Sunset Challenge: Will Services to Most Vulnerable Texans Hold Steady During a New Re-Organization?

This month’s release of the Texas Sunset Commission’s staff report on the Texas Health and Human Services Commission gave health and wellness advocates things to cheer—and also brought a few sighs and shudders.
At 225 pages and 15 chapters, the report includes important research and covers a giant swath of operations and programs that are hard to lump together: apples, oranges, cats and dogs all at once. Here are my initial thoughts on the overarching Article II health and human service agency re-re-re-reorganization (since the agency has done this before) proposed in the report, as well as the challenges of Medicaid Managed Care and consumer information, supports, and complaint resolution.
Let’s get the sighs and shudders out of the way first. The Sunset Commission staff report makes little reference to the world before 2003 and the HB 2292 reorganization, but many advocates and stakeholders have seen multiple Texas HHS agency reorganizations over the last 30 years. Increasing integration, communication and coordination of services for Texans is a critical, long-standing, and elusive goal. Like many of my colleagues, I fear that diverting limited staff resources to a major reorganization creating a single HHS agency will challenge and disrupt care for the direct needs of Texans. The Legislature has steadily cut the number of state employees over the years, and as the graphic below illustrates, Texas HHS agency staff numbers since 2000 have declined relative to total state population. The declines are even deeper relative to the low-income Texans who are the agencies’ primary clients.
CPPP’s observation is that, far more important than the specifics of agency structure, it is critical to have leadership that expects—and a culture that allows and rewards—working across agency and program lines to put meeting Texans’ needs, quality, and outcomes first. The 2003 reorganization eliminated the HHS agency governing boards from communities across Texas, essentially making the agencies accountable to the Governor’s office that hires the HHSC Commissioner. The new single-agency structure proposed seems likely to further dilute any remaining accountability to the public at large.
I strongly agree with the Sunset conclusion that directing nearly all of Texas’ annual $26-billion-plus in annual Medicaid direct service spending through risk-based Health Maintenance Organizations demands some important restructuring. Without that, expertise in critical areas of policy–mental health, community services and supports–can be “siloed away” from the oversight of Medicaid Managed Care. Isolating key expertise from the agency actually funding care puts Texas at risk for the best practices, quality standards, and consumer protections in the state not ending up in our Medicaid HMO contracts and oversight.
The report refers to the need to monitor for both the over-provision of services and the suspected failure to provide necessary services. This is an important balance to strike, because while old fee-for-service models can create financial rewards for providing excess services, in Medicaid Managed Care insurers’ profits and be gained from under-serving clients.
We give another big round of applause for the Sunset staff’s research and observations that toll-free numbers and web-based information to help clients navigate health and human services—and especially Medicaid Managed Care—need to be much better coordinated, easier to find, and more robust. And I agree that regulators need to collect and analyze information on complaints and problems so Texans know whether and how problems were actually resolved for the clients.
As we move toward the 2015 legislative session, CPPP will work with allies to support changes that address the real problems that the Sunset staff have highlighted. We remain skeptical that a single-agency reorganization is the silver bullet.
HHSC blog chart 102314
CPPP Analysis by Eva DeLuna Castro
Texas State Auditor’s Office, Full-Time Equivalent (FTE) Employee System, for 2003 on
Prior to 2003: State Auditor FTE Turnover reports
State population and below-200-percent-of-poverty estimates are from U.S. Census Bureau, Current Population Survey March Supplement.

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