Guided by a set of priorities and girded by grassroots physician advocacy, the Texas Medical Association entered the 2023 legislative session with a laser focused approach and came out hitting targets in every area of medicine’s agenda.
That success included bringing to fruition several multi-session efforts, even amid a record-breaking number of bills filed and inter-chamber conflict over diverging priorities that threatened to sideline health care issues.
TMA’s new tactical lobby team attributes these wins to a novel approach to advocacy; medicine’s allies at the Capitol; and, most importantly, a groundswell of grassroots support.
More than 450 physicians, medical students, and alliance members attended First Tuesdays at the Capitol – the association’s signature advocacy event; 61 physicians showed up to testify at the Capitol; and more than 1,700 emails and calls were sent or made to educate lawmakers on TMA’s top issues.
For the first time, TMA’s Council on Legislation culled a top-10 list of those legislative priorities, a strategy Tilden Childs, MD, a radiologist in Fort Worth and chair of TMA’s Council on Legislation, described as critical to managing the 2,000-plus health care-related bills filed this session. (See “The Top 10,” page 22.)
“There are always other issues that come up that are going to be important,” he told Texas Medicine. “But the top-10 list was a very good guide.”
As important, the list helped lawmakers understand where medicine stood firm, says TMA Vice President of Advocacy and Chief Lobbyist Clayton Stewart.
Ultimately, TMA delivered on each of those goals, having maneuvered around a minefield of sensitive topics, says TMA Immediate Past President Gary Floyd, MD, a pediatrician in Corpus Christi who presided during the 2023 legislative session.
“You have to have a realistic view of the political environment we’re in,” he said. “Based on [that], we made significant headway for physicians in Texas.”
In some cases, the session resulted in an outright defensive win, such as the total shutout of any legislation that would have expanded scope of practice for nonphysician practitioners (NPPs).
“It was a very, very good session, maybe the best we’ve ever had, with stopping the scope bills,” Dr. Childs said.
In other cases, TMA built on the success of past sessions – such as achieving 12 months of postpartum coverage and targeted payment increases under Medicaid, and new network adequacy protections – or laid the groundwork for future legislative gains.
For instance, TMA sensed an opening this session given the U.S. Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization regarding abortion, which prompted lawmakers to look more closely at funding health services for women and children.
Because it is the state’s largest budget line item, lawmakers often resist adding to Medicaid expenses, says Caitlin Flanders, TMA’s lobbyist on women’s health and budget issues.
Despite this resistance, TMA swayed lawmakers on targeted rate increases given the anticipated baby boom and long-standing access issues. Medicine also pointed to evidence showing Texas physicians caring for Medicaid patients hadn’t seen a cost-of-living adjustment in 20 years, meaning they essentially had taken a pay cut.
The 2023 legislature’s receptiveness suggests a piecemeal approach could work again in future sessions. “With everything in the legislature, especially in Texas, it’s baby steps,” Ms. Flanders said.
TMA’s evidence-based approach helped medicine navigate another challenge this session: the increasing complexity of TMA’s legislative goals – and those of its opponents. TMA frequently had to educate lawmakers about the unintended consequences of proposed bills as well as the sometimes-false claims underlying them.
On the scope front, this meant pushing back against NPPs’ argument that scope expansion was necessary given Texas’ physician workforce shortage.
Michelle Romero, TMA’s lobbyist on scope issues, stressed this purported solution would do little to ameliorate the shortage while removing physicians from the health care team and relegating patients to a lower standard of care.
“This session gave us the opportunity to help lawmakers understand the unintended consequences [of such efforts] using evidence,” she said, pointing to a growing body of research on the subject that TMA relied upon during those discussions. “If there’s a problem with access in rural Texas, then we have to train up more doctors to practice there.”
Anticipating an uphill battle – nurse and health plan groups used the same lobbyist, Mr. Stewart pointed out – TMA also sought and won grant funding from the American Medical Association’s Scope of Practice Partnership to hire an additional lobbyist dedicated to preventing scope creep.
This multipronged strategy paid off. None of the 134 scope-related bills filed this session passed, and the legislature granted what Ms. Romero describes as a “windfall” for the graduate medical education (GME), rural residency, and medical education loan repayment programs TMA strongly advocated for as sustainable workforce solutions.
On the public health front, TMA similarly worked to educate lawmakers about certain vaccine-related bills – and their potentially chilling side effects.
Matt Dowling, TMA’s lobbyist on public health issues, says many such bills were informed by opposition to COVID-19 vaccine mandates issued during the earlier stages of the pandemic. Whereas in past sessions TMA’s conversations with lawmakers centered on the science, this year’s discussions revolved around the unrelated, yet far-reaching consequences of certain bills proffered, such as new liability threats and exacerbation of network inadequacies.
On insurance matters, TMA’s task was to expose the disingenuous framing behind some health plan-backed bills that purported to lower patients’ out-of-pocket health care costs – a major focus for lawmakers this session, says TMA lobbyist Ben Wright. But those goals would have been achieved by eschewing meaningful, quality coverage and existing patient-physician protections.
TMA’s grassroots army helped get that message across in fending off the dozen or so bad health insurance bills filed this session. For instance, with House Bill 2414 – which would have allowed health plans to steer patients – “the direct feedback we got from lawmakers was that those phone calls [from physicians] made the difference,” Mr. Wright said.
TMA’s fresh new approach would not have paid off were it not for medicine’s long-standing relationships with state lawmakers and a network of physician testifiers, alliance advocates, and other supporters, all of whom Mr. Stewart says were “massively important” and “paramount” to this session’s success.
Inside the Pink Dome, TMA worked closely with Texas’ five physician legislators, many of whom made appearances at this year’s First Tuesdays at the Capitol events along with nonphysician allies like Reps. Ann Johnson (D-Houston) and Toni Rose (D-Dallas).
“We are still one of the most, if not the most, respected professions in the building,” Rep. Tom Oliverson, MD (R-Cypress), an anesthesiologist and chair of the House Insurance Committee, said during the Feb. 7 event. “Whether you’re Republican, Democrat, [or] independent, when doctors put their white coats on and come in the doors of the Capitol and visit with offices, the staff and legislators know, ‘There is a medical expert [here]. This is someone I can feel safe [with] to ask a question.’”
TMA relied on lawmakers like Representative Oliverson, who fought scope expansion on the House floor; Sen. Donna Campbell, MD (R-New Braunfels), an emergency physician who worked tirelessly to kill the only scope bill to make it to the Senate floor; Rep. Suleman Lalani, MD (D-Sugar Land), who championed GME funding increases during his first term with the help of Rep. Greg Bonnen, MD (R-Friendswood), chair of the House Appropriations Committee; and Sen. Charles Schwertner, MD (R-Georgetown), who with Representative Bonnen helped pass the TMA-backed network adequacy reform bill.
Throughout the session, TMA physicians, medical students, and alliance members visited all 181 legislative offices during its First Tuesdays events.
“It helps lawmakers know that if they vote for a scope bill, they’re voting against a physician in their district,” Ms. Romero said.
Mr. Stewart also points to the influence of individual physicians.
Like the 60 other physician-testifiers this session, TMA Council on Legislation Chair Dr. Childs took time off from his Fort Worth practice to be in Austin. The frequency of his visits – in each week of the session – earned him a nickname among the lobby team: The Intern. Other physicians placed calls to their representatives at key moments, sometimes finding them on the House floor just before a vote.
The job of advocacy is not limited to the 140 days of the regular Texas Legislature, which as of this writing went into the second of several expected special sessions.
Dr. Floyd says TMA members continue to play a critical role during the interim, during which they can visit with their representatives and senators in a “relaxed atmosphere” and establish themselves as a resource ahead of the next go-round.
“We have to be vigilant.”
The Top 10
Physician-Led Results #1: Scope Creep/GME Funding
Physician-Led Results #2: Women's Reproductive Health
Physician-Led Results #3: Medicaid Payment Increase
Physician-Led Results #4: Medicaid Coverage for Women and Children
Physician-Led Results #5: Medical Liability Reforms
Physician-Led Results #6: Physician Autonomy/Corporate Practice of Medicine Protections
Physician-Led Results #7: Prior Authorization Reforms
Physician-Led Results #8: Vaccines, ImmTrac2 Modernization
Physician-Led Results #9: Network Adequacy, Surprise Billing
Physician-Led Results #10: E-Cigarette Regulation and Taxation