On Friday, May 7th, Every Texan submitted this letter from our Legislative & Policy Director Luis Figueroa to Senate and House Conferees detailing our concerns and recommendations for the most recent version of Senate Bill 1. It is published here in its entirety.
TO: Senate Conferees House Conferees
The Honorable Jane Nelson, Chair The Honorable Greg Bonnen, MD, Chair
The Honorable Joan Huffman The Honorable Giovanni Capriglione
The Honorable Lois Kolkhorst The Honorable Mary González
The Honorable Robert Nichols The Honorable Armando Walle
The Honorable Larry Taylor The Honorable Terry Wilson
Every Texan (formerly Center for Public Policy Priorities) appreciates the opportunity to communicate our key concerns regarding Senate Bill 1. We thank you for your service in drafting our state’s budget and tackling the reconciliation of differences between the chamber’s recommendations for 2022-2023. We recognize that the ongoing global COVID-19 pandemic and its economic consequences have created extraordinary challenges for our lawmakers.
Recognizing the timeline you face for decisions, we have attempted to keep this document as concise as possible.
Article II – Health and Human Services
Uninsured Texans
Our organization was established in 1985 by the Benedictine Sisters of Boerne, Texas, to advocate at the Legislature to improve access to care for low-income and other disenfranchised Texans. With that in mind, we urge the conferees to take the strongest possible concrete steps to reduce the number of uninsured Texans. Ensuring that our 1115 waiver can be part of the solution, preserving but going beyond the current uncompensated care pools and directed payment programs, can help transform opportunities for health and economic security for our lowest-wage working families, currently excluded from both Texas Medicaid and from the Affordable Care Act marketplace subsidies.
The newest federal COVID-19 relief law, the American Rescue Plan Act (ARPA), offers Texas a one-time “bonus payment” over a two-year period, if Texas accepts federal funds to provide Medicaid health coverage for poor and near-poor adults—funds that 38 other states have already accepted. These dollars are in addition to the 90% federal matching funds already available to cover these adults— funds that will endure beyond the 2-year bonus.
To this end, Every Texan urges the conferees to adopt the Health and Human Services Commission House Rider 150: 1115 Transformation Waiver. “It is the intent of the Legislature that the commission seek a renewal or extension of the 1115 Transformation Waiver from the Centers for Medicare & Medicaid Services.”
Women’s health
Every Texan urges conferees to improve women’s health and Texas mothers’ birth outcomes by:
- ensuring robust funding for Texas’ women’s health programs;
- establishing a full year of Medicaid postpartum coverage (contingent on enactment of House Bill 133, legislation to provide one-year postpartum coverage);
- Adopting HHSC House Rider 37: Women’s Health Programs: Savings and Performance Reporting. For the past six sessions, the budget has included a rider directing the commission to report to the legislature on key metrics pertaining to women’s health program enrollment, utilization, and costs. Rider 37 includes additional data elements on which HHSC must report.
- Adopting HHSC House Rider 123: Funding for Healthy Texas Women. In 2020, Texas received approval for its Medicaid 1115 Women’s Health Waiver, providing Texas 90% federal matching funds for women’s preventive health services. The rider specifies that in the event the waiver is rescinded, HHSC must seek approval to transfer funds from other sources before making cuts to HTW service levels.
- Adopting HHSC House Rider 138: Report on Continuity of Care for Women Aging out of CHIP and Medicaid. The rider will help policymakers and stakeholders better understand the impact of Texas’ administrative renewal process on women’s enrollment into women’s health programs. In principle, we support electronic verification because it will minimize the need for women to complete more paperwork. However, in practice the data sources Texas uses for administrative renewals have proven unreliable. In fact, the Kaiser Family Foundation reported Texas ranks low for successful administrative renewals, renewing fewer than 25%.
- Adopting HHSC House Rider 140: Feasibility of Postpartum Medicaid Expansion. According to the state’s own panel of maternal health experts, for Texas to significantly reduce incidence of maternal mortality and morbidity, it must ensure postpartum women have access to a full year of comprehensive health services following delivery. Unfortunately, women on Medicaid lose coverage 60 days postpartum. Studies show that women living in states with comprehensive health care coverage have better health outcomes, including fewer maternal complications and deaths. Rider 140 requires HHSC to explore the feasibility of extending such coverage in Texas using new authority under the American Rescue Act Plan.
Children’s Health
Every Texan supports passage of House Bill 290, to provide children enrolled in Medicaid continuous eligibility for two consecutive six-month periods, and which has a $0 fiscal note, to enhance access to and continuity of care for children enrolled in Medicaid.
- Adopt HHSC House Rider 131: Report on Periodic Income Checks. In the event lawmakers fail to pass HB 290, this rider specifies that HHSC must evaluate the number of children whose Medicaid health coverage is impacted by periodic income checks, including the number of children whose Medicaid is terminated due to a procedural reason; i.e., without actual documentation that the child is no longer eligible. Texas has the highest number and rate of uninsured children in the country, and has experienced a decline in children enrolled that this bill will go far to address.
- Maintain level funding for Early Childhood Intervention (ECI) as recommended by the House. Last session, lawmakers made significant investments to restore funds previously cut from ECI. Still, many children eligible for ECI do not receive services because of inadequate funding. A 2020 survey of ECI providers found that one in six “seriously considered NOT renewing their ECI contract with the state” due to financial challenges.
- We also urge adoption of HHSC House Rider 141: Study Private Insurance Coverage of Early Childhood Intervention Services. Requiring private insurers to cover these vital services will improve children’s health while also reducing Texas’ state budget ECI expenditures.
Child Abuse Prevention
Neither the Senate nor House proposals continue vital funding for the Medical Child Abuse Resource Education Systems (MedCARES), a critical public health resource to keep children safe. We urge restoration of $5.96 million to continue it in 2022-23. MedCARES provides grants to hospitals, academic health centers, and health care facilities with expertise in pediatric health to prevent, assess, diagnose, and treat child abuse and neglect.
Seniors and Texans with Disabilities
Every Texan urges the conferees to:
- Fully fund the HHSC exceptional item request for 3,512 Medicaid waiver slots, and ensure individuals who need slots for Promoting Independence have access to a waiver slot to avoid requiring an unneeded admission to an institution before they can transition back to the community setting that they actually desire.
- Increase attendant wages to $15.00 per hour. Tens of thousands of our frail seniors and people with disabilities need to access safe and qualified attendant care. This becomes ever more difficult when Texas Medicaid wages fall so far below entry-level pay at big box stores and fast food restaurants.
- Fully fund access to the Medicaid Autism benefit to ensure access to services and implement no later than September 1, 2021.
Items with Broad Impact
- Ensure full reversal of 5% budget reductions to Medicaid, Children’s Health Insurance Program (CHIP), SNAP, and TANF eligibility staff funding. These reductions in HHSC’s reduction schedule called for “reduced or delayed hiring for approximately 741.6 Eligibility Operations positions.” Supplemental appropriations bill HB 2 reversed the 5% cuts in the current biennium, but it is unclear whether the two chambers’ bills mirror that decision. Without adequate eligibility staffing, HHSC will be challenged to ensure it can timely renew and process applications for Texans eligible for these programs. This is likely to be especially challenging at the end of the federal Public Health Emergency, when the resumption of normal recertification processes will be demanding and require extensive outreach and enrollee supports.
Ensure adequate funding for life-sustaining drugs for patients living with chronic hepatitis C or HIV.
Hepatitis C. Texas has one of the most restrictive Medicaid hepatitis C drug prior authorization policies in the country, meaning patients cannot obtain treatment until they have advanced liver disease. This results in avoidable disability and irreversible liver damage. HHSC recently announced it will extend hepatitis C treatment to additional Medicaid patients, but needs your legislative approval to ensure all eligible Medicaid patients can obtain cost-effective hepatitis C medication. Funding is literally a matter of life and death.
- Adopt HHSC Senate Rider 109: Cost Effective Treatment for Chronic Hepatitis C Virus. Subsection (a) allocates $51 million All Funds over the biennium to partially cover Medicaid and state hospital costs associated with providing direct antiviral medications for patients with chronic hepatitis C. Texas Medicaid currently covers these drugs but requires burdensome prior authorization to ration them based on the severity of a patient’s illness, contrary to established medical best practices.
HIV: Support State Health Services (DSHS) Senate Rider 26: Texas HIV Medication Program. The rider will increase funding by $31.2 million to maintain services in the Texas HIV Medication Program. The costs of life-saving HIV medications have risen sharply in recent years, and thus increased funding is needed to ensure people continue to receive treatment.
Should the program lack sufficient funds over the biennium, we support the Texas Medical Association in recommending the rider be amended to direct DSHS to provide a report to the governor and Legislative Budget Board at least 30 days prior to pursuing cost-containment measures that articulates the likely client impact.
Reject HHSC Senate Rider 112: Health and Human Services Cost Containment, which directs the commission to achieve $350 million in general revenue cost savings in 2022-23. HHSC and LBB data make clear that Texas has strictly limited growth in Medicaid per-enrollee costs over the last 20 years, including nearly a decade of Medicaid cost-containment riders. For every dollar reduction in state Medicaid spending, Texas will lose another $2 in federal funds under routine conditions, and currently even more because of the enhanced federal dollars available throughout the federal Public Health Emergency under the Families First Coronavirus Response Act of March 2020. The Texas Comptroller and HHSC confirm that caseload growth, not per-person expenditures, are driving Texas Medicaid costs. We respectfully request the conferees to reject Rider 112.
Adopt HHSC House Rider 132: Rate Setting to Improve Health Outcomes. The rider directs HHSC to evaluate Medicaid managed care rate setting strategies that can address barriers to good health, such as lack of nutritious food, or unstable housing.
Provide $5.4 million to establish the Office for Health Equity within HHSC (contingent upon passage of HB 4139). If implemented, the office will work with the agency, public health departments and stakeholders to identify health disparities throughout Texas’ diverse regions, populations, ages, and cultures and develop targeted strategies to address them.
Article III – Education
Public PreK-12 Schools
We ask that SB 1 conferees adopt the House riders for the Texas Education Agency (Riders 81 and 87) expressing legislative intent that federal COVID-19 relief funds be distributed to public schools in a timely way, and that the federal aid supplement, rather than supplant, state funding for public schools.
The House’s Article XI includes $18.5 million for HB 1744, creating a career and technology education program (Texas Education Agency) and financial incentives for high school students to become teachers in bilingual education, English as a Second Language, or Spanish (Texas Higher Education Coordinating Board). We recommend including this contingent funding in the conference committee report on SB 1.
We join Disability Rights Texas in supporting the House version of riders for the Texas Education Agency, 67: Funding for Special Education Strategic Plan FTEs and 69: Grants for Students with Disabilities who Benefit from Behavioral Supports, along with the House’s rider in Article X, Legislative Budget Board, 4: Special Education Status and Funding Report. The House riders would avoid the misimpression that some student disability eligibility categories receive less of a priority from the state, and would communicate the importance of successfully implementing the Special Education Strategic Plan.
Public Higher Education
We ask that SB 1 conferees fund student financial aid at the Higher Education Coordinating Board at the higher level ($110 million more) recommended by the House. The House proposals would, for example, ensure that TEXAS Grants can continue serving the same number of students (87,000) as were reached in fiscal 2020, before the 5% interim reduction directive.
Thank you very much for your consideration of our recommendations. As always, our team of experts are available as a resource to you if you have any additional questions.
Luis Figueroa (figueroa@everytexan.org)