Health Care Reform, Texas-Style


It is time for Texans to roll up their sleeves and implement health care and health insurance reform, Texas-style.

The provisions of the Patient Protection and Affordable Care Act (ACA) aren’t perfect, but it is the law. Rather than simply resist and delay, it is time for everyone—state and federal officials, health care providers, insurers and those we insure—to work collaboratively, utilizing flexibility in the federal laws to implement the ACA and improve the lives of millions of Texans, Texas-style.

Yet last week, in another example of resist and delay, rather than roll up our sleeves and do something, the state of Texas announced it would not set up its own health insurance exchange, and instead would allow the federal government to set one up for all Texans. That’s not Texas-style health reform. We can do better.

Here are the four steps I think we need to take to achieve Texas-style health reform:

  1. Cover everyone with basic, common-sense benefit plans. The remaining critical steps will not work with six-million Texans uninsured. This includes an “exchange-like” market where everyone can buy health insurance at reasonable prices, without pre-existing conditions exclusions, and with subsidies for the working poor.
  2. Build personal accountability with co-payments for services, the expectation that everyone should pay something, and better transparency of both health care and insurance costs. We can all become better educated health care consumers and take responsibility for our own health through personal behaviors such as diet, exercise and not smoking.
  3. Transform the provider payment philosophy and tie payments to healthy outcomes, care coordination, and integrated delivery of care, rather than simply paying for additional procedures. Moreover, we need to reduce waste and fraud and simplify payment administration.
  4. Consolidate program funding. With comprehensive programs, we can eliminate fragmented funding and stop the fights over supplemental payments. We can develop holistic programs that control and even reduce state costs, while improving quality, coordination, and the health care experience for all Texans.

We can creatively use the ACA to achieve the first and most important step. Twenty-five percent of Texans are uninsured, most of them falling into a category described as “the working poor.” These citizens are working in low-income jobs; after paying the rent, feeding their families, and clothing their children, there is no money left over for health insurance. No insurance means no visits to primary care providers, which means illnesses are left untreated until they become severe and are expensively treated in an emergency room.

I believe Texans can do an excellent job of designing and administering our own customized state health insurance exchange. The subsidies available through the exchange will connect uninsured, low-income, working Texans with affordable, quality health care insurance that is good for businesses, big and small. More covered employees means higher productivity, since employees and family members will have affordable access to primary care providers and therefore lose fewer days to personal or family illness. It also would be very good for our health care provider community, replacing uncompensated care with paid care.

We can also utilize that exchange to cover low-income adults who under the ACA would become eligible for Medicaid. The Governor and other state officials reasonably have concerns about expanding Medicaid, but Texas can and must find a way to draw down the billions of federal dollars available to expand Medicaid, and do it in a more cost-effective way.

Texas has implemented cost-effective and sustainable Medicaid programs for more than 10 years through managed care organizations. We have increased access, improved health outcomes, and even reduced the amount of money spent per Medicaid enrollee.[1] We could use our new Texas exchange to phase in coverage for low-income adults over two years, using a benefit design similar to what small employers cover, with copayments and cost-sharing requirements. We can implement new compensation models for providers already in development. And by expanding through the exchange, what otherwise would be Medicaid, we can reduce or eliminate fragmented funding for other state and local health care programs.

Many of us who work in the safety net health care community have developed more details around this approach, but we are open to other ideas and suggestions.  What we cannot do is simply keep fighting the federal government while doing nothing to reduce the number of uninsured. Let’s get to work on solutions.

[1] Analysis of Medicaid Health Plan Financial Statistical Reports from the Texas Health and Human Services Commission.  Data from 2001-2011 for Harris, Tarrant, Dallas, and Bexar Service Delivery Areas.



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