attorney General Dan Morales. The MOU outlined the health care priorities to be funded with the state's first tobacco settlement installment. Among the items agreed to in the MOU were funding for CHIP, a pilot program on tobacco cessation, and endowments and permanent funds for children's health care, MD Anderson Cancer Center, medical schools, and health-related higher education. While the MOU had no legal standing, it set a clear course on how best to allocate the tobacco settlement proceeds.

To ensure enactment of the MOU funding priorities, TMA and the Texas Hospital Association co-founded the Coalition for Healthy Texans, an organization comprising more than 40 provider and consumer organizations. The coalition advocated vigorously throughout the session to dedicate the tobacco funds to health care. Thanks to strong legislative leadership and the commitment of the coalition, attempts to divert tobacco dollars to fund non-health care related projects were soundly rejected.

Unfortunately, the MOU signed by Senator Ratliff, Representative Junell and Attorney General Morales affected only the 1999 legislative session. No similar agreement exists for future sessions. As a result, numerous interest groups already are emerging to challenge health care for a piece of the tobacco pie. Not only do these groups want a share of new monies, but some may also attempt to raid existing endowed funds. In the closing days of the session, several House resolutions were adopted allowing the legislature to make last-minute structural changes to the permanent funds. Instead of being established as permanent funds outside the treasury, as originally envisioned, the funds are now dedicated funds within the treasury, giving them less protection from future incursions.

Thwarting the above efforts will be a challenge. However, strong grassroots support exists to earmark tobacco funds for health care. A poll commissioned earlier this year by the Coalition for Healthy Texans showed that more than 80 percent of Texans favor dedicating money from the tobacco settlement to meet current and future health-care concerns. TMA and its coalition partners will build on this support throughout the interim session to ensure future tobacco monies address Texas' vast health needs.

Following is a brief summary of the three tobacco-related bills enacted this session - HB 1161, HB 1676, and HB 1945. 

  • HB 1161 by Representative Junell, et. al., creates a permanent fund and advisory committees to handle the investment, management, and distribution of tobacco settlement receipts specifically earmarked for reimbursing counties and public hospitals for indigent health care. This bill codifies the Texas Supreme Court order to provide counties and hospital districts with an initial cash distribution and interest payments (over five years) to be used to reimburse indigent care.
  • HB 1676, also by Representative Junell, creates five permanent funds for certain public health purposes. These permanent endowments provide a stable base of funding for long-standing and long-term health care-needs in Texas. The creation of these funds does not bind the Legislature to future appropriations. The legislature could increase or decrease state appropriations to these programs as needed. This legislation takes effect on Aug. 31, 1999.

Permanent Fund for Tobacco Education and Enforcement
This $200 million endowment is housed within TDH. The interest (approximately $11.2 million per year) from this fund would pay for programs to reduce the use of tobacco products in Texas, including smoking cessation, public awareness programs, enforcement of sales and distribution laws, and specific programs for communities traditionally targeted through advertising by tobacco companies. The Board of Health will adopt rules governing any grant program established under this fund.

Permanent Fund for Children and Public Health
Interest from this $100 million fund is appropriated to TDH to establish a foundation to develop and demonstrate cost-effective prevention and intervention strategies for improving health outcomes for children and the public, providing grants to local communities to address public health priorities, and for providing grants to local communities for essential public health services in Texas. The interest from the endowment should provide approximately $5.6 million per year for programs. The Board of Health has rule-making authority to develop this foundation.

Permanent Fund for Emergency Medical Services and Trauma Care
The earnings on this fund are appropriated to TDH to establish programs or award grants to provide emergency medical services and trauma care in this state. This permanent fund will utilize interest (approximately $5.6 million per year) from a $100 million statewide emergency medical services/trauma care endowment. The Board of Health has rule-making authority over these funds.

EMS and trauma services have never been adequately funded to meet statewide needs. This fund will assist the 22 Regional Advisory Councils in the development of a trauma response system. All Texans will benefit from an improved trauma system, especially one that fills in the gaps of services in the rural areas.

Permanent Fund for Rural Health Facility Capital Improvement
Interest from this $50 million endowment ($2.8 million per year) will provide low-interest loans to a city, county, hospital district, or hospital authority that owns or operates a public hospital in a rural county. The loans could only be used to make capital improvements on existing public health facilities, to construct new public health facilities, or to purchase capital equipment for a public health facility. The Center for Rural Health Initiatives will adopt rules governing this program and will oversee administration of this project.

Community Hospital Capital Improvement
available earnings from this $25 million fund will be appropriated to TDH to provide grants, loans or loan guarantees to public or non-profit community hospitals with 125 beds or fewer, located in an urban area of the state. The Board of Health will adopt rules governing this program.

Funds Management
The Comptroller of Public Accounts will manage the assets of each permanent fund and will provide an annual distribution of available earnings to the appropriate state agency. The comptroller also will provide a report on these funds to the Legislative Budget Board (LBB) by Nov. 1 each year. The report will include the total amount of money distributed from each fund, the purpose for which the money was used, and any additional information that is requested by the LBB.

  • HB 1945 created a permanent health fund for higher education and set forth a formula for distributing the funds to certain health-related institutions of higher education; and created separate permanent funds for those institutions. The permanent health fund for higher education received $350 million and will be administered and managed by the UT System. The board will determine the amount available for distribution and funds may be appropriated only for programs that benefit medical research, health education, or treatment programs at the following institutions of higher education: UT Health Science Center at San Antonio; UT M.D. Anderson Cancer Center; UT Southwestern Medical Center at Dallas; UT Medical Branch at Galveston; UT Health Science Center at Houston; UT Health Science Center at Tyler; Texas A&M University Health Science Center; the University of North Texas Health Science Center at Fort Worth; the Texas Tech University Health Sciences Center; and Baylor College of Medicine, if a contract between Baylor and the Texas Higher Education Coordinating Board is in effect.

Seventy percent of the funds shall be distributed in equal amounts to each institution. The remaining amount will be distributed in equal amounts for (a) instructional expenditures; (b) research expenditures; and (c) unsponsored charity care. Distribution will be based on the amount that the institution spent in each category in the preceding fiscal biennium.

The two separate funds that allocate money to Baylor may be used only to support programs that benefit medical research, health education, or treatment programs at Baylor. The college may elect to administer the fund and its board must enter into a contract that requires the institution to administer the fund subject to the same regulations as would apply to the comptroller, if the comptroller were administering the fund.

The Permanent Fund for Health-Related Institutions creates a separate permanent fund to benefit the following institutions: UT Health Science Center at San Antonio ($200 million); UT M.D. Anderson Cancer Center ($100 million); UT Southwestern Medical Center at Dallas ($50 million); UTMB ($25 million); UT Health Science Center at Houston ($25 million); UT Health Science Center at Tyler ($25 million); UT at El Paso ($25 million); Texas A&M University Health Science Center ($25 million); UNT Health Science Center at Fort Worth ($25 million); Texas Tech University Health Sciences Center in El Paso ($25 million); the other components of the Texas Tech University Health Sciences Center at locations other than El Paso ($25 million); the regional academic health center ($20 million) and BCOM ($20 million).

The governing board of an institution may administer the fund, or they may request the comptroller to provide this administration. These funds may be appropriated only for research and other programs that benefit public health. The legislation states that UT Health Science Center funds may be used to establish, maintain, and operate a children's cancer center and the campus extension in Laredo. Appropriated funds for Texas Tech University Health Sciences Center in El Paso and for UT at El Paso may be used to establish and operate an institute of public health in El Paso. The components of Texas Tech other than the El Paso site may use funds for research and other programs that benefit public health in areas outside El Paso. The amount allocated to Texas A&M University Health Science Center may be used to establish and operate the Coastal Bend Health Education Center in Corpus Christi.

The Permanent Fund for Higher Education Nursing, Allied Health and other Health-related programs will receive $45 million. The investment returns from the fund will be appropriated to the Coordinating Board to provide grants to public institutions of higher education that offer upper-level academic instruction and training in nursing, allied health, or other health-related education. The Coordinating Board will adopt rules relating to the award of grants. 

The Permanent Fund for Minority Health received $25 million for minority health research and education. The fund will be administered by the Coordinating Board to provide grants to higher education institutions, including Centers for Teacher Education, to conduct research or educational programs that address minority health issues, or form partnerships with minority organizations, colleges, or universities to conduct research and educational programs that address minority health issues. The Coordinating Board shall adopt rules relating to the awarding of grants.

Tobacco Settlement Distribution Staff Contacts
Gayle Harris, Public Health: (512) 370-1670
Helen Kent Davis, Governmental Affairs: (512) 370-1401
Matt Thompson, Legislative Affairs: (512) 370-1355 

Indigent Health Care

County Indigent Health Care
In 1985, Texas adopted legislation implementing the County Indigent Health Care Program. This legislation strengthened the health care safety net for low-income Texans residing in counties without hospital districts or public hospitals. Since the adoption of the original act, significant changes have occurred in Texas' health care delivery system, yet CIHCP has not been substantially updated for nearly 15 years. HB 1398 by Representative Coleman is a much-needed effort to modernize CIHCP by making it more consistent with current standards of care delivery and improving programmatic efficiency.

Major goals of this legislation include putting greater emphasis on preventive and primary care, which will stretch limited health care dollars by detecting and treating more costly illnesses sooner; giving counties positive incentives to participate in the program; increasing coordination between local, state, and federal programs; and simplifying and updating eligibility guidelines. The bill represents the consensus recommendations from rural and urban counties, hospitals, medical professional societies, state agencies, consumer advocates, and other interested parties.

Highlights of HB 1398 include:

  • Establishes minimum eligibility criteria at 25 percent of the federal poverty level for residents eligible for CIHCP. Prior to HB 1398, the eligibility floor was 17 percent of poverty. Counties are authorized to set higher eligibility levels at their discretion. The minimum standard will be phased in by 2002.
  • Expands basic, mandatory CIHCP health care services to include primary and preventive health care, including medical screenings, immunizations, and annual exams. Counties may add additional services as well. Upon approval from TDH, counties can apply to receive state funds for optional services such as durable medical equipment, diabetic supplies, psychological counseling, dental care, and vision care.
  • Authorizes health care providers to require patients to provide information demonstrating residency and to authorize the release of necessary information for submitting claims.
  • Requires participating health care providers, in order to receive reimbursement, to notify the patient's county of residence that services have been or will be rendered. Notice must be made by telephone not later than 72 hours (instead of as soon as possible) after the provider determines the patient's county of residence or by mail postmarked not later than the fifth working day after determining residency, instead of three.
  • Lowers the threshold for counties to qualify for state-matching funds. Instead of 10 percent, counties now have to spend at least 8 percent of their annual general revenue tax levy on indigent care to qualify for state assistance. Counties also are obligated to report monthly expenditures to TDH and to notify TDH when spending has reached 6 percent. Under defined situations, TDH may authorize state assistance for counties spending less than 8 percent annual general revenue tax levy.
  • Establishes a tertiary care facility account to reimburse trauma facilities, including primary teaching hospitals, for unreimbursed out-of-county tertiary medical expenses.
  • Instructs HHSC to continue to pursue a federal 1115 waiver to allow the state to expand Medicaid eligibility for children and their families and other low-income adults.
  • Directs HHSC to establish by Jan. 1, 2000 a regional health-care delivery system. The pilot must emphasize preventive services, continuity of care, maximize local and state funds to secure additional federal matching dollars, and simplify eligibility criteria and determination.
  • Expands the number of rural hospitals eligible to receive reimbursement for telemedicine consultations and directs HHSC to establish an advisory committee to develop policies regarding telemedical consultations.

Health Insurance Access
Though HB 1398 makes much needed progress in reforming the County Indigent Health Care Program, 25 percent of Texans still cannot afford health insurance. Mirroring national trends, the majority of uninsured Texans work in low-wage jobs and cannot afford premiums for private health care coverage. Instead these patients postpone treatment, ending up in costly hospital emergency rooms when an illness becomes acute, or they rely upon charity care from counties, hospital districts and individual physicians. The new Children's Health Insurance Program will address one segment of Texas' uninsured population, yet, after the implementation of CHIP, many parents and childless adults will remain uninsured.

To address this growing problem, the legislature adopted Senate Concurrent Resolution 6 by Senator Harris and Rep. Bob Glaze (D-Gilmer). The resolution calls upon the governor, lieutenant governor, and speaker of the House to appoint a blue ribbon task force to conduct an in-depth study of the uninsured. Task force members will include nine members - three senators, three representatives, and three consumers, including representatives from the employer, consumer, and health care provider communities. Specific charges for the task force include performing targeted studies on the unique problems faced by uninsured patients with chronic illnesses, reviewing demographic data on the uninsured, examining other states' approaches to resolving this issue, and developing a market-based plan to ensure access to cost-effective health insurance.

A task force has not yet been named. However, TMA, which has long-standing policy urging the state to take action on this issue, has encouraged the legislative leadership to implement SCR 6.

Additional Funds for UTMB To Cover Indigent Health Care
UTMB will receive additional state funds for indigent health care costs through a fund assigned to TDH from unclaimed state lottery winnings. Under HB 1799 by Rep. Phil King (R-Weatherford), up to $40 million can be deposited in this account each biennium. This could alleviate some financial pressures for UTMB and decrease the need for increasing patient care revenues to cover the deficits.

Indigent Care Staff Contact
Helen Kent Davis, Governmental Affairs: (512) 370-1401
Matt Thompson, Legislative Affairs: (512) 370-1355

Public Health Development

Local Public Health Infrastructure
HB 1444 by Rep. Dianne Delisi (R-Temple) creates a grant program to award cities and counties funds for essential public health services. The bill establishes a public health consortium of health science facilities in Texas. This consortium will perform certain public health services, such as developing curricula for public health training and developing performance standards for local public health units. The bill reflects the recommendations of a broad-based workgroup formed under HCR 44 by the 75 th Legislature to study the role of local government in providing public health services.

Specific recommendations:

  • HB 1444 amends Chapter 121 of the Health and Safety Code by defining "essential public health services," providing grants to local governments for essential public health services, and establishing a public health consortium composed of the state's nine major university health-related institutions and any other public institution of higher learning choosing to join.
  • The TDH will be responsible for developing rules to govern the allocation and awarding of funds to counties, cities, and public health districts.
  • Essential public health services are defined in the bill as monitoring community health status, diagnosing and investigating community health hazards, enforcing public health rules and laws, educating the community on health matters, and ensuring a competent public health workforce.
  • The responsibilities of the public health consortium will include developing curricula to train public health workers, developing certification standards for public health workers, conducting research on improving health outcomes, developing performance standards for local health departments, and studying the technology available to local health entities in order to improve statewide communications on disease surveillance and to improve immediate access to public health information among professionals.
  • Funding for this bill was included under the Children and Public Health Endowment Fund, which was allocated $5 million from the state's tobacco settlement. TDH will have discretion over how these funds will be used, as it was not specified in the bill how funds within the fund must be spent.
  • The bill takes immediate effect .

This legislation makes great strides by defining essential public health services and creating a public health consortium. However, the funding appropriated for this bill will do little to make a significant dent in providing essential public health services to the approximate 20 percent of Texans who lack these services. Hopefully, this important piece of legislation will receive more funding from the Texas Legislature during its next session.

Public Health Enforcement
HB 247, which was opposed by the TMA Council on Public Health, passed but fortunately was subsequently vetoed by Governor Bush on June 20, 1999. The bill would have allowed municipalities to use volunteers from neighborhood associations to help enforce certain municipal health and safety ordinances.

Public Health Infrastructure Staff Contacts
Susan Griffin, Public Health: (512) 370-1462
Gayle Harris, Public Health: (512) 370-1670 

Border Health

Border Health Development
Throughout the legislative session, there was considerable interest among state-level officials in border health issues. The Texas Senate appointed a Special Committee on Border Affairs, which resulted in the passage of several bills to study and improve border health conditions for Texas residents. All of these bills will successfully raise the profile of border health issues and will infuse the area with much-needed funds. While these funds will not completely ameliorate the problems facing the border, they will go a long way toward helping improve the situation.

Border Health Institute
HB 2025 by Rep. Joseph Picket (D-El Paso) an Sen. Eliot Shapleigh (D-El Paso) establishes the Border Health Institute in El Paso. The institute will receive oversight by the Coordinating Board and will research public health issues affecting the border region such as diabetes, Hispanic health issues, infectious diseases, emerging infections, environmental health issues, and children's health issues. The institute also will deliver health care and provide health education to persons living in the border region.

The institute received $50 million in proceeds from the state's tobacco settlement. Half of this money will go to Texas Tech University and the other will be allocated to UT El Paso. The institute also is permitted to accept additional public or private funds, including pledges, gifts, and endowments. The Border Institute is initially composed of the following institutions:

  • UT El Paso;
  • Texas Tech University Health Sciences Center at El Paso;
  • El Paso Community College District;
  • R. E. Thomason General Hospital;
  • El Paso City/County Health District;
  • UT Health Science Center at Houston, School of Public Health;
  • El Paso County Medical Society;
  • Paso del Norte Health Foundation; and

The Coordinating Board is required to present an impact statement on the bill to the Texas Legislature by Jan. 1, 2001. The bill takes immediate effect.

Border Health Medical Training and Education
See  Medical Education .

Border Health Advocacy
HB 564 establishes a border advocacy division in the Governor's Office or the Secretary of State's Office. This new division will act as an ombudsman for government agencies within the Texas and Mexico border region and will deal with trade and transportation issues, border crossing needs, will strive to increase funds for the North American Development Bank to finance water and wastewater facilities, and will explore the sale of excess electric power from Texas to Mexico. The division also will improve communication and cooperation between federal, state, and local governments. The bill takes immediate effect. 

Promotora Program Development
HB 1864 requires TDH to establish a temporary Promotora Program Development Committee to develop a framework for a promotora development program and to advise TDH, the governor, and the legislature regarding its findings and recommendations by Dec. 31, 2000. The committee is authorized to establish a series of neighborhood-based peer health outreach and education pilot projects to demonstrate the feasibility and benefits of employing promotoras to assist beneficiaries of the Medicaid managed care program and CHIP. The bill authorizes funding for to up to five local pilot projects.

The bill also requires TDH to establish and operate (1) a voluntary program for training and educating promotoras and (2) an optional certification program for promotoras. No new dollars were allocated for implementation of this bill. The certification program must be in effect by Jan. 1, 2000.

Border Environmental Health
HB 565 requires the Coordinating Board to encourage institutions of higher education and other entities using state research or technology funds to apply those funds to environmental issues on the border. This bill will be effective upon passage.

Border Health Staff Contacts
Susan Griffin, Public Health: (512) 370-1462
Gayle Harris, Public Health: (512) 370-1670
Matt Thompson, Legislative Affairs: (512) 370-1355

Infectious Diseases

Several important bills relating to infectious diseases were passed during the legislative session. These bills address the provision of tuberculosis services, as well as conditions such as HIV, hepatitis B and C, as well as the regulation of body piercing facilities.

South Texas Hospital
HB 3504 by Rep. Juan Solis (D-San Antonio) requires TDH to contract to build a new facility for health-care services for residents of the Lower Rio Grande Valley. The facility would be located at the site of the South Texas Hospital or at a site adjacent to the Regional Academic Health Center in Harlingen. The bill also requires TDH:

  • To contract with one or more public or private entities to provide inpatient and outpatient health care services, including tuberculosis treatment and related laboratory services;
  • To contract for minimal renovations to South Texas Hospital for continuing outpatient services until the new facility is completed;
  • To give the Texas Department of Mental Health and Mental Retardation the first option to lease the current physical facilities of South Texas Hospital; and
  • To the extent possible within available appropriations, reassign South Texas Hospital employees displaced by the bill to open positions within TDH.

Hepatitis C Education and Prevention
HB 1652 by Representative Maxey establishes a statewide education and prevention program to control hepatitis C to be administered by TDH. TDH will provide a voluntary testing program, training for individuals providing hepatitis C counseling, and a seroprevalence study to determine the impact of the disease in Texas. TDH also will:

  • Conduct health education, public awareness, and community outreach programs on risk factors, screening, treatment options, and the value of early detection;
  • Provide training to public health clinic personnel;
  • Promote the benefits of prevention among health care providers and employers; and
  • Develop a prevention program to reduce transmission risk.

The legislature allocated more than $3 million dollars over the next biennium for implementation of this bill.

This bill will increase public awareness of hepatitis C and provide much-needed education and counseling to those who suffer from this condition. Moreover, with increased education and public awareness, transmission of the disease will hopefully be prevented in a significant number of cases.

Patient Consent for Hepatitis Testing
SB 99 by Senator Carona authorizes hospitals to perform tests for hepatitis B or hepatitis C without patient consent, in cases where a health-care worker is accidentally exposed to a patient's blood or body fluids. Hospitals will be required to notify the patient and health-care worker of the test results.

Hepatitis B Screening in Pregnant Women
SB 519 by Senator Zaffirini requires physicians to screen all pregnant women for hepatitis B and requires medical information to be supplied to individuals who test positive.

Nursing Home Flu and Pneumonia Vaccines
HB 1677 by Representative Janek requires nursing homes to offer pneumococcal and influenza vaccines to their residents. The bill also gives the Texas Board of Health the authority to develop an immunization schedule for nursing home residents for nursing home compliance. TDH will have to coordinate with the TDHS to implement this bill.

Rotovirus Immunizations
In addition to addressing genetic screening issues, HB 2748 by Representative Smithee requires insurance companies to provide coverage for immunization against rotavirus and any other immunization required for a child by statute or rule. This bill takes effect immediately.

HIV Testing
SB 567 by Senator Moncrief increases the minimum civil penalty for disclosing an individual's confidential HIV test results from $1,000 to $5,000.

Body Piercing
See Child and Adolescent Health 

Infectious Disease Near Misses and Narrow Escapes
HB 717 by Rep. Warren Chisum (R-Pampa), which was opposed by TMA's Committee on Infectious Diseases, would have required couples applying for marriage licenses to have a medical procedure or test to determine HIV, HIV antibody, or AIDS status. This bill would have required a couple to supply this information to the county clerk prior to receiving a marriage license. HB 2393 by Representative Maxey, which reflects TMA policy on needle exchange, would have allowed community-based organizations with a memorandum of understanding with TDH to provide harm reduction services to address risks associated with intravenous drug use, including health and substance abuse referrals and prevention information about HIV and hepatitis. The bill also would have authorized certain persons involved with the program to dispense needles and syringes and provide for their storage and disposal.

Infectious Diseases Staff Contact
Gayle Harris, Public Health: (512) 370-1670

Emergency Medical Services and Trauma

Reporting of Drug Overdoses
SB 43 by Sen. Florence Shapiro (R-Plano) requires a physician who attends or treats, or who is requested to attend or treat an overdose of certain controlled substances, or the administrator, superintendent, or other person in charge of a hospital, sanatorium, or other institution to report at once the overdose to TDH. The report will not include the person's name or address or any other information concerning the person's identity.

Individuals and institutions that make good-faith reports under this section are not subject to civil or criminal liability for damages arising out of the report. It is a criminal offense to intentionally fail to file a required report.

The bill also requires TDH to maintain a central repository for the collection and analysis of information gathered on incidents of controlled substance overdose. TDH is prohibited from including in the repository any information the physician or other person is precluded from reporting under that section. TDH also is required to release statistical information from the central repository on the request of a medical professional or a representative of a law enforcement agency.

External Defibrillators
HB 580 by Representative Janek addresses the use of automatic external defibrillators. The bill exempts from civil liability: (1) physicians who authorize the acquisition of an automated external defibrillator, (2) persons who provide training in the use of a defibrillator, and (3) people or entities responsible for the defibrillator, unless the act performed with the device was willfully or wantonly negligent.

To be immune from liability, HB 580 requires people or entities that acquire automated external defibrillators to ensure that each user of the device has received standard training in cardiopulmonary resuscitation and in the use of an automated external defibrillator. TDH has to offer or approve the training and take into consideration national guidelines approved by the American Heart Association, the American Red Cross, or another nationally recognized association. A licensed physician has to be involved in the training to ensure compliance.

HB 580 also exempts from liability anyone who, in good faith, administers an automated external defibrillator outside the hospital setting.

Tertiary Medical Care
The Indigent Health Care and Treatment Act, enacted in 1985, has not addressed all out-of-country issues impacting reimbursement of facilities for care provided to indigent patients. Tertiary medical centers, which provide and coordinate care for trauma and seriously ill patients, as well as injury prevention, research, public education, and continuing education for rural providers, have experienced increased costs for care provided to out-of-country indigent residents. Currently, taxpayers of the county bear the added costs incurred by the centers, which provide health care to these indigent residents.

HB 2573 by Rep. Steve Wolens (D-Dallas) requires the Texas Board of Health to adopt minimum standards and objectives to implement a system that encourages hospitals to provide tertiary medical services and increases the availability of these services, as well as providing funding for those services. Language identical to HB 2573 also was included in HB 1398 relating to indigent care (see above).

The bill establishes an account in the state treasury to reimburse tertiary care facilities for any unreimbursed tertiary medical services provided to persons living outside their service areas. The legislature allocated approximately $17 million for this fund. TDH will be required to increase the availability to tertiary care, to encourage hospitals to provide tertiary care, and to designate various hospitals as tertiary care facilities.

A tertiary care facility is defined as any facility that is a primary teaching hospital of a medical school, a Level I or Level II trauma center, or a Level III trauma center that is more than 100 miles from a Level I or II trauma center. Tertiary medical services include pediatric and trauma surgery, organ transplants, neurosurgery, services related to high-risk pregnancies or cancer, or services provided by burn centers and neonatology Level III units.

TDH is required to propose rules relating to minimum standards and objectives to implement a tertiary medical services system and to certify reimbursement amounts to the comptroller.

EMS/Trauma Staff Contacts
Helen Kent Davis, EMS/Trauma Committee: (512) 370-1401
Gayle Harris, Public Health: (512) 370-1670 


Interagency Council for Genetic Services
SB 602 by Senator Moncrief will strengthen the role of the Interagency Council for Genetic Services in the rulemaking process by requiring its member agencies to work in coordination with the council when initiating, considering, or proposing rules relating to genetics or genetic services. It will also replace membership on the council of the TDHS with representation from the TDI.

The IAC was established in 1987 to evaluate the need and availability of genetic services throughout the state and to assist in coordinating statewide genetic services for all state residents. It is responsible for maintaining a database of human genetic epidemiology and developing guidelines for the provision of human genetic services. The need for genetic services will increase dramatically with the development of new technologies such as gene therapy. Lack of appropriate communication between the IAC and its member agencies regarding rulemaking that impacted genetic services contributed to the filing of this legislation.

Genetics Staff Contact
Barbara James, Science and Quality: (512) 370-1400 

Other Significant Public Health Initiatives

Cardiovascular Disease
Legislation to create a Council on Cardiovascular Disease and Stroke at TDH was added to the TDH sunset bill, HB 2085 by Representative McCall and Sen. J.E. "Buster" Brown (R-Lake Jackson). The council would act as an advisory panel to TDH and would be charged with developing a plan to reduce the morbidity, mortality, and economic burden of cardiovascular disease and stroke in Texas, and maintaining a database on the prevalence of CVD and stroke and available clinical resources. Representative Delisi and Senator Nelson partnered with the Texas Coalition on CVD and Stroke , which TMA helped create in early 1998, to draft the original legislation which was subsequently incorporated into the TDH sunset bill. The council will work with the Texas Education Agency, health-care providers, employers and insurers to promote effective strategies for a statewide and community-based approach for CVD and stroke prevention.

Organ Donation and Allocation
At the request of a hepatitis C patient advocacy group, Senator Gallegos filed SB 862 to keep organs donated in Texas in the state. The bill was amended in the Senate Health Committee by Senator Nelson, the committee chair, to include language mandating a statewide waiting list and abolition of current organ procurement organization boundaries. Following a storm of controversy, the Texas Transplantation Society convened a meeting to hammer out a compromise, which gained the support of most of the transplant community. The compromise calls for a "Texas-first" policy on organ allocation but leaves out language to abolish existing OPO boundaries. Instead, SB 862 creates a task force that will be appointed by TDH to "develop and implement an optimum allocation plan" for organ allocation in Texas. The bill would allow organs to be sent out of Texas under certain pre-existing organ sharing arrangements or if no suitable match could be found in Texas.

By Dec. 1, 2000, the task force will report to the governor and the legislature on the optimum allocation plan and present recommendations for any needed legislation. For more information, contact Laurie Reece, Executive Director, TTS, (512) 370-1522.

Regulation of Dietary Supplements
HB 3420 prohibits school district employees from selling, marketing, distributing, or suggesting the use of dietary supplements that contain performance-enhancing compounds to primary or secondary school students with whom the employee has contact as part of his or her duties. Violation of this law would be a Class C misdemeanor, punishable by a maximum fine of $500. The bill defines performance-enhancing compounds as manufactured products that contain substances other than essential vitamins and minerals and that are designed to improve muscle growth, endurance, or athletic or intellectual performance.

Another bill regulating dietary supplements is SB 656 by Sen. Jeff Wentworth (R-San Antonio), which prohibits the sale, transfer, or other provision of ephedrine to children under age 18. This does not apply to a parent, guardian, or managing conservator of the child or to licensed practitioners or health-care providers who have lawful consent to treat the child. This also doesn't apply to children who are 17 years old and financially self-supporting or to children who are 16 years old and financially self-supporting and living apart from their parents or guardians. The prohibition also doesn't apply if the product containing ephedrine is a drug. The first offense under this bill is a Class C misdemeanor, punishable by a maximum fine of $500. A repeat offense is a Class B misdemeanor, punishable by up to 180 days in jail and/or a maximum fine of $2000. 

Public Health Near Misses and Narrow Escapes

There were several bills introduced during the session that would have presented a setback to public health concerns. Two of these focused on ImmTrac, the statewide immunization registry operated by TDH. One of these, HB 1381 by Rep. Carl Isett (R-Lubbock), would have repealed ImmTrac. Although TMA has expressed concerns over the implementation of ImmTrac, physicians recognize the importance of having the registry and did not want to see it completely removed. The other bill, HB 2722 by Rep. Suzanna Hupp (R-Lampasas), addressed information disclosure and parental consent issues with the registry. Although it tackled some of the parental concerns with the registry, the bill didn't address, and would have further complicated, physician concerns with ImmTrac's reporting requirements. Another bill introduced by Representative Isett (HB 3439) would have prohibited school health clinics from existing within a five-mile radius of a practicing physician. Although the spirit of this bill was to preserve existing medical relationships and health care systems in the state, the bill would have prevented the establishment of school clinics in areas of the state where they are much needed.

Another bill that was supported by TMA and reflective of TMA policy did not pass. HB 673 by Rep. Bill Carter (R-Fort Worth) would have required children younger than 18 to wear bicycle helmets. Parents could not knowingly or recklessly permit their children to ride a bicycle without wearing a helmet without being subject to a penalty.

Public Health, General, Staff Contact
Gayle Harris, Public Health: (512) 370-1670 


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