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Medicaid

The nursing home vaccination mandate

This just seems obvious to me.

President Joe Biden announced on Wednesday that he is directing all nursing homes to require their staff be vaccinated against Covid-19 in order to continue receiving Medicare and Medicaid funding.

Biden said he is directing the Department of Health and Human Services to draw up new regulations making employee vaccination a condition for nursing homes to participate in Medicare and Medicaid. The decision on nursing home staff represents a significant escalation in Biden’s campaign to get Americans vaccinated and the tools he is willing to use, marking the first time he has threatened to withhold federal funds in order to get people vaccinated.

“Now, if you visit, live or work at a nursing home, you should not be at a high risk of contracting Covid from unvaccinated employees. While I’m mindful that my authority at the federal government is limited, I’m going to continue to look for ways to keep people safe and increase vaccination rates,” the President said during a speech at the White House.

[…]

The move comes as the more transmissible Delta variant now accounts for 99% of Covid-19 cases in the United States and as data shows a link between low vaccination rates in certain nursing homes and rising coronavirus cases among residents.

The Delta variant has spurred a jump in daily new cases from a low of 319 on June 27 to nearly 2,700 on August 8, according to Centers for Medicare & Medicaid Services. Many are in facilities in areas with the lowest staff vaccination rates.

In the seven states in which less than half of nursing home staff is vaccinated, weekly cases were 7.9 times higher in the week ending August 1 than they were in the week ending June 27. Meanwhile, in states that have vaccinated a larger share of staff than average (more than 60%), cases reported in the week ending August 1 were only three times higher than cases reported in the last week of June.

The new regulations could go into effect as early as next month, but Johnson said the CMS will work with nursing homes, employees and their unions to ramp up staff vaccinations before the regulations go into effect.

About 1.3 million people are employed by the more than 15,000 nursing homes that participate in Medicare and Medicaid. Some 62% of those workers are vaccinated nationwide, according to CMS data, but the figure ranges from 44% to 88% depending on the state.

“We have seen tremendous progress with low Covid rates within the nursing home population and I think we’re seeing signs that it is starting to tip the other direction. We don’t want to go backwards,” said Jonathan Blum, CMS’ principal deputy administrator.

Blum said CMS officials are “confident we have the legal authority” to implement the new regulation, noting that the law allows CMS to take action as it relates to the health and safety of nursing home residents.

As the story notes, this came a day after Biden directed the Education Department to get involved in the mask mandate fight. You would think, given how devastating the first wave of COVID was to the residents of nursing homes, that their staffers would be highly vaccinated as well, but you would be wrong.

Nationwide, most of the elderly and vulnerable in long-term care facilities have taken the coronavirus vaccine, but many of the staff caring for them have refused it. The federal program responsible for bringing vaccines to the vast majority of nursing homes and similar settings inoculated roughly half of long-term-care workers in the nation, and in some states a much slimmer percentage, as of March 15, according to new data from the Centers for Disease Control and Prevention provided to the Center for Public Integrity.

In seven states and the District of Columbia, the program vaccinated less than a third of staff members.

Now the federal program is winding down in the coming days, leaving states and facilities to figure out how to vaccinate the remainder of workers in settings where COVID-19 has already taken a heavy toll.

Though they represent a tiny fraction of the American population, long-term-care residents made up 34% of the nation’s COVID-19 deaths as of March 4, according to the Covid Tracking Project. Low vaccination rates among staff at these facilities mean that workers continue to have greater risk of contracting COVID-19 themselves or passing the virus to their patients, including residents who can’t be inoculated for medical reasons. Low staff uptake can also complicate nursing homes’ attempt to reopen their doors to visitors like Caldwell, who are striving for some sense of normalcy.

“Going into it, we knew it was going to be a problem,” said Ruth Link-Gelles, who led the team at CDC working on the federal initiative that’s now closing up shop, the Federal Pharmacy Partnership for Long-Term Care Program.

She cited past years’ low vaccination rates among long-term-care workers for diseases such as the flu. “We were disappointed, but I don’t think anyone was shocked to see the low uptake. … There is a stubbornly large portion of the population that really doesn’t want to get vaccinated, and we have a lot of work to do generally and in this community in particular.”

Federal agencies and states have poured resources into a #GetVaccinated educational campaign, hosting listening sessions, live chats and virtual town halls for long-term-care staff to get their questions answered.

In spite of all these efforts, many workers are reluctant to take the shots because they don’t trust information about the vaccines’ safety or they don’t wish to be among the first to take them, experts said.

“There are many reasons to blame nursing homes and the federal government,” said David Grabowski, a professor of health care policy at Harvard Medical School who studies long-term care. “We knew this coming in — that this was a group that was not very trusting of leadership and frankly not very trusting of the vaccine so it was going to take some work in terms of building that trust.”

That story was from late March, so things may be better by now. According to the map embedded in this story, as of that time about 54% of the long-term care workers in Texas who have been vaccinated got their shots through this federal program. But as usual, the overall story in Texas is not great.

The number of nursing homes across the state with at least one active COVID-19 case has shot up nearly 800% in the past month — while nearly half of nursing home employees in Texas remain unvaccinated.

Nursing home residents were among the hardest hit by COVID-19 last year as the virus tore through facilities at an alarming rate. More than 400 Texas nursing home residents died during a single week in August 2020; since the pandemic began, 9,095 have died after contracting COVID-19, according to the Texas Health and Human Services Commission. As of Aug. 11, that’s 17% of the state’s COVID-19 deaths.

To slow the virus’s spread, Gov. Greg Abbott shut down nursing home visitation in March 2020, then eased those restrictions five months later for facilities that didn’t have active cases in the previous two weeks. HHSC’s current visitation guidelines for nursing homes require visitors to wear a mask at all times and limits visitation to no more than two “essential caregivers” per resident.

But after seeing infections remain relatively low in recent months, the state’s more than 1,200 nursing homes are seeing a new wave of infections as COVID-19 cases explode around the state, driven by the highly contagious delta variant:

  • The number of Texas nursing homes with active COVID-19 cases has risen by 773% in the past month, from 56 in mid-July to 489 on Aug. 11. That’s still well below the peak in January, when more than 900 facilities had at least one active case.
  • Deaths are increasing as well. From July 21 to Aug. 11, 84 nursing home residents died from COVID-19, compared to seven deaths during the four-week period before.
  • Roughly 76% of nursing home residents in Texas have been fully vaccinated, putting the state 46th nationally. The national average is 82%.

But the current surge in nursing home cases hasn’t triggered renewed restrictions by the state.

“We continually assess what actions are necessary to keep people safe in the facilities we regulate,” HHSC spokesperson Helena Wright-Jones said in a written statement.

Meanwhile, just over half — 56% — of nursing home staff have been fully vaccinated, below the national average of 59%, which puts Texas 33rd nationally for nursing home staff vaccination rates.

In other words, the usual indifference from state government and general mediocrity, which puts a whole lot of people at risk. What do the nursing homes have to say for themselves?

Kevin Warren, the president and CEO of the Texas Health Care Association, whose members include both for-profit and nonprofit long-term health care facilities, said nursing homes are hesitant to require staff to be vaccinated because they are fearful of losing employees who might look for other jobs that don’t require vaccinations.

“Right now, we have a severely stretched workforce,” Warren said. “And when we see this surge occurring again, the stress and the emotional toll it places on staff and others that are in the building, the concern is: ‘If I put this vaccine mandate on, am I potentially going to lose staff?’”

The percentage of nursing home staffers who are unvaccinated is similar to the general population, Warren added, “so let’s not set them out to the side.”

Except they’re in close contact with the most vulnerable people in the state, and not enough of them are vaccinated, either. The DMN has a whole story on that, and while I can believe it to some extent, there’s a quote from a nursing home operator whose staff is 70% vaxxed, and I cannot see how this is any less urgent than getting hospital staff vaccinated. We’ve tried the carrot, now there needs to be a stick. There’s plenty of polling data to suggest that a non-trivial number of people who are vaccine hesitant will give in and get the shot if their workplace mandates it. Let’s put that to the test.

Texas gets its Medicaid 1115 waiver back

Hrmph.

It’s constitutional – deal with it

A federal district judge on Friday temporarily reinstated a 10-year extension of a federal health care program that Texas uses to help pay for health care for uninsured Texans and is worth billions of dollars annually.

The agreement was set to expire next year after federal health officials in April rescinded the Trump-era extension to the 1115 waiver agreement — which Texas has had with the U.S. Centers for Medicare and Medicaid Services since 2011 and is up for review every few years — and ordered Texas to collect public input, as the agreement requires, while it renegotiates a new extension beyond its original October 2022 expiration date.

The decision did not stop the funding for the current waiver, which provides $3.87 billion in annual funding to partly offset free care provided by Texas hospitals to the uninsured, and to pay for innovative health care projects that serve low-income Texans, often for mental health services.

In his order on Friday, the U.S. District Judge J. Campbell Parker granted a preliminary injunction sought by Texas to block the federal government from rescinding the original Trump-era agreement. The decision removes the requirement, at least for now, for Texas to negotiate its deal with CMS if it wants 1115 funding beyond October 2022.

The decision by CMS was “likely unlawful” and resulted in “turmoil in the state’s Medicaid program,” in part because the state had already begun “reassigning staff, making plans, appropriating money, passing regulations, and engaging stakeholders to work towards implementing the necessary changes” allowed by the original deal, which was confirmed in January before it was rescinded by the Biden administration in April, Barker said in the order.

[…]

The 1115 waiver was meant to be temporary while Texas transitioned to an expanded Medicaid program under the Affordable Care Act of 2010, but that never happened because the U.S. Supreme Court ruled in 2012 that states couldn’t be forced to expand Medicaid.

Since then, the state has relied on the waiver for various programs to care for Texas’ uninsured, with Republican state leaders frequently leaning on it in their arguments against Medicaid expansion.

See here, here, and here for some background. I don’t know the technical details well enough to know if this is a reasonable decision on the merits or if Paxton once again found himself a super friendly judge. I’m not even sure if this means that the entire Trump-approved ten-year extension is back in play, or if there will be another opportunity for the Biden administration to force the issue, perhaps next year when the previous agreement was to expire. Perhaps if one of the alternate means of allowing/forcing Medicaid expansion is part of the reconciliation package, the issue can be revisited, or perhaps largely rendered moot. It does seem likely to me that Congress could change the terms of the 1115 waiver, as the issue here was over the executive action, I just don’t know who would be pushing that in the legislative process. All in all, a deeply unsatisfying state of affairs at this time.

UT/Trib: More polls that say permitless carry is not popular

The UT/Texas Tribune polling machine did a whole bunch of issue polls following the end of the legislative session. That’s a long article that gives the highlights on each question – they covered a wide range of topics, some of which the respondents knew more about than others – and I will focus on three of them.

Texans had split reactions to the state’s actions on abortion policy, with 42% disagreeing with the state’s policies and 32% agreeing. Those sentiments fell largely along party lines, with 78% of Democrats disapproving and 56% of Republicans agreeing.

Voters were sharply divided over whether to ban most abortions after six weeks except in medical emergencies. Lawmakers passed a bill to implement that policy in Texas, creating one of the strictest abortion laws in the nation.

Forty-four percent of voters supported such a policy, while 46% opposed it. The policy fell predictably along party lines, but independents broke against it with 34% supporting the ban and 46% opposing it.

A majority of Texans opposed automatically banning all abortions if the U.S. Supreme Court overturned the landmark abortions case Roe v. Wade, an idea which lawmakers passed into law this session. Fifty-three percent of voters said they opposed the move, while 37% supported it. Again, independents broke against the policy, with 58% saying they strongly opposed the automatic ban and 20% saying they supported it.

“It’s a very small minority of voters who would ever ban abortion outright in all circumstances,” Blank said. “Generally speaking, Texans are open to some limited restrictions on abortion. You start to see pushback when you get to the point of restricting access outright.”

Voters disapproved of the Legislature’s handling of gun violence, with 43% saying they disapproved of legislative actions on the subject, while 32% said they approved.

Voters showed particular disapproval for allowing legal gun owners over the age of 21 to carry handguns in most places without a license or training, a policy conservatives call “constitutional carry.” Fifty-seven percent of voters said they disapproved of that policy, which lawmakers passed into law during the session. Thirty-six percent said they supported it.

That policy had 59% support among Republicans and a disapproval rate of 86% among Democrats.

Conversely, voters showed strong support for requiring criminal and mental health background checks for all gun purchases. Seventy-one percent of voters supported the policy, while only 21% opposed. Bills on that subject were not passed by the Legislature despite bipartisan support from 88% of Democrats and 61% of Republicans.

This is the seventh time the poll asked about background checks and it has received support from more than 70% of voters each time, Blank said.

Among Republicans there was majority support for both background checks and allowing legal gun owners over the age of 21 to carry handguns without a license or training.

“You can be a Republican who is happy with the way the Legislature addressed protecting Second Amendment rights but also think that maybe they could have done more to address gun violence, and those two things are not necessarily inconsistent,” Blank said.

Sixty-seven percent of Texans support Medicaid expansion, giving overwhelming support to an issue that’s been soundly rejected by Republican state leaders since the passage of the Affordable Care Act during Barack Obama’s presidency. Only 22% of voters opposed the policy.

Supporters included 50% of Republicans and 90% of Democrats.

“As long as it’s not directly tied to Barack Obama, generally people are more open to it than you think,” Blank said. “It just requires us to update our thinking about Republican orientations towards health care.”

Only 13% of voters think marijuana should not be legal under any circumstances. Twenty-seven percent believe it should be legal for medical purposes, 31% believe small amounts should be legal for any purpose and 29% believe any amounts should be legal for any purpose.

Support for some sort of marijuana legalization spans across party lines. Younger people between 18 and 29 are the most supportive of its legalization with only 4% saying it should not be legal under any circumstance. Fifty-one percent of those in that age group said any amount of marijuana should be legal for any reason.

Not sure why Medicaid expansion and marijuana reform were lumped together in that last section, but whatever. The point is that all of these results are consistent with other polls done in the past, though there is some range in the outcomes, as the much stronger opposition to permitless carry from that Quinnipiac poll shows. The campaign themes for 2022 couldn’t be clearer. The Republicans prioritized their own little hot-button issues over more important business like fixing the electric grid. Democrats support the things that voters actually want. The ads truly write themselves.

The poll also included questions about the voter suppression bill, and that got its own separate story.

Despite ceaseless Republican assertions that Texas’ voting rules must be tightened to prevent electoral fraud, only a small slice of the state’s registered voters believe ineligible voters often cast ballots in Texas elections, according to the University of Texas/Texas Tribune Poll.

In a June UT/TT poll, just 19% of voters indicated they think ineligible people frequently cast ballots. A bulk of voters — 42% — believe ineligible votes are rarely or never cast. Even among Republicans, a minority of voters — 31% — believe ineligible votes are frequently cast.

[…]

During the regular legislative session that wrapped up in May, Republican lawmakers attempted to reframe their legislative proposals by offering that even one instance of fraud undermines the voice of a legitimate voter.

“At some point, I think Republicans have run into the lack of evidence … and so they have gone to this ‘anything is a taint’,” said James Henson, co-director of the poll and head of the Texas Politics Project at UT-Austin. With 25% of voters believing ineligible people sometimes vote in elections, he said Republican leaders have “something to work with” as they adjust their messaging.

“The Republican argument has had to make adjustments as they run into, frankly, evidentiary problems and dissonance caused by a lack of evidence for some of their response, so that may be part of the explanation here,” Henson said.

[…]

Heading into that special legislative session, 35% of registered voters say they would make voting rules more strict, while 29% would leave them as is and 26% would loosen them. Among Republicans, a large majority of voters (60%) want the rules to be more strict. A majority of Democrats (54%) want less strict rules. Almost the same share of both Republicans (30%) and Democrats (29%) would maintain the status quo.

Couple things here. One is that apparently there are some limits to lying your ass off. Who knew? Doesn’t mean that will be enough to stop the bullshit legislation said lies are built on, but at least it’s a rougher road. Two, the stricter/easier/same numbers on voter restrictions are pretty close to the numbers we have seen in previous polls about abortion. There may be a slight plurality for “stricter”, but a far larger number opposes that. Again, that is an issue you can run on.

Finally, while there is a partisan divide in all of these issues, there is also a difference in intensity in many of them. For some, Republicans are far more unanimous in their position while Dems are more diffuse, and for others it is the reverse. Whether there is an overall majority for one position, and if so which one, is usually determined by this difference in intensity. Sometimes, the level of intensity is about the same each way (and that may mean that neither side is all that worked up about it), and when that happens you have an even split, with at best a small plurality for one position. I find this to be the most useful way of thinking about this sort of poll. It’s still not clear how much any of these results translate into voter persuasion or enthusiasm, but it does at least give you some idea of where you are or are not out of step, and how much resistance you may get on a particular subject. As I said, on these issues (and some of the others that I didn’t comment on), the arrow is pointing clearly in the direction Dems should want to go.

An alternate route to Medicaid expansion

I’m okay with this.

Texas Democrats have tried for years to convince Republican state leaders to increase access to Medicaid. Now they think they have found a way to do it with or without their help.

U.S. Rep. Lloyd Doggett and lawmakers from 11 other GOP-led states introduced a measure this week that would give money directly to local governments that want to provide coverage for hundreds of thousands of low-income Texans who currently fall into what is known as the “coverage gap.”

The Cover Outstanding Vulnerable Expansion-eligible Residents (COVER) Now Act would allow counties to apply for the money directly with the federal government, and it would prohibit state leaders from retaliating against them if they do.

Doggett said his aim is to avoid conflict with Republicans.

“You have your ideological objections to Medicaid expansion — I don’t agree, but I accept your position,” he said. “At least let those local leaders who want to take advantage of this and who recognize both the health and economic advantages of doing it, at least let them do that, and walk away and see how it works.”

[…]

Doggett estimated that if Houston, San Antonio and Dallas alone signed on to the proposal, half of the state’s eligible uninsured population would gain access. All three cities are led by Democrats and have pushed for Medicaid expansion.

Statewide, more than 1.2 million Texans would be eligible for Medicaid if state officials were to expand the program, according to a study by the The Bush School of Government and Public Service at Texas A&M University

More than two million people are thought to be in the coverage gap today, meaning they make too much to qualify for traditional Medicaid but not enough to qualify for subsidized insurance under the Affordable Care Act. Most are people of color, and the biggest group is in Texas, a state that has long had the highest uninsured rate in the country.

Anne Dunkelberg, a policy analyst for the left-leaning think tank Every Texan, said the new legislation would also increase funding to state health officials for any added administrative costs.

“Congressman Doggett’s bill really recognizes how entrenched the ultra conservative opposition to expansion is in Texas and the need to really connect the dots about what it’s going to take for us to get possibly a million and a half uninsured adults — the vast majority of them working — coverage,” she said.

I don’t know if the reconciliation process that Rep. Doggett envisions for this would be part of the infrastructure package or as a later budget bill, but either way there will be opportunities. I think the odds of it avoiding conflict with Republicans is basically zero, so the more important consideration is how well-defended it will be from Republican attempts to screw with it or obstruct it. We have seen too many examples in recent times of the state having control over federal money intended for local governments that have resulted in all kinds of bad outcomes, from the delays in appropriating COVID relief to the GLO’s screw job against Houston and Harris County. Cut the state completely out of it, and then hope it’s too difficult for a future Republican Congress or President to mess with it.

Assuming this does go through, I would expect quite a few more counties than those three cited would jump at this. Travis, El Paso, Fort Bend, Cameron, Webb, some other South Texas counties, probably Hays, would certainly take advantage. Nueces, Tarrant, and Williamson would be interesting to watch, and I bet this would add some spice to county races in Collin and Denton and maybe Brazoria. It’s possible that some Republican counties, especially ones with hospitals teetering on the brink of financial disaster, might decide to put aside politics and grab the money, as several Republican states have done. I could definitely see this making a huge dent in the uninsured population, and providing some fodder for the 2022 elections as well. It’s mostly a question of how durable it is, and that’s something that Rep. Doggett can work on. Here’s hoping.

Paxton sues over revocation of Medicaid 1115 waiver

Someone please explain to me if this has any merit.

Best mugshot ever

Texas Attorney General Ken Paxton sued the Biden administration Friday to reinstate an eight-year extension to a federal health care funding agreement, worth billions of dollars annually and set to expire next year, that the state uses to help pay for health care for uninsured Texans.

Last month, federal health officials rescinded the Trump-era extension to the 1115 waiver agreement — which Texas has had with the U.S. Centers for Medicare and Medicaid Services since 2011 and is up for review every few years — and ordered Texas to collect public input, as the agreement requires, while it renegotiates a new extension beyond its current October 2022 expiration date.

The decision did not stop the funding in the current waiver, which will continue to provide $3.87 billion in annual funding for 2021 and 2022 to partly offset free care provided by Texas hospitals to the uninsured, and to pay for innovative health care projects that serve low-income Texans, often for mental health services.

The extension, granted in the waning days of Donald Trump’s presidency, would have continued hospital reimbursements until September 2030 but allowed the innovation fund to expire.

In his lawsuit filed Friday, Paxton said the decision was a political move by President Joe Biden that was meant to force Texas to expand its Medicaid program under the Affordable Care Act of 2010.

Forcing Texas back to the drawing board on negotiations over the extension, which Paxton said would have amounted to $30 billion in federal funding through 2030, threatens to “destabilize” the programs the state funds through the waiver, he said.

[…]

The 1115 waiver was originally granted to Texas as a temporary funding bridge while the state developed its plan to expand its Medicaid program, but the U.S. Supreme Court ruled in 2012 that the ACA could not require states to do so — and Texas has since leaned on the 1115 waiver to help pay for care for the uninsured.

Supporters of Medicaid expansion have said that the state should utilize both 1115 waiver funding and expanded Medicaid eligibility, and have expressed confidence that the state would be able to negotiate the extension — with the required public input — before it expires.

“We have an attorney general and other state leaders who have made crystal clear the last few months and last few years that they have little interest in health care for working Texans — although they do have an obsession with filing lawsuits against the White House,” said Patrick Bresette, executive director of Children’s Defense Fund-Texas. “This misguided lawsuit is the cherry on top of a legislative session in which state leaders shot down all attempts to give an affordable health insurance option to janitors, cooks, grocery store clerks, and other Texans.”

“This would be a disaster for our state, and yet President Biden seems intent on thrusting his bloated model of government on everyone — including Texas,” he said in a statement Friday.

See here and here for some background, and here for a reminder that the Republicans have once again passed on the opportunity to fully expand Medicaid and make this issue moot. Let’s put aside the irony of a guy who is the lead attorney on a still-active case that would entirely kill the Affordable Care Act if he wins suing to keep federal funds flowing into Texas and ask the key question: This is a federal program, which requires federal approval. Doesn’t that mean that the federal government has some discretion here? If one accepts the premise that this move by the feds was purely capricious and driven by partisan motives, then sure, a lawsuit would be an appropriate remedy. On the other hand, if the feds reasonably believe that the extension, granted in the waning days of a President that gave little care to details and openly favored Republican states, was done in error, well, don’t they have the authority to correct that? I’m asking because I have no idea what the fine points of the law are here, and I have no reason to believe anything Ken Paxton says. That by itself doesn’t mean that the law couldn’t be on his side, though. I welcome any informed feedback on this. The Chron has more.

House passes its budget

The rites of spring in Texas: The start of baseball season, the first 90-degree day, and in odd-numbered years, the House Budget Amendment-Palooza.

The Texas House on Thursday night unanimously passed its proposed two-year, $246 billion state budget after members spent hours deliberating which tweaks to make to the massive spending plan.

The House’s proposed budget includes measures that would ban school vouchers, empty the governor’s economic development fund and cap some attorney general spending. But such amendments are not guaranteed to remain in the final spending plan. The proposal now heads back to the Senate, where the legislation will all but certainly then head to a conference committee for the two chambers to hash out their differences before it can be sent to the governor’s desk.

In a statement after Thursday’s vote, House Speaker Dade Phelan, R-Beaumont, said the chamber passed “a balanced budget that keeps spending in check while addressing the multitude of challenges that our state experiences, especially those experienced over the past year.”

One of the more notable votes happened Thursday afternoon when state Rep. Garnet Coleman, D-Houston, introduced an amendment that aimed to expand state and federal health care coverage for uninsured Texans. After a brief debate though, the amendment failed 68-80, with one Republican — state Rep. Lyle Larson of San Antonio — voting for it.

Later Thursday, House members also tackled another point of contention that’s emerged in recent weeks at the Legislature: What to do with tens of billions of dollars in federal funding for coronavirus relief. The chamber unanimously adopted an amendment by state Rep. Geanie Morrison, R-Victoria, to require a special legislative session to appropriate billions in funds that may come in after the Legislature adjourns from its regular session in May.

Before the vote, Morrison said “it is clear … that our founding fathers intended for appropriations to be handled by the Texas Legislature.”

House members also signed off Thursday on a supplemental budget to cover expenses from the current budget. The vote on that legislation, House Bill 2, was also unanimous.

See here for a bit of background. One sign that the ground on which we fight the big culture wars these days has shifted is that I hadn’t given a single thought to school vouchers this session. That great bugaboo from the early to mid-2000’s has lost its luster as a divisive force. Even Dan Patrick had bigger fish to fry this session. I’m perfectly happy to give vouchers a kick in the nads every other year, but I do wish some of the newer culture war hot button issues were as beatable.

Of interest.

The Texas House moved Thursday to rein in Attorney General Ken Paxton’s spending on outside attorneys that are costing taxpayers up to $3,800 an hour.

A state budget amendment brought Thursday by Rep. Jessica González, D-Dallas, caps the amount that Paxton’s office can pay for outside legal expenses at $500 an hour. The amendment passed the House 73-64.

The House version of the budget, once finalized, will still need to be reconciled with the Senate’s version.

Paxton found himself in hot water with Texas lawmakers this budgeting cycle after he requested more than $43 million for an antitrust lawsuit he launched against Google and hired attorneys at a rate that could cost the state as much as $3,780 an hour for the most senior attorneys, according to their contract.

González, who is an attorney, said her bill is aimed at avoiding such costs in the future.

“Think about all the good we could do with that money,” she said. “How many lives could we improve by spending this money on public education or health care? While our indicted attorney general is dealing with scandal in his own agency, we as legislators need to ensure our constituents’ tax dollars are being used to help people, and not being wasted on exorbitant legal fees.”

During a tense hearing in February, the Texas Senate’s Finance Committee chastised Paxton for his spending on outside counsel in that suit. Paxton had argued that the lawyers were necessary because the case involves a specialized area of law, and the body ultimately did not slash his budget.

See here for some background on that. It’s not clear to me what effect this amendment would have, assuming it survives in the Senate and the conference committee. Maybe Paxton will still be able to pay those fancy outside lawyers as much as he agreed to pay them, they’ll just have to bill for more hours in order to be able to claim all of it. My guess is that this is a symbolic slap on the wrist, but I’ll be happy to be proven wrong.

Today is not the day we expand Medicaid

Tomorrow isn’t looking so good either.

It’s constitutional – deal with it

The Texas House on Thursday rejected an attempt to direct the governor and state health officials to use billions in federal dollars to expand health care coverage for uninsured Texans, including working poor who earn too much to qualify for Medicaid but too little to afford their own health insurance.

On a vote of 80-68, lawmakers voted down the proposal, which was floated as a two-page amendment to the state budget on Thursday.

The debate, which was highly anticipated by advocates of expanding coverage for uninsured Texans, was expected to be heated and drawn out. It lasted less than 20 minutes.

[…]

State Rep. Garnet Coleman, a Houston Democrat who sponsored the amendment, said it wouldn’t force the state to expand traditional Medicaid but would direct Abbott and the Texas Health and Human Services Commission to negotiate a federal funding agreement, known as a 1115 demonstration waiver, to create a plan that would cover more uninsured Texans, including those who would qualify for coverage under a traditional Medicaid expansion plan.

The resulting plan could have been a traditional expansion of Medicaid to cover adults who earn up to a certain amount, or a “look-alike” that combines state and federal funds to create a state program that accomplishes a similar goal, Coleman said.

Such state-crafted plans have been passed in several states, mainly conservative states like Indiana and Ohio.

“I would like for us to expand traditional Medicaid in the optional way that the ACA says you can do it,” Coleman said on the House floor. “But we can’t do that. And we know that … That is not what this amendment does.”

Rep. Richard Peña Raymond, D-Laredo, said the idea “puts Texas in the driver’s seat, and really Gov. Abbott in the driver’s seat” instead of forcing their hand or pushing through a program unpopular with conservatives.

But Republican state Rep. Giovanni Capriglione, the only House member to speak against the bill during Thursday’s debate, said that creating a new health care program — Medicaid or otherwise — is far too complicated an endeavor to tackle in a two-page amendment and cautioned that it in fact looked like a way to expand Medicaid without a public hearing or extended floor debate.

“This topic is incredibly important, it’s complex, and frankly, it’s not appropriately handled in this amendment,” Capriglione said.

House Democrats, a handful of Republicans, and health care advocates, as well as nearly 200 groups and community leaders across Texas, still have some hope for House Bill 3871 by state Rep. Julie Johnson, D-Carrollton. That bill creates the “Live Well Texas” plan that uses a 1115 waiver to capture the federal dollars and expand Medicaid eligibility, and it includes incentives for people to continue working as well as increases in Medicaid reimbursements to attract more doctors to the program.

The bill has 76 House sponsors, nine of whom are Republicans, giving it enough support to pass the House. But it has been stuck in the GOP-led House Human Services Committee since March, waiting on a hearing that becomes increasingly less likely as the Texas Legislature barrels toward its final days at the end of May.

Only one of the Republican sponsors of HB 3871 voted for the Coleman amendment.

See here and here for the background. In a vacuum, I can accept Rep. Capriglione’s explanation for why this was the wrong vehicle to handle a complex health care topic, but given that the Lege has refused to consider Medicaid expansion for a decade, and as Rep. Coleman notes we’re only trying to do this the hard way because Republicans refuse to do it the easy way, I’m less sympathetic. Even if this amendment had been adopted, there would be no guarantee it would be in the final budget – as Scott Braddock notes, what matters is the conference committee. In theory, that means this could be revived there, but let’s just say one should not bet on that outcome. All respect to Reps. Coleman and Johnson, but we’ve seen this movie before, and I don’t expect it to end any differently this time around.

Medicaid expansion by any means necessary

Whatever it takes. But I’ll believe it when I see it, and I have a very hard time believing that the current cast of characters will do anything to make it happen.

It’s constitutional – deal with it

Texas Republicans have been swift to condemn the Biden administration for rescinding early approval of a multibillion dollar Medicaid program that would help fund emergency care for the state’s booming uninsured population through 2030.

Gov. Greg Abbott said the federal government was “deliberately betraying Texans.”

Attorney General Ken Paxton vowed to “use every legal tool available to regain the assistance Texans need.”

But the decision federal health officials announced Friday could end up being one of the biggest steps yet to extend government health coverage to low-income people in Texas since the Affordable Care Act, according to health advocates and political observers. That’s true even if it doesn’t spur immediate change.

“The Biden administration has all the cards here,” said Brandon Rottinghaus, who teaches political science at the University of Houston. “They aren’t playing nice anymore with health care expansion. They’ve got the money, so they have the leverage.”

Pressure is also coming from inside the state. On Tuesday, a group of more than 150 organizations, including chambers of commerce, trade associations and local officials signed a letter calling on lawmakers to “support increased health coverage for Texans.”

“We specifically support a coverage initiative that is bipartisan, funded through available federal dollars, structured to be neutral for the state’s budget, and designed to meet Texas’ specific needs, values and circumstances,” it said.

The letter notably did not include the Texas Hospital Association, which criticized Friday’s decision. It has supported expanded coverage in the past.

[…]

Health care advocates have been quick to downplay Friday’s announcement, saying there is still plenty of time for the state to apply again for the waiver before next year. Texas was originally approved for the extension as part of a flurry of eleventh-hour orders by Trump health officials. In doing so, it allowed the state to forgo the normal comment period.

“I think of it in terms of, Texas didn’t follow the rules, and now it’s being told to follow the rules,” said Elena Marks, president of Episcopal Health Foundation in Houston. “It’s not being told, ‘you can’t have an uncompensated care pool.’ In fact, we need an uncompensated care pool, we ought to have one. But we have to follow the rules.”

See here for the background. Rescinding the 1115 waiver extension and making Texas follow the process to re-apply for it is a shot across the bow, but a limited one. If Texas does re-apply correctly, that extension will almost certainly be granted, though perhaps for a shorter period of time or with more strings attached. The current position of the Texas Hospital Association, which is on the sharp end of the stick right now, gives Abbott et al some cover. And as the story notes, Abbott has a primary election coming up, and the very last thing he will want to do before he wins that is anything that will make it look like he capitulated to Joe Biden and the Democrats. Maybe something happens after that, but politically speaking the incentives are all wrong.

This Trib story from Wednesday afternoon appears to offer a bit of hope, but don’t be fooled into thinking it’s more than that.

Among several bills filed in the conservative Texas Legislature is a Medicaid expansion plan with bipartisan support that is similar to those adopted in some Republican-led states.

Nine House Republicans and all 67 House Democrats have publicly signed on to House Bill 3871, which would give it enough votes to pass the 150-member chamber. Although none of the proposals have gotten a hearing this session, Medicaid expansion is expected to be introduced in some form as a floor amendment Thursday when the House debates the state budget.

[…]

“The time to do this is now,” said state Rep. Julie Johnson, D-Carrollton, the author of House Bill 3871. “The deal on the table that the [federal] government offered to us is, in my opinion, irresponsible not to accept.”

Conservative lawmakers are weighing their historic opposition to Medicaid expansion against the potential of billions in federal incentives coming to Texas during a tight budget cycle.

“There is a bipartisan desire to see the cost of health care decrease. The unsustainable increase in prices, whether at the hospital, the doctor, or in health insurance premiums hits all Texans,” GOP state Rep. James Frank, chair of the House Human Services Committee, said in emailed comments to the Tribune. “But there is also concern that when Medicaid expands, that adds pressure to the private insurance market to make up the difference in reimbursements. Hence, expansion is a hidden tax on those who have private insurance, driving up the cost of care for everyone.”

[…]

Lt. Gov. Dan Patrick’s and Gov. Greg Abbott’s offices did not respond to requests for comment, but both have opposed expanding Medicaid in the past. In January, House Speaker Dade Phelan expressed doubt that Medicaid expansion would happen this session.

Among other arguments, opponents say it would crowd out current Medicaid patients who are already getting a low quality of care due to the limited number of physicians who accept Medicaid patients because of low reimbursements.

It’s nice that there are 76 votes for a bill that hasn’t gotten a hearing and would still have to get through the Senate and be signed by Greg Abbott, but it’s still vaporware for now. (Rep. Frank, the House Human Services Committee Chair, is not among the nine Republican co-authors.) The same old tired arguments against Medicaid expansion, by people who don’t like Medicaid but claim to want to “protect” it, continue to have sway. Honestly, about 95% of this story could have been written in 2019, or 2017, or 2015, or 2013. It’s a tale as old as time at this point. The urge among Republicans to stick it to Obamacare at all costs has not abated. I don’t see anything to suggest to me that something has changed in this dynamic. I will be delighted to be wrong, but until I am proven wrong I say it ain’t gonna happen until we elect enough Democrats to make it happen.

Now it really is time for Texas to expand Medicaid

Good for the Biden administration putting the pressure on.

It’s constitutional – deal with it

The Biden administration on Friday rescinded changes to a federal funding agreement, known as a 1115 waiver, that would have extended for 10 years Texas’ health care safety net for uninsured residents — teeing up a new round of negotiations before the existing waiver expires in 2022.

The Centers for Medicare and Medicaid Services said in a statement that it erred in exempting the state from the normal public notice process before granting an extension to the waiver in the waning days of the Trump administration.

The agency “has rescinded the extension approval, which corrects this oversight with as little impact as possible to the people of Texas, since the original demonstration remains intact through September 30, 2022,” it said in a statement.

The Washington Post, citing two federal health officials, said the decision was a bid to push Texas toward expanding Medicaid to cover more low-income adults, a move the state and eleven others have resisted.

The 1115 waiver reimburses hospitals for the “uncompensated care” they provide to patients without health insurance and pays for innovative health care projects that serve low-income Texans, often for mental health services. The extension — worth billions of dollars a year — would have continued hospital reimbursements until September 2030, but allowed the innovation fund to expire this year.

The earlier waiver is still in effect, and federal authorities “stand ready to work with the state” if it wishes to extend it beyond next year, according to a Friday letter from the Centers for Medicare and Medicaid Services.

The state’s rationale to get out of the normal public notice process was that health care providers needed financial stability during the coronavirus pandemic, the letter said. But the state’s request did not “meaningfully explain why the extension request addressed the COVID-19 public health emergency or any other sudden emergency threat to human lives,” it said, in part.

See here for some background, and be sure to click on the NBC News link in that post. The 1115 waivers were used during the Trump years to approve the skinniest and stingiest Medicaid expansions possible, and in typical Trump fashion were done with zero regard for existing law or protocol. The Chron has some more details.

While the state’s current 1115 waiver won’t expire until September of next year, the reversal has immediate political impacts because the state Legislature has only weeks left in its session and won’t meet again until 2023. Without certainty over how much the federal government will contribute going forward, lawmakers risk leaving huge funding gaps for counties and hospitals.

Texas Republicans, who control the state government, have long campaigned against the Affordable Care Act and have declined to expand Medicaid under the act’s provisions as they seek to overturn the law in court. The state has depended on the waiver system as a cheaper alternative that nonetheless leaves millions of Texans uncovered.

Today, Texas has the highest uninsured rate in the country, with nearly 1 in 5 people lacking coverage. That results in staggering amounts of uncompensated emergency room visits each year, some of which is reimbursed by the 1115 waivers.

[…]

Earlier this year, a group of national health associations including the American Cancer Society, the American Heart Association and the American Lung Association called out the Trump administration’s expedited approval, saying there was plenty of time to hold a public comment period before the existing waiver expires next year.

“The waiver application was hundreds of pages, I don’t think it even mentioned COVID,” said Joan Alker, a Medicaid expert at Georgetown University who had signed on to the letter. “So it was a blatant disregard of what the exemption was supposed to be for.”

The Texas Hospital Association said it was disappointed with the decision.

“This action undermines the safety net and hospitals’ ability to protect people,” president Ted Shaw said in a statement. “It puts the state’s health at serious risk and creates unprecedented levels of uncertainty for an industry that is charged with saving lives.”

Others noted that the waiver was never meant to be a permanent solution.

“The waiver was always intended to serve as a temporary bridge until the state implemented an insurance option — with federal Medicaid expansion funds — for low-wage workers whose jobs don’t provide health coverage,” said Patrick Bressette, who directs the Children’s Defense Fund Texas. “Now would be a good time to have a real conversation about Medicaid expansion.”

Texas Sen. Nathan Johnson, a Democrat from Dallas who authored an expansion bill that has some Republican support, said the state should immediately reapply for the waiver while also taking up the expansion question.

“The story being told on the Republican side is Biden’s taking away resources from vulnerable people. False,” he said. “There’s still time left under the old waiver protections to do this the right way.”

I can understand why the Texas Hospital Association is unhappy with the decision, but the root of that is the failure to expand Medicaid, which has cost Texas hospitals tons of money. The waiver lets them get a few of those dollars back, but why settle for pennies when the dollars are available? Do the expansion, like we should have done a decade ago, and everyone is better off. It may be late in this session but there will need to be at least one special session for redistricting anyway, so the legislative calendar isn’t actually a problem. The choice and the benefits are clear, and the only reason not to is sheer partisan obstinance. Quit whining and get it done already.

Planned Parenthood not booted from Medicaid yet

A (likely very) temporary reprieve.

It’s constitutional – deal with it

Responding to an emergency lawsuit filed hours earlier, a Travis County judge issued an order Wednesday blocking Texas from removing Planned Parenthood as a Medicaid health care provider beginning Thursday.

The 14-day temporary restraining order, granted by state District Judge Maya Guerra Gamble after a brief hearing Wednesday afternoon, allows Planned Parenthood to continue providing health care to about 8,000 low-income Texans.

The judge also set a Feb. 17 hearing to determine whether a temporary injunction should be issued to keep Planned Parenthood in Medicaid.

In its lawsuit, Planned Parenthood argued that state officials did not follow the legally mandated process for kicking its health clinics out of Medicaid. Wednesday was supposed to be the final day Planned Parenthood clinics could receive Medicaid reimbursement for care that can include contraceptives, cancer screening and testing and treatment for sexually transmitted infections, but not abortions.

[…]

Planned Parenthood’s lawsuit argued that the termination letter did not comply with state law, including requirements that reasonable notice, and an opportunity for a hearing, be given.

The organization is seeking a court order blocking its removal until it exhausts all available administrative protests and appeals.

Texas officials, however, have argued that Planned Parenthood’s attack on the Jan. 4 notice of termination was misguided because a notice sent in January 2016 — kicking off years of litigation — complied with all necessary state laws and Medicaid regulations.

As the story notes, this has been going on since 2015. The state officially gave notice to Planned Parenthood patients that they needed to find a new doctor on January 5. I didn’t blog about it then because it was too depressing, and we know what else was going on at that time. It was a Fifth Circuit ruling that allowed the state to take the final steps in this process, so I don’t expect there to be much future to this litigation. Even the argument being made is just to buy time, as there are no questions of law remaining. You know my mantra: until we start electing different people to office, nothing is going to change. The Trib and the Chron have more.

The Republicans are not going to expand Medicaid

Maybe there was a brief moment, when the budget situation looked dire, when the forbidden topic could have been quietly whispered about. But come on, we know the score.

It’s constitutional – deal with it

Texas Republicans have long resisted expanding Medicaid under the Affordable Care Act, unswayed by the promise of billions in new federal aid for a state perennially ranked last in health coverage. But last fall, with their state House majority on the line and the uninsured rate climbing again amid the pandemic, conservative support seemed to be building.

On the campaign trail, Rep. Angie Chen Button, R-Richardson, said she was newly open to expanding the public insurance program under limited conditions. Rep. Morgan Meyer, R-Dallas, expressed support for a broader expansion than he had previously. Rep. Lyle Larson, R-San Antonio, tweeted that lawmakers should “seriously consider accessing federal Medicaid funding” in the next legislative session.

“This is money we’re sending to the federal government and not getting back,” he wrote.

With the session now underway, the party is facing a reckoning on the issue. All but a dozen states including Texas have expanded Medicaid since President Barack Obama’s signature health care law passed in 2010. It is broadly popular in Texas, according to polls. And Republicans in swing districts have come under increasing pressure from voters to address the state’s ballooning uninsured rate, which was at 18.4 percent before the pandemic, or about 5.2 million people.

House Republicans have yet to file any bills, though lawmakers said work is happening behind the scenes on a measure that could satisfy the GOP majority. Staffers for Button, Meyer and Larson either did not respond to messages or said they were unavailable to comment.

Finding widespread approval will be tough, and proponents lost a key leverage point this month when the outgoing Trump administration extended part of a waiver that helps Texas hospitals cover uncompensated care. While the move does not expand health coverage, it does ensure that emergency care is reimbursed for struggling hospital systems that treat low-income patients.

“The 1115 waiver was never meant to be a permanent fix,” said Sarah Davis, a former Republican state representative who favors expansion. “It was really supposed to be kind of like a bridge, because we were assuming — or the government was assuming — that the state would be expanding Medicaid.”

In the Senate, Republicans are likely to oppose any expansion bills. The upper chamber has blocked past attempts and killed legislation last session that sought even a narrow expansion, for new moms. A Senate committee omitted the option entirely in a report last year on ways to lower the state’s uninsured rate.

See here for more on the 1115 waiver. As the story notes, Greg Abbott has no interest in expanding Medicaid, either. I can believe there are some Republican State Reps, especially in tight-margin urban/suburban districts, who’d vote for some form of Medicaid expansion if a bill came up, but that’s a long way away from convincing Greg Abbott and Dan Patrick. You want to expand Medicaid, you need to vote for the candidates from the party that wants to expand Medicaid. It ain’t happening otherwise. This is our sixth regular session post-Obamacare, the track record should be perfectly clear by now.

UH Hobby School poll: Popular things are popular

That’t the main takeaway here.

More than two-thirds of Texans support raising some new taxes and using the state’s rainy day fund to patch budget shortfalls from the pandemic, according to a new survey by the University of Houston’s Hobby School of Public Affairs.

The survey, conducted online earlier this month, comes as lawmakers are back in Austin to consider a raft of new bills, many of them centered on the health crisis and other recent events, including protests over police brutality and the November election.

In addition to overwhelming support for new taxes on e-cigarettes and vaping products, respondents also heavily favor closing loopholes that allow large companies to lower their property taxes, raising the franchise tax on large businesses and legalizing casino gambling and marijuana, which would generate new tax revenue.

Just over 80 percent of respondents oppose a universal state income tax, but a majority, 62 percent, support taxing income on those earning more than $1 million a year.

[…]

In election reforms, two thirds of Texans support online voter registration and universal mail-in voting, according to the poll. The state currently does not have widespread online voter registration and limits mail-in voting to those over 65 or living with a disability. Texas is considered to have the most restrictive voting process in the country.

Another big issue this year will be redistricting, in which lawmakers redraw the state’s political boundaries for the next ten years. The process is currently controlled by Republicans, who hold majorities in both state legislative chambers. According to the poll, however, 70 percent of respondents support turning the process over to an independent commission, as is done in some other states including California.

Separately, 72 percent of respondents support criminal justice reforms spurred by the killing last summer of George Floyd by Minneapolis police. The George Floyd Act, as it’s known, includes changes such as prohibiting chokeholds and limiting police immunity from civil lawsuits. While it is widely supported, fewer than half of Republican respondents favor the legislation.

And with the state’s uninsured rate ballooning further, 69 percent of respondents support expanding Medicaid under the Affordable Care Act.

There are multiple polls being conducted under this umbrella, and you can find executive summaries and links to poll data here. The legislative issues poll data is here, and the media release is here, while the state budget poll data is here and the media release is here.

There are a couple of caveats to apply to this set of results. One is that this is a poll of adults, not registered voters. I’ve talked many times about the schism between what polls say are popular policies and what people actually vote for, and that is a key distinction to keep in mind. Two, likely related to item one, is that the composition of this sample is 31% Democrat, 27% Republican, 30% Independent, 8% Unsure, and 4% Other. I think we can make some guesses about where the non-voters are. Three, there are some serious partisan splits on questions like no-excuses mail voting, online voter registration, and the independent redistricting commission, with Dems vastly more in support than Republicans. Finally, some of these questions have a high “Don’t know” response to them (33% for the redistricting commission, for example), but the topline numbers being reported in the story are the recalculated percentages after the “don’t know” respondents are removed. These are some pretty big qualifiers, and you should very much keep them in mind.

That doesn’t mean this kind of poll has no value, just that it needs to be kept in perspective. As Grits notes, the poll wording on some complex issues like criminal justice reform is quite precise, so at least the people who did respond had a clear idea of what they were supporting or opposing, unlike the vaguely-worded Texas 2036 poll. And of course popular ideas can be a way to bring out less-likely voters, if one can get one’s message out in adequate fashion. Medicaid expansion and marijuana legalization both scored pretty well, with a lesser partisan split than the election-related questions. That’s good news for my suggested 2022 platform, but also a reminder that the other side gets to express an opinion and to influence the outcome. Being popular only goes so far.

The Texas 2036 poll

Texa 2036 is a new (to me, anyway) organization with a mission “to enable Texans to make policy decisions through accessible data, long-term planning and statewide engagement”. Mostly, they seem like good-government-through-good-data types who favor things like public education and health care. Fine things indeed. Towards their goal, they have a new poll:

As the work of the new legislative session begins, far more Texans than a year ago are concerned about the future, and public confidence in state government has declined considerably.

Those are key findings from a new poll we conducted in January 2021. The poll also shows that nearly a year of the COVID-19 pandemic, far fewer Texans rate the state’s ability to solve problems as “good” or “excellent,” and 4-in-5 say the legislature needs to take action this year to address the challenges Texas now faces.

[…]

Key Highlights

  • Prior to the pandemic, 50% of Texas voters rated the Texas state government’s ability to solve problems and serve the needs of its residents as “good” or “excellent,” compared to 36% after the pandemic.
  • “Politics, government and civility” was cited as the number one issue Texas needs to address to be successful 15 years from now, followed by “economy, jobs and trade” and “education.” “Immigration and the border,” which topped the list a year ago, is now tied for fourth place with various wedge and social issues.
  • 8-out-of-10 Texas voters think the Texas State Legislature should act during the current legislative session to address any challenges or issues highlighted by the coronavirus pandemic.

Here’s the press release with more data:

The poll of registered Texas voters revealed significant shifts from a poll that the organization conducted of registered voters for Texas 2036 in January of last year:

• The percentage of voters who are extremely or very concerned about the future of Texas increased from 31% in January 2020 to 47% in January 2021. Overall, 87% are concerned about the future of Texas.

• Prior to the pandemic, 50% of Texas voters rated the Texas state government’s ability to solve problems and serve the needs of its residents as “good” or “excellent,” compared to 36% after the pandemic. The economy was cited as the primary reason voters rated state government positively.

• “Politics, government and civility” was cited as the number one issue Texas needs to address to be successful 15 years from now, followed by “economy, jobs and trade” and “education.” “Immigration and the border,” which topped the list a year ago, is now tied for fourth place with various wedge and social issues.

• In 2020, 34 percent of Texans felt they were better off than they had been the year before, compared to 14 percent who felt they were worse off. In 2021, those levels are nearly even, with 22 percent believing they are better off and 21 percent believing they are worse off.

[…]

The poll was conducted by Baselice & Associates, Inc. a prestigious Texas polling firm. It surveyed 1,021 Texas voters via cell phones, land lines and the Internet. The margin of error for the results is +/- 3.1 percent at the .95 confidence level.

It revealed widespread support for legislation and policy changes that will help strengthen the Texas economy and set a groundwork for a thriving future:

• 64% of voters support Texas making Medicaid or free government health insurance available to adults with no children who earn $17,609, which is equivalent to 138% of the Federal Poverty Level, the eligibility threshold set by the federal government for Texas to receive billions of dollars in enhanced federal funding (today, able-bodied childless adults are ineligible for Medicaid in Texas.)

• 86 percent support changes that ensure more of the Medicaid tax dollars that Texas sends to the federal government are actually spent in Texas.

• More than two-thirds of Texans believe the state should use all available tools, including standardized tests, to address learning loss caused by the pandemic.

• 79 percent support better teacher training to improve fourth grade reading levels, and 84 percent support high-quality tutoring to close COVID learning gaps.

• 91 percent believe Texas students need access to the most up-to-date information on jobs and wages so students can make informed decisions about their higher education and colleges can help students get good jobs.

• 84 percent agree that because a high school diploma usually isn’t enough to get a good, well-paying job, the state needs to better orient education programs, degree plans and certifications toward jobs of the future.

• 91 percent support modernizing and increasing health care options in rural areas where there is a shortage of doctors, hospitals and clinics.

• 83 percent support market reforms and financial incentives to bring broadband to low-income and rural areas.

• And 86 percent say state and local governments should use better technology to avoid wasting taxpayer dollars and better serve Texans.

Some of this is encouraging, like the support for Medicaid, which as you know is something I think should be a cornerstone of the next statewide Democratic campaign. Some of it is anodyne to the point of meaninglessness. I mean, literally no one supports “wasting” money. It’s just that opinions differ as to what constitutes “waste”. Some of it feels inadequate – if we believe that a high school diploma is largely insufficient for getting a good job, then maybe we could do something about increasing access to college as well? There’s something here for everyone, it’s just not clear how much of it there is.

The bigger point here is that if one genuinely supports these things, then one has an obligation to support politicians who will pass laws to make them happen, and fund them adequately. The fact that we’re still talking about expanding Medicaid more than a decade after the passage of Obamacare tells you all you need to know about who does and doesn’t support that part of their plank. “Better teacher training” and “high-quality tutoring” sound expensive – who’s going to support spending the money on those things? You know where I’m going with this. Texas 2036 has some Very Serious People on its board, and likely the ability to put some money behind serious candidates who agree with their vision, however bland it is. What action do they plan to take in support of that vision? That’s the question to ask.

Here’s the official budget forecast

“Could be worse” remains the watchword.

Texas lawmakers will enter the legislative session this week with an estimated $112.5 billion available to allocate for general purpose spending in the next two-year state budget, a number that’s down slightly from the current budget but is significantly higher than what was estimated this summer when the coronavirus began to devastate the economy.

Texas Comptroller Glenn Hegar on Monday announced that number in his biennial revenue estimate, which sets the amount lawmakers can commit to spending when they write a new budget this year. But he acknowledged that Texas’ economic future remains “clouded in uncertainty” and that numbers could change in the coming months.

Hegar also announced a nearly $1 billion deficit for the current state budget that lawmakers must make up, a significantly smaller shortfall than Hegar expected over the summer. That number, however, doesn’t account for 5% cuts to state agencies’ budgets that Gov. Greg Abbott, House Speaker Dennis Bonnen and Lt. Gov. Dan Patrick ordered this summer or any supplemental changes to the budget lawmakers will have to make.

Hegar’s estimates portend a difficult budget-writing session for lawmakers. But Hegar acknowledged that things could have been a lot worse. The $112.5 billion available is down from $112.96 billion for the current budget.

See here for the previous update. I continue to hope that Congress will throw a boatload of state and local aid our way in the coming months, which will also help, but at least we’re not in truly dire territory. And bizarrely enough, there may be a silver lining in all this.

But advocates hope the pandemic, combined with the revenue crunch, could lead to an unlikely bipartisan agreement. Before the pandemic hit, Democrats saw a takeover of the Texas House as key for advancing the prospects of Medicaid expansion in the state. But as COVID-19 has ravaged the state economy and thrown even more Texans into the ranks of the uninsured, Democrats are guardedly optimistic this could persuade enough Republicans to put aside their political hangups and support expansion—even as Republican Attorney General Ken Paxton leads a national lawsuit to eliminate the entire Affordable Care Act.

Texas is one of 12 remaining states that have refused the federally subsidized Medicaid expansion, despite having the highest rate and largest population of uninsured residents in the country. Expanding Medicaid would cover 1 million uninsured Texans and bring in as much as $5.4 billion to the state, according to a September report by researchers at Texas A&M University.

State Representative Lyle Larson, a moderate Republican, voiced his support for expanding Medicaid soon after the election, pointing to six GOP-led states that have done so in the past three years. “It is a business decision,” Larson wrote on Twitter, noting that the move would help with the revenue shortfall and COVID-19 response, address rural hospital closures, and expand access to care. Dallas County Representatives Morgan Meyer and Angie Chen Button, both Republicans, pulled out razor-thin victories to keep their House seats after voicing support for some type of Medicaid expansion in their campaigns.

Even conservative state Senator Paul Bettencourt acknowledged that the fiscal crunch will force consideration of Medicaid expansion. “My back-of-the-napkin analysis shows that’s a $1.6 billion item, like that—boom!” he told the Dallas Morning News in September. “I’m pretty sure we don’t have that falling out of trees,” he said. “You can put Medicaid expansion up at the top of the list. There will be a debate.”

But there’s still plenty of staunch opposition. “For those that promote [expansion], I haven’t heard what they’re willing to cut,” state Senator Kelly Hancock, a Republican who chairs the Business and Commerce Committee, said in November. “It’s easy to talk about it until you have to pay for it, especially going into this budget cycle.”

As with casinos and marijuana, the smart money is always to bet against Medicaid expansion happening. But this is a bigger opening than I’ve seen in a long time, and while that’s still not saying much, it’s not nothing.

Looking ahead to 2022

Continuing with the brain dumps, which are my post-election tradition. This is a collection of thoughts about the next big election, in 2022.

As I said earlier, I take no position on the question of what effect the disparity in door-to-door campaigning had. I can buy there was some effect, but we have no way of how much of an effect it was. The good news is, whatever the case, this isn’t a trend, it’s a one-time effect of an election in a pandemic. I feel pretty confident saying that barring anything extraordinary, traditional door-knocking will be a big component of everyone’s 2022 campaigns. Perhaps Democrats will have learned something useful from this year’s experience that will enhance what they can do in 2022; admittedly, what they have learned may be “this sucks and we never want to do it this way again”.

There are a couple of things that concern me as we start our journey towards 2022. The first is that after four long years of hard work, with one rewarding election cycle and one disappointing cycle, people will be less engaged, which needless to say will make keeping the ground we have gained, let alone gaining more ground, that much harder. I think people will be focused on bringing change to our state government, but we can’t take this for granted. People are tired! These were four years from hell, and we all feel a great weight has been lifted. I get it, believe me. But we felt this way following the 2008 election, and we know what came next. We cannot, absolutely cannot, allow that to happen again. We know what we need to do.

Second, and very much in line with the above, the national environment matters. What President Biden will be able to accomplish in the next two years depends to a significant extent on the outcome of those two Georgia Senate runoffs, but however they go we need to remember that there are significant obstacles in his way. Mitch McConnell and the Republicans were greatly rewarded for their all-out obstructionism throughout the Obama presidency. We can’t control what McConnell et al do, but we can control our reaction to it. Do we get discouraged and frustrated with the lack of progress, or do we get angry with the people whose fault it really is? How we react will be a big factor in determining what the national mood in 2022 is.

I’m already seeing people give their fantasy candidate for Governor. They include the likes of Beto O’Rourke, Julian Castro (my choice), Cecile Richards, Lina Hidalgo, and others. I don’t know who might actually want to run – it is still early, after all – but we just need to bear in mind that every candidate has their pros and cons, and we need to worry less about matters of personality and more about building coalition and continuing the work we’ve been doing.

For what it’s worth, four themes I’d like to see our eventual candidates for Governor and Lt. Governor emphasize: Medicaid expansion, marijuana legalization, emergency/disaster preparedness and response, and improving the voter experience, with a focus on online voter registration. The first two have proven they are popular enough to be adopted by voter initiative in deep red states, the third is obvious and should include things like hurricanes, flooding, and drought in addition to pandemics in general and COVID-19 in particular, and the fourth is something there’s already bipartisan support for in the Lege. Let Greg Abbott and Dan Patrick defend the status quo here.

(Increasing the minimum wage was also a ballot initiative winner in states like Florida, and it generally polls well. I very much support raising the minimum wage, but don’t have as much confidence that it would be an electoral winner here. I’m open to persuasion otherwise.)

Here are some numbers to contemplate as we look towards 2022:

I’d attribute the regression in performance in the biggest 15 counties to Republican improvement more than Democrats falling short – as noted multiple times, Democrats hit new highs in the big urban counties, but so did the GOP. There’s still room for growth here, especially in an environment where turnout level is much more volatile, but the marginal growth is smaller now. Putting that another way, there’s no longer a deficit of voter registration in these counties. We need to maintain and keep up with new population growth, but we’re not behind where we should be any more. If we do that, and we prioritize maximizing our own base, we’ll be fine.

It’s the bottom two groups that we need to pay some attention to. A lot of these counties have medium-sized cities in them, and that’s an obvious place to focus some effort. (I’ve been beating that drum for months and months now.) But we really need to do something about the small rural counties, too, or face the reality of huge vote deficits that we can’t control and have to overcome. I know this is daunting, and I have no illusions about how much potential for gain there is here, but I look at it this way: If Donald Trump can convince some number of Black and Latino people to vote for him in 2020, after four years of unrelenting racism and destruction, then surely nothing is impossible. I think marijuana legalization could be a good wedge issue here. Remember, the goal is to peel off some support. A few points in our direction means many thousands of votes.

It’s too early to worry about legislative and Congressional races, because we have no idea what redistricting will wrought. I think we should be prepared for litigation to be of limited value, as it was this decade, and for the Republicans to do as much as they can to limit the number of competitive districts. They may be right about it in 2022, but that doesn’t mean they’ll be right in subsequent years.

In Harris County, we should expect competitive primaries for all of the countywide positions, and for many of the judicial spots. Judge Lina Hidalgo has done an outstanding job, but we know there are people who could have run in 2018 who are surely now thinking “that could have been me”. Don’t take anything for granted. We need to keep a close eye on the felony bail reform lawsuit, and news stories about how the current judges are handling bail hearings, because we are going to have to hold some of our folks accountable. We need to make sure that all of the Republican justices of the peace have opponents, especially the ones who have refused to do same-sex marriages.

Overall, there’s no reason why we can’t continue to build on what we have done over the past decade-plus in Harris County. Complacency and disunity will be our biggest opponents. The rest is up to us.

Endorsement watch: The Susan Collins of Texas

Three things in life are certain: Death, taxes, and certain Chron endorsements.

Rep. Sarah Davis

The voters in state House District 134 — a swing district that covers all or parts of River Oaks, Bellaire and Meyerland and includes the Texas Medical Center — face a tough choice in the Nov. 3 election.

Five-term Republican incumbent Rep. Sarah Davis and Democratic challenger Ann Johnson are both well-qualified, skilled communicators whose many talents would serve them well in the Legislature.

We recommend Davis, 44, based on her experience, growth in office and independence.

A rare Texas Republican who supports abortion rights, she has moved from the tea party positions of her first 2010 victory to embrace the Affordable Care Act provisions of Medicaid expansion and coverage of pre-existing conditions as well as bucking her party on other issues.

[…]

Johnson has stressed her policy differences with Davis on immigration and gun control, where the incumbent is more in line with the GOP. Johnson has criticized Davis’ vote to let school districts arm teachers and to require universities to permit guns in campus parking lots and her sponsorship of a “show me your papers” bill to allow local law enforcement officials to ask about immigration status.

Those are not measures supported by the editorial board.

And yet. In the same way that the Chron endorsed Orlando Sanchez for Treasurer in four straight elections, so have they endorsed Sarah Davis consistently since 2012. Look, if you want to believe that Sarah Davis is a force for good for reproductive rights and LGBTQ equality and even expanding Medicaid, I can’t stop you. I happen to think that campus carry and “sanctuary cities” legislation are indelible stains on her record, but you do you. My opinion is that it’s better to maximize the odds of a Democratic House than to depend on a singular Republican savior. Your mileage may vary.

(Where the post title came from.)

Why endorse Sarah Davis?

It’s a good question.

Rep. Sarah Davis

Planned Parenthood’s Texas political arm on Thursday endorsed state Rep. Sarah Davis, rebuffing abortion rights activists who had lobbied the group to deny political support for the Houston Republican.

The efforts to deny Davis the endorsement had revolved around a petition circulated by Sherry Merfish, a deeply connected Democratic donor and former Planned Parenthood board member. The petition concedes that Davis “may have met the minimum standards of what it means to be ‘pro-choice,’” but argues that “the rest of her record stands completely at odds with the cause of reproductive justice and the purported mission of Planned Parenthood.”

It had gathered some 450 signatures by Wednesday afternoon, including numerous Planned Parenthood donors and two board members of the group’s Houston affiliate. One of the board members, Peggie Kohnert, had circulated her own petition.

The lobbying effort has revealed a fracture between key members of Houston’s abortion rights community and the leaders of Planned Parenthood Texas Votes, a political action committee that defines itself as nonpartisan but has struggled to find Republicans like Davis to endorse. As the debate plays out, Texas Democrats — desperate to capture a House majority before next year’s critical redistricting battle — are making an all-out push to unseat Davis, whom they view as one of the most vulnerable Republican legislators in the state.

Davis’ stances on abortion have angered members of her party but helped garner support from moderate voters. In the last two cycles, she won re-election while her party’s standard-bearers, Donald Trump and Ted Cruz, each failed to crack 40 percent in her district.

Houston lawyer Ann Johnson, Davis’ Democratic opponent, argues the incumbent has worked against women’s reproductive issues by opposing the Affordable Care Act and declining to vote for the law’s optional expansion of Medicaid. Davis disagrees, saying she has voted against “every anti-choice bill” during her time in office.

Some of Johnson’s supporters say groups such as Planned Parenthood Texas Votes have allowed Davis to carefully curate her moderate reputation while she aligns with her party on immigration and gun policies. Merfish said the group also would paint a misleading picture of Johnson by backing Davis.

“By endorsing Sarah, in people’s minds who may not be as familiar with Ann, it would cast doubt on whether Ann is aligned with them on these issues,” Merfish said. “Because, then why wouldn’t they endorse both of them, or why wouldn’t they stay out of it?”

Planned Parenthood Texas Votes announced the Davis endorsement Thursday as part of a slate of 18 new endorsements. Davis is the only Republican among the 27 candidates the group is backing this cycle.

In a news release, Planned Parenthood Texas Votes said it is “working to elect officials not to just defend access to sexual and reproductive health care, but to repair and expand the public health infrastructure damaged by Governor Abbott and other extremist politicians.”

There was a preview story about this on Wednesday, which covered much of the same ground. As the story notes, Davis also received the endorsement from the Human Rights Campaign, despite Ann Johnson being an out lesbian. The story goes into a lot of detail about Davis’ career and various votes and issues that are at the heart of the dispute, so I encourage you to read the rest.

On the one hand, I get why PPTV and the HRC want to endorse Republicans like Davis, who are an increasingly rare breed. It’s in their best interests, at least as they see it, to be non-partisan, which means they need to find Republicans they can support. From a national perspective, Democrats may be the majority in Congress now, but partisan control is likely to swap back and forth over time, and you need to have some connections to the Republican majority when it exists, no matter how otherwise hostile it is, because you can’t afford to be completely shut out. Long term, I’m sure groups like these very much want for their issues to not be seen as strictly partisan, but to have broad consensus across party lines, and the only way to do that is to have Republican faces you can point to and say “see, they support us, too”. They have done this for a long time, and it’s just how they operate.

On the other hand, the simple fact of the matter is that having Sarah Davis in the State House makes it that much more likely that the Republicans will maintain their majority in that chamber, and a House with a Republican majority and a Republican Speaker is absolutely, positively, one hundred percent going to pass at least one major anti-abortion bill in 2021, just as it has every session since 2003, when the Republicans first took the majority and thus gained trifecta control of Texas state politics. A State House with a Republican majority and Speaker will absolutely not pass a bill to expand Medicaid. I agree, such a bill would almost certainly be DOA in the Senate, but at least it would get there, and the voters in 2022 would have a tangible example of what they’ve been missing out on. And of course, a State House with a Republican majority and Speaker will absolutely make further cuts to women’s health (which is already happening without any legislative input) and add further restrictions to Planned Parenthood, again as they have been doing for years now. All of this would happen regardless of the virtuous votes that Sarah Davis would cast. I mean, it may be true that she has helped stop some things and reverse some cuts and spoken against some other things, but all this has happened regardless. She’s only one member, and they have always had the votes to do all that without her.

This debate has played out for several years at the national level, with the national Planned Parenthood PAC being criticized in the past for supporting the likes of Arlen Specter and Susan Collins and a handful of Congressional Republicans for their reasonably pro-choice voting records while overlooking the “which party is the majority” aspect. Indeed, for the first time ever, Planned Parenthood has endorsed Collins’ challenger, with her vote for Brett Kavanaugh being the proverbial last straw. Activists, including blogs like Daily Kos, have made the same argument about control of the chamber versus individual members with acceptable voting records. However you feel about what PPTV and HRC did here, it’s not at all a surprise to see this debate arrive here on this level.

Ann Johnson

Though individual endorsements rarely have the power to swing elections, Planned Parenthood Texas Votes holds more sway in House District 134 than the average political group, said Renée Cross, senior director of the Hobby School of Public Affairs at the University of Houston. The district, which covers Bellaire, West University Place, Southside Place, Rice University and the Texas Medical Center, is home to some of the most affluent, educated and politically engaged voters in the state and contains what Merfish described as a “trove of Planned Parenthood voters.”

The group’s endorsement is particularly significant for Davis, Cross said, because of President Trump’s struggles among suburban women.

“Just like the tea party helped bring her in back in 2010, the anti-Trump movement could help move her out, especially among women,” Cross said.

I agree that Davis is better positioned with these endorsements than without them. A bigger concern for Davis is just simply how Democratic HD134 was in 2018, when Beto took 60% of the vote, and Davis was fortunate to not have had a serious challenger. I see a parallel to Ellen Cohen, who won re-election in 2008 by a 14-point margin over a non-entity opponent, even as Republicans were carrying the district in nearly every other race. 2008 was a strong Democratic year overall in Harris County, but HD134 was actually a bit more Republican than it had been in 2006, when something like seven or eight downballot Dems also carried the district. Cohen still vastly outperformed other Dems in the Republican tidal wave of 2010, but that wave was too big for her to overcome. I get the same feeling about Davis this year. Maybe I’m wrong – no two elections are ever alike, and HD134 has been a Republican district far longer than it’s been a Democratic district – but there’s a reason why neutral observers view Davis as being endangered.

One last thing: When I say that groups like PPTV and HRC want to be supportive of Republicans like Sarah Davis, it’s because there’s literally no other Republicans like Sarah Davis, at least at the legislative level in Texas. The thing is, Republicans like her have been extremely endangered for some time now. Go ahead, name all of the Republican legislators you can think of from this century that you could classify as “pro-choice” with a straight face and without provoking a “no I’m not!” response from them. I got Joe Straus, Jeff Wentworth (primaried out by the wingnut Donna Campbell), and that’s about it. I’m old enough to remember when Gary Polland and Steven Hotze ousted Betsy Lake, the nice River Oaks Planned Parenthood-supporting lady who had been the Harris County GOP Chair in the 90s, thus completing a takeover of the party that has lurched ever further rightward since. If they can’t support Sarah Davis, I have no idea who else in the Republican Party they could support.

We don’t need a vote to expand Medicaid

There’s a fundamental truth that needs to be addressed in this.

It’s constitutional – deal with it

On Tuesday, Missouri became the 38th state to expand Medicaid, opening healthcare to over 230,000 Missourians. It joins a lengthy list of GOP-led states in expanding healthcare, including Nebraska, Utah, and Oklahoma. Meanwhile in Texas we still lead the country in the number of uninsured and, since the COVID-19, pandemic another 650,000 have lost their health insurance.

The ballot initiative to expand Medicaid passed in Missouri by 53 percent, with several suburban counties in St. Louis and Kansas City voting overwhelmingly for the measure. The governor of Missouri, a staunch conservative, actually added the ballot initiative to the August primary ballot instead of November’s presidential ballot, hoping a smaller turnout would defeat the measure.

Clearly, the voters of Missouri felt expanding Medicaid was important for their state. The vote also comes as the Trump administration continues its effort to dismantle the Affordable Care Act, potentially kicking 20 million Americans off their health care and denying preexisting conditions coverage to over 120 million. Both Gov. Greg Abbott and Texas Attorney General Ken Paxton support ending the ACA.

Texas has been in a health crisis for a long time, well after the state decided not to expand Medicaid through the ACA. According to a report from 2018, over 17 percent of Texas residents lacked health coverage. That’s about 5 million Texans without access to health care.

With COVID-19, that health crisis has only exacerbated. While cases and hospitalizations from COVID-19 have gone down in parts of the state, those numbers will likely rise precipitously as schools open. Over 7,000 Texans have died from the coronavirus. Many hospitals, particularly rural ones, are overwhelmed. The health care status quo has never felt so dangerous and untenable.

So will Texas ever get a chance to vote on expanding Medicaid? According to Republican lawmakers in the state, that would be a “no.” Rep. Celia Israel commented on Twitter that she and Rep. John Bucy sponsored a bill in the last legislative session that would allow voters to “weigh in and expand Medicaid,” but that it never got a hearing.

[…]

If Texans do get a chance to vote on expanding Medicaid, it will surely be opposed by Republicans statewide and in the legislature. If history is any guide, however, improving health care will transcend partisan lines.

The people of Missouri voted on the question of expanding Medicaid because the state of Missouri allows for laws to be enacted by referendum. In other words, in the state of Missouri and a number of others, you can collect petition signatures to put a proposed law up for a vote by the people, which is then enacted if it passes. Different states have different rules for this, but that’s the basic idea. The city of Houston allows for charter amendments to be put up for a vote via the petition process, which is always a fun thing to endure. For better or worse, the state of Texas does not allow for this.

The key thing to understand here is that the folks who pushed Medicaid expansion in Missouri via referendum did so for the explicit purpose of bypassing Missouri’s legislature and governor, both of which opposed Medicaid expansion. Most states early on passed Medicaid expansion via their legislatures, including some Republican states, but in recent years most of the action has come via the ballot box, in states like Idaho and Nebraska and Oklahoma. The key ingredients there were a combination of legislators and governors that opposed expanding Medicaid, and a petition process that allowed for the legislative process to be circumvented.

So if you’ve wondered why if those states can vote to expand Medicaid why can’t Texas, the answer is because the law doesn’t allow for it. It can only be done via the Legislature. Indeed, bills to do some form of Medicaid expansion have been proposed but have not gotten anywhere. The reason for that of course is intransigent Republican opposition, but guess what: The Democrats have a shot at taking the majority in the State House this year (as you may have heard), which would overcome one of those obstacles. We’d still need to take the Senate and elect a new Governor to finish the job, but at the very least the House could pass a Medicaid expansion bill, or put something for it in the budget, and dare the Senate and Greg Abbott to oppose it. I for one would be fine with having the 2022 Governor’s race be defined in large part by expanding Medicaid (in addition to, you know, COVID-19 response).

If that’s the case, then what was Rep. Israel tweeting about? Very simply, it was a political move to try to force the issue in a slightly different way. What Reps. Israel and Bucy proposed was a Constitutional amendment, which is something that the voters have to approve, which would have expanded Medicaid. Why propose a Constitutional amendment, which requires a two-thirds vote in both chambers, instead of a regular old bill that needs only a simple majority? Three reasons: One, constitutional amendments do not need the governor’s approval, so it would go to the voters regardless of what Greg Abbott wanted. Two, it offered Republican legislators who opposed Medicaid expansion but might have felt the need to do something a way out, as in “just vote to let the people decide, and we’ll never bother you about it again”. And three, constitutional amendments can only be changed or repealed by subsequent constitutional amendments, with their two-thirds-majority requirements, thus protecting Medicaid expansion via this avenue from the whims of a future Republican legislature.

The point is, though, we don’t need to vote to expand Medicaid. At least, we don’t need to vote on a ballot proposition to do it. We just need to vote for a Legislature and a Governor who are willing to do it. We’re a lot closer to that than we’ve ever been, and we’re closer to it than states like Missouri and Idaho and Nebraska and Oklahoma had any hope of being. The votes we need to expand Medicaid are this November, and November of 2022. Those are the prizes to keep your eyes on.

A new homelessness initiative

Good.

Harris County Commissioners Court voted unanimously on Tuesday to authorize $18 million for a two-year program serving the homeless as advocates project a rise in homelessness with the novel coronavirus.

The program is the county’s most ambitious partnership with the City of Houston for people experiencing homelessness, with $29 million to be pledged by the city and an additional $9 million or more from private donors. The city and county’s dollars come from federal money allocated through the CARES Act.

While the city and county have collaborated on homeless initiatives in the past, this is their biggest joint investment yet.

“With the current COVID-19 crisis putting so many people’s living situations at an increased risk, having access to stable housing options is vital for the entire community,” Precinct 2 Commissioner Adrian Garcia said in a press release. Garcia brought the funding request to the county court. In commissioners court, Garica said, “This will have the most significant impact on the camps we see.”

Not only are people experiencing homelessness more vulnerable to coronavirus because of preexisting chronic conditions and a lack of even basic hygiene options, they are at higher risk of spreading it to others because people living on the streets have nowhere to self-quarantine.

“Housing is healthier for people experiencing homelessness during the coronavirus,” said Catherine Villarreal, communications director for the Coalition for the Homeless. The Coalition will be administering the programs. “People experiencing homelessness are uniquely vulnerable to coronavirus because of chronic conditions.”

The Coalition hopes that the programs can begin by mid-August and will roll out in stages pending city and county funding and contract approvals, said Ana Rausch, vice president of operations for the Coalition for the Homeless.

The initiative will provide rental assistance for about 1,700 newly homeless people who don’t need much case management, house about 1,000 people experiencing homelessness, support about 200 people at risk of homelessness, provide more mental-health case management and begin a homelessness diversion program. The Coalition projects the program will help about 5,000 people.

The best evidence we have now says that the most effective way to ameliorate homelessness is to provide housing or housing assistance to the people who need it. Other services may be needed for people with addition or mental health issues (by the way, expanding Medicaid would help a lot with those, too), and it turns out that having a stable place to sleep and eat and keep clothes and other possessions makes addressing those issues a lot easier, too. It seems to me that the main objection to providing this kind of direct aid is that it’s some kind of moral hazard, as in “well, if we help SOME people then we have to help EVERYONE, and if we do that then who’s ever gonna want to do for themselves” or some such. Putting aside the fact that such sentiments are facially untrue, if there’s one thing we should be learning from the coronavirus pandemic it’s that everyone does in fact deserve help. Hard times can come for any of us, at any time, without warning and without it being anyone’s “fault”. I want to live in a society that recognizes this truth, because the next person who needs it could be me or someone I love. Imagine how much more progress we could make on controlling this pandemic if everyone whose business or employment is threatened by it knew they would be tided over until it passed. Maybe now that we’re starting to take this kind of action, we’ll recognize the need to continue it after the current crisis has passed. Houston Public Media has more.

Abbott declares a state of emergency

Seems like it’s called for.

Gov. Greg Abbott on Friday declared that the new coronavirus is a statewide public health disaster and said that Texas is on the verge of being able to significantly ramp up its testing capacity.

At the same time he announced that he was directing day cares, nursing homes and prisons to limit visitations.

He said San Antonio is opening on Friday the first state drive-through with testing capabilities that will initially prioritize health care workers and high-risk patients.

Abbott also finally clarified the state’s testing history so far and current capabilities. In total, he said there have been 220 Texans tested by either a state public lab or by the Centers for Disease Control and Prevention. There are another 75 Texans being tested currently.

On Friday, the state’s testing capacity was roughly 270 people per day, but he said next week that capacity will expand into the thousands as private labs come online.

The Chron adds some more details.

The governor didn’t provide details on where and when the lab would open. But he credited Mayor Ron Nirenberg and his team for leading the way on the issue.

The facility will initially be only for first responders, health care workers, operators of critical infrastructure and key resources and certain high-risk patients, Abbott said.

He said the state has tested 220 Texans so far for the virus and he expects public and private labs to exponentially increase the capacity next week. The labs will be able to test several thousand people a week.

It’s a good and necessary start, but there’s a lot more that can be said and done. What about paid sick leave, which the state is fighting tooth and nail in court, for one? What about the millions of people with no health insurance, including all those who would have benefited from an expansion of Medicaid? It may seem crass and opportunistic to bring up heated political points like these right now, but we’d be in a much stronger position now if Abbott and his fellow Republicans hadn’t so fiercely opposed these things. Policy and politics matter. We shouldn’t let Abbott off the hook for these things just because he did his job today. WFAA and the DMN have more.

Medicaid and hospitals

I have three things to say about this.

A proposed change in Medicaid rules could cost Texas hospitals billions of dollars, forcing many to cut services and some rural hospitals to close their doors, health care industry officials said.

The change, aimed at increasing the transparency of how the program’s money is spent, narrows the definition of state and local funds that can be used to determine federal matching funds. That, in turn, would reduce federal funding and cost Texas hospitals an estimated $11 billion a year, industry officials said.

Houston hospitals would lose an estimated $500 million a year, said Tim Ottinger, director of governmental relations at CHI St. Luke’s Health.

A drop in funding would mean extreme hardship for many of Texas’ rural hospitals, which stand to lose some $900 million a year. The Texas Organization for Rural and Community Hospitals (TORCH) found that 46 percent of the state’s rural hospitals operate at a loss. Over the last decade, 26 rural hospitals have closed in Texas, the highest rate in the nation.

It’s unclear how many more rural hospitals could close if the proposed rule goes into effect as written, but it would be devastating to pull so much money from their budgets, said John Henderson, president of TORCH.

“A business can’t survive,” Henderson said. “But this isn’t just a business, it’s a service.”

1. I mean, you’d think that a policy that would cost the state billions of dollars and would have such a negative impact on rural areas, where access to health care is already severely lacking, would call for some kind of response from our state government. Turns out they like it, because they say it would let them cut costs. Just in the state budget, though. Counties and hospitals and the rest are on their own.

2. That said, some of those rural communities don’t seem to be too concerned about their hospitals. So maybe I shouldn’t be all that concerned on their behalf.

3. Of course, this proposed change will not survive the end of the Trump administration. None of the Democratic Presidential candidates, whatever their health care plans are, will allow this to stand. So, you know, make sure you vote for one of them this November.

The extraordinary danger of being pregnant and uninsured in Texas

So utterly appalling.

Right there with them

From 2012 through 2015, at least 382 pregnant women and new mothers died in Texas from causes related to pregnancy and childbirth, according to the most recent data available from the Department of State Health Services; since then, hundreds more have likely perished. While their cases reflect the problems that contribute to maternal mortality across the United States — gross medical errors, deeply entrenched racism, structural deficiencies in how care is delivered — another Texas-size factor often plays a significant role: the state’s vast, and growing, problem with health insurance access.

About one in six Texans — just over 5 million people — had no health insurance last year. That’s almost a sixth of all uninsured Americans, more than the entire population of neighboring Louisiana. After trending lower for several years, the Texas rate has been rising again — to 17.7% in 2018, or about twice the national average.

The numbers for women are even worse. Texas has the highest rate of uninsured women of reproductive age in the country; a third were without health coverage in 2018, according to a DSHS survey. In some counties, mainly along the Mexico border, that estimate approaches 40%.

Public health experts have long warned that such gaps can have profound consequences for women’s health across their lifespans and are a critical factor in why the U.S. has the highest rate of maternal deaths in the developed world. Texas’ maternal mortality numbers have been notably troubling, even as errors in key data have complicated efforts to understand what’s going on and led skeptics, including the governorto question whether there’s really a crisis.

Hardly anyone outside the policy world has taken a deep look at how these insurance gaps play out for women in the second-largest state in the U.S. — at how, in the worst-case scenarios, lack of access to medical care endangers the lives of pregnant women, new mothers and babies.

ProPublica and Vox have spent the last eight months doing just that — combing through government data and reports, medical records and research studies, and talking with scores of women, health care providers, policymakers and families of lost mothers around the state. We learned about Rosa Diaz and dozens of others, mostly women of color, by scouring medical examiner’s databases for sudden, “natural” deaths, then inspecting investigator and autopsy reports for clues about what went wrong.

The picture that emerges is of a system of staggering complexity, riddled with obstacles and cracks, that prioritizes babies over mothers, thwarts women at every turn, frustrates doctors and midwives, and incentivizes substandard care. It’s “the extreme example of a fragmented system that cares about women much more in the context of delivering a healthy baby than the mother’s health in and of itself,” said Eugene Declercq, professor of community health sciences at Boston University School of Public Health.

Most of the mothers whose cases we examined were covered by Medicaid for low-income pregnant women, a state-federal health insurance program that pays for 53% of the births in Texas, more than 200,000 a year, and 43% of all births nationwide. In Texas, the program covers OB-GYN visits, medications, testing and nonobstetric care, from endocrinologists to eye exams.

But the application process is so cumbersome that women in the state have the latest entry to prenatal care in the country, ProPublica and Vox found. It can take months to be seen by regular providers and even longer to access specialists. This poses the greatest danger for high-risk mothers-to-be — as many women on Medicaid are, having had no medical care for significant parts of their lives. Then, roughly two months after delivery, pregnancy Medicaid comes to an end, and the safety net gives way to a cliff. For many new mothers, the result is a medical, emotional and financial disaster.

More than half of all maternal deaths in the U.S. now occur following delivery, according to the Centers for Disease Control and Prevention, with as many as 24% happening six or more weeks after a woman gives birth. In Texas, the proportion of late-postpartum deaths is closer to 40%, with black women bearing the greatest risk. “To lose health care coverage really has a tremendous potential to worsen outcomes,” said Dr. Lisa Hollier, chief medical officer for obstetrics and gynecology for Texas Children’s Health Plan and chair of the state’s maternal mortality review committee.

This is a long excerpt, but there’s a lot more to the story, so please read the whole thing. There are numerous policy decisions at fault here – not expanding Medicaid, low Medicaid reimbursements, cutting off Planned Parenthood and substituting in wholly inadequate alternatives, and more – and all of them can be laid at the feet of the state’s Republican leadership. Whoever runs against Greg Abbott and Dan Patrick and Ken Paxton in 2022 should loudly and repeatedly assert that every maternal death in Texas is their fault. I keep saying this, and it keeps being true: Nothing will change until we have different, and better, government in this state. There’s no other way to do it.

Let this finally be the end of the Heidi Group’s grift

And you should all be thoroughly appalled at the waste, fraud, and abuse committed in the name of screwing Planned Parenthood.

Right there with them

An anti-abortion group that came under fire for failing to provide services to thousands of Texas women must repay $1.5 million in overpayments and prohibited costs, state investigators said Thursday.

The findings, announced by the office of the health inspector general, are a new blow to the Heidi Group. The organization had hoped to replace Planned Parenthood as a top family planning provider, but was cut off from millions in funding last year after failing to serve tens of thousands of low-income women.

The office said on Thursday it had uncovered “serious contractual violations” and is expanding its inquiry to the entire span of the Heidi Group’s contracts, going back to 2016. That could mean additional repayments.

Forensic accountants found the group had paid medical providers hundreds of thousands in excess fees, had overspent on payroll and fringe benefits, and had expensed thousands in unallowable costs like food, gift cards, clothing and retail membership fees, according to a copy of the internal investigation obtained by the Houston Chronicle.

The inquiry covered a seven month period, from September 2017 to March 2018.

“It’s a travesty when you look at all the women who should have been receiving services and were not because of this,” said Rep. Donna Howard, D-Austin. “We’re talking about women who don’t have means to afford health care like many of us do.”

See here for a deeper dive on the Heidi Group’s utter failure, and here for all previous blog posts. As the Observer notes, the state finally canceled their contracts last month, after three years of shoveling good money after bad. In the meantime, thousands of women were denied the health care the needed and deserved. This is what happens when you put rabid ideology over reality. Until we get better government in this state, there’s always a chance it will happen again.

Other counties also considering property tax rate hikes

I have four things to say about this.

A statewide property tax relief plan that takes effect next year is prompting hefty tax increases this fall in many of the biggest cities and counties in Texas, even in places that have historically kept rates flat or decreased them.

Elected officials in some cities and counties say they have no choice but to raise taxes as high as they can this year to brace for the implementation of property tax reforms that Republican Gov. Greg Abbott and the Texas Legislature called historic earlier this summer. The average effective tax rate for single-family homes in Texas was 2.18 percent in 2018, third-highest in the nation, according to a study by ATTOM Data Solutions.

Starting next year, cities and counties will be barred from increasing property tax collections more than 3.5 percent in any year without a vote of the public. Currently, the state has an 8-percent limit, called the rollback rate, that state lawmakers say has allowed cities and counties to overtax homeowners. The lack of a state income tax makes Texas municipalities especially reliant on property tax revenue.

A look around the state shows many counties and cities are pushing rates to the 8-percent rollback rate this year to bank money or, in a few cases, even to fund pay raises for themselves, in reaction to the new law. El Paso, Harris, Tarrant, Webb and Travis counties are among those pushing to the current rollback rate, or near it. And cities including El Paso, Arlington, Corpus Christi and Austin are similarly considering rates at or near the 8-percent limit.

“I think a lot of cities and counties know that we are putting them on a diet and they are going on one last bender before it happens,” said State Rep. Dustin Burrows, R-Lubbock, who was a key player in crafting the property tax reforms as the leader of the House Ways and Means Committee.

[…]

In Harris County, which hasn’t raised the tax rate in decades, county officials say the state’s new restrictions are forcing them to react by raising the tax rate by 2.26 cents per $100 of assessed value. County Judge Lina Hidalgo said the county needs to create a contingency fund to ensure it can pay for services, such as health care, transportation and flood control, once the state’s 3.5-percent cap goes into effect. The rate increase, if approved next month, would allow Harris County to collect more than $200 million extra in tax money than last year.

1. There are some extremely bitchy quotes in the story from Sen. Paul Bettencourt, who pushed the bill that led to this in the Senate. I may have rolled my eyes so hard that they will never unroll.

2. The counties and cities that are considering this are acting in what they believe is their best interest, and the best interest of their residents. Plenty of expenses that counties and cities face, from disaster relief to health care to salaries and pensions, aren’t subject to any kind of rate limit. HB3 radically changed their long term financial picture. They had no choice but to adjust.

3. Just as a reminder, there are plenty of things the Legislature could have done to improve our property tax system without putting the squeeze on local governments. The Lege could also greatly help counties on the expenditure side of the balance sheet by expanding Medicaid, which would do a lot to reduce the cost of health care on counties. The whining from the likes of Bettencourt on this is just beyond rich. All that is without even pointing out that having a property tax-based system, in which the main expense is completely disconnected from people’s annual incomes, instead of an income tax-based system, is always going to have problems like this.

4. The same voters who will be given the power to approve or reject future tax collection levels also have the power to approve or reject the local officials who may be raising tax rates now ahead of that. They also have that power over people like Paul Bettencourt and Dustin Burrows and Greg Abbott and so forth. Maybe some day that power will be exercised.

The lawsuit to kill Obamacare has its hearing at the Fifth Circuit today

Brace yourselves.

It’s constitutional – deal with it

Last year, after a federal judge in Texas declared the entirety of the Affordable Care Act unconstitutional, throwing into question millions of Americans’ health coverage, the state’s Republican leaders promised they would come up with a plan to replace it.

But on Tuesday, after a legislative session that seemed to have no room for issues other than property tax reform and school finance, Texas will ask a federal appeals court in New Orleans to end the law in its entirety — without offering a replacement plan.

The conservative crusade against portions of the act, known as Obamacare, has spanned a decade. But Texas’ latest lawsuit, filed in February 2018, became an existential threat to the law after U.S. District Judge Reed O’Connor ruled in December that it is unconstitutional in its entirety. At stake: the subsidized health coverage of roughly 1 million Texans, sweeping protections for patients with preexisting conditions, young adults staying on their parents’ insurance plans until age 26 and a host of low-cost benefits available to all people with health insurance, including those covered through their employers.

Texas already has the highest uninsured rate in the nation.

In a highly unusual — if not entirely surprising — move, the U.S. Department of Justice has declined to defend the federal law, leaving a California-led coalition of blue states to protect it. As the case proceeds, Obamacare has remained in place, and likely will until the litigation is finally resolved.

Attorneys for the state of Texas argue the health law cannot stand since the Republican-led Congress in 2017 zeroed out Obamacare’s individual mandate — a penalty imposed on people who chose to remain uninsured. Democrats had favored the penalty as a way to induce more people to purchase health insurance, with the goal of reaching near-universal coverage. Without it, Texas argues, the whole law must fall.

But the state’s Republican leaders have offered few ideas about what should replace Obamacare, a law that touches practically every aspect of health care regulations and includes several popular protections for patients. Gov. Greg Abbott — a vocal critic of the law — pledged in December that if the law remained struck down on appeal, “Texas will be ready with replacement health care insurance that includes coverage for pre-existing conditions.”

Since then, he’s been quiet on the issue, including during this year’s 140-day Texas legislative session. Abbott did not respond to questions for this story.

See here for the background. And of course Greg Abbott doesn’t have a single thing to say about reducing the extremely high uninsured rate in Texas. That’s because Abbott’s plan to reduce the uninsured in Texas, supported by Dan Patrick and Ken Paxton and the rest of the Republicans, is for more of them to die. Just as a reminder, Republicans have been in complete control of Texas government since 2003. Not once during that time have they taken any steps to improve access to health care in the state. Indeed, on multiple occasions, beginning in 2003 with the savage cuts to CHIP and continuing through their assault on women’s health via attacks on Planned Parenthood, they have time and time again make accessing health care harder. That’s what is at stake here. The only fix, regardless of the ruling in this case, is to vote them out. The WaPo, the Chron, and Think Progress have more.

Maybe rural counties don’t want hospitals

That’s what the evidence says.

The voters of Fayette County have spoken, and they’ve said that they don’t need a hospital in this rural community of 322,000 people, one hour southeast of Austin — or at least not enough to pay for it. In a landslide vote Thursday night, county residents overwhelmingly rejected a proposition to create a taxing district for St. Mark’s Medical Center in La Grange, which would have kept the deeply indebted hospital open for the foreseeable future. As the polls closed, it was clear that the idea of propping up the institution with public money didn’t have a snowball’s chance in Central Texas. The final tally was 1,360 for, 5,600 against.

“I’m very proud of the grassroots effort that stood against the taxes,” Deborah Frank, the chair of Fayette County’s Republican Party and a member of Concerned Taxpayers of Fayette County PAC, told the Observer Friday. Her group swiftly mobilized an opposition campaign against the proposition after it was put on the ballot in April, holding public meetings and distributing yard signs reading “NO NEW TAXES.” Their message: People here are already taxed enough and shouldn’t be forced to bail out a private institution simply because it’s made what they see as bad financial decisions.

Voters apparently took the message to heart.

The resounding loss is expected to push the 65-bed hospital, which is at least $14 million in debt, even closer to financial collapse. And it comes at a time when the headwinds against rural hospitals in Texas are especially strong.

Across the state, roughly 20 rural hospitals have shuttered since 2013 — casualties of low patient volumes, stingy Medicaid and Medicare reimbursement rates, and the burden of operating in Texas, which has more uninsured people than any other state. Seventy-five more are at risk of closing down.

One point to note: I have no idea where that “rural community of 322,000 people” figure comes from. Fayette County had 24,554 people as of the 2010 Census, and while it’s been growing over the past few decades, I’m pretty sure it hasn’t grown that much since then. I don’t live in La Grange and I don’t know anything about St. Mark’s Medical Center, so maybe it was a fiscally sound decision to not try to prop it up with a taxing district. I do know that if I lived in La Grange and faced the prospect having to travel 20 miles to Smithville or 26 miles the other direction to Columbus to find an emergency room, I’d be a little concerned about the risks to my health going forward. But hey, at least their taxes won’t go up.

A starter agenda for when we have a Democratic state government

I’ve been pondering the recent legislative session, which as we have discussed wasn’t great but also wasn’t nearly as bad as some other recent sessions have been. The qualification for all this is that the key defining factor for our legislative sessions is defense. How well did we do preventing bad bills from becoming law? Oh, there are occasional good bills, on things like criminal justice reform and medical marijuana and the injection of money into public education this session, which should be good until the lack of a funding mechanism becomes an issue. But actually moving the ball forward, on a whole host of items, is a non-starter.

That’s not a surprise, with Republicans in control of all aspects of state government. But Dems picked up 12 seats in the House and two in the Senate, and came close in several statewide races in 2018. There’s a decent chance that Dems can win the House in 2020, and I have to believe we’ll have a stronger candidate for Governor in 2022. The Senate remains a challenge, but after the 2021 redistricting happens, who knows what the landscape may look like. Dems need to aim for the House in 2020, and have a goal of winning statewide in 2022. It won’t be easy, and the national landscape is a huge variable, but we know we’re moving in the right direction, and if not now then when?

And if these are our goals, and we believe we have a reasonable chance at achieving them, then we need to talk about what we want to accomplish with them. It’s a cliche that our legislature is designed to kill bills and not to pass them, but having a unified, overarching agenda – which, let’s not forget, can get a boost by being declared “emergency items” by the Governor – can help overcome that.

So towards that end, I hereby propose a starting point for such an agenda. Moving the ball forward is the ultimate aim, but I believe we have to first move the ball back to where it was before Republicans assumed full control of the government in 2003 in order to really do that. That’s the idea behind this list, which I want to stress is a starting point and very much open to discussion. There are a lot of things a Democratic government will need to do, from health care to voting rights to equality to the environment to climate change and so much more, but we can’t overlook fixing the bad things first.

My list, therefore, covers bills passed since 2003 when Republicans took over. I am skipping over constitutional amendments like the 2003 tort “reform” item, because they will require a supermajority to pass, which we surely will not have. I’m aiming for simplicity, in that these are easy to understand and rally around, and for impact. So without further ado, here are my ideas:

1. Repeal voter ID.
2. Repeal “sanctuary cities”.
3. Repeal anti-Planned Parenthood legislation, from prohibitions on PP receiving Medicaid to this session’s ban on cities partnering with PP on anything, and restore the previously used Women’s Health Program.

Like I said, simple and straightforward, with a lot of impact. The first two are obvious and should have unanimous Democratic support. The third is more of a challenge because even with a Democratic majority in the Senate, we won’t necessarily have a pro-choice majority. Eddie Lucio, and to a somewhat lesser degree Judith Zaffirini, are both opponents of reproductive rights, though Zaffirini is more nuanced than Lucio and ought to be gettable on this kind of bill via an appeal to health care access.

As I said, this is a starting point. There are things I have deliberately left off this list, though I am not by any means discounting or overlooking them. The “Save Chick-fil-A” bill from this session, whose real life effect is not yet known, needs to go but might be better handled as part of a statewide non-discrimination law. (Also, too, there’s the Eddie Lucio problem in the Senate.) Campus carry and open carry are terrible laws, but might be better handled via comprehensive gun control legislation. Tuition deregulation, a big cause of skyrocketing college costs at public universities, which was passed in 2003 as one of many cut-the-budget effort over the years, will be a more complex issue that may require time to study before a consensus solution can be brought forward. All these things and more need to be on the agenda, but some things are more involved than others.

Again, this is a starting point. I make no claim that this is a be-all or end-all. Hell, I make no claim that I’m not forgetting anything equally simple and substantive. I welcome all constructive feedback. Ultimately, what I want out of this is for Dems to recognize the need to decide what our priorities are before we get handed the power to affect them, and to make it part of the case we will be making to the voters to give us that power. I believe having some uniformity to our message will help us. Now it’s up to us to figure out what that message needs to be.

Another dive into the Heidi Group grift

The Observer is on it this time, and as before if you’re not mad by the time you’ve finished reading you’re doing it wrong.

Right there with them

The state of Texas has poured hundreds of thousands of taxpayer dollars into [Carol] Everett’s clinic, which opened in a strip mall in Round Rock last spring, and millions through her anti-abortion organization, the Heidi Group. Everett’s group was tapped as a test case in the effort to defund Planned Parenthood and lift up faith-based, anti-abortion clinics in state and national family planning programs. It didn’t go well. In September, the state announced it would end Everett’s funding, two weeks after the Observer reported that the group had served just 5 percent of the patients promised in its first year.

Now, internal documents, communications and financial statements obtained by the Observer, along with state records and interviews with half a dozen former Heidi Group employees and with Everett, paint a picture of mismanagement, contract violations, lack of oversight and misuse of taxpayer funds — problems that state officials knew about even as they continued to extend the Heidi Group’s contract for more than two years.

[…]

State lawmakers have funnelled millions into the kind of clinics that Everett has championed. The budget for Texas’ Alternatives to Abortion program, which funds faith-based pregnancy centers, has grown 16-fold since its inception in 2006, following this legislative session, with a total investment of about $170 million through 2021. In 2011, Republican lawmakers slashed the state’s family planning budget by two-thirds, shuttering 82 clinics. Two years later, they kicked Planned Parenthood and other abortion provider affiliates out of the state’s low-income women’s health program, forgoing millions in federal dollars to begin a state-funded program instead. At the time, less than a quarter of the estimated 1.8 million poor Texas women in need of publicly funded contraceptive services were getting them. The cuts resulted in tens of thousands more women losing access to reproductive health services like gynecological exams, birth control, cancer screenings and STD testing.

Then, in 2016, the state’s goals and Everett’s aligned in what she called “the greatest possibility for expansion of pro-life care for the poor ever.” Texas’ health agency had scrambled for years to rebuild the reproductive health care safety net without established family planning providers like Planned Parenthood. Now, the Health and Human Services Commission (HHSC) was launching a replacement program called Healthy Texas Women, which would provide reproductive health care and preventive screenings to low-income women. Officials needed someone to fill the gap left by Planned Parenthood, which had previously served 40 percent of patients in Texas’ women’s health program.

Everett had no experience with state family planning programs. But officials awarded her multimillion-dollar contracts to find and oversee providers in Healthy Texas Women and in the Family Planning Program, the state’s other reproductive health program that also covers men and undocumented patients. Everett pledged to serve an astounding 69,000 patients in the two programs during her first year — more than Planned Parenthood.

The experiment failed dramatically. For fiscal year 2017, the Heidi Group was awarded $1.6 million to serve 51,000 patients in Healthy Texas Women; it spent $1.3 million and served 2,300, according to HHSC data. In the Family Planning Program, the group got $5.1 million to serve nearly 18,000 people. After realizing the Heidi Group was falling short of those targets, the state clawed back and reallocated funds mid-year. It ended up spending $605,000 to serve just over 1,000 patients. HHSC released data for fiscal year 2018 in May, but did not specify the number of patients served by contractors. According to an Observer analysis, which added the patients served by Heidi Group subcontractors and the Heidi Clinic in each program in 2018, roughly 4,000 patients were served through Healthy Texas Women and about 2,700 through the Family Planning Program. The state ended Everett’s contracts in December, and launched an investigation into more than $1 million in questionable spending. Her own clinic, which has served just a few hundred women, faces an uncertain future.

Read the rest. The Chron wrote a similar story a couple of months ago, and it’s just as infuriating. Ultimately, I think Carol Everett was a true believer who got way in over her head by being in the right place at the right time with the right things to say. She’s not evil, she’s just Forrest Gump’s incompetent anti-abortion zealot cousin. It’s everyone who enabled the system to throw millions of dollars at her, all the while consigning thousands of poor women to crappy-at-best health care, who deserve all the scorn. That’s Greg Abbott, his appointed flunkies at HHSC like Stuart Bowen, Dan Patrick, Ken Paxton, and every Republican legislator who voted to kick out Planned Parenthood. They made this mess, and some day it will be up to the rest of us to clean it up.

Who cares about new mothers?

Not the Lege.

The new mothers contracted infections. They overdosed on drugs. Their hearts failed. They committed suicide.

The women died in different ways, but all perished within a year of giving birth. Rising rates of maternal mortality spurred Texas leaders in 2017 to reauthorize a special task force to study the deaths and figure out what to do.

But at the end of this year’s legislative session, public health advocates are frustrated that lawmakers left Austin without adopting the task force’s top recommendation: giving women access to health care for a full year after they give birth.

The Legislature agreed to spend $15 million over the next two years on postpartum depression and substance abuse treatment for some low-income women. But a far more sweeping and higher cost plan to expand Medicaid coverage for all eligible new mothers failed, despite having support from Republicans and Democrats.

“We’re disappointed state leaders basically ignored the needs of uninsured moms and uninsured low wage workers this session, by not taking action on bills to extend postpartum coverage,” said Adriana Kohler, a senior health policy associate for the Austin-based advocacy group Texans Care for Children.

[…]

The funding, however, will likely cover only some of the roughly 136,000 pregnant women on Medicaid in any given month. And pregnant women who relied on Medicaid for their diabetes medication or other prescription drugs could still lose those benefits in the transition, some public health advocates said.

Other bills filed by Republicans and Democrats to expand the state’s Medicaid coverage for new mothers from two to 12 months, post delivery failed. The change would have cost the state upwards of $75 million a year, according to a fiscal note. The legislation passed the House, but died after not receiving a public hearing in the Senate.

Rep. Garnet Coleman, D-Houston, chalked it up to politics. “Republicans don’t want to be viewed as expanding Medicaid,” he said.

Just as a reminder, Greg Abbott made a last-minute attempt to put an extra $100 million into the budget for “border security”. The budget as adopted is spending over $5 billion to buy down property taxes. The Lege passed a tax cut on yacht sales, which won’t actually cost that much money but is still a tax cut on yacht sales. My point here is that this was not a decision based on a lack of available funds. It was a failure to act because the Republican leadership had no interest in doing it, for the reason Rep. Coleman cites. It was a choice they made, one that reflected their values. Keep that in mind when you hear the usual blather about being “pro-life”.

House approves budget, and other news

Always a major milestone.

In Dennis Bonnen’s first major test as speaker of the Texas House, the chamber he oversees resoundingly passed a $251 billion budget Wednesday after a long but largely civil debate — a departure from the dramatics that have typically defined such an affair.

Though lawmakers proposed more than 300 amendments to the spending plan, Bonnen, an Angleton Republican, and his chief budget writer, state Rep. John Zerwas, R-Richmond, finished the night with their budget plan largely intact. After 11 hours of relatively cordial discussion, lawmakers agreed to withdraw the vast majority of their amendments or move them to a wish list portion of the budget, where they are highly unlikely to become law.

The budget passed unanimously on the final vote. The legislation, House Bill 1, now heads to the Senate, whose Finance Committee was set to discuss its budget plan Thursday.

“I’m proud of where we are in the bill that we are sending to the Senate,” Zerwas said at the end of the marathon debate. “Each and every one of you should be incredibly proud of the work that you’ve put in here.”

The two-year spending plan’s highlight — a $9 billion boost in state funding for the public education portion of the budget — remained unchanged. Of that, $6 billion would go to school districts, and the remaining $3 billion would pay for property tax relief, contingent on lawmakers passing a school finance reform package.

The budget plan would spend $2 billion from the state’s savings account, commonly known as the rainy day fund, which holds more than $11 billion.

“I’m not here to compare it to previous sessions,” Bonnen told reporters after the House budget vote. “But I’m here to tell you we had a great tone and tenor tonight, and I’m very proud of the business that we did.”

[…]

So while Bonnen’s first budget night as speaker was hardly free of controversy — an argument over the effectiveness of the state’s “Alternatives to Abortion” program, for example, derailed movement on amendments for nearly an hour — the occasional spats paled in comparison with those of years past. There were no discussions at the back microphone of lawmakers’ sexual histories, as happened in 2015, and no one had to physically restrain House members to prevent a fistfight over the fate of a feral hog abatement program, as happened in 2017.

Still, state Rep. Jonathan Stickland, R-Bedford, continued his long-running campaign against the feral hog program. And though the exchange ranked among the evening’s rowdiest, it was more than tame by last session’s standards.

State Rep. Drew Springer, R-Muenster, again opposed Stickland’s amendment to defund the program, which reimburses local initiatives to eradicate wild hogs. Stickland responded, “Members, although I respect the thoughtful words of Rep. Springer … let’s end this program right here, right now.”

Stickland’s amendment failed, with just four votes in favor.

See here for more on last session’s House budget debate. One should never miss an opportunity to illustrate Jonathan Stickland’s failures. The House also approved a supplementary budget for the previous biennium, to cover expenditures that were not previously appropriated, such as the traditional underestimating of Medicaid’s costs and all of the Harvey recovery funding.

Speaking of revenues:

House Republicans muscled a heavily altered version of their property tax reform bill through a committee early Thursday, notching a single Democratic vote and swiftly shooting down attempts to further modify the draft.

A top priority for state leaders, House Bill 2 would require cities, counties and other taxing units to receive voter approval before levying 2.5 percent more property tax revenue than the previous year. A vote was expected to come Wednesday morning on a new draft of the legislation, which contains changes likely to appease small and special taxing units but leave big municipal leaders staunchly opposed.

But the hearing on the new version was postponed until past midnight. The 16-hour delay gave an unusual cluster of critics time to trumpet their concerns with the measure — and then for top House leaders to respond in an informal late-night news conference.

“Sometimes when everyone’s a little bit upset with you, maybe you have a good balance — that’s probably a good sign,” said House Ways and Means Committee Chair Dustin Burrows, the author of the legislation and a Lubbock Republican. “We worked really hard; we talked to a lot of different constituencies” and a lot of members. “I think you’ll see in the committee substitute, the work product and a lot of collaboration.”

As amended, HB 2 now exempts community colleges, emergency service districts and hospital districts from abiding by the 2.5 percent election trigger. Another provision lets certain districts, including cities and counties, bank unused revenue growth, so long as they average below 2.5 percent over five years. And new “revenue enrichment” language could cushion some taxing units by letting them raise $250,000 in new property taxes a year, even if it exceeded the growth rate. The threshold, set at $250,000 for 2020, would be adjusted by the state comptroller annually, based on inflation.

[…]

Currently, voters can petition for an election if property tax revenue growth exceeds 8 percent, a rate set during a period of high inflation in the 1980s. State leaders have touted the lower chamber’s proposal and a Senate companion as an overdue correction and as a needed check on spiraling property tax bills. But critics say the reform efforts would not reduce tax bills, just slow the rate at which they grow — and, in the process, hamper local officials’ ability to provide public services for growing populations.

As you know, I oppose revenue caps, no matter how well intentioned. The reason the Lege ties itself into knots every two years in a vain attempt to limit property tax growth is that a taxing system that so heavily relies on property taxes fundamentally relies on a system that is divorced from people’s ability to afford their taxes. As I muse every two years, if only there were some system of taxation that was proportional to how much money people made in a given year, that would solve so many of these problems. Too bad no such system exists anywhere in the world.

Of course, another way to limit property tax growth for homeowners would be to ensure that everyone is paying their fair share of property taxes.

As state leaders promote their property tax reform package as needed relief for everyday Texans, some Democrats and county appraisers suggest a provision in the tax code has stacked the system in favor of corporations that can appeal their valuations with a combativeness most homeowners can’t muster.

At issue: a 1997 amendment, drafted by a prominent tax attorney, that critics say has allowed business and industry to lower their property tax burden at the expense of other taxpayers. The provision offers all Texans a way to fight their appraisals by arguing they were treated unfairly compared to other properties. But critics say large property owners have capitalized on it to drive down their costs, while residences and small businesses can’t afford to do the same.

“If you have a whole category of property that is nonresidential systematically paying less, well who do you think is paying more?” said Bexar County chief appraiser Michael Amezquita.

Amezquita is one of several officials who say their districts have been inundated by appeals and lawsuits from commercial owners trying to lower their appraisals, which determine what taxes are owed on a property. Supporters of the “equity” provision say it’s a critical tool for all property owners, and that commercial properties aren’t afforded the tax exemptions many home and agricultural land owners receive. Critics counter only well-funded property owners can afford to sue — and when they do, there’s often little an appraisal district can do to fight back.

“The deck is stacked against us,” said Amezquita, who has been sued by a J.W. Marriott resort seeking to have its taxable value reduced. A spokeswoman for the hotel declined comment.

I’ve written about this before. This issue of equity appeals was a cornerstone of Mike Collier’s campaign for Lt. Governor. We’d be having a much broader conversation about fairness and equity in taxation if he had won that race, but he didn’t and so we aren’t. Better luck next time, I guess.

Anyway. The Senate still has to approve its budget, and school finance reform remains a work in progress. There’s a decent amount of harmony now, but plenty of opportunities for tension, drama, and good old fashioned nastiness remain. Which is as it should be.

Rideshare for Medicaid?

This could make sense.

Rep. Dade Phelan

Texas would soon start relying on Uber, Lyft and other ridesharing services to shuttle Medicaid patients to and from the doctor, if a new House bill becomes law.

The state is one of several eyeing rideshare as a way to save money and ensure Medicaid patients make it to their health care appointments. Each year an estimated 3.6 million people delay or forgo care due to lack of transportation, studies have found, leaving providers with cancellations and patients with potentially more costly medical issues in the future.

“It’s about better outcomes for patients, health care providers and, at the end of the day, much better outcomes for the taxpayers,” said state Rep. Dade Phelan, R-Beaumont, who authored the bill, HB1576.

The proposal, which has wide support in the Texas House, comes roughly a year after Uber and Lyft broke into the health care market with services that let hospitals order rides for patients. With some 4.3 million low-income residents on Medicaid, most of them children, the bill could dramatically expand the business in Texas.

The state already pays several transportation firms roughly $160 million a year to arrange free rides for Medicaid patients to visit the doctor, dentist and pharmacy. But the trips must be scheduled at least two days in advance, Phelan said.

His bill would let Medicaid managed care companies order a ride for patients who can’t give advanced notice, including those who come down with a sudden illness or are discharged from the hospital early. The legislation would also let the existing transportation firms use rideshare, in addition to their own vehicles.

[…]

Under the bill, Medicaid managed care companies would take on the responsibility of ordering rideshares for patients. The Texas Association of Health Plans, which represents many of the managed care companies, didn’t return a request for comment.

Hannah Mehta, with the group Protect TX Fragile Kids, said there’s no question the Medicaid transportation system needs improvement. A 2017 report by the Legislative Budget Board found the shifting of rides to private firms increased costs and client complaints, while decreasing access.

But Mehta is worried about handing the coordination of rideshares over to Medicaid managed care companies, which a recent Dallas Morning News series found have denied patients critical care. Mehta, whose son is covered by Medicaid, also questioned which patients would qualify and how that would be determined.

“Accessibility is a great goal,” she said. “But the devil’s in the details.”

Here’s HB1576, which as you can see has a slew of co-authors. The story notes that ensuring accessible rides for people with disabilities would be necessary; having the managed care companies in charge of arranging the rides, which would include the existing transportation companies as options, should handle that. The basic idea here is to make transportation to medical services for people who need it easier to arrange, which is something Uber and Lyft are good at, and presumably also to reduce costs. This at least sounds good in theory, but we’ll see how it develops.

The Heidi Group grift

You’re not mad enough right now. Read this, that’s fix it.

Right there with them

On a Monday evening in May 2016, Carol Everett sent an email to fellow anti-abortion activists detailing “an extraordinary pro-life opportunity.” Her nonprofit, the Heidi Group, she said, had spent the past year pushing for nearly $40 million in funding to help Christian pregnancy centers “bless many poor women” across Texas.

“It is no exaggeration to say this is the greatest possibility for expansion of pro-life care for the poor ever,” she wrote.

The enthusiasm might have sounded familiar to those who knew Everett, whose decades of work in the anti-abortion movement had earned her accolades from the state’s leading conservatives. But this wasn’t an advocacy project she was describing, and these weren’t private dollars. It was an application she had just submitted to become one of the state’s leading family planning providers.

Everett had never contracted with the state and had no clinical background. Many of the pregnancy centers she cited don’t provide contraception, a core service. Yet state health officials gave her much of the money anyway, ignoring warning signs and overruling staff who recommended millions less in funding, according to a review of the contracting by the Houston Chronicle. When Everett’s clinics began failing, the state delayed for months in shifting money to higher performing clinics, instead devoting vast amounts of time to support Everett and her small, understaffed team.

Though it’s impossible to say how many more women could have been served had the resources been shifted sooner, several competing clinics burned through their funding early in the grant cycle, surpassing their targets for both spending and patients treated. Had they been sent some of the $6.75 million sitting in wait for the Heidi Group, the door could have opened for thousands more women to receive access to contraception, STD screenings and breast exams.

It goes from there, and you should read the rest. I’ve blogged about the Heidi Group before. They’ve wasted millions of your tax dollars not providing health care to women who desperately need it, all in the service of ideology. If this doesn’t make you mad, I don’t know what it’s going to take.

Texas is not going to expand Medicaid

Don’t get me wrong, Texas should have expanded Medicaid at its first opportunity. It would do so much to improve health care in the state, including and especially mental health care, which would have significant spillover effects on criminal justice. Other states have passed voter referenda mandating Medicaid expansion, but those states can do that via citizen petition. They don’t have to go through their legislature, which is a requirement here and the place that the effort will go to die.

Rep. Celia Israel

Seeing other states take Medicaid expansion to voters is what Rep. Celia Israel, D-Austin, says gave her the idea to file House Joint Resolution 40. She said she’s frustrated that Texas “has not shown the political fortitude” to expand the program and that giving the decision to voters may take political pressure off of Republicans.

Expanding Medicaid through the Affordable Care Act — also known as Obamacare — has been a nonstarter in the GOP-dominated Texas Legislature. Republicans including Gov. Greg Abbott, Lt. Gov. Dan Patrick and former Gov. Rick Perry have argued that expanding Medicaid would increase health care costs for the state — especially if the federal government ever breaks its promise to help pay for the surge of newly eligible people.

Israel’s strategy so far has included courting Republicans in districts that have lost rural hospitals. Nineteen rural hospitals have closed permanently or temporarily since 2013, according to the Texas Organization of Rural & Community Hospitals.

“I’m getting mixed responses,” Israel said of her progress. “I’m making the case that we have lost so many rural hospitals in Texas, and one of the reasons we wouldn’t have lost those rural hospitals is if we had said yes to expanding Medicaid.”

Anne Dunkelberg, associate director of the Center for Public Policy Priorities, a left-leaning policy organization, said the 2018 election cycle and polls showed that health care is a top issue for voters.

“The bottom line is even though individual members have seen desirability moving in this direction, it’s not something they’re going to fall on their sword and buck their leadership over,” Dunkelberg said.

[…]

State Rep. John Zerwas, chairman of the House Appropriations Committee, attempted an alternative to Medicaid expansion during the 2013 session. The Richmond Republican’s House Bill 3791 would have allowed Texas to receive federal money in the form of block grants to enroll individuals in a private health plan using a sliding-scale subsidy, rather than expanding Medicaid to cover them. The bill also had a “pull the plug” provision if the federal government failed to continue funding. It had some bipartisan support but never reached the House floor for a vote.

He said Medicaid expansion in general still “comes with political radioactivity” that Republicans are hesitant to deal with. Just pursuing a waiver is still “a pretty steep hill to climb.” Zerwas said he doesn’t plan on bringing his bill back and also doesn’t believe Medicaid expansion needs to be taken to voters. He acknowledged that Texas has the highest number of uninsured people in the country but says there’s not a cost-effective way to provide care for the Medicaid population.

“It’s just politics, you know, and I’ve lived through this by virtue of carrying the bill in 2013 and was portrayed as someone who just loved Obamacare and was looking to grow it in the state of Texas,” Zerwas said. “Politically and in my party especially at that time and still so … it continues to be one of those things that Republicans rail against because they see it as a very heavy cost to the state.”

But Sen. Nathan Johnson, D-Dallas, who filed Senate Joint Resolution 34, which also would create a constitutional amendment to expand Medicaid, said that “it should not take a leap of courage to put this on the ballot.” Amid Texas’ problems with the opioid epidemicmaternal mortality and access to mental health services, he said, it would be difficult for lawmakers to go back to their constituents and tell them why they refused to put Medicaid expansion on the ballot.

“It starts to become a bit of an embarrassment,” Johnson said. “I think we have the potential to be a leader in health care. … We have vast resources and tremendous amount of power and will when we decide to employ it.”

I agree with everything Rep. Israel and Sen. Johnson say. As you know, I’ve been beating the drum for Medicaid expansion in Texas since 2011. It’s just that there’s zero Republican support for it – Rep. Zerwas’ watered-down version went nowhere, and no one is coming up behind him with something else. A constitutional amendment, which is what a Joint Resolution is and the only way the Lege can send something to the voters, requires a two-thirds majority in each chamber to pass. It’s highly unlikely there’s a simple majority for this in the House, and zero chance of that in the Senate. What Israel and Johnson and others are doing is valuable and necessary and sure to be a big campaign issue again in 2020. What it’s not is legislation that will pass, not while Republicans are in charge.

The state of the state 2019

Sometimes it’s what you don’t say that gets noticed.

Gov. Greg Abbott, in his biennial State of the State address Tuesday, stayed on message about schools and taxes, continuing state leaders’ so far unified focus on bread-and-butter policy reforms in a forum where he has in the past served up red meat.

Speaking in the Texas House to both chambers of the Legislature, Abbott named as emergency items the consensus priorities of school finance reform, teacher pay raises and property tax relief, the issues he and the state’s other top two Republican leaders have trumpeted almost single-mindedly in the months since the midterm elections. In doing so, he carefully avoided controversial social issues like the ones that headlined last session’s speech.

Also topping the governor’s priority list: school safety, disaster response and mental health programs. Abbott’s designation of those priorities allows lawmakers to take up such measures sooner, lifting the usual constitutional limitation that prevents the Legislature from passing bills within the first 60 days of the session.

“Our mission begins with our students,” Abbott said as he began to lay out his legislative priorities. To improve lackluster student outcomes — only 40 percent of third-graders are reading at grade level by the end of their third-grade year, he said, and less than 40 percent of students who take the ACT or SAT are prepared for college — “we must target education funding.”

[…]

Unlike in his first two State of the State addresses, Abbott did not deem ethics reform an emergency item. He tagged that issue with top priority status in 2015 and 2017, but didn’t mention it this year. Nor did he raise any proposals related to abortion. And there was hardly any other mention of health care, an expense that takes up nearly as large a share of the state’s budget as does education.

House and Senate Democrats called it “disappointing” that the governor didn’t propose expanding access to pre-K or lowering the costs of teachers’ health care.

And state Rep. Toni Rose, D-Dallas, who serves as the caucus’ second vice-chair, said that Abbott, for all his bragging on the state of Texas during his speech, failed to mention the state’s high uninsured rate for health care.

“Texas needs to expand Medicaid,” Rose said during the conference, “and we need to expand it today.”

Still, Democrats were optimistic about some of the notable absences. Two years ago, Abbott’s address was headlined by his call for an anti-“sanctuary cities” bill that Democrats would staunchly oppose. This year, the governor mostly stayed away from hot-button social issues.

“It certainly was a different speech than we heard two years ago,” state Rep. Chris Turner, the Democrat who heads his party’s caucus in the House, said after the speech. “It seems as though election results have consequences.”

Another conspicuous absence from the speech was the voter rolls debacle that has dogged state leaders in recent weeks. Last month, Texas Secretary of State David Whitley flagged for citizenship review nearly 100,000 Texas voters; in the weeks since, the list has been revealed to be deeply flawed, and civil rights groups have sued the state three times.

There’s still plenty of reason to be wary of the property tax proposals Abbott has made, and one reason why there are fewer red meat items on his agenda is that a lot of them – voter ID, “sanctuary cities”, campus carry – have already been passed. I will agree that this was much more temperate than the address from two years ago – there’s no way Abbott would admit this, but I think Rep. Turner is right in his assessment – and there are issues on Abbott’s list that will get broad bipartisan support. Let’s be glad for the small victories, and work to make them bigger. Ross Ramsey, Texas Monthly, and the Observer have more.