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The limitations of Plan B

A helpful and timely explainer from the Associated Press.

WHAT ARE EMERGENCY CONTRACEPTIVES?

Emergency contraceptives are used to prevent pregnancy after unprotected sex or if a method of birth control fails.

Two types of medications, sometimes referred to as “morning after pills,” are available: levonorgestrel, known by the popular brand name Plan B; and ulipristal acetate, known under the brand ella. They should be taken as soon as possible after unprotected sex.

The pills prevent ovulation, which is when an egg is released from an ovary, said Dr. Jonah Fleisher, director of the Center for Reproductive Health at the University of Illinois in Chicago. If an egg is not released, it cannot be fertilized.

ARE THEY THE SAME AS ABORTION PILLS?

No. Emergency contraceptives prevent a pregnancy. The abortion pill, mifepristone, ends a pregnancy after a fertilized egg has implanted in the lining of a woman’s uterus. It’s commonly administered with the drug misoprostol and can be taken up to 11 weeks after the first day of a woman’s last period.

DOES EMERGENCY CONTRACEPTION WORK?

Not 100% of the time. The pills’ effectiveness improves the sooner they are taken after unprotected sex, doctors said. The drugs won’t prevent pregnancies if they are taken before sex, Fleisher said.

The Food and Drug Administration has approved Plan B for use up to 72 hours, or three days, after unprotected sex. Ella is approved for up to 120 hours, or five days.

Timing is important because sperm can live inside a woman’s body for up to five days, so a woman can still get pregnant if ovulation occurs after intercourse, said Dr. Dana Stone, an OB-GYN in Oklahoma City. If a woman has ovulated prior to intercourse, the pills are unlikely to help.

“So that’s where the failure comes in. It’s based on the timing,” Stone said.

[…]

WHAT ABOUT RAPE VICTIMS?

Most rape victims don’t report the crime to law enforcement, according to Jude Foster, advocacy medical forensic and prevention programs director for the Minnesota Coalition Against Sexual Assault. Many also may not go in for immediate medical care. Not everyone knows that emergency contraceptives are an option and part of a routine rape exam, or that such an exam is free.

“Why is sexual assault used as a political football when you are talking about access to reproductive care?” Foster said. “Please don’t. It just really frustrates me.”

Stone said the belief that a woman can just take Plan B if she is raped is misguided.

“We need all kinds of options for women because nothing is a one size fits all,” Stone said. “People have transportation problems, they have financial problems. There are always barriers to some percentage of women that will keep them from accessing this in the short time frame that they have.”

See here for the reason I’m blogging about this. Note also the mention of cost in that last section. Cost is a legitimate concern.

Plan B One-Step usually costs about $40-$50. Generics like Take Action, My Way, Option 2, Preventeza, My Choice, Aftera, and EContra generally cost less — about $11-$45. You can also order a generic brand called AfterPill online for $20 + $5 shipping. (AfterPill can’t be shipped quick enough to use if you need a morning-after pill right now, but you can buy it and put it in your medicine cabinet in case you need it in the future.)

The brand of EC you buy or how much you pay for it doesn’t matter — all brand-name and generic levonorgestrel morning-after pills work just as well.

You may be able to get the morning-after pill for free or low cost from a Planned Parenthood health center, your local health department, or another family planning clinic. Call your nearest Planned Parenthood to see if they can help you get emergency contraception that fits your budget.

If you have health insurance or Medicaid, there’s a good chance you can get Plan B for free — you just have to ask your nurse or doctor for a prescription so your health insurance will cover them (even though you don’t need a prescription to buy these types of morning-after pills over-the-counter). The staff at your local Planned Parenthood health center can also help you figure out if your health insurance will pay for your morning-after pill. Read more about using health insurance to pay for emergency contraception.

Boy, it sure is a good thing that everyone has either health insurance, or Medicaid, or easy access to a Planned Parenthood near them in Texas, isn’t it? This sure would be a much bigger problem, one that would require engagement and compassion from our state leaders to solve otherwise. So clearly, anyone who needs Plan B can get it any time they want, right?

Plan B

I have three things to say about this.

On Friday, Gov. Greg Abbott told The Dallas Morning News that rape victims can take emergency contraception, like Plan B, to prevent a pregnancy. With abortion now banned in Texas, even in instances of incest or rape, the governor recommended the use of emergency contraception to ensure a victim of rape does not become pregnant.

But for the lowest-income people in Texas, emergency contraception isn’t widely accessible, advocates said — a consequence of the significant number of people of childbearing age who are uninsured and the state’s lack of programs that provide access to treatment like Plan B.

During a pre-recorded segment of Lone Star Politics, Abbott said of rape victims, “By accessing health care immediately, they can get the Plan B pill that can prevent a pregnancy from occurring in the first place. With regard to reporting it to law enforcement, that will ensure that the rapist will be arrested and prosecuted.”

[…]

After signing Senate Bill 8 into law last September, which banned abortions after about six weeks of pregnancy and didn’t provide exceptions for rape or incest, Abbott said the state’s goal was to eliminate rape. Abbott’s office did not return a request for comment on Saturday.

In 2020, Texas ranked 16th in the nation for total number of forcible rape cases per capita.

Emilee Whitehurst, the CEO of Houston Area Women’s Center, said a significant number of rapes aren’t reported, and the actual number of victims is higher than those that seek treatment at a hospital.

Whitehurst added that emergency contraception is not a substitute for abortion access in any way, but those responsible for the abortion ban in Texas have left victims of sexual assault with few options. She said it was insulting to hear that Plan B should be relied on to prevent pregnancies given the dangers victims of sexual assault already face.

“To presume Plan B could be a substitute for abortion care represents such a fundamental misunderstanding of the reality of women’s lives and our biology,” Whitehurst said.

While emergency contraception is available for purchase over the counter, it can cost $50 at a pharmacy. Some insurance plans cover the cost of emergency contraception, but those who are uninsured have to pick up that additional expense.

For women of childbearing age in Texas, more than a quarter had no health insurance in 2017 — the highest rate in the nation. This is caused, in part, because Texas has not expanded Medicaid and has one of the lowest eligibility standards in the country. A single parent with three children would have to earn less than $400 a month to qualify for Medicaid.

In addition to the lack of coverage, the state’s programs that target women’s healthcare don’t provide emergency contraception. Neither the Family Planning Program nor the Healthy Texas Women Program provide emergency contraception.

Title X clinics remain one of the few options for low-income people to access emergency contraception at an affordable cost. However, these federally-funded reproductive health clinics don’t operate in every community in the state.

1. How’s that plan to eliminate rape going, Greg? Making any progress on it?

2. Boy, it sure is a good thing that health care is so easily and affordably accessible in this state, especially for women and people of color and people who don’t have insurance.

3. It is true that Plan B remains legal in Texas, and that the author of SB8 insists that he doesn’t want to make Plan B illegal – for now, anyway. But come on, does anyone believe that the forced-birth fanatics don’t have the various types of emergency morning-after contraception in their sights? Those people already think Plan B is an abortifacient. It’s just a matter of time, unless there are other laws in place to ensure that it remains legal. In the meantime, here’s a question Greg Abbott will not want to answer: If a bill to ban Plan B passes the Legislature, would he sign it or veto it? We know what Beto would do. I think we can also be pretty sure about Abbott.

At least you’re (probably) not giving birth in West Texas

This is a long story about the lack of prenatal and obstetric care in West Texas. It’s mostly set in Alpine, Presidio, and Big Bend, which are the “big cities” in the area that actually have doctors and medical facilities in them. The one hospital in the area is in Big Bend, and its labor and delivery unit is now closed much of the time, for a variety of reasons. This is a small taste of what it’s like to be pregnant in this part of the state.

Big Bend is the only hospital in a 12,000-square-mile area that delivers babies. If Billings’s patient goes into labor when the maternity ward is closed, she’ll have to make a difficult choice. She can drive to the next nearest hospital, in Fort Stockton, yet another hour away. Or, if her labor is too far along and she’s unlikely to make it, she can deliver in Big Bend’s emergency room. But the ER doesn’t have a fetal heart monitor or nurses who know how to use one. It also doesn’t keep patients overnight. When a woman gives birth there, she’s either transferred to Fort Stockton—enduring the long drive after having just had a baby—or discharged and sent home.

This situation is stressful and dangerous for pregnant women. Uterine hemorrhages, postpartum preeclampsia (a potentially deadly spike in blood pressure), and other life-threatening complications are most likely to occur in the first few days after childbirth. This is why hospitals usually keep new mothers under observation for 24 hours to 48 hours. “This is not the ‘standard of care’ that women should receive,” Billings says. “You’re not supposed to discharge patients and leave it up to chance.”

Big Bend doesn’t really have a choice. In the past two years, almost all its labor and delivery nurses quit. The hospital has tried to replace them, but the national nursing shortage caused by the pandemic has made that impossible. When Big Bend is too short-staffed to deliver a baby safely, its labor and delivery unit has to close.

[…]

Medicaid pays for 42 percent of all hospital births, but it doesn’t reimburse hospitals for the full cost of care. (In most states it pays between 50 cents and 70 cents on the dollar, which means a hospital loses money when it cares for someone on the program.) To offset its losses, a hospital often charges its privately insured patients significantly higher fees. But if it’s in a poor neighborhood and doesn’t have enough privately insured patients, it can’t recoup the money. So most pre-pandemic maternity ward closures were in low-income areas and disproportionately affected pregnant women of color. Pandemic-related nursing shortages have only made the situation worse. Nowhere is this problem more evident than in Texas.

The state is the national leader in maternity ward closures. In the past decade, more than twenty rural hospitals have stopped delivering babies. More than half the state’s rural counties don’t even have a gynecologist. Texas has some of the lowest income eligibility limits for Medicaid and has declined to expand them, as allowed by the Affordable Care Act. (Childless adults don’t qualify for the program unless they’re disabled.) As a result, more than 18 percent of Texans don’t have health insurance, the highest percentage of uninsured residents in the U.S. Income eligibility limits jump for pregnant women—$36,200 for single mothers, $45,600 for married ones—but the application process takes at least a month. According to the March of Dimes, a fifth of all pregnant women in Texas don’t get prenatal care until they’re five months along. In other words, when a poor woman gets pregnant in Texas, it’s hard for her to find a doctor or even a hospital.

“What we’re seeing in terms of health outcomes, it’s not good,” says John Henderson, chief executive officer and president of the Texas Organization of Rural & Community Hospitals. “We have lower birth weights, more preterm births. When it comes to caring for pregnant women and their babies, Texas does not compare favorably to other states.”

Like I said, this is a long story and it’s worth your time to read. I’m old enough to remember when tort “reform”, in particular putting a cap on damage awards that can be given in medical malpractice lawsuits, was supposed to usher in a new era of doctor abundance in Texas. I don’t think that has worked out in the way we were promised. Towards the end, one of the doctors the author spoke to for the story notes that since abortion was already impossible to get in their region, the new state ban on abortion likely won’t result in more babies being born there. These docs will still deal with miscarriages and ectopic pregnancies and other life-threatening situations – they tell some amazing stories – despite the threat to their own safety. Click over and read on for more.

The birth control gap

The state of Texas will do nothing to address this as long as the current government is in place.

Ramírez’s situation reflects an immense need in the country: 21 million women of reproductive age needed publicly funded contraceptive care as of 2016, according the Guttmacher Institute. Demand is expected to increase in states like Texas, where strict abortion laws mean many people, mostly in poor communities of color, now will have to carry pregnancies to term.

But Texas is ill prepared, healthcare advocates and policy experts warn. Significant policy changes and funding cuts over the last decade make it more difficult for low-income patients to access contraceptives, threatening to worsen the already poor maternal health outcomes in the state.

“A lot of this (new) legislation is focused on protecting the rights of the unborn, but we need to be equally focused on protecting the rights of women and their ability to make decisions about their health,” said Dr. Rola El-Serag, director of the Baker Institute’s Center for Health and Biosciences at Rice University and former expert educator in women’s health with the Department of Veterans Affairs.

[…]

Planned Parenthood Gulf Coast, which covers eight clinics in the greater Houston region, has seen a 67 percent increase in patients seeking long-term reversible contraceptives, such as IUDs and implants, according to a spokesperson.

Legacy Community Health, the largest federally qualified health center in Texas, and the four family planning clinics operated by the Houston Health Department also have experienced a surge of interest in long-acting contraceptives, officials told the Chronicle. Other news outlets have reported similar trends elsewhere in the state.

“Anecdotally, I can tell you, now women are taking family planning a lot more seriously, because they know an unplanned pregnancy is not going to be something that they can easily mitigate,” said Dr. Devanshi Somaiya, chief of family planning for the Houston Health Department.

Clinics are facing this growing interest after a decade of significant changes to the state’s family planning programs. Family planning includes contraceptive access as well as pregnancy testing, counseling and STD testing.

In 2011, the legislature slashed the family planning budget dramatically, from $111 million to $38 million, and made it harder for Planned Parenthood and other specialized family planning organizations to access the remaining funds, according to the researchers at the Texas Policy Evaluation Project based at the University of Texas at Austin.

As a result, 82 clinics across Texas closed or stopped providing family planning services, and fewer organizations provided IUDs, implants and female sterilization and vasectomy due to high costs.

Lawmakers reinstated funding over the next several years, which helped some providers rebuild services, while continuing to steer money away from Planned Parenthood, which serves a disproportionately high share of family planning patients. Even as funding stabilized, the state has struggled to fill coverage gaps and has consistently declined to expand Medicaid coverage.

Uninsured and publicly insured women commonly report issues paying for care, finding a provider that accepts their insurance and locating providers that offer the services they need, according to the policy evaluation project. Research also shows most women in that population are not using their preferred birth control method. Meanwhile, the state continues to boost funding for an anti-abortion program that supports faith-based pregnancy centers, which generally do not offer contraceptives.

The record speaks for itself. There will be nothing done to address this problem as long as the Republicans are in charge. This is one of those times where I don’t feel the need to embellish the argument. The facts are as plain as day.

The empty “mental health” promise

What’s going on in Uvalde these days.

Days after the May 24 shooting, Texas Gov. Greg Abbott promised an “abundance of mental health services” to help “anyone in the community who needs it … the totality of anyone who lives in this community.” He said the services would be free. “We just want you to ask for them,” he said, before giving out the 24/7 hotline number — 888-690-0799.

That’s a tall order for a community in an area with a shortage of mental health resources, in a state that ranks last for overall access to mental health care, according to a 2022 State of Mental Health in America report.

Mental health organizations are assembling a collection of services to assist those who seek help in Uvalde. But there have been hiccups and hitches along the way.

There is worry that what’s being offered is not coming together as fast or efficiently as it could be, and that it’s being assembled without keeping in mind the community it serves: Many residents are lower income, and some may have difficulties with transportation, or are mainly Hispanic. Many are not accustomed to seeking out therapy, or are distrustful of who is providing it.

Quintanilla-Taylor didn’t believe many would use the mental health services and had doubts about their long term availability.

“It’s not going be prevalent. … I don’t trust the resources, and that’s coming from an educated person,” said Quintanilla-Taylor, who’s pursuing a doctorate in philosophy and specializing in organizational leadership at the University of Texas at San Antonio.

[…]

Uvalde County Commissioners, the countywide government body, voted Thursday to purchase a building to create the Uvalde Together Resiliency Center to serve as a hub for long-term services, such as crisis counseling and behavioral health care for survivors.

Abbott set aside $5 million in funding for the center, which has been operating at the county fairgrounds.

Texas Sen. Roland Gutierrez, whose vast district includes Uvalde, said the community needs continuity of care and rather than create a new building the state could invest in the existing local community health clinic, in operation for 40 years and already serving 11,000 uninsured Uvalde residents.

“These are people who have behavioral health on the ground. They actually have the one psychiatrist in Uvalde right here,” Gutierrez said Friday referring to the clinic. “We needed to have the budget so that we can bring in therapists, which we would have been able to do with that money. Instead, they’re starting from whole cloth this promised center you’re going to have the district attorney run?”

Gutierrez, who has shifted a district office from Eagle Pass to Uvalde, said he met with 11 families whose children survived the shootings and were either wounded or sent to the hospital.

“What the families have been telling me is they don’t want to see one therapist one week, a different one the following and another one yet maybe the next week,” he said. “So, they are having trouble with appointments, with continuity and that’s very, very important, especially when we are talking about young children.”

Gutierrez said he sent a letter to Abbott asking for $2 million for the existing free community clinic to provide crisis care but has not heard back.

I’ve discussed this before, and this is another illustration of the problem. We can count on hearing two things whenever there’s a mass shooting in Texas. One is the usual blather about guns and why restricting access to guns isn’t the answer. The other is a rush to talk about mental health, both as a means of explaining the shooter’s actions and now more regularly as an alternate mitigation for gun violence that doesn’t restrict access to guns. It was a big component of the Cornyn bill, and may have been a key to its passage since there’s no question that more mental health services and funding for those services are badly needed. I’m happy to see that happen, it’s just that we all know this is only one piece of a much larger puzzle.

From the state perspective, any and all talk of mental health and services for mental health that comes from our state leaders is guaranteed to be little more than hot air. We have the longstanding issue of healthcare in general being out of reach for too many people because of lack of insurance, and the continued resistance to expanding Medicaid, which would be the single biggest step forward in that regard. We have the also longstanding issue of healthcare in rural areas, from hospitals closing for lack of funds to scarcity of doctors in rural areas, a problem that was supposed to have been solved by the passage of the tort “reform” constitutional amendment nearly 20 years ago. More recently there was Abbott’s redirection of over $200 million in funds from the Department of Health and Human Services to his never-ending border boondoggle. At every opportunity, the Republican leadership has made it clear that they don’t care about funding healthcare in general, and mental health services in particular. But they are willing to use the promise of mental health services as a distraction when the next crisis hits. That’s where we are now, and where we will be again if nothing changes.

Republicans are not going to stop passing anti-abortion bills

It’s what they do. There is no finish line for them.

During their 20 years in control of the Texas Legislature, Republican lawmakers have steadfastly worked to chip away at abortion access.

Bound by the limits of Roe v. Wade, which stopped them from enacting an outright ban on the procedure, lawmakers got creative. They required abortion clinics to have wide hallways and deputized private citizens to sue providers in an effort to shut down facilities that offer the procedure.

Future lawmaking on the topic will likely not require such ingenuity. A leaked draft of a U.S. Supreme Court opinion, published last week by Politico, suggests the court will reverse the landmark abortion ruling in the coming weeks, allowing states to regulate abortion as they see fit. Texas has a “trigger law” that would make performing an abortion a felony, which would go into effect 30 days after the Supreme Court overturns Roe.

Their decadeslong goal achieved, Republican lawmakers said there’s still work to be done. Texas GOP leaders and members of the Legislature said it is now time to turn their attention to strengthening the social safety net for women and children and investing in foster care and adoption services.

“It only makes sense,” said Rep. Steve Toth, R-The Woodlands. “The dog’s caught the car now.”

At least some of the more conservative members of the House said they also want to ensure strict enforcement of the abortion ban and to prevent pregnant Texans from seeking legal abortions in other states.

“I think I can speak for myself and other colleagues that align with my policy beliefs — we’ll continue to do our best to make abortion not just outlawed, but unthinkable,” said Rep. Briscoe Cain, R-Deer Park, a member of the far-right Freedom Caucus.

Texas already has an arsenal of statutes to punish virtually anyone involved in the procurement of an abortion, said University of Texas at Austin law professor Liz Sepper. These include last year’s Senate Bill 8, which empowers private citizens to sue anyone who “abets” an abortion after six weeks of gestational age, as well as unenforced pre-Roe abortion statutes criminalizing a person who gets the procedure, which the Legislature never repealed — some dating to the 1850s.

“If Roe is overturned, there’s already a criminal ban, there’s already an aiding and abetting ban, there’s already a ban on mailing medication abortion,” Sepper said. “In terms of law’s ability to change behavior, they’ve almost filled all the gaps — with the exception of criminalizing the pregnant person involved in an abortion.”

And you better believe that’s where they’ll be going next, though to be sure there are plenty of other avenues for them to pursue as well. This is what gives creeps like Briscoe Cain their purpose in life. If somehow they do eventually run out of things to ban, next up after that is increasing penalties and making it easier for law enforcement to go after whoever the likes of Cain thinks are getting away with something. Listen to what they’re saying – they are not being coy at all about this.

Now as for the claims that maybe now it’s time to do a little something to “strengthen the safety net”, well, let’s just say that they are starting from a position of abolutely no credibility.

With a near-total abortion ban looming in Texas, advocates and experts say the state’s support systems for low-income mothers and children are already insufficient — and won’t easily bear an increase in need.

“When you say ‘social safety net’ in Texas, it sounds like a joke,” said D’Andra Willis of the Afiya Center, a North Texas reproductive justice group. “Everything they could have set up or increased to protect people if they really cared, they’re not doing it here.”

Pregnant women in Texas are more likely to be uninsured and less likely to seek early prenatal care than the rest of the country. They’ll give birth in one of the worst states for maternal mortality and morbidity. And low-income new parents will be kicked off of Medicaid sooner than in many other states.

This would make many Texans want to avoid pregnancy altogether. But learning about, let alone accessing, contraception can be a challenge in a state that does not require sex education and has narrowed family planning options in recent years.

Republican lawmakers, many of whom have focused on restricting abortion access in recent years, have said strengthening the state’s social safety net will now become a top priority. But advocates who have been working on these issues for years say any help will likely be too little, too late.

“People fail to realize that this is bigger than abortion access,” Willis said. “We’re going to be setting people up for generational poverty.”

As with so many other policy items, like boosting mental health care as their prescription to reduce mass shootings, the single biggest thing they could do to achieve that goal would be to expand Medicaid. More than 55% of all births in Texas are paid by Medicaid. I think you can guess how high that is on their priority list. But even if you want to give them a tiny bit of benefit of the doubt, note that it’s just now that they are on the verge of achieving an abortion ban that they’re even beginning to think about maybe doing something to benefit those who are pregnant and have given birth. Look at their priorities, that will tell you how much that counted for them. Why would you expect that to change going forward?

Time once again for Texas hospitals to struggle financially

I feel their pain, but…

More than $3 billion in federal money has flowed to Texas health care providers in recent months to help pay for COVID-19 treatments, tests and vaccines for patients without health insurance, according to national health officials.

Of that, a tiny fraction — some $2.2 million — went to the local independent hospital in rural Titus County for treating patients during wave after overwhelming wave of the devastating virus in an area where 1 in 3 residents are uninsured.

But the 174-bed Titus Regional Medical Center in northeast Texas needed every penny it could get as it struggled to cover the sudden, skyrocketing expenses of the pandemic: paying staff competitive wages to keep them on the job, keeping up with federal safety rules and managing record-breaking numbers of patients pouring into in the intensive care unit from a 150-mile radius, said CEO Terry Scoggin.

Now, after sending some $19 billion to hospitals and other health care providers nationwide, the fund known as the Health Resources and Services Administration COVID-19 Uninsured Program — created to help hospitals like Titus Regional pay for the care of uninsured COVID patients — has dried up.

While the halting of funds comes as Texas has seen infection numbers fall dramatically, the virus is still largely uncontrolled, causing surges and lockdowns in other countries. In the past, those surges abroad have always occurred before new cases rise again here in the United States, including Texas, which has more uninsured residents than any other state.

The failure to renew the program in time to continue reimbursing providers means that hospitals, clinics, private practices and others that don’t get public health funding from the state will have to “eat the cost” if they don’t charge for COVID-related services, Scoggin said.

“It’s a huge issue for us because we have so many adults who are uninsured,” Scoggin said. “And so it was kind of a kick in the gut for us when they shut that program off because I thought it was a good use of funds for the COVID piece.”

Refusing care to those patients who can’t pay is not an option, legally or morally, he said.

“We can’t turn people away, so we’re still going to pay for it,” Scoggin said. “It just shifted the expense of the uninsured from federal funds to individual hospitals.”

We’ve discussed the financial straits of rural hospitals in Texas before. I am once again pointing out that the locale in which this story is sited, Titus County, is yet another place that votes heavily Republican – Trump and Cornyn in 2020 and Abbott and Cruz in 2018 all topped 70% of the vote. I continue to have empathy for the employees of these hospitals, who for all I know may be habitually voting for politicians whose stated policy preferences are to help them. But I’m also saying it would be nice for these stories to include that easy-to-look-up data, because the simple fact is that if the likes of Greg Abbott or John Cornyn wanted to help the Titus Regional Medical Center, by expanding Medicaid or helping to push through more federal funds for the care of uninsured COVID payments, they could absolutely do so. The dots are just sitting there, waiting to be connected. We should do that.

How the 2030 Census could be different

A very early preview of some possibilities, which may or may not come to fruition.

Beyond the reports of undercounts and overcounts in population totals, there is another takeaway from the post-mortem of 2020 census data issued on Thursday: This could be the last census of its kind.

The next census will be taken in a nation where Amazon may have a better handle on where many people live than the Census Bureau itself. For some advocates of a more accurate count, the era in which census-takers knock on millions of doors to persuade people to fill out forms should give way in 2030 to a sleeker approach: data mining, surveys, sophisticated statistical projections and, if politics allows, even help from the nation’s tech giants and their endless petabytes of personal information.

The Census Bureau itself has yet to leap very far into that new era. But it has hinted recently at a “blended” approach in which official census figures could be supplemented with reliable data from government records and other sources.

[…]

It is an article of faith among data experts and the Census Bureau itself that data obtained directly from people are more reliable than secondhand or thirdhand data from other sources. And experts are wary that other data can raise privacy issues or allegations that it was cherry picked to fit an agenda.

The bureau itself considered tapping secondhand sources like state records to fine-tune its 2020 portraits of the population, but it often shied away unless it could find corroborating information elsewhere, according to Amy O’Hara, a former Census Bureau official who is now the executive director of the Federal Statistical Research Data Center at Georgetown University.

Professor O’Hara said the gusher of public and available data opens new avenues to a far more accurate census, but only if the numbers can be proven accurate and the Census Bureau can navigate the tricky boundary between tapping private research and issuing public statistics.

“There is no significant buy-in yet” to major changes in the census, Terri Ann Lowenthal, a longtime census expert and consultant to governments, businesses and other census “customers,” said in an email. “Too early without research, testing and transparency on those sorts of questions. And there probably will be even greater caution about using third-party commercial data.”

That said, she added, many users of census data agree that better use of outside records, conducted in a way that preserves privacy and credibility, could increase the accuracy of the head count and reduce its staggering cost — $14.2 billion, or about $117 per household counted in the 2020 census.

[…]

Mr. Prewitt and other experts say some solutions are obvious. For decades, the Census Bureau has undercounted some groups, including poorer residents and children, in part because they can be harder to find — they move more frequently, for example — and because census forms can be more confusing to people with less education or poorer language skills.

But state governments maintain accurate birth and death records and manage a range of federal programs aimed at the poor and children, such as Medicaid; the Supplemental Nutrition Program for Women, Infants and Children, or WIC; and the SNAP program once known as food stamps. None shares data with the bureau, but an agreement to do so “could probably put a bigger dent in the problem than putting more enumerators on the street,” Mr. Jost said.

There are countless other ways to improve census results. Public and private utility records, for example, assiduously track which residences are occupied or vacant, potentially making it easier for the Census Bureau to compile a more complete and accurate list of households to survey.

Consider this to be a response to the issues raised here. One thing I hadn’t realized in reading this story is that the Census first mailed forms to households in 1960, and first did online forms in 2020, and yet the non-response rate has remained at about one third over the decades. That’s what the Census workers knocking on doors are there to deal with. Obstacles to this kind of data mining plan include the questions about accuracy as noted above, questions about legality considering the 1999 SCOTUS ruling, and of course the political blowback from the revanchist wingnuts who are perfectly happy to undercount communities of color. I fully expect we’ll still be having these fights in 2030, so we may as well know what they’re going to be about.

How about a new Ken Paxton scandal?

Funny how these things keep cropping up. It’s almost as if it were habitual or something.

Best mugshot ever

In late 2018, Conduent Business Services, the giant information company formerly part of Xerox, was on the edge of a financial cliff.

For more than four years, the Texas attorney general’s office had aggressively pursued the company for what it asserted was Conduent’s massive fraud overseeing a government program to fix poor children’s teeth. Instead of evaluating treatment requests as it had been hired to do, Conduent simply rubber-stamped them while taxpayer dollars streamed out the door. The company tried to blame the dentists, but in June 2018 the Texas Supreme Court said Conduent alone was responsible.

A trial that could cost the company billions of dollars was rapidly approaching. Texas had indicated it would settle, but Conduent had a money problem: Its liability insurance policy refused to pay legal costs involving fraud.

So with the help of Attorney General Ken Paxton’s office, Conduent hatched a plan to trick the insurer into paying up to tens of millions of the legal settlement, according to documents the insurer, AIG, filed in Delaware state court. Two weeks ago, a jury found the deal defrauded AIG.

The jury’s verdict did not implicate Texas, Paxton or his lawyers in the scheme to deceive the insurer. Yet trial documents also show the attorney general’s staff knew Conduent was asking the agency to manipulate its case against the company to help with insurance claims, and that they agreed to the plan.

[…]

Problems in the State of Texas’s Medicaid dental program first became public in 2011, when a Dallas television station reported some clinics were billing more for children’s orthodontic care than entire states. Although the practitioners were first to be blamed, court documents later revealed Xerox had hired workers with little or no knowledge of dental procedures to process the applications for treatment as quickly as possible, with scant review.

About 90 percent were approved, often in a matter of seconds. Evidence such as molds and X-rays that dentists submitted with the applications often were never even looked at. Xerox had only a single dentist to review hundreds of daily requests.

The company said Texas officials were aware of how it was handling the Medicaid work and did nothing, but the state removed Xerox from the dental program in 2012 and fired it two years later. Since then the case has spawned a thicket of legal disputes as the various parties have tried to pin blame and costs on the others.

Texas has re-paid the federal government $133 million, the amount the U.S. Department of Health and Human Services calculated it was due for the state allowing Xerox to approve unnecessary dental payments. Texas regulators, in turn, have tried with limited success to recover money from dentists they say abused the program.

But the state’s main target has been Xerox, which in 2016 spun off its business services division into Conduent. Launched in 2014, the state’s Medicaid fraud lawsuit against the company meandered through the court system for years. By late 2018 a trial was scheduled.

Texas was seeking $2 billion. Conduent denied it committed fraud, but it had reason to avoid risking a bad verdict at trial. The federal government prohibits companies convicted of fraud from contract work; a jury finding against it would jeopardize Conduent’s business in other states.

The company entered a round of intensive negotiations with the attorney general’s office in late 2018, legal documents from the Delaware case show. With AIG already having denied its liability insurance claims, Conduent needed the foundation of the case against it to fundamentally change if it wanted to collect.

And for that it required an assist from Paxton’s office.

[…]

But in early January 2019, Conduent asked the attorney general’s office to file a new petition, court documents filed by AIG said. Typically, defendants try to convince prosecutors to drop crimes they’ve been accused of. In this case, Conduent asked Paxton’s office to add two new charges against it: breach of contract and negligence.

The reason, according to the Delaware lawsuit: If Texas prosecutors officially declared they were pursuing Conduent for those violations, AIG’s liability insurance policy would kick in, allowing the company to collect tens of millions of dollars.

Paxton announced a $236 million settlement with Conduent in January of 2019, shortly after the new charges were filed. AIG’s attorney argued that the state never intended to pursue those charges, they were just included to get Conduent to settle because then they could recover the funds from their insurer. The jury agreed with AIG and called what Conduent did “insurance fraud”. For which they got an assist from the Texas Attorney General’s office.

There’s a lot we don’t know yet. Maybe Conduent blatantly misrepresented their intentions to the AG’s office, and is solely responsible for all fraudulent actions. Maybe the AG’s office just erred in adding those extra charges, and didn’t pursue them because they were never going to get anywhere. Maybe all of the fault for the AG office’s activities belongs to the attorneys on the case, while Paxton himself wasn’t involved. I hope that now that we have this story, we’ll find out more. It’s obviously easy to believe that Paxton did something shady – it’s his brand, after all – but we need more information before we can conclude anything like that. Let’s see what else gets dug up. Reform Austin has more.

“Maternity deserts”

I have three things to say about this.

A few weeks ago, a woman gave birth at Hereford Regional Medical Center, a critical access hospital in the Texas Panhandle.

Or, rather, the woman gave birth in the parking lot at Hereford Regional Medical Center after driving over an hour to get there, according to Jeff Barnhart, the hospital’s chief executive.

Barnhart said he’s heard it all over the years: patients giving birth at rest stops and in ambulances and in the car on the side of the road. The hospital’s patients come from a 1,600-square-mile area in the Texas Panhandle, and some of them just don’t make it in time.

But now, even patients who do make it to the hospital have another variable to contend with: critical staffing shortages and exploding COVID-19 case counts. There are days when Hereford Regional doesn’t have enough nurses to operate the labor and delivery unit, forcing it to divert patients 50 miles northeast, to Amarillo.

“We give them a medical exam and see if there’s time to get them in an ambulance to another hospital that can take them,” he said. “But sometimes, that baby’s coming and there’s just not time.”

Those patients give birth in the emergency room, an increasingly common occurrence as rural hospitals limit or cease labor and delivery services due to insufficient staffing.

Nationally, the health care system is facing an unprecedented labor shortage as nurses retire, resign, burn out or leave staff positions for more lucrative travel nursing contracts. Rural hospitals, many of which already operate with a shoestring staff, are especially hard hit.

Declining populations and cuts to Medicaid and Medicare funding have made Texas the national leader in rural hospital closings, with some 26 closures — permanent or temporary — of rural facilities in the last decade. Two-thirds of the state’s 157 rural hospitals are public, which means less flexibility in salary negotiations. Administrators also say it’s often difficult to recruit medical personnel to smaller towns in remote counties.

Struggling to survive, the remaining hospitals in Texas’ rural communities have had to cut back services. And when that happens, labor and delivery is often the first to go.

Only 40% of Texas’ rural hospitals still have a labor and delivery unit, according to the Texas Organization of Rural and Community Hospitals, leaving whole swaths of the state without access to nearby obstetrics care.

“If we’ve got nurses to cover a day, of course, we’re going to try to take care of everything that we can here,” Barnhart said. “But it’s just a scheduling crisis, and whenever we can’t make it work, we just let the hospitals in Amarillo know so they can expect it.”

Before I get to my points I want to say this is a good story and you should read the rest. Now…

1. There have been a lot of stories in recent years about the serious problems that rural communities have in accessing emergency health care because so many rural hospitals have closed down. This is a corollary of that problem, and I have a lot of sympathy for everyone involved. But as is my wont, I can’t help but see these stories through a political lens. These areas are overwhelmingly Republican. Republican politicians like Greg Abbott have done everything in their power to continue that cycle, with the fanatical refusal to expand Medicaid at the top of the list. To be sure, there are problems beyond that, and the overall demographic trends are a big factor as well, but however you look at it their representatives and the state leaders that they keep voting for have done nothing to help them. Just once, in one of these stories, I’d like to see that question explored.

2. I should note that while Abbott and state leadership and Republicans in Congress and the Lege are the main actors in this drama, sometimes it’s these same rural communities that bring the damage on themselves. I say I have sympathy and I really do, but boy does it get tested sometimes.

3. I’m old enough to remember that one of the arguments made by the defense (i.e., the state of Texas) in the Whole Women’s Health v Hellerstedt case, in which a very different SCOTUS decided that the 2013 version of Texas’ radical anti-abortion law was unconstitutional, was that forcing women to travel up to 250 miles to get an abortion because all of the clinics closer to her had been closed down as a result of that law represented an “undue burden”. I wonder what those folks think about forcing women who are actively in labor to drive a hundred miles or more to give birth because your healthcare policies have resulted in the closure of hospitals and maternity wards closer to them. Haha, I’m kidding, I don’t wonder that at all. I know for a fact that they don’t care. But still. You, a normal person, might think that’s not such a great thing. Yet here we are.

Texas sues over the health care workers vaccine mandate

It’s a trifecta.

In Texas’ latest legal challenge targeting federal vaccination mandates, Attorney General Ken Paxton is suing the Biden administration over its recent order requiring health workers to receive the COVID-19 vaccine.

The Biden administration issued an emergency order, which went into effect Nov. 4, requiring eligible workers at health care facilities participating in the Medicare and Medicaid programs to get the first shot of a two-dose vaccine or a one-dose vaccine by Dec. 6.

Paxton called the mandate “an unprecedented federal vaccine decree” on health care workers.

“At a time when we need healthcare workers more than ever before, amid a harrowing worker shortage, the Biden Administration has prioritized this unlawful vaccine mandate over the healthcare of all Americans,” Paxton said Monday night in a statement. “We need healthcare workers, regardless of their vaccination status, and this decision puts us on track for an impending disaster within the healthcare industry.”

Texas joins 10 other states suing the Biden administration over the mandate.

This joins the federal contractors mandate lawsuit and the employer mandate lawsuit, which by the way will now go to the Sixth Circuit, which may not be an improvement. There’s no point in making arguments about public safety or any other merit-base claim. The Fifth Circuit is gonna do what the Fifth Circuit does, and then either SCOTUS will step in or they’ll wave their hands at the complex legal complexities of it all and hope it’s all moot by the time it gets back to them. If you want to do something about it, support the Democratic nominee for AG against Ken Paxton or one of the Ken Paxton wannabes in 2022. That’s the one fully clear thing in this mess.

Michelle Beckley files for Lt. Governor

And now there are three.

Michelle Beckley

Democratic state Rep. Michelle Beckley of Carrollton, who gained national attention for joining lawmakers who fled to Washington, D.C., to block a Republican election bill this summer, is running for lieutenant governor, expanding her party’s primary to three contenders.

In her campaign announcement on Tuesday, Beckley said she was running because Republican incumbent Dan Patrick is implementing policies that “hurt Texas business and make life harder for all Texans.”

“I’m running for Lieutenant Governor because politicians are putting ideology ahead of results that matter to Texans,” she said. “In the last legislative session alone, they worked to limit voters’ rights, put bounties on women, marginalize minorities, and make-up false boogeymen in our schools, and the health and wealth of Texans suffered. I’m running to stop them.”

Beckley joins a race that already includes political commentator Matthew Dowd and Houston accountant and auditor Mike Collier, who was the Democratic nominee for the position in 2018 and came within 5 percentage points of beating Patrick. She said she was recruited to run for the position but did not say by who.

Beckley said she joined the race to give Democratic voters another option and a candidate with more legislative experience.

“Neither one of those candidates has won an election,” she said. “I won an election in a hard district and improved my margins.”

[…]

Beckley said Republicans will have a fundraising advantage over her, but she plans to raise enough money to get her message out and win over voters.

“I was outspent 10-to-1 my first election. Nobody thought I was gonna win that either,” she said. “I’ve done it before. So I’m confident I could do it again. I wouldn’t be running if I didn’t think that.”

Beckley said her top priorities as lieutenant governor would be expanding Medicaid, fixing shortcomings in the state’s power grid and fully funding public education. Those issues are in line with the priorities of the other candidates in the Democratic primary.

But Beckley, one of the most liberal members of the Texas House, is also known for her support for marijuana legalization, abortion rights and her call for more gun control after the 2019 mass shootings in El Paso and Midland-Odessa.

Beckley said she is a candidate who can bring “balance” to the position of lieutenant governor. Issues like marijuana legalization and Medicaid expansion would benefit rural communities whose farmers could benefit from growing marijuana for business and whose struggling hospitals would be helped by a change in the health care system, she said.

But she does not back down from the positions she’s taken on immigration, abortion rights and guns, saying she’s portrayed as a liberal when she believes her actions are in step with the majority of Texas voters.

“Our state has gone to the extreme and I am the values of the moderate,” she said. “In many other states I would not be considered liberal at all.”

I don’t know about that last statement, but as we know there’s been consistent polling in recent years showing popular support for marijuana legalization and Medicaid expansion, with at worst modest support Roe v Wade and not making abortion more illegal in Texas. Whether any of that can flip her some votes in East Texas is another question – and I say this as someone who advocates for the Medicaid and marijuana issues as a way to appeal to rural constituencies – but she will hardly be out on a limb campaigning for them.

As the story notes, Beckley had announced a candidacy for CD24 before the map was redrawn to make it a Trump +12 district. Her HD65 was also made to lean Republican, though it would not surprise me to see it flip in a cycle or two. If she can win the nomination, it’s likely that she has at least as good a shot at beating Dan Patrick as she would have had in either of those races.

She does have to win the primary first. As a two-term State Rep, her name ID will not be very high – I’d say Mike Collier is much better known, at least among Dem primary voters, thanks to his past candidacies – but being the only woman on the ballot (if no others join in) will help her. She had $25K on hand as of July, so fundraising is going to be a high priority for her – there’s only one way to get your name out there in a statewide race, and it doesn’t come cheap. I welcome her to the race and look forward to seeing what she has to say. The more people out there telling everyone what a lousy Lite Guv we now have, the better.

Medicaid and the “heartbeat” law

Of interest.

Texas’ new abortion ban makes no exceptions for pregnancies that result from rape or incest. Nearly a month after it was enacted, state health officials still won’t say whether that includes Texans on Medicaid, a small but critical population that they are required to help access the procedure.

Under federal Medicaid rules, states are obligated to cover abortions in rare circumstances, including for victims of sexual abuse. The new Texas law prohibits abortions after six weeks of pregnancy and allows nearly anyone to sue those who defy the restrictions. It is at least temporarily in place while state and federal courts review whether it is constitutional.

The law appears to have forced the state Health and Human Services Commission into a predicament: either it flouts the state ban or it violates the longstanding federal guidelines.

The agency has not said how it is complying with either directive; a spokeswoman declined to comment, citing the pending litigation. In its Medicaid handbook, the agency still provides instructions for submitting abortion claims for reimbursement.

The Department of Justice pointed to the Medicaid impact in a lawsuit it filed earlier this month against the Texas ban. A hearing on that suit is scheduled for Friday.

“The statute arbitrarily denies Medicaid beneficiaries coverage of a procedure for which Medicaid coverage is mandatory,” lawyers for the department wrote in their complaint.

See here and here for some background on the DOJ lawsuit. The subject of Medicaid did come up in oral arguments on Friday, but it didn’t appear to be a main topic of interest. As this story notes, the main lever the federal government has to enforce this is to threaten to withhold Medicaid funding, but that would mostly hurt Medicaid recipients, and it is not at all clear that Greg Abbott would be inclined to give an inch. Some states like South Dakota have routinely violated this law, without consequence. Maybe it matters in this lawsuit and maybe it doesn’t, I don’t know. But there it is.

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.