Victory! TMA Preserves Patient Care in Legislative Session

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Cover Story - August 2007   

By   Ken Ortolon
Senior Editor  

When legislators came back to Austin for the 2007 session, Texas Medical Association members were waiting for them with an ambitious agenda of proposed legislation that boiled down to one goal: preserving patient care. After two years of preparation that began when the 2005 session ended, TMA asked lawmakers to reduce the state's embarrassingly high rate of uninsured residents, reform the health insurance industry, enhance access to care, and bolster the public health infrastructure.

And when the legislature adjourned at the end of May, it had done just that, thanks to the hard and almost around-the-clock work of TMA physicians, medical students, alliance members, and staff; the support of political and business leaders gained through TMA's three Healthy Vision 2010 summits last year; and numerous legislative champions of both political parties. Dozens of Texas physicians testified on bills before legislative committees. And thousands of physicians, medical students, and TMA Alliance members helped back TMA legislative priorities during First Tuesdays at the Capitol events or through personal contact with lawmakers.

The result was a resounding victory for patients and physicians that one key lawmaker called a "watershed moment" for health care in Texas.

TMA enjoyed many successes in the 80th Texas Legislature. Physician leaders and lobbyists say these are the top 10:

  1. Approval of a 25-percent increase in physician payment rates for children's Medicaid, as well as a 10-percent hike in fees for adult Medicaid;
  2. Creation of the Cancer Prevention and Research Institute of Texas and submission of a proposed constitutional amendment to sell $3 billion in general revenue bonds to fund it to voters in November;
  3. Restoration of Children's Health Insurance Program (CHIP) cuts;
  4. Passage of legislation that will require greater transparency from health plans, physicians, and hospitals in terms of both pricing of services and adequacy of health plan networks;
  5. Passage of a bill expanding to middle school students the same mandatory physical education (PE) requirements already in place for elementary school students;
  6. Defeat of attacks on the 2003 medical liability reforms;
  7. A $35 million graduate medical education funding and appropriation of new funds to enable Texas Tech University Health Science Center at El Paso to complete its conversion to a full four-year medical school;
  8. Defeat of scope-of-practice legislation, including a bill to lessen physician supervision of retail health clinics;
  9. Workers' compensation reforms that require peer review to be done by Texas-licensed physicians in specialties appropriate to the care being provided; and
  10. Increases in Texas Medical Board funding - without licensure fee hikes - to help process physician license applications.

Austin obstetrician-gynecologist Albert T. Gros, MD, chair of TMA's Council on Legislation, says the results are "very encouraging" for patients and their physicians.

"It's been a whirlwind session," Dr. Gros said, "but overall, in spite of all the adrenalin and excitement of the session, when it all came down to it in the final analysis, we came out with a result that we should be very happy with."

One of TMA's legislative champions, Sen. Jane Nelson (R-Lewisville), chair of the Senate Health and Human Services Committee and author of some of the key health care bills this session, says TMA's efforts this year were critical to development of good health care policy.

"TMA is an invaluable resource to us, especially in the legislative session,"   she said. "We had 7,000 bills filed this session, and you can't be an expert on all those issues. I have learned to depend on those who are experts. TMA, during the legislative session, is here almost 24 hours a day every day, making sure legislators have the information we need, making sure we know the pros and cons of those issues that TMA's directly involved with, and then following up.



Tumult in   Austin  

If asked, Gov. Rick Perry and legislative leaders probably would admit that the session did not exactly come off without a hitch.

Lawmakers balked early at major initiatives Governor Perry laid out to require human papillomavirus immunizations for all Texas schoolgirls and to sell the state lottery to pay for such things as the $3 billion cancer research fund.

In the Senate, a dustup over a voter identification bill between senators and Lt. Gov. David Dewhurst left some senators questioning the lieutenant governor's leadership style. And, as the session wound down, some House members were in open revolt against House Speaker Tom Craddick (R-Midland), even mounting a late effort to unseat him.

Despite what some political observers have labeled as some of the most interesting "political theater" in quite a few sessions, however, lawmakers were able to work through their differences and accomplish a great deal, particularly on the health care front.

"We set forth a new blueprint for Medicaid and the uninsured," said Senator Nelson. "We invested in cancer research. We expanded our provider network. And my war song about preventive health finally started to catch on."

While the trials and tribulations of legislative leaders may not have had a direct impact on organized medicine's issues, political observers say they truly defined the session.

"This is the session in which the Republican leadership pretty much hit the wall," said Harvey Kronberg, publisher of the online political newsletter Quorum Report .

Mr. Kronberg has been following the Texas Legislature for nearly 20 years and says this session provided "some of the best theater I've seen."

Despite those distractions, however, lawmakers were able to concentrate on a number of key issues for organized medicine. And TMA was well prepared to help frame the debate on those issues.

As in past legislative sessions, the association used a number of ad hoc committees between the 2005 and 2007 sessions on issues such as Medicaid, commercial health insurance, and scope of practice to identify key issues facing medicine and potential solutions. Those ad hoc committees also gave TMA a ready pool of physicians with specific expertise who could be called on to testify or lobby for TMA's goals. (See " Physician Testimony Plays Key Role in Legislative Victories .")

In addition, TMA convened three Healthy Vision 2010 summits that brought physicians together with business leaders, insurance executives, and others to look for opportunities where groups with very diverse interests might be able to work together to address issues such as the uninsured or wellness and prevention.

Darren Whitehurst, director of the TMA Division of Public Affairs, says the summits differed from other coalitions TMA has been involved in because this time physicians partnered with groups that "don't necessarily agree with us on all of our legislative agenda."

TMA also once again joined state specialty societies in the PatientsFirst Coalition to help block any scope-of-practice expansion efforts by allied health practitioners.

Dr. Gros says all that groundwork truly paid off during the session.

"I think it was a very good session," he said. "We managed to kill off a lot of bad bills, and we managed to get some notable successes, particularly with regard to CHIP and Medicaid funding restoration."



Finding a Medical Home  

Indeed, the 80th legislature produced a historic Medicaid physician payment increase that could dramatically impact access to care for low-income Texans.

TMA helped convince lawmakers to appropriate nearly $2 billion in new state and federal funds to boost Medicaid physician and dental payments and to increase access to services within children's Medicaid by improving outreach, case management, and transportation services. Still to be negotiated are other "strategic" initiatives as part of the settlement of the Frew vs. Hawkins lawsuit, a federal class action suit challenging the adequacy of the state children's Medicaid program. For children's services, the funding pool will increase by 25 percent for medical services and by 50 percent for dental services. The funding pool for adult medical services will increase by 10 percent.

If Health and Human Services Commissioner Albert Hawkins approves recommendations of the Medicaid Physician Payment Advisory Committee (PPAC), physicians will see their Medicaid reimbursement rates improve considerably. Vaccine administration fees, for example, would go up by 30 percent under the PPAC recommendation, and all evaluation and management codes would increase 27.5 percent, in addition to other changes.

Going into the session, TMA made a strong push to improve Medicaid payment rates in the face of declining participation in the program. In a letter to key legislative leaders in October, then-TMA President Ladon W. Homer, MD, urged lawmakers to push Medicaid fees up to a level comparable to Medicare and commercial health plan payment rates.

Armed with a substantial budget surplus, lawmakers seemed inclined to enact at least a 10-percent fee increase for both children's and adult Medicaid services, but then the Frew settlement resulted in an even larger increase in children's payments.

Meanwhile, lawmakers also restored most of the cuts made to CHIP in 2003, including the 2.5-percent cut in physician fees. They eliminated the 90-day waiting period and restored 12 months continuous coverage for children whose families earn less than 185 percent of the federal poverty level. The increases will allow an estimated 127,500 additional children to qualify for CHIP during the next two years.

Dr. Gros says these increases are encouraging for both patients and physicians.

"We not only restored the cuts that were made previously but we also managed to actually get an increase,"   he said. "That's definitely moving in the right direction."

Senator Nelson says the political climate was right to not only restore the 2003 Medicaid and CHIP cuts but to also enact the first significant fee increase in some 15 years.

"Having a good economy and a budget surplus certainly helped," she said. "However, we had great momentum heading into this session. The nation's focus is on health care right now, and we needed to seize this opportunity to make progress while there is political will for change."

The senator believes the payment increases will ensure that Medicaid patients will have access to a "robust network of providers."

Abilene otolaryngologist Austin I. King, MD, immediate past chair of the TMA Council on Legislation, also says he is "ecstatic" with the Medicaid fee increases.

"This is going to be extremely helpful to physicians who have a large majority of their practice that is Medicaid, particularly the [Lower Rio Grande] Valley physicians," he said.

TMA was disappointed lawmakers chose not to increase adult Medicaid and CHIP rates by the same amount as the children's Medicaid increases, but TMA President William W. Hinchey, MD, of San Antonio, says he will personally urge physicians to return to the program or open their practices to new Medicaid patients in light of the fee hikes. If physicians do not return to the program, TMA leaders fear lawmakers may turn to limited licensed providers to solve access problems in Medicaid. (See " Medicaid Rate Hike an Enormous Opportunity .")

A more detailed look at the fee increases can be found in the July issue of Texas Medicine . (See " A Historic Increase .")       

Another significant advance in Medicaid and the uninsured was passage of legislation to promote healthy lifestyles, improve cost efficiency in Medicaid, and expand coverage for the uninsured. Senate Bill 10, authored by Senator Nelson, directs the Texas Health and Human Services Commission (HHSC) to seek federal waivers to conduct a pilot program to provide positive incentives, such as expanded benefits or value-added services, for Medicaid recipients who participate in weight loss, smoking cessation, or other disease management programs.

The bill also creates a Medicaid health savings account pilot program for adult patients. It also authorizes HHSC to seek waivers to create tailored packages of benefits customized to meet the specific health care needs of certain recipients and authorizes HHSC to seek a waiver to create a Texas Health Opportunity Pool to help uninsured Texans purchase private insurance. The pool would use hospital disproportionate share and upper payment limit funds in addition to any new federal funding to help subsidize private insurance through Three-Share - which provides coverage by having the government, the employer, and the employee share the cost of health insurance - or other programs.



Clear as Glass  

In 2005, there was considerable debate about the adequacy of health plans' physician networks and physicians, particularly hospital-based physicians, balance billing patients for charges not covered by their health plan. Some lawmakers sought to ban balance billing, while TMA wanted legislation to set adequacy requirements for networks.

Lawmakers failed to resolve that debate then, so transparency, as the issue came to be known, became a major buzzword this year.

TMA worked very closely with Sen. Robert Duncan (R-Lubbock) to craft a balanced bill that puts new transparency requirements on health plans, hospitals, and physicians, and gives employers purchasing health coverage for their workers, as well as the enrollees themselves, plenty of information about what they are getting for their premium dollars.

The plan requires facility-based physicians to tell patients in advance that they may not be in their health plan's network. If they provide out-of-network care, the physicians also must tell patients that they are being billed for out-of-network services and provide a phone number to call to discuss the charges and set up a payment plan. Physicians also must give a cost estimate in advance to patients who are paying all or part of the cost of treatment out of their own pockets.

Hospitals similarly are required to inform patients that they may be seen by out-of-network physicians and make arrangements for payment plans.

Health plans must publish in any of their product literature information that patients may be responsible for out-of-network charges. If a plan sends a statement to a patient indicating that he or she has seen an out-of-network physician, the plan must give the patient the Texas Department of Insurance (TDI) Consumer Protection Division's telephone number so that he or she can complain about the amount the health plan paid.

Finally, the bill sets up a network adequacy study group within TDI and requires development hospital, physician, and health plan report cards so consumers can compare prices.

Dr. King applauded Senator Duncan's willingness to work with TMA and other stakeholders to come up with a balanced approach to the transparency issue. And Dr. Gros says the final legislation was a "very positive step that we were able to achieve."

Also on the health plan front, lawmakers passed legislation creating a pilot program to test the use of "smart card" technology to deliver real-time information between physicians and health plans on patients' health coverage, deductibles or copayments, and other information.

The legislature also approved a bill by freshman member Rep. John Zerwas, MD (R-Richmond), that will spare some patients from out-of-network charges. Under the bill, a physician who joins a group practice already in a health plan's network would be paid as an in-network physician while the credentialing process is under way.

For more on health plan transparency, see " A Clear Win ."



Getting the Fat Out  

While Medicaid funding and the Frew  settlement grabbed much of the headlines this session, lawmakers put a lot of emphasis on public health issues, as well.

The legislature passed a TMA-backed bill by Senator Nelson that strengthens physical education (PE) requirements in middle school and mandates an annual physical fitness assessment of students in kindergarten through grade 12. It also approved legislation by Rep. Dianne Delisi (R-Temple) to create worksite wellness programs for state employees. The measure establishes a Worksite Wellness Advisory Board under the Texas Department of State Health Services and calls for biannual studies of existing worksite wellness programs to determine best practices. The advisory board will include a TMA representative.

Senator Nelson says she thinks the new PE requirements could have the most immediate impact on improving health in the state.

"We desperately need to restore basic health and exercise in our schools to prevent our young people from becoming the first generation in modern history to live shorter lives than their parents," she said.

While she was pleased lawmakers passed her worksite wellness bill, Representative Delisi was disappointed they did not provide funding for wellness programs in the budget. She plans to work with the executive branch to try to find other funding, she says.

Representative Delisi is a "big believer in primary preventative care" and thinks wellness initiatives ultimately will cut state health care costs.

On another front, legislators recognized the need to improve the availability of public mental health care by investing $82 million in state funds to improve community and crisis stabilization services.

But probably the most significant action was passage of legislation creating the Cancer Prevention and Research Institute of Texas and a proposed constitutional amendment to sell $3 billion in general revenue bonds to fund cancer research, prevention, and treatment. The proposed constitutional amendment authorizing the bonds will be on the ballot for voter approval in November. (See " TMA Takes on Cancer .")

TMA counts approval of the cancer research initiative among its top legislative achievements this session, and Senator Nelson says the research institute eventually could extend the lives of nearly 90,000 Texans who are diagnosed every year with some form of cancer.



More Wins  

TMA had success on a number of other fronts. Most notably, medicine won almost $35 million in new graduate medical education funding over the last biennium, helped secure needed funding for the Texas Medical Board to hire additional staff to clear a backlog in licensing applications, and gained significant workers' compensation reforms that will require peer reviewers to be Texas-licensed physicians and in a specialty appropriate to the care being reviewed. (For more on graduate medical education funding, see " Keeping Them Home .")

Beaumont orthopedic surgeon David Teuscher, MD, says those reforms will add some accountability to the workers' compensation peer review process by making reviewers subject to oversight by the Texas Medical Board.

"Hopefully, this will stem the tide of abuse that continues to go on and streamline the system so that it works for both the injured workers as well as the physicians who are trying to take care of them," he said.

And, TMA won reforms in the new state business tax that will lessen the potential tax burden on some physicians, while maintaining the tax credits for physicians who care for Medicare, Medicaid, uninsured, workers' compensation, and other patients.

TMA also worked closely with Representative Delisi on legislation to establish a public-private partnership known as the Texas Health Services Authority to serve as a catalyst for creating a seamless interoperable electronic medical record (EMR) system in Texas.

Representative Delisi says that the critical issue for physicians and other stakeholders in developing EMRs is interoperability and that bringing a private component into the effort is critical to ensuring interoperability.

"It became apparent to me that we could not do electronic records within state government," she said. "It had to have a private component that is at the cutting edge of all of this software."

Other issues, such as privacy, ownership of the medical records, and compliance with the federal Health Insurance Portability and Accountability Act will be studied as the bill rolls out, Representative Delisi says.



On the Defensive  

Possibly even more significant is what TMA prevented from passing. Trial lawyers made a run at the 2003 medical liability reforms with legislation that would have lowered the burden of proof in liability cases involving emergency care. (See " Tort Reform Protected .")

Under the 2003 reforms, plaintiffs must prove that gross negligence occurred in emergency cases. A bill filed by Sen. Rodney Ellis (D-Houston) would have lowered that standard to simple negligence.

The bill was approved unanimously by the Senate State Affairs Committee but went no further.

An effort by chiropractors to gain authority to perform school physicals also failed. Chiropractors were able to amend a bill in committee to add language granting them authority to do physicals, but TMA convinced lawmakers to remove that provision. TMA also succeeded in adding language to another bill banning chiropractors from doing school physicals, but it was later stripped off the bill.

In addition, TMA defeated measures to expand the number of advance practice nurses and physician assistants that a single physician could supervise at retail health clinics. That measure also would have reduced the amount of time supervising physicians would have to spend on site at such clinics.

TMA leaders credit the PatientsFirst Coalition with playing a major role in keeping scope issues off the agenda. The coalition, created two years ago by TMA and some two dozen specialty societies, gives physicians a forum to talk to lawmakers with one voice on scope issues, they say.

Arden Aylor, MD, a former chiropractor who recently completed a stint as chief resident at Scott and White Hospital in Temple, testified on the chiropractor bills on behalf of TMA. He says chiropractors simply don't have the training or experience to detect pathological issues that could put student athletes' health at risk.

"If we're trying to decide if a kid has the dexterity to participate in sports, then chiropractors are great at that," Dr. Aylor said. "They do well with musculoskeletal stuff. But if we're trying to uncover an undiagnosed pathology that may put these kids at risk, then they don't have the adequate training."

Dr. Gros says this session saw few attempts by allied health practitioners to expand their scope of practice, but that could change in 2009. A moratorium on scope expansions agreed to several years ago between TMA and advance practice nurses expires after the current legislative interim, and Mr. Kronberg of the Quorum Report says nurses and other practitioners are already talking among themselves about potential scope agendas.

"I don't know whether a serious coalition is going to emerge next session, but there is at least some talk of the scope-of-practice challengers trying to come on as a united front," he said.

Regardless of how scope issues develop, medicine is well prepared to confront the issues with a united voice through the PatientsFirst Coalition.

"We're obviously looking ahead to next session," Dr. Gros said. "With the drop of the moratorium, it's going to be open season on scope again."

The ability to celebrate successes on the legislative front is short lived. The fight for the 81st session has already begun with the upcoming campaign cycle.

"The challenges facing medicine are more acute today than ever. We are finding it more and more difficult to care for our patients. We must be proactive legislatively to ensure our patients can get the care they need and deserve," said Manny Acosta, MD, the 2008-09 chair of the Texas Medical Association Political Action Committee (TEXPAC). "As such, if you are engaged in the practice of medicine, then you are involved in the politics of medicine. The decision to participate is yours. I am asking that each of you take up this call to action and participate in TEXPAC so that we can elect legislators who will help medicine address these challenges."

Ken Ortolon   can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon.  




Physician Testimony Plays Key Role in Legislative Victories

Arden Aylor, MD, says he used to just sit back and gripe about things going on in health care that he didn't like. Then he decided those problems might be at least partially his fault for not getting involved in medical politics and voicing his opinion.

So he got involved.

Dr. Aylor, a former chiropractor, was one of dozens of Texas physicians who helped secure legislative victories for organized medicine this year by testifying before House and Senate committees.

"It was a little stressful," said Dr. Aylor, who made his first appearance before a legislative committee when he testified on a chiropractic scope-of-practice bill, "but it was something I felt passionate about and had experience in with the scope of practice of chiropractors."

Darren Whitehurst, director of Texas Medical Association's Division of Public Affairs, says the importance of having a physician serve as the face and voice of medicine before the legislature cannot be overstated.

"You're talking about a citizen legislature for the most part, and they certainly are not going to understand what happens in real life in a doctor's office," Mr. Whitehurst said. "Most of the members of the legislature have no idea what goes on in the day-to-day practice of medicine. So it is critical to put a face on what is happening to physicians on a day-to-day basis."

Former TMA President Jim Rohack, MD, says testifying before legislative committees can be nerve-racking if you've never done it before.

"The first time is always intimidating," said Dr. Rohack, a member of the American Medical Association Board of Trustees. "You're in a crowded hearing room, the legislators sit on an elevated platform looking down on you, and you may have to wait hours for your turn to address the committee."

In fact, there are many uncertainties for those who are testifying. Most committee hearings are held on adjournment of the House or Senate for that particular day. If House or Senate sessions run long, the start of the hearing can be delayed. And, if the committee has a lengthy agenda or a hot issue that draws a lot of interest, the hearing could extend into the wee hours of the morning.

Also, committee members frequently come and go from hearings to meet with constituents, attend other committee meetings that are going on at the same time, or carry out other business. So, a physician may get to give his or her testimony to only one or two lawmakers.

Finally, witnesses can face tough questioning from the lawmakers, particularly lawmakers who are on the opposite side of the issue.

Dr. Rohack, who testified this year on Medicaid and the uninsured at the initial meeting of the House Public Health Committee, says those factors may be disconcerting to physicians but are just part of the process. Physicians who want to get involved in the legislative process should not let those factors stand in their way, he says, adding that TMA advocacy staff members do a good job preparing physicians on the issues at hand and what to expect from the committee.

Austin orthopedic surgeon Stephen Norwood, MD, also has been a frequent participant in legislative hearings, particularly on workers' compensation issues. He says physician testimony can have tremendous influence if the doctor can tie the issue to specific patient-physician experiences.

"The more a physician can draw on an experience he's had in the last couple of weeks, especially a patient encounter experience, the more engaged these committee members seem to be," Dr. Norwood said.

Dr. Aylor's experience as a former chiropractor made him uniquely qualified to testify about the pitfalls of legislation that would have allowed chiropractors to perform school athletic physicals.

"Ten years ago if you had asked me about this, I would have been on the other side of the fence," Dr. Aylor said. "But knowing what I know now and didn't know then about the subtle changes in heart rhythms when you're listening to somebody with a stethoscope and knowing whether something's physiological or pathological, these are things that it takes experience to learn, not just a course on physical exams."

Dr. Rohack believes his testimony helped frame for lawmakers the challenges faced by both physicians and patients in Medicaid and CHIP.

"Clearly, physicians felt in a difficult position of trying to take care of patients but also keep their offices open," he said. "The reimbursement rates were woefully inadequate. But more important, the administrative hassles that patients and their families have to go through trying to get good care and having to fill out onerous forms just wasn't making a lot of sense in terms of getting the best possible care, especially for patients with chronic diseases. So I was pleased that as a result of framing the situation for lawmakers, we helped convince them ultimately to do the right thing."

Dr. Aylor says he definitely would represent medicine again.

"I really enjoyed it. I learned so much," he said. "That was the amazing thing - learning how the process really works."

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First Tuesdays Vital to Medicine's Legislative Success

Nearly 1,000 physicians, medical students, Texas Medical Association Alliance members, and county medical society executives turned themselves into lobbyists, at least for one day, to help organized medicine score major victories in the Texas Legislature.

Some 915 members of the TMA family took time out from their practices, their studies, and their lives to participate in First Tuesdays at the Capitol, TMA's successful grassroots lobby program that for the past three sessions has blanketed the Capitol with white coats on the first Tuesday of each month during the legislative session.

Organized each session by the TMA Alliance, First Tuesdays has become such an integral part of TMA's lobby efforts that it has become something of an institution in Austin and now serves as a model for programs being started by medical societies in other states.

"I don't think we can overestimate the importance of First Tuesdays," said Fort Worth pathologist Ladon W. Homer, MD, immediate past president of TMA. "We've had numerous legislators - some who had not been very familiar with TMA activities in the past - say to us that this showing of white coats in the Capitol was an extremely important event in helping them make certain decisions. I have had in the past many of these folks tell me that of all the things that TMA does in the legislative arena, this First Tuesday effort with white coat participation in the Capitol is the most important activity."

Susan Todd was TMA Alliance president in 2003 when First Tuesdays was launched, and she chaired the First Tuesdays program this year. She says no one realized then "the huge impact the program would have."

"As many of you may remember, 2003 was the year when medicine scored an astounding victory in our struggle for tort reform," Ms. Todd told participants at the February First Tuesdays event. "And then our efforts with Proposition 12 made the legislation 'stick' as the Texas constitution was changed to make the legislation binding. In 2005, medicine was able to fend off scope-of-practice attacks and keep a business tax at bay."

TMA held four First Tuesdays events this year, during which physicians, alliance members, medical students, and county medical society executives met at the TMA building for legislative briefings, then fanned out around the Capitol to visit with their lawmakers on key health care issues.

In March, the TMA Alliance also sponsored an AMPAC campaign school the Monday before the First Tuesdays event. The campaign school, which AMPAC only offers to two state medical societies each year, drew 117 participants.

Dr. Homer participated in all but one of the First Tuesdays events this year. He says the program has become so important to medicine's success in the legislature that "you're not likely to see us give it up any time soon."

Dr. Homer says First Tuesdays truly complements the more traditional grassroots efforts that always have been at the heart of TMA's legislative advocacy program.

"What we have seen is that most of the people who have already been active at the grassroots level with their legislators at home come to the First Tuesdays events and help us in that program," he said. "However, one of the things we've also seen is that there are a lot of new faces. Folks who have not been involved in legislative efforts on the county level are now coming to First Tuesdays and they're telling us they're going back and are going to make those contacts back at home with their legislators. All of that is extremely important as this momentum builds."

TMA and the TMA Alliance will once again sponsor First Tuesdays at the Capitol during the 81st Texas Legislature in 2009. Those events will be held on Feb. 3, March 3, April 7, and May 5.

For more information on First Tuesdays, contact Sandy Solis with the TMA Alliance at (800) 880-1300, ext. 1328, or (512) 370-1328, or by email at  Sandy Solís .



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