10 questions for TAFP’s lobby team

By Jonathan Nelson

This session promises to be one of the toughest in years, with the state facing an enormous budget shortfall, physicians under siege by nurse practitioners seeking independent practice of medicine, the sunset of several major agencies including the Texas Department of Insurance, and—oh, by the way, it’s a redistricting year.

To get a 30,000-foot perspective on what can be expected from the 82nd Texas Legislature, we asked 10 questions of TAFP’s crack lobby team as well as the Academy’s CEO, Tom Banning.

The lineup:

Marshall Kenderdine
Representing TAFP under the dome since 2006, Kenderdine is a former aide to two chairmen of the Texas House Appropriations Committee, including the committee’s current chair, Rep. Jim Pitts, R-Waxahachie. Kenderdine managed the initial campaign for office of Rep. Byron Cook, R-Corsicana, and served as legislative aide to former Sen. Todd Staples, the state’s current commissioner of agriculture.

Dan Hinkle
A longtime advocate and fixture on the Texas political scene, Hinkle joined the TAFP lobby team before the 2009 legislative session. He has represented some of the state’s most powerful interests, including several companies in the oil and gas industry.

Kurt Meachum | Jerry Philips
After many years of working in and around the Texas House for multiple Democratic members, Kurt Meachum and Jerry Philips joined forces in 2009, hanging a shingle under the name Philips & Meachum Public Affairs. They have each served as chair of the House Democratic Campaign Committee, thereby playing an integral role in electing the vast majority of House Democrats. Last session, they took up the cause with TAFP, helping get the new physician education loan repayment program through the House.

Tom Banning
Banning came on board as a lobbyist for the Academy in 1998, and took over the helm as CEO in late 2007. This session will be his seventh serving as an advocate for the family physicians of Texas.

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Q1) Facing a possible $18 billion budget shortfall, how likely is it that physicians will suffer a pay cut in state health care programs and why?

KM: It is certainly a possibility. When you face a budget deficit this large, everything is on the table. The two biggest pieces of the state budget are health and human services, and education. If you subscribe to the belief that the votes do not exist for a tax bill, then there are only two other ways to bridge the budget gap: new sources of revenue and budget cuts.

MK: Physician fees under Medicaid and CHIP will come under serious scrutiny, but since providers already received a 1-percent reduction in the current biennium, and since HHSC has testified to legislative leaders about the negative implications associated with further reductions, there is some hope.

Q2) In what other ways do you expect the state to make up the deficit that might affect Texas’ patients and family medicine practices?

JP: I think you’ll see a combination of accounting gimmicks, new and increased fees—not to be confused with taxes—new revenue sources like gaming, potentially, perhaps some privatization of state services, and a host of other budget cuts. Graduate medical education, statewide preceptorship programs, and physician education loan repayment programs are among the funds we’ll be fighting to protect.

MK: Like 2003, legislators could try to implement tactics in the public health programs like waiting lists, enrollment verification, means tests—anything to push more people off the Medicaid and CHIP rolls.

DH: My sense is everything that we are getting now will be on the table for discussion, so we really need to look at our priorities and know early on what our list is.

Q3) What is redistricting, why is it important, and how do you predict it will affect what organized medicine can achieve this session?

KM: Every 10 years states use new census information to redraw congressional and legislative boundaries to ensure equal and fair representation. Nothing is more important to elected officials than redistricting and the overall make-up of their own districts, which means redistricting sessions are extremely contentious, partisan, and unproductive.

JP: When you consider the fact that along with redistricting, this session features an $18 billion budget deficit, it’s unreasonable to expect any other major piece of legislation to make it through both chambers.

Q4) How will the new health care reform law come into play this session?

TB: Despite a lot of political rhetoric, the Health and Human Services Commission and the Texas Department of Insurance are already working on how to implement federal health care reform legislation in Texas and will make recommendations to the Legislature on needed statutory changes, which will range from building a health insurance exchange to piloting different payment models in Medicaid.

DH: We do have to keep in mind that there are a number of legislators who see the new health care reform bill as a huge drain on the budget, and there will be those who will want to postpone action on it under the belief that Republicans will take the Congress and repeal it.

Q5) Will any major managed care issues be on the docket this session?

TB: Yes and no. The Texas Department of Insurance is up for sunset, meaning every law governing the oversight of managed care operations from prompt payment to standardized credentialing will be up for review and open to hostile amendments. Additionally, there will be a concerted effort to roll out an HMO Medicaid model in the Rio Grande Valley.

Q6) What is sunset, and what do you predict for TDI in the process?

KM: Every 12 years, state agencies go through the sunset process in which the Sunset Commission looks at whether the agency is achieving its core purpose. TDI is up for sunset again after the TDI sunset bill failed to pass last session.

JP: Democrats believe that the insurance industry is a liability for Republicans, and they will be pressing hard to ensure that this bill comes to the floor where hundreds of amendments will likely be offered to force folks to take politically difficult votes. I think the bill will come to the floor this session, and there will be fireworks.

DH: Lots of folks have real problems with the insurance industry and TDI, so when that bill is on the House and the Senate floors, we should expect a real battle and we shouldn’t be surprised that some of those amendments hurt rather than help the process.

Q7) What should TAFP members expect from the advanced practice nurses?

JP: All-out war. Unless it gets bottled up in committee, you should expect a huge fight on scope of practice. The nurse practitioners have only one request: independent practice including diagnosis and treatment. It’s tough for an elected official to say no when a constituency asks for only one thing.

DH: Right now they have no downside to their strategy, and they have not indicated that there is any middle ground.

Q8) What are the difficulties of fighting a scope of practice battle, or any other turf war in the Legislature?

MK: Legislators don’t like to get in the middle of a fight between competitors in a market. No matter who wins the fight, the legislator makes enemies of the losing side, and refereeing a scope battle goes against most legislators’ belief that it’s better to let these sorts of problems work themselves out in the marketplace.

DH: In this particular fight, we are somewhat the victims of our own success. We did a wonderful job of educating the Legislature on the need to address medically underserved areas. Now the nurses are using that very issue against us to argue that they should be allowed to expand their scope of practice to provide care to the underserved.

Q9) Given the chaos and complexity of a session encompassing redistricting and a massive budget shortfall, what would constitute a successful session for organized medicine—and family doctors in particular?

DH: My list is short. Defeat of the scope of practice bill and stay even in the budget process, and we’ll have achieved success.

MK: I’d add that lawmakers block any adverse changes to TDI.

Q10) We’re asking members to sign up as Key Contacts, to serve as Physician of the Day, to stay informed on the issues, to become members of the TAFP Political Action Committee, and to nurture relationships with their legislators. Do these tactics work for associations in effecting positive policy changes?

MK: Absolutely they work. Look at the physician loan repayment bill passed last session. Because legislators constantly heard from their physician constituents on the need to ensure more medical students go into primary care, we were able to pass a bill that was opposed by nearly $2 million worth of big tobacco lobbyists.

DH: When a family doctor calls their legislator, that legislator listens and in most cases does everything he or she can to honor the request. Building those relationships with your representative and senator can be the difference in our efforts to pass or defeat legislation.

TB: The most powerful legislative advocacy begins and ends with a strong grassroots effort. The cynic will argue that politics is a fixed game and lobbyists are all-powerful. The truth is lobbyists are a dime a dozen in Austin; they’re important in that they help open the doors and explain the rules of the game, but it is the constituents back in the district to whom legislators ultimately have to answer. When you think about how complex and far-reaching health care policy is, legislators desperately want to hear from family physicians. They are listening and they want feedback.