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Harris County Hospital District

Trumpcare would be a hospital killer

This is hardly a new problem, but it’s yet another aspect of Trumpcare that gets too little attention.

Texas hospitals stand to lose billions under the Republican-backed health plan, as federal Medicaid dollars shrink, leading to a rise in uncompensated care, according to a new analysis by the Commonwealth Fund, a national health policy foundation.

The study looked only at the U.S. House plan passed last month. It has not yet examined the impact of the U.S. Senate’s version unveiled late last week, which experts have predicted will bring even deeper cuts to Medicaid.

In Texas, uncompensated costs in the state’s 304 acute care hospitals could increase by 7 percent, rising to $38.4 billion over the next decade, the study found.

That compares with an estimated $35.8 billion over the next decade under the current Affordable Care Act.

At issue is a spike in the number of the nation’s uninsured whose care is often absorbed by hospitals. As many as 23 million Americans could become uninsured over the next decade under the House bill because of cuts to Medicaid, and the recalculation of insurance plans and how people afford them, the Congressional Budget Office estimated late last month.


Texas already leads the nation in the number of uninsured and hospital executives have cautioned that their institutions would be hard pressed to take a bigger hit should the uninsured rate go higher.

“If people think Harris Health can absorb this, that is a miscalculation,” said George Masi, president and CEO of Harris Health System, in a January interview with the Chronicle.

This is basically what the world was like before the Affordable Care Act. People who had no insurance would use hospital emergency rooms for care when they really needed it, which is inefficient and dangerous and super expensive and many other negative things, all of which get picked up by local taxpayers. There are so many things that are wrong with and bad about the GOP’s “health care” plan that it’s hard to focus on any one thing and even harder to prioritize, but this one is really big. And it will hurt rural areas at least as much as urban areas. Not that the Republicans who represent rural areas care, and it’s not clear that the voters who would be affected have figured it out, or if they have if they’re capable of getting past their faith in the Charlatan in Chief. But the facts are stubborn things. The Rivard Report has more.

Steve Radack supports Medicaid expansion

I have three things to say about this.

It's constitutional - deal with it

It’s constitutional – deal with it

When Harris County commissioners were asked this week by a member of the public to lower the property tax burden, Steve Radack had a response prepared: tell Austin to let millions of Medicaid dollars flow to the county – then the commissioners might be able to lower taxes.

The comment may come as a surprise from the Precinct 3 commissioner, one of the most outspoken conservatives on the court who has been a vocal critic of Harris Health System, the county’s health care system for the poor.

But his comment adds to the number of local voices that have challenged state Republican leaders to accept the federal money at a time when the county’s population and medical needs continue to grow. Radack said he will keep up the drumbeat.

“So, let’s go after the state,” he said at the meeting Tuesday. “Let them just simply accept the money, send it to us, we’ll cut taxes.”


Last year, Harris Health System officials estimated there were 70,000 uninsured patients in the county public hospital system who would have benefited from the Medicaid expansion, translating into about $70.3 million.

That money, said CEO George Masi, is instead picked up by the Harris County taxpayer when uninsured patients can’t pay their bills.

“That’s what’s so compelling about this,” Masi said. “This is 70.3 million, that would accrue immediately to Harris County.”

Masi said the number was similar each year since Texas opted against expanding Medicaid.

1. This is very good to hear. I have plenty of disagreements with Commissioner Radack and plenty of reasons why I’d like to see someone else in that office, but he’s 100% dead on right here, and he deserves to be applauded for it.

2. That said, how long has he felt this way? Judge Emmett has been a supporter of Medicaid expansion for a few years now. If Radack has felt this way all along, he’s kept it pretty close to the vest. Be loud and proud, Commissioner!

3. I hate to be the one to bring up uncomfortable topics here, but the only way we’re going to get Medicaid expansion in Texas is to elect more people who support it. There are some Republicans in the Legislature who support Medicaid expansion – off the top of my head, I don’t know of any from Harris County, though that may just be because they’ve also been quiet about it – but the majority of them do not, and our Governor and Lt. Governor are especially antagonistic to it. As long as that is the case, the status quo will remain firmly in place. The words are nice and necessary, but without action to accompany them, that’s all they are.

Keeping an eye on Katy ISD

This could be interesting.

Some of the details of George Scott’s “shadow school board” are still that – shadowy.

But as the conservative blogger has assembled a group to meet regularly to reach its own conclusions about the business of the fast-growing Katy ISD board, his mission is clear: to use public data to take aim at the district’s use of high-stakes testing.

He hopes the approach has far-reaching effects beyond the Katy ISD boundaries and will serve as a model for other districts.

“I’ve known George since I first became the president of the local, well over 30 years” said Gayle Fallon, the recently retired president of the Houston Federation of Teachers. “He and I have not always agreed, but I think he’s got a good idea here and one that if it takes off, could have a national impact.”

Scott and Fallon don’t necessarily see eye to eye on many things. But their interests align when it comes to the burden that they say standardized tests have placed on classroom teachers and students.

“With this new emphasis on data,” said Fallon, “teachers spend hours they used to spend with kids just doing data for school districts.”


If he can raise $13,000 through his Kickstarter campaign, Scott said the board will meet on Saturdays starting next year for all-day sessions reviewing data from ongoing public information requests. The money would go toward information requests, facility rentals and meals during the meetings but participants wouldn’t be otherwise compensated, according to Scott. If he raises more than expected, then the shadow board would prepare a budget. All the financials would be publicly available. In April, the board would produce a position paper with recommendations on how to push back on testing’s impact in the classroom as well as on other issues.

“There is an immense amount of data and the typical school board member hasn’t a clue,” said Scott. “They don’t have anybody getting a real actual understanding of the correlation between all of this testing they have and what it means in the organization and delivery at the campus level and the concept of holding people accountable.”

As noted, Scott is a blogger and former member of the Board of Managers of the Harris County Hospital District, among many other things. He’s also been a voice for fairness and transparency in how properties, especially commercial properties, are appraised – I’ve cited his work here more than once. Like Gayle Fallon, I don’t see eye to eye with him on many things, but I respect him and his work, and I think this is a worthwhile project, whatever they ultimately do or don’t find. I wish you and your team good luck, George, and feel free to send me a press release any time you unearth something interesting.

Harris Health wants more people to enroll in Obamacare

Who can blame them?

Harris County’s public health care agency, responding to a budget crisis, will eliminate more than 19,000 people next year from eligibility for free or nearly free services, hoping most of these patients will obtain coverage through the Affordable Care Act.

The board of the agency, Harris Health, voted Thursday to reduce its income threshold for subsidized care from 200 percent of the federal poverty level to 150 percent, saving the system a projected $21.3 million in fiscal year 2017.

Of those losing coverage, more than 15,000 would be eligible to purchase insurance plans through, the health insurance exchange created by the federal law widely known as Obamacare. Most would qualify for large subsidies that would lower the cost of their premiums, deductibles and co-payments.

“We know the seriousness of what is about to take place, but something is going to have to take place for us to survive” in the face of a $53 million budget deficit, board chairman Elvin Franklin said before the vote. “We have to make some hard decisions from time to time, and sometimes those decisions are not going to reflect what everybody wants.”

Under the revised guidelines, an individual making more than $17,655 annually or a family of four with income exceeding $36,375 would no longer be eligible for subsidized care. The change would affect an estimated 19,527 patients, about 6 percent of the 325,000 clients the agency serves.


Harris Health and local advocacy groups will have a major challenge in helping people, like Walker, understand their options and how health insurance works.

Plans sold through the exchange are arranged into four tiers – platinum, gold, silver and bronze. Platinum and gold plans generally have higher premiums but lower deductibles and copayments. Bronze plans have the lowest premiums but high deductibles and copayments.

Federal subsidies, provided through tax credits, and cost sharing help are only available through silver plans. Often, paying a higher monthly premium for a silver plan will be less expensive in the long run for an individual patient.

“We’re talking to people who have never had health insurance before,” said Tiffany Hogue, policy director for the Texas Organizing Project, an advocacy group for the poor that has been conducting enrollment outreach. “Unless they’re sick, this is not their top priority or concern. And it’s complicated to show them the value of why they need it now.”

The education effort may get a significant boost from the federal government. Health and Human Services Secretary Sylvia Burwell announced Tuesday that Houston was among the five areas the agency will target with expanded enrollment outreach because they have high levels of uninsured people.

“We’ve found that costs are still a big concern – about half of the people who are uninsured have less than $100 in savings,” Burwell said. “And people are worried about fitting premiums into their budgets. Almost 60 percent of people who are uninsured are either confused about how the tax credits work or don’t know that they are available.”

While their monthly costs may increase, patients who enroll in the exchanges will have other benefits of health insurance. For example, they can seek care from doctors and hospitals outside the Harris Health System. And their plans can provide coverage when they travel out of the area.

This has been under discussion for several weeks now, as Harris Health has tried to deal with its deficit. They could apply some of the savings they’ll get from 15,000 people signing up for Obamacare to help the 4,000 or so that don’t qualify for subsidies, and still come out way ahead. It’s going to be hard on a lot of people, and some will unfortunately fall through the cracks, but it doesn’t make sense for Harris Health to not do this. Let’s put the blame for any problems that arise – indeed, for the shortfalls that are forcing this in the first place – where it belongs: on the state, particularly Greg Abbott and Dan Patrick and the Legislature, for refusing to expand Medicaid. That would have provided coverage to a large number of the people that will still be serviced by Harris Health. Medicaid expansion would also provide coverage to many people who suffer from mental illness, including a significant portion of the homeless and the people who make frequent trips to the local jails. Our state leadership isn’t interested in any of that. They want to push those costs down to the local level, where they don’t have to take responsibility for it, and they want to arbitrarily cut costs despite the huge negative effects that has. That is the root cause of these problems, and it will remain so until we have different leadership. I hope I live long enough to see it. KUHF and the Chron editorial board have more.

Watch the county’s business

I wholeheartedly approve of this.

Meetings of the Harris County Commissioners Court and the governing boards of the Port of Houston Authority, the Harris Health System and the Harris County Department of Education soon could be streamed live online.

County Judge Ed Emmett on Tuesday [asked] the court for permission to find a vendor to provide “live-streaming and archiving services for Commissioners Court and other public meetings” held in the ninth-floor chamber of the county administration building.

On Friday, Precinct 3 Commissioner Steve Radack added a supplemental item to Tuesday’s meeting agenda calling for that search to include other taxpayer-supported agencies – the port, Harris Health System and the county education department – and for them to foot the bill.

Radack said Emmett has “got a good idea and I think we might as well expand it to include those other people and see if the other members of court agree or disagree.”

“Frankly, I would like to tune into some of them myself just to see what they do,” said Radack said, a frequent critic of the hospital district and port.

He added that including more agencies could reduce the overall cost quoted by a vendor.

Emmett applauded the expanded proposal, and most commissioners expressed support for it.

“I think my original proposal was quite good and I think the supplemental just makes it that much better,” Emmett said. “My attitude is that if you’re going to have public meetings and it’s an easy way to allow the public to look in on your public meetings, I’m all for it.”

About time, I say. This should be the norm for government entities. It’s inexpensive to provide, it promotes transparency and involvement, and it’s just the right thing to do. Kudos to Judge Emmett for proposing it and to Commissioner Radack for improving on Judge Emmett’s idea.

Harris Health System plans to serve more patients via Medicaid waiver

The story about what they’re going to do leaves a few details out, however.

Harris Health System leaders plan to serve 100,000 new patients in the next three years. That is a 37 percent increase from today, and is particularly ambitious when you consider how many patients the system added in the last year: about 500.

To bridge the enormous gap by the end of 2016, the county hospital district is counting on state and federal approval of a $1.2 billion plan that represents the ambitions of health care providers throughout the region. The plan grows out of the federal government’s decision to grant Texas a waiver from Medicaid rules, allowing it to reimburse providers for charity care and for delivering care in new ways.

The plan, awaiting approval in May, envisions unprecedented cooperation between the district and local private and nonprofit providers.

“That’s a major undertaking. We’re very committed to it. We feel it’s very doable,” Harris Health CEO David Lopez said. “We cannot do it all by ourselves. We need partners with us to help us address the needs of our community.”


Among the district’s proposals awaiting approval: Build nine new primary care clinics during the next three years, build “quick” clinics next to its emergency rooms where patients who are not in crisis can be seen, outsource more primary care visits to private clinics, and leverage federal funds to support Memorial Hermann and Texas Children’s Hospital’s expansion of primary care services.

Members of Harris County Commissioners Court, which appoints the hospital district’s board, say the waiver plans are too slow in cutting the backlog of patients who cannot get primary care appointments. That waiting list, first identified in fall 2011, is estimated between 91,000 and 104,000 a year.

Commissioner El Franco Lee last week issued a memo with the phrases “reduce waiting lists” and “get patients moving through the system” underlined, calling on Lopez to cut the backlog by outsourcing more doctor visits.

I had a few questions about this after I read the story, so I sent some inquiries to the Harris Health System’s media relations email address. Here are the questions I sent, along with the answers I got:

1. The article says that “the county hospital district is counting on state and federal approval of a $1.2 billion plan”. Where is the money for this coming from? Are there new funding sources being sought, or is this a repurposing of existing funds?

Answer: The $1.2 billion plan in the article refers to the Delivery System Reform Incentive Payments (DSRIP) projects available under the 1115 Medicaid Transformational Waiver Program. Harris Health System serves as the anchor entity for the regional planning for several counties in SE Texas. The Waiver primarily does two things: 1) expands Medicaid managed care to the entire state 2) replaces the Upper Payment Limit (UPL) program with two new pools of funding, The Uncompensated Care Pool and the DSRIP Pool. Detailed information about the proposed local regional health plan may be found at

2. What entities are being asked to approve this plan? What exactly are they being asked to approve? What happens if they reject some or all of it?

Answer: The state of Texas and U.S. Centers for Medicare and Medicaid Services (CMS) will approve all plans.

3. The story says that this plan is unrelated to the Affordable Care Act. How will the plan be affected if the state changes course and decides to pursue Medicaid expansion, or a law is passed that grants counties the authority to pursue it on their own?

Answer: The 1115 Medicaid Transformational Waiver Program should not be affected by Medicaid expansion since it is unrelated. Detailed information about the 1115 Medicaid Transformational Waiver at-large, may also be found at the state’s Web site.

4. Are details of this plan available on the HHS website? If not, is there a document you could send to me with plan details?

Answer: Detailed information about the proposed local regional health plan may be found at

In other words, if you want to know more, you’re going to need to get your wonk on. State Rep. Garnet Coleman has discussed the 1115 waiver before – see here and here for two examples – and there’s some further discussion here. Basically, this is about delivering health care services via public hospitals and their partners more effectively and efficiently, with some extra federal funds available. It’s not fully clear how this will all work out, and there won’t be a decision on the waiver request until May, but this is what’s coming. Let’s hope it lives up to its promise.

Yes, Ed Emmett supports Medicaid expansion

As I’m sure you’re aware, I’ve been banging the drum pretty much nonstop for Medicaid expansion. I see it not only as a state issue but a county issue as well, which is why I’ve made a big deal about what Harris County is or isn’t doing about it. I haven’t seen the subject come up in Chronicle reporting on health care issues relating to Harris County, nor have I seen a news story devoted to the matter. I finally got an answer to one of my biggest questions on Sunday in the form of this Chron editorial.

Judge Ed Emmett

Near the top of the to-do list is lessening burden of indigent health care, which costs county taxpayers close to $600 million in unreimbursed expenses annually.

Emmett, a mainstream conservative Republican, makes no bones about the solution. He says he is “full bore” for expansion of Medicaid, the federal program that addresses the health care needs of the poor and indigent. That means pressing the GOP majority in Austin to do what does not come naturally: Recognize the utter necessity of accepting federal dollars to pay for Medicaid expansion in Texas.

Emmett’s dollars-and-cents argument, borrowed from the Legislative Budget Board, is compelling: If Texas contributes $50.4 million in the next two years, he says, the state will receive $4 billion in funding from Washington in the coming biennium – and much of that is money Texans sent to the nation’s capital in the first place.

Getting relief for Harris County Jail as a dumping ground for our mentally ill is another priority. Making fuller use of the Harris County Psychiatric Center is one likely solution.

Well, that’s very good to see. I had not seen any clue about how Judge Emmett felt before that, and I think it’s fair to say that I’ve been paying close attention to the matter. Still, it’s certainly possible that there had been some reporting on it by the Chron that I’ve missed, or some reporting elsewhere. I did a search on “Emmett Medicaid expansion” in the Chron archives, both at the legacy site and the subscriber-only site. I got three results – the editorial noted above, an unrelated story about Virginia, and this editorial from a couple of days earlier:

The problem of the uninsured in Texas is numerically daunting. More than 6 million of our fellow Texans go without insurance, including nearly 2.7 million whose incomes are between zero and 133 percent of the federal poverty level. About 800,000 are undocumented workers, but 5 million are citizens.

Community Health Choice is calling for what it describes as a “unique Texas solution” that would acknowledge the political reality in this state where federally administered registries are unacceptable.

Instead, it backs a system that would cut down on the complexity of Obamacare while matching up well with the needs of huge numbers of Texans all across the income strata.

Houston and Harris County property taxpayers have an enormous stake in the successful creation of such a program. Each year more than $500 million in county property taxes goes to fund health care expenses. This burden is dumped on local taxpayers by the refusal of the state to create a fair and equitable system.

Harris County Judge Ed Emmett, who is on the very front lines in this battle, supports the expansion of Medicaid, noting that “it doesn’t make any sense for the state not to take federal dollars.” Emmett is a mainstream Republican whose views should be heeded in Austin.

I also did a Google search on the same terms. I got the same Chron pieces, some of my own writing, a number of irrelevant matches, and on page two, this Guidry News story from last week, reporting from an H-GAC meeting:

Harris County Judge Ed Emmett discussed two issues, indigent health care and transportation funding.

“While it’s nice to say that the state’s going to stand up against Obamacare, the truth of the matter is indigents are going to get health care and it’s going to be paid for by somebody,” Emmett said. “So one of the issues – and we have no position on it yet, but something everybody needs to be aware of, particularly those at the county level – if we don’t go with Medicaid expansion then that means the local property tax(payers) are going to foot the bill for indigent health care. It’s that simple.”

I presume Judge Emmett was not using the royal “we” in that sentence but was speaking about Commissioners Court. Given all this, I think I can reasonably exonerate myself for my ignorance. And in case anyone else had been wondering about this, Judge Emmett addressed the matter directly in his State of the County 2013 speech, which he delivered yesterday. Here’s the crucial bit from the speech:

The second looming issue is health care. Harris County is home to the Texas Medical Center, arguably the greatest concentration of health care expertise in the entire world. Yet, almost with in the shadows of this institution exists a huge uninsured and underinsured population. The Harris County Hospital District has a legal and moral obligation to provide indigent health care. The best value for taxpayers and the best outcome for patients comes from establishing medical homes through neighborhood clinics. I believe we must do a better job of coordinating public and private resources to meet the health care needs of the entire county. This is not just about the health of individuals. It is critical to the health of our entire community.

With the advent of the Section 1115 waiver process, the State of Texas is taking a big step toward creating an indigent health care delivery system that crosses county lines and encourages innovative approaches.

In the debate about health care, it must be remembered that in any delivery system, someone has to pay. The Texas Hospital Association, the Texas Medical Association and even the Legislative Budget Board believe Texas should expand Medicaid coverage in order to take advantage of the federal matching funds. I agree with the health care professionals. While the political debate over the Affordable Care Act continues, poor people will continue to get sick and need care. Harris County taxpayers should not have to foot the bill while our federal tax dollars are sent to other states.

Of course, with the Legislature in session, there is one subject about which I am obsessed. Funding for mental health care must be increased at the state level, and a plan must be implemented to divert those with mental health issues from the criminal justice system. The Harris County Jail should not be the largest mental health facility in the state. The Harris County Psychiatric Center should be fully utilized, and Harris County should take the lead in developing a pilot project that will make the entire nation take notice. State Sen. Joan Huffman and members of the county legislative delegation are working on legislation to create just such a pilot project. It is shameful that Texas ranks 51st in spending for mental health. It is also wasteful of taxpayer dollars. By spending wisely on mental health, we can save much more in the criminal justice arena. Even more importantly, we can improve lives and do what is right.

I’m glad to hear it. It’s what I expected from Judge Emmett, who’s always been more about doing things than making political points. Obviously, Rick Perry doesn’t care about any of this, but I have some hope that what he’s saying here can sway a few people. It must be noted that doing the right thing carries some risk for Judge Emmett, as there’s already talk about a primary challenge to him. I rather doubt this stance will be an asset to him in such a campaign, if one materializes, but maybe it won’t be that much of a burden if the trend of Republicans coming to accept Obamacare and Medicaid expansion as the law of the land makes its way here. Maybe. In any event, I’m glad this has been cleared up. Now I hope that Commissioners Court follows the Judge’s lead and passes a resolution calling on the Lege to do its part.

UPDATE: Here’s the Chron story:

Emmett, using the bully pulpit of his sixth annual State of the County speech to the Greater Houston Partnership, drew widespread applause when he said he agrees with recommendations from the Texas Hospital Association, Texas Medical Association and Legislative Budget Board on expanding the federal health care program for the poor.


Ron Cookston, executive director of Gateway to Care, a health care education and outreach group, called Emmett’s announcement “oustanding.”

“Leaders in Fort Worth and Bexar County and other counties across Texas are beginning to step up and recognize the importance of moving forward with the expansion,” Cookston said. “That’s just huge in terms of the working poor that would have access to adequate health care resources.”

Emmett, like Perry, a Republican, said after his speech that his address was not meant as an appeal to political moderation, but to logic. No one has accused Republican governors Rick Scott of Florida, John Kasich of Ohio or Jan Brewer of Arizona of being liberals, he said, but each has decided to support Medicaid expansion.

“To me, it is conservative to spend $50 million to get $4 billion,” he said. “When things are going well, that’s when we need to spend money to make sure things keep going well in the future. If I got that across, then I accomplished my purpose.”

I’d use other words than “conservative” in that last paragraph – “sensible”, “smart”, “a no-brainer” – but whatever works for you is fine by me. It’s just unfortunate that none of these words have any meaning to Rick Perry.

Inside baseball with the hospital district

I’m not really sure what I’m supposed to learn from this article about the political relationship between the Harris County Hospital District and Commissioners Court.

New name for HCHD

You have to wonder if David Lopez ever feels like he’s in the circus.

When Lopez, the CEO of Harris Health System, Harris County’s public hospital district, visits Commissioners Court to present a proposal, purchase, or budget, he tends to play the role of target in a precision knife-throwing act, facing a flurry of sharp questions.

So it was last week, when Lopez sought to buy a mothballed outpatient surgery center on the Southwest Freeway for $7.8 million. Frowning court members said it was the first they had heard of the item, and nearly rejected the matter outright before sending it to the county infrastructure director for further study.

It was the latest example of disconnect between the hospital district and the county’s leaders. The district operates separately from the county, but its board is appointed by Commissioners Court and the court approves its annual budget, tax rate and long-term real estate leases and purchases. Aides to the court members attend the board’s meetings to monitor operations and, presumably, report back to their bosses.

Yet, Lopez and HHS cannot seem to get buy-in from the court on a consistent basis.

“The district is adrift in a sea of uncertainty, and they can’t really figure out what they need to do or should do. It’s a moving target,” said Commissioner Steve Radack, the health system’s most vocal critic on the court. “They say one day they need a hospital in this area, then they go to another area, then they come back to the first area. They really don’t know what they want.”

Things that I did learn from this story: Harris Health System, formerly known as the Harris County Hospital District, and Commissioners Court sometimes don’t see eye to eye on what HHS wants to do. Better communication between them might or might not help.

Things that I did not learn from this story: First and foremost, whether an outside observer would be inclined to agree with the HHS’s vision for primary care and prevention or if such an observer would agree with the Court that the HHS isn’t focused enough on primary care and prevention. Or perhaps that observer would tell us that it’s not so much a matter of vision as it is one of execution on HHS’s part or expectations on the county’s. It would also be nice to know what an outside observer thinks the county’s needs are and what the priorities should be, and how those compare to what HHS and the county say HHS is doing. Unfortunately, the whole story was basically a he said/she said, and that left me unable to properly evaluate either side’s position. It’s good to know that HHS and the Court disagree on things, but it would be even better to know, or at least suspect, that one or both of them is talking out of something other than their mouths. I don’t have any way of drawing that kind of conclusion or inference from this story, and that’s a shame.

Counties may try to expand Medicaid on their own

The Washington Post reports on the efforts of county and hospital district officials in some of Texas’ largest counties to bypass Rick Perry’s refusal to expand Medicaid for Texas and seek approval to do it themselves for their own jurisdictions.

It's constitutional - deal with it

George Hernandez Jr., CEO of University Health System in San Antonio, came up with the idea of the alternative, county-run Medicaid expansion, and said he has been discussing it with other officials in his county, Bexar. “They are all willing,” he said. He added that he has also been talking up the proposal with officials in other big counties, such as those including Houston and Dallas, and is optimistic they’ll support the idea.

Robert Earley, CEO of JPS Health Network, the public hospital system serving Tarrant County, which includes the Fort Worth area, said he could see the idea catching on.


Under the federal health law, the Medicaid expansion would begin in 2014, and would cover people with incomes of up to 133 percent of the poverty level. The federal government would pay the entire bill for the first three years and 90 percent thereafter. If there were a county-backed expansion in Texas, the local hospital districts would tax residents to come up with the 10 percent state share. Texans living in counties that participated in the expansion would be eligible for Medicaid under the less restrictive rules, while those living in the rest of the state would not.

An official from the U.S. Department of Health and Human Services declined to comment on the idea, but said, “We look forward to continuing our dialogue with states . . . as we work to meet the law’s goals.”

Alan Weil, executive director of the National Academy for State Health Policy, said that the idea, despite its challenges, “is certainly not far-fetched.”

Weil noted that there is precedent for a federal waiver of this type: After California declined to take advantage of a provision in the health-care law that allows states to accelerate their Medicaid expansion, the leaders of several counties got permission from the Obama administration to do so on their own.

The Texas proposal, of course, represents more than a temporary bridge to statewide expansion; it could be a permanent arrangement.

“And federal authorities might feel differently about that,” Weil said. “But as a general proposition, could you have different counties with different eligibility standards? I think the answer would be yes.”

We first heard about this a few weeks ago, after the Perry announcement and the sheepish admission by outgoing HHSC Chair Tom Suehs that Medicaid expansion would not cost nearly as much as his agency had first claimed. It’s an interesting approach, one that I could see being allowed to happen, and I admire creativity and perseverance of the officials who are pursuing it, but let’s be clear that it’s at best a kludge designed to work around a bad decision. For one thing, it cannot possibly be more efficient to have up to 254 potentially different standards for eligibility in Texas than just one statewide standard. For another, while I expect that many counties would do this if they are permitted to do so, some others will choose instead to be free-riding parasites on their neighbors; this is another reason why a statewide solution is better. Given the choice between no Medicaid expansion and a patchwork of Medicaid expansion done by the counties, I’ll gladly take the latter – it’s way better than the status quo, and could easily wind up covering a significant portion of the large uninsured population in Texas, many of which are now served by these overburdened hospital districts. But again, it’s a patch that’s being applied to a strictly self-inflicted wound.

And this approach now has a champion in Congress.

Congressman Henry Cuellar is asking the U.S. Department of Health and Human Services if Texas counties can bypass their state government in order to expand Medicaid coverage.

The Laredo Democrat says he supports giving counties the choice. He said he set up a teleconference call with HHS after reading an article in the Washington Post that said some of Texas’ largest counties want to make an end run around Gov. Rick Perry’s opposition to the expanded Medicaid program included in President Obama’s health-care law.

“I will be talking to HHS next week. I want to know if it is up to the Texas Legislature to decide if counties can do their own thing or whether it is something we can make happen at the federal level. I want to do all I can to give counties the choice,” Cuellar said, in an interview with the Guardian in Rio Grande City on Tuesday.


Cuellar recalled his time in the state legislature when he wanted to give Texas counties the opportunity to expand the Children’s Health Insurance Program. “We do not do as good a job with the CHIP program as other states do and I wanted to negotiate with HHS to give our counties the chance to expand it. I was opposed by the other states. They understood that if Texas sent CHIP money back, they could get some of it,” Cuellar said.

The Washington Post story focused on the larger Texas counties that have large public hospitals and hospital districts. Many border counties do not. Asked if border counties could bypass the state government in order to secure expanded Medicaid coverage under the ACA, Cuellar said he is going to ask HSS if such a maneuver is possible. “I want to see if the border counties can group together. I want to see if we can give them an option,” Cuellar said.

Again, given the constraints of Rick Perry’s obstinacy and antipathy towards non-rich people, that’s a great idea. Any opportunity to bypass the Lege should be grasped with both hands. Make that option available to any group of counties that don’t have a hospital district but want to do right by their taxpayers, too. If there’s any justice, Texas would achieve near-complete coverage by this method. It will probably take something like that to change the status quo. It’s still a stupid way to do business, but you gotta do what you gotta do.

There’s one remaining question that I have about all this, and that’s what Harris County intends to do. Bexar County has been the driving force behind this movement. Harris has the same need and a much bigger population, so its participation would be a big deal. I placed a call and was informed that Harris County Hospital District CEO David Lopez is “not granting interviews” on this topic at this time. Disappointing, but I suppose the politics of this are rather tricky for them, and they want to get as many ducks in a row as possible before deciding on a course of action. If you’re an officeholder in Harris County and you like the idea of providing coverage to the million or so uninsured residents of this county, I suggest you bring this up to Mr. Lopez at your next opportunity. You never know who else might be talking to him if you aren’t.

Harris County prepares to get hammered

The House budget will cost Harris County a bundle if it passes as is.

Harris County health care providers would lose more than $2 billion in Medicaid funding under the Texas House budget that passed Sunday night, according to an Austin think tank.

The Center for Public Policy Priorities’ county-by-county analysis found the hit, by far the most in the state, would reduce overall Medicaid funding for Harris County hospitals, doctors, nursing homes and other providers by 38 percent from the amount spent on such care in 2009.

“That would certainly be a body blow for the county, one I’d expect it to try to make up through tax and fees,” said Vivian Ho, a Rice University health care economist. “As private practice doctors get out of Medicaid, I’d also worry about the spillover effect at hospitals, like Texas Children’s, that provide care to low-income and privately insured patients.”

Houston health care providers said it was too early to know how they’d respond if such a cut were signed into law. But they were unanimous in saying it would have a huge negative impact.

You can see the CPPP’s reports here. Nobody doubts that there will be an effect, and given the scope of the cuts at the state level, that it will be a large effect, right? And nobody doubts that the people who will be directly affected by this won’t just go away but will find some other way to get medical attention, right? That means more people showing up at emergency rooms. You can do the math from there.

Members of the Harris County Commissioners Court in 2009 said they were committed not to raise property taxes, but the district is coping with reduced tax revenues because of a decline in county property values in addition to coming legislative cuts.

Noting the court is still six months away from setting tax rates, a spokesman for County Judge Ed Emmett said Friday that nothing is on or off the table for the hospital district tax rate.

Yes, it’s still early in the process, the Senate is likely to make changes, and you shouldn’t read too much into such an equivocal statement. But if Harris County winds up raising taxes as a result of this, please be sure to put the blame for it where it belongs, on the Republicans in the Lege who voted for HB1.

There is a solution for this

Yet it manages to go completely unmentioned in this story.

The Harris County Hospital District has begun turning away uninsured patients from other counties who show up in its facilities and do not need urgent care, unless they pay cash up front.

The policy is one of several strategies the district is pursuing to prevent “cataclysmic” effects on patients as the state considers cuts that could take nearly 10 percent of the district’s budget, president and CEO David Lopez said.

If a patient enters a hospital or clinic with a medical emergency, federal law mandates treatment. Many people, however, visit emergency rooms with routine illnesses, said Dr. Shkelzen Hoxhaj, chief of emergency medicine at Ben Taub General Hospital, the district’s flagship facility.

It cost the hospital district about $3.9 million to treat uninsured, out-of-county, non-emergency patients during the fiscal year that ended Feb. 28, said district chief financial officer Mike Norby. About $200,000 of that will be collected, he said.

In a $1.06 billion budget, the loss is a fraction of 1 percent. No savings is too small when state cuts could cost the district as much as $110 million, Norby said.

“We need to just hold the line and say, ‘Folks, we need cash up front.’ It’s the principle of the thing,” Lopez said. “We knew we were going to have to start doing things differently. This is not going to solve our problem, but there’s no one single strategy to addressing our loss of revenue.”

It’s true that there’s only so much that the hospital district itself can do about this, and all of their solutions are going to be of the every-little-bit-helps variety. The underlying problem, however, is that there are too many people in Texas who lack health insurance, and thus must rely on emergency rooms for their care. Fortunately, we now have a way to deal with that problem. It’s called the Affordable Care Act, and it will greatly reduce the number of uninsured residents in Texas, which will make life a lot easier for county hospital districts. I don’t know why this wasn’t discussed in the story, especially since we have a new County Commissioner who ran on a platform of fighting against the implementation of the Affordable Care Act, but I’m pretty sure it will have a bigger effect than anything the HCHD can do. Not that they shouldn’t take whatever reasonable steps they can to control their costs – every little bit does help – it’s just that there’s more to it than their own efforts.

A related matter is discussed in this Houston Politics post, namely why are there all of these out-of-county indigent people coming to Harris County for treatment?

Most surrounding counties use the minimum standard allowed by law — 21 percent of the federal poverty guideline — to decide who qualifies as “indigent” to receive free or discounted health care.

Under these rules, a family of four earning $4,632 per year or more is not eligible for discounted care.

“If a family is making $7,000 a year for a family of four and they show up in your clinic or your facility, you know they’re indigent,” [HCHD CEO David] Lopez said. “They don’t have $150, $200 to pay. So we’re going to have to tell those people, ‘We’re sorry, we can’t see you, because you don’t qualify for care in our community and you don’t qualify for indigent care in your community.’ So what happens to them? … Is that right? That makes it somewhat difficult.”

In Harris County, that same family of four earning up to $55,875 in annual income could receive discounted care. Its care could be free if its annual income is less than $22,350.


Commissioner Steve Radack, a frequent critic of the hospital district, found himself in the same foxhole with Lopez on this topic.

“Harris County government, and the Harris County Hospital District, as well, needs to send a strong message to other counties: ‘Stop shirking your responsibility of taking care of your indigent patients and trying to send them to the the Harris County Hospital District,'” Radack said. “These counties probably set (their poverty levels) that way so that, ‘Hey, these people are going to go somewhere else.’ They can’t just get it done in that county. They don’t have the money to pay for it.”

“It’s a way to literally push people into the Harris County hospital system who aren’t qualified to be in it.”

I agree, and it should start with Harris County officials calling out the free riders by name. There should also be a concerted push by Harris and other big urban counties to get the Lege to put an end to this nonsense, as this kind of mooching exists elsewhere in the state as well. It’s time for every county to be responsible for its own residents.