The 82nd Texas Legislature: Game on!

By Jonathan Nelson

The opening bell has rung and the gavel has dropped in Austin as lawmakers grapple with a massive budget shortfall, the sunset of several important state agencies, a divisive voter identification measure, and what is certain to be a vicious backroom brawl over redistricting.

Topic number one on everyone’s docket is passing a balanced budget for the 2012-2013 biennium. On opening day, the Senate’s chief budget writer, Sen. Steve Ogden, R-Bryan, delivered a stark assessment of the difficulty of that task as he was sworn in as president pro tempore of the Texas Senate. Earlier that week, Texas Comptroller Susan Combs had announced that general revenue for the 2012-2013 biennium will likely be $72.2 billion, $14.8 billion less than the general revenue budget for the current biennium. She estimated the shortfall in the current biennium would be $4.3 billion, but she did not quantify the size shortfall expected in the next biennium.

Ogden told the audience in the Senate chamber that since 81 percent of general revenue appropriated by the Legislature goes to education and health and human services, it is impossible to balance the budget without cutting those two areas. “How we deal with Medicaid will determine how the rest of the budget goes,” he said.

Last session, lawmakers appropriated $44 billion in all funds to the Medicaid program; 70 percent of that came from the federal government and 30 percent came from the general revenue budget. The federal match was richer than usual because it included money from the federal stimulus package. Ogden predicted the match in the next biennium would be closer to 60:40, a difference of approximately $4.5 billion. “Our first job, senators, is to figure out how to save Medicaid.”

The exact size of the budget shortfall confronting lawmakers is a point of contention. The Center for Public Policy Priorities has calculated the cost of providing existing levels of services in the coming biennium at $99 billion, which puts the shortfall at $26.8 billion.

Talmadge Heflin of the Texas Public Policy Foundation argues that figure is based on the assumption that the state should continue providing the same level of services as in the past. He says the impending shortfall is somewhere between $12 billion and $16 billion, according to a story by John Reynolds of Quorum Report.

Gov. Rick Perry, Lt. Gov. David Dewhurst, and House Speaker Joe Straus have pledged to balance the budget without raising taxes and without tapping the $9.4 billion Rainy Day Fund, and the base budgets introduced in both the House and the Senate seek to do just that. The House budget would spend $156.5 billion in all funds in 2012-2013, $31.1 billion less than in the current biennium, while the Senate version would spend $158.7 billion, a reduction of $28.8 billion from current spending. Neither budget assumes any caseload growth in Medicaid and CHIP, even though the Commission on Health and Human Services estimates Medicaid will swell by more than 200,000 by 2013.

Both budgets cut Medicaid and CHIP provider rates by 10 percent. That comes on top of a 2 percent cut in the current biennium. HHSC Commissioner Tom Suehs has made it clear to lawmakers that such reductions will restrict access to patients as physicians are forced to limit their participation in the programs. He suggested that the Senate Finance Committee spare primary care physicians the full weight of the proposed cuts. “I’m really concerned about having to cut primary care rates for physicians treating children,” he told the committee on Feb. 1. “We’ve already cut 2 percent this biennium from when y’all wrote the [2010-2011] budget. I believe that’s about as far as I can tolerate to maintain the access to primary care so I’m asking to put back not all 10 percent, but 8 percent.”

Both budget drafts also include significant savings from implementing bundled payments in Medicaid, rolling out Medicaid managed care in the Valley, reducing ER utilization in Medicaid and CHIP, cuts to mental health programs, and a host of other programs administered by HHSC.

Several programs designed to improve the state’s primary care physician workforce would be eliminated in the House budget and would be severely reduced by the Senate. Included among them are the funding initiatives administered by the Texas Higher Education Coordinating Board for family medicine residency programs and other primary care residency programs, the State­wide Primary Care Preceptorship Programs, and the state’s newly enhanced Physician Education Loan Repayment Program. The coordinating board would receive 29 percent less funding for family medicine residencies in the Senate version; the preceptorship program and the loan repayment program would both be cut by 25 percent.

Graduate medical education formula funding was cut by 32 percent in the House version, and 28 percent by the Senate. Total GME spending under the House budget would fall 44 percent; in the Senate, 26 percent.

These programs make up the bulk of the state’s efforts to promote primary care, and they comprise some of TAFP’s greatest legislative achievements toward the Academy’s goal of improving the quality of care patients receive while controlling the cost of that care.

“The spending proposals in the base budget don’t reflect the policy goals that the state is working toward,” said TAFP CEO Tom Banning in a TAFP news story posted on www.tafp.org. “There is overwhelming evidence that high-quality, cost-effective health care systems are built on a strong primary care foundation, and now is the time when we should be investing in our primary care physician workforce.”

To further complicate the workforce conundrum, the Legislative Budget Board recommended that the state grant nurse practitioners the authority to diagnose and prescribe without any physician collaboration or supervision.

“Allowing APRNs to diagnose and prescribe up to the limits of their education and certification would allow them to provide lower-cost primary care for patients within their professional scope,” the LBB advised in a report released with the draft budgets.

Two bills filed in the House would carry out this scheme. House Bill 708 by Rep. Kelly Hancock, R-North Richland Hills, and H.B. 915 by Rep. Wayne Christian, R-Center, would allow nurse practitioners, nurse anesthetists, and clinical nurse specialists to diagnose, prescribe, and institute therapy or referrals of patients to health care agencies, health care providers, and community resources. Nurse practitioners would not be required to collaborate with physicians in any way, and all regulation of their practice would remain the purview of the Texas Board of Nursing. Rumors of more bills to expand nurse practitioners’ scope of practice abound, and there is no doubt this will be one of TAFP’s primary challenges this session.

TAFP has a strong advocacy team and has nurtured beneficial relationships in both the House and the Senate over the years, but the most influential advocacy comes from the grassroots. You can help by staying alert and informed of what is happening at the Capitol. Watch for TAFP’s Capitol Update and our webcast news video, Capitol Report. You’ll see them in your e-mail inbox in every edition of the TAFP electronic newsletter, QuickInfo.

You can also sign up to serve as Physician of the Day at the Capitol—a great opportunity to show lawmakers the importance and value of family medicine. And you can sign up to be a TAFP Key Contact. Just go to www.tafp.org to take part in both programs.

As the session heats up, more and more contentious items are certain to arise, including the sunset of the Texas Department of Insurance, voter identification, and legislative redistricting. Stay tuned and rest assured that your Academy is fighting to protect your patients and your practice.