The 2009 session of the Texas Legislature opened session Jan. 13 but lawmakers didn't exactly bolt from the starting gate like thoroughbreds. Political observers say the legislature is off to a slow start, due largely to the transition to a new speaker of the House. This, coupled with a tight budget situation, may have dampened lawmakers' enthusiasm for passing a lot of legislation this session.
Still, organized medicine has staked out an ambitious agenda of issues it wants lawmakers to address, including requiring more transparency in the health insurance market, boosting physicians' pay in Medicaid, protecting tort reforms, defending the ban on the corporate practice of medicine, and fending off efforts by nonphysician practitioners to expand their scope of practice. Physicians already are taking their message on those and other issues directly to lawmakers. Read all about those issues and the Texas Medical Association's 2009 legislative agenda in Doctor's Orders .
Meanwhile, on Feb. 3, TMA kicked off this year's First Tuesdays at the Capitol program and saw more than 200 physicians in white coats, TMA Alliance members, and county medical society officials flood the capitol.
As of mid-February, both the House and Senate still were trying to organize for business. After much consternation following the November election, the House elected Rep. Joe Strauss (R-San Antonio), as expected, speaker of the House, replacing Rep. Tom Craddick (R-Midland) who had served in that role since 2003.
The transition to a new speaker slowed the pace of business in the House as he worked to hire necessary support staff and appoint House committees, which occurred on Feb. 12.
TMA leaders anxiously awaited appointment of several key committees that will hear many of medicine's issues this session. They were delighted to see the appointment of Rep. Jim Pitts (R-Waxahachie) to chair the House Appropriations Committee, Rep. Lois Kolkhorst (R-Brenham) to chair the Public Health Committee, and Rep. John Smithee (R-Amarillo) to return as chair of the Insurance Committee.
Two of medicine's own, Reps. John Zerwas, MD, and Susan King, a TMA Alliance member, also were named to the House appropriations and public health committees.
On the Senate side, Lt. Gov. David Dewhurst announced his committee assignments in early February, and most of those committees have already held their organizational meetings.
Sen. Jane Nelson (R-Flower Mound) once again chairs the Senate Health and Human Services Committee, and Sens. Bob Duncan (R-Lubbock) and Steve Ogden (R-Bryan) remain as chairs of the Senate State Affairs and Senate Finance Committees, respectively. Lieutenant Governor Dewhurst also created three new committees, including a new Senate Higher Education Committee, chaired by Sen. Judith Zaffirini (D-Laredo), a long-time champion of many of medicine's issues.
TMA leaders say the Senate State Affairs Committee again will be a key panel for many health care issues, including health insurance company transparency, medical liability, and potentially even the corporate practice ban.
The fact that the Texas Department of Insurance (TDI) is going through the sunset review process this year likely will provide an opening for TMA to address transparency, silent PPOs, economic credentialing, and other insurance issues in another venue. Sunset bills, including the TDI sunset legislation, likely will go through the Senate Government Organization Committee, chaired by Sen. Rodney Ellis (D-Houston).
Where's the Money?
TMA leaders say the budget debate likely will dominate the entire session, and the budget outlook is increasingly bleak. State Comptroller Susan Combs estimates lawmakers will have $9 billion less in state general revenue to spend than they had in the 2008-09 biennium, and some lawmakers say they may need to dip into the state's Rainy Day Fund simply to maintain current services. Already, Speaker Straus and Lieutenant Governor Dewhurst have asked state agencies to help identify ways to trim 2.5 percent from the general revenue portions of their budgets.
Austin obstetrician-gynecologist Albert Gros, MD, chair of TMA's Council on Legislation, says advocating any spending increases in the current budget environment will be problematic. However, TMA will continue to seek increased Medicaid physician fees, additional funding for graduate medical education, an expanded physician loan repayment program to encourage doctors to practice in underserved areas, and other funding priorities.
The Texas Health and Human Services Commission (HHSC) estimates it needs at least $2.6 billion in additional funding to cover caseload growth in Medicaid. A preliminary budget prepared for the Senate by the Legislative Budget Board, however, included only $2 billion in new funding for HHSC and not all of those dollars would go to Medicaid.
While lawmakers are already looking at some spending cuts, they may get some budget relief from the economic stimulus package passed in Congress. That bill includes billions of dollars in funding to help states with health and human services, transportation, and public and higher education. Some estimates say Texas would receive up $15 billion from the stimulus bill, including $5 billion for health and human services, including Medicaid.
Meanwhile, Gov. Rick Perry declared as an emergency item a supplemental appropriation to state agencies and institutions for response and recovery from last year's hurricanes. The emergency declaration allows lawmakers to take up that item immediately. That supplemental appropriations bill almost certainly will include funding for The University of Texas Medical Branch in Galveston, which suffered more than $700 million in damage from Hurricane Ike.
While legislation on many of medicine's issues has not yet been filed, at least one fight is shaping up. One proposed bill allows independent practice by nurse practitioners, while a second bill increases from three to eight the number of nurse practitioners or physician assistants that a physician can supervise.
TMA opposes independent practice for nurse practitioners, but is working with retail clinics on compromise legislation that would increase the number of midlevel practitioners a physician can supervise. As part of that effort, however, TMA wants to ensure that the physician remains accountable for the decisions of the nurse practitioners or other physician extenders he or she supervises. That could include requiring the Texas Medical Board to collect information on these practice arrangements.
"As we focus on the health care delivery model, the health care team, and the physician as the leader of the team, we've got to get a better handle on making sure that physicians are actively involved in the clinical decision-making and whether patients are receiving quality care in an accountable delivery in the system," said Darren Whitehurst, TMA vice president of public affairs.
Lawmakers may have started slowly but TMA's lobby activities have not. A record crowd of 215 physicians, TMA Alliance members, and county medical society officials participated in TMA's First Tuesdays at the Capitol on Feb. 3. The white coat brigade fanned out around the capitol, meeting with a number of key lawmakers about medicine's issues.
Since bills on a number of TMA's issues have not yet been filed, most of the discussions focused generally on TMA's priorities for health insurance reforms, Medicaid and medical education funding, taxes, tort issues, and others. TMA leaders say future First Tuesdays events will focus on specific legislation and target members of key House and Senate committees. Remaining First Tuesdays for this session are March 3, April 7, and May 5.
Check out the latest Podcast TMA , "The Magic of First Tuesdays."
Texas Medicine Senior Editor Ken Ortolon prepared this special addition to Action .