DFC 2019 Policy Priorities

Why Access to Care

Texas has both the highest number and highest percentage of uninsured residents in the United States – and the uninsured rate is actually getting worse. The state’s uninsured rate went up from 16.6% (4.5 million people) in 2016 to 17.3% (4.8 million people) in 2017.

A high rate of uninsured Texans is bad for Texas. Uninsured Texans are more likely to delay care or forego preventive care. This leads to more expensive emergency room care or diagnosis of advanced stage disease requiring costly specialized therapies. This also leads to a lack of access to vital services like prenatal care or mental health care. Uninsured patients are less likely to receive follow-up care for chronic medical conditions. Overall, this impacts Texas businesses with a depleted workforce and missed days of work.

We want to improve access to care. It is critical that Texans receive access to health care so they can seek timely medical expertise and avoid delays in diagnosis. This will reduce preventable mortality and improve productivity in the workforce.

Medicaid and the Children’s Health Insurance Program(CHIP) currently provide essential access to health care for over 4 million Texans. Eighty percent of Medicaid enrollees are children, parents, and pregnant women. Fifty-three percent of births are paid by Medicaid. Without Medicaid and CHIP, many hard-working, low-income parents and their children will be uninsured with no access to primary or specialty care.

Doctors for Change strongly believes that the BEST way our state can improve mental health, prevent maternal morbidity/ mortality, keep rural hospitals open, and help children grow into healthy adults is to reduce the uninsured rate in our state. We can make improvements to the Medicaid program to optimize health outcomes for Texans.

Recommendations for improving access to care include:

1. Limit Medicaid funding cuts and fully fund access to Early Childhood Intervention (ECI)

Initial drafts of the budget propose enough funding to cover caseload growth for Medicaid but do not account for the expected increase in health care costs. This is the same approach we have taken in the past regarding Medicaid – and will require that lawmakers to pass a supplemental budget for health care costs in 2021 to make up for this deficit.

We would like to see the full $71 million needed for the critical Early Childhood Intervention (ECI) program.ECI is a statewide program for families with children (0-3 years) with disabilities and developmental delays. For over 30 years, ECI has supported more than 800,000 families to help their children reach their potential through targeted developmental services and parent counseling and training. What makes ECI different than other services is its focus on training parents and other caregivers, such as grandparents, or child-care facilities on how best to aid their child to achieve specific goals and developmental milestones. Unfortunately, we have seen a reduction in the number of contractors providing ECI services from 58 in 2010 to 40 in 2018 – more than a 30% drop.

Two major factors have overburdened many contractors to shut their doors:

• A state obligation passed onto contractors to serve every child deemed eligible without the matching funds to do so
• Decreasing per-child allotments to contractors who now must serve a higher need population of children based on eligibility restrictions
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2. Children’s Medicaid 12-month continuous coverage

Texas has the highest rate and number of uninsured children in the country — and the problem is getting worse. One in five uninsured children in the U.S. is from Texas. Allowing children to stay in Medicaid for a year is the single most effective step state leaders can take to keep kids connected to care. Currently, with extra paperwork and income checks at months 5, 6, 7, and 8, the combined effect of this excess red tape can cause eligible children to lose their Medicaid coverage. Streamlining Medicaid increases efficiency, improves our ability to track and pay for quality in Medicaid managed care and keeps children from falling on and off Medicaid. We recommend that children be allowed to stay enrolled in Medicaid until (1) the first anniversary of the date on which the child’s eligibility was determined; or (2) the child’s 19th birthday.

A Quote From DFC Member and Local Pediatrician:

“As a pediatrician working at a federally qualified health center, I see many families who depend on Medicaid to get medical care for their children. The renewal process every 6 months can be a barrier that impacts a child’s care. I often see children who have missed or delayed checkups and vaccines because they can’t afford to pay for the visit out of pocket. Specifically, I cared for one 9-month-old boy who had delayed surgery for an undescended testicle because hi-s Medicaid coverage lapsed. Early surgery is standard of care to avoid problems later in life, such as with fertility or cancer. Luckily, he was eventually able to have the surgery a few months later through renewed coverage with Medicaid, but it was delayed more than necessary because of the missed appointments in the interim.”

Pertinent legislation includes:

• HB 342 (Cortez): Relating to the period of continuous eligibility for the medical assistance program. Left pending in committee on 3/12 in Human Services
• HB 829 (Rose): Relating to the period of continuous eligibility for the medical assistance program. Referred to Human Services 2/25.
• SB 637 (Zaffirini): Relating to the period of continuous eligibility for the medical assistance program. Reffered to Health and Human Services 3/1. 
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3. Women’s Medicaid coverage for 12 months after giving birth

Texas’ Medicaid for Pregnant Women program provides insurance to low-income, uninsured women while they are pregnant, but this coverage ends 60 days after delivery. Our state continues to struggle with high maternal morbidity and mortality rates – and the state’s Maternal Mortality and Morbidity Task Force recommended 12-month postpartum coverage as a means to address this issue. In addition, data from DSHS suggest that the loss of insurance coverage 60 days after childbirth contributes to the under-diagnosis of and difficulties accessing care for postpartum depression.

Pertinent legislation includes:

• HB 241 (Farrar): Relating to the Medicaid eligibility of certain women after a pregnancy. Referred to Human Services 2/19.
• HB 411 (Thierry): Relating to the Medicaid eligibility of certain women after a pregnancy. Referred to Human Services 2/20.
• HB 610 (Walle): Relating to the Medicaid eligibility of certain women after a pregnancy. Referred to Human Services 2/21.
• HB 744 (Rose): Relating to the Medicaid eligibility of certain women after a pregnancy. Left pending in committee on 3/19 in Human Services.
• HB 1110 (Davis, Sarah): Relating to the Medicaid eligibility of certain women after a pregnancy. Scheduled for public hearing in Human Services on 4/9.
• HB 1589 (Ortega): Relating to providing notification to certain pregnant women regarding their eligibility for coverage under Medicaid and the Healthy Texas Women program. Considered in Calendars on 4/2
• SB 147 (Rodríguez): Relating to the Medicaid eligibility of certain women after a pregnancy. Referred to Health & Human Services 2/1.
• SB 308 (Watson): Relating to the Medicaid eligibility of certain women after a pregnancy. Referred to Health & Human Services 2/7.
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4. Accept federal Medicaid expansion funding to cover as many low-income adults as possible

The federal government offers states Medicaid expansion funding to provide a health coverage option to low-wage workers who do not receive insurance from their employers. Texas remains one of the minority of states that continue to turn down this funding. With the nation’s highest uninsured rate and with rural hospitals closing at an alarming rate – there is a growing urgency for Texas to draw down these funds and improve health coverage.

Pertinent legislation includes:

• HB 565 (Coleman): Relating to healthcare coverage in this state. Left pending in Insurance committee on 3/5. This bill would expand Medicaid to cover janitors, child care teachers, cashiers, and other low-wage workers. It also codifies the essential health benefits and protections under the Affordable Care Act (ACA) into state law. This bill would help over one million Texans gain health coverage.
• HB 590 (Israel): Relating to the expansion of eligibility for Medicaid to certain persons under the federal Patient Protection and Affordable Care Act. Referred to Appropriations 2/20.
• HB 816 (Bernal): Relating to the expansion of eligibility for Medicaid in certain counties under the federal Patient Protection and Affordable Care Act. Referred to Human Services 2/25.
• HB 840 (Bucy): Relating to the expansion of eligibility for Medicaid to certain persons under the federal Patient Protection and Affordable Care Act. Referred to Appropriations 2/25.
• HB 1210 (Beckley): Relating to the expansion of eligibility for Medicaid in certain counties. Referred to Human Services 2/26.
• HB 1395 (Reynolds): Relating to a “Texas Way” to reforming and addressing issues related to the Medicaid program, including the creation of an alternative program designed to ensure health benefit plan coverage to certain low-income individuals through the private marketplace. Referred to Human Services 2/27.
• HJR 40 (Israel): Proposing a constitutional amendment requiring the state to expand eligibility for Medicaid to certain persons under the federal Patient Protection and Affordable Care Act. Referred to Appropriations 2/12.
• HJR 46 (Bucy): Proposing a constitutional amendment requiring the state to expand eligibility for Medicaid to certain persons under the federal Patient Protection and Affordable Care Act. Referred to Appropriations 2/25.
• SB 327 (Alvarado): Relating to the expansion of eligibility for Medicaid in certain counties under the federal Patient Protection and Affordable Care Act. Referred to Health and Human Services 2/7.
• SB 524 (Johnson): Relating to the expansion of eligibility for Medicaid to certain persons under the federal Patient Protection and Affordable Care Act. Referred to Health and Human Services 2/14.
• SJR 34 (Johnson): Proposing a constitutional amendment requiring the state to expand eligibility for Medicaid to certain persons under the federal Patient Protection and Affordable Care Act. Referred to Health and Human Services 2/14.

5. 5. Establish seamless transition for young women from Children’s Medicaid and the Children’s Health Insurance Program (CHIP) to Healthy Texas Women

In a report released by HHSC in May 2018, the commission found that the state could stand to save approximately $58.7 million in general state revenue over the course of five years by implementing this auto-enrollment measure. HHSC found that the state could realize such savings through the fact that they would be providing auto-enrolled women with better access to family-planning services and therefore preventing an estimated 11,275 unplanned pregnancies.

Pertinent legislation includes:

• HB 606 (Thierry): Relating to the automatic enrollment of certain women in the Healthy Texas Women program. Referred to Public Health 2/21.
• HB 1879 (Sarah Davis): Relating to the automatic enrollment of certain women in Medicaid and the Healthy Texas Women and CHIP perinatal programs. Referred to Public Health 3/5.
• SB 189 (Miles): Relating to the automatic enrollment of certain women in the Healthy Texas Women program. Referred to Health & Human Services 2/1.
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• 6. Medicaid coverage of transportation to prenatal and postpartum doctor’s visits with children

Medicaid transportation does not permit women with medical appointments to bring other children with them in the transport vehicles. The Houston Endowment/Steering Committee for Reducing Maternal Mortality included lack of transportation to prenatal visits as a reason many women may not access prenatal care. The Fetal and Infant Morbidity Review/Syphilis and HIV (FIMRSH), which identifies barriers to health care that may account for perinatal HIV and syphilis transmission in Texas, also identified this as a barrier to prenatal care, citing three tragic cases in which infants were infected with HIV or syphilis due to this issue (2 of these infants died).

A Quote From DFC Member and Local Obstetrician/Gynecologist:

“I cannot count the number of calls we receive in our clinic from women who have to cancel last minute because a baby sitter did not show up or because they have limited social support to guarantee childcare while they go to an appointment.”

A Quote From DFC Member and Local Obstetrician/Gynecologist:

“Yesterday, my social worker fought tooth and nail to obtain Medicaid transportation for one of our women living with HIV to attend a postpartum visit. She was scheduled to come in 10 days postop after a Cesarean section for a post-surgery check and to attend her group’s final two hour Centering Pregnancy session. She was traveling with her newborn in a stroller and infant carrier. Medicaid said she was eligible for bus transportation only. Our social worker said, “I am sorry. This woman just had surgery. She has a newborn to take care of and she needs to be seen.” They said the baby needed to also have an appointment. Our social worker therefore scheduled a pediatric visit, just so it was on the record. A Medicaid vehicle finally was arranged. It should not be so hard.”

Pertinent legislation includes:

• HB 25 (González, Mary): Relating to the provision of services to certain children under the Medicaid medical transportation program. Committee report sent to Calendars on 4/5.  
• HB 1114 (Davis, Sarah): Relating to the provision of services to certain children under the Medicaid medical transportation program. Referred to Human Services 2/26.
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• 7. Continued development of telemedicine to improve access of quality care at a fraction of the cost

The 2017 Texas Legislature passed a law that defines telemedicine as a way to deliver health care, not a health care service. It also clarifies that the standard of care for a telemedicine visit is the same as when a physician sees a patient in person. Now Texas has the opportunity to address additional barriers and expand the use of telemedicine to help address our many health care shortage areas. We recommend that the Texas legislature now:

• Improves broadband access across Texas to accelerate telemedicine adoption and implementation.
• Supports innovative uses and applications of telemedicine.
• Ensures that patients’ regular physicians can use telemedicine to treat their patients (i.e. not require the use of an outside vendor). Requires health plans to reimburse patients’ physicians utilizing telemedicine. This is especially critical within the Medicaid program.

Pertinent legislation includes:

• HB 870 (Price): Relating to Medicaid telemedicine and telehealth services. Left pending in Public Health on 4/3.
• SB 670 (Buckingham): Relating to Medicaid telemedicine and telehealth services. Out of the Senate and referred to Public Health on 4/1.
• HB 871 (Price): Relating to use of telemedicine medical service by certain trauma facilities. Left pending in Public Health on 4/3.
• HB 1111 (Davis, Sarah): Relating to maternal and newborn health care. “STUDY ON PROVIDING CERTAIN MATERNAL CARE MEDICAID SERVICES THROUGH TELEMEDICINE MEDICAL SERVICES AND TELEHEALTH SERVICES.” Left pending in Public Health on 4/3.

• 8. Maintain funding for Graduate Medical Education primary care through the Texas Higher Education Coordinating Board

Texas has a severe physician shortage. From the TMA: “The state currently has 12 medical schools — three of which opened since 2016 and have yet to produce a graduating class. Three more are scheduled to open by 2021. The annual number of graduating physicians will grow from about 1,800 in 2019, to more than 2,200 by 2024. But becoming a physician is a two-part process: four years of medical school, followed by three or more years in residency, or graduate medical education (GME). Texas retains 80 percent of physicians who complete medical school and residency in Texas, but a much smaller share of those who go out of state for GME (after Texas taxpayers spent about $180,000 each to support their medical education). Thanks to strong, continued support from the Texas Legislature, the state has engaged in a steady expansion in the number of GME slots available. In 2018, Texas finally reached its goal of having 1.1 GME positions for every medical school graduate. A much larger investment will be needed to keep up with all the new medical schools and to keep as many new doctors in Texas as possible.” We recommend that the Texas legislature now:

• Continue to fund the Primary Care Statewide Preceptorship Program.
• Increase the permanent funding for residency positions to cover a ratio of 1.1 entry level residency slots/medical school graduates.
• Fully fund the Physician Education Repayment Loan Program to cover 200 physicians in each of the key primary care areas: internal medicine, family medicine, pediatrics and obstetrics/gynecology (this will help recruit more physicians to practice in rural areas).
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• 9. Incorporate more funding for intergenerational health services within the Medicaid program

Caregiver health is important in the medical outcomes of the child. Intergenerational family services involve providing health services to caregivers and improving their mental and physical well-being in the pediatric setting to maximize the health of children. In 2017, the Texas legislature changed Texas Medicaid policy to allow pediatricians and family physicians to screen mothers for PPD during well-child visits and reimburse screening costs through the children’s Medicaid coverage. This is a great start, but other states cover so much more through the children’s Medicaid program – and data show improved outcomes for both the parents and the children. We therefore recommend that the state consider covering the following intergenerational health services through the children’s Medicaid program:

• Treatment for maternal/postpartum depression (other states will fund 1-6 counseling sessions through the child’s Medicaid coverage)
• Parenting education (which has been shown to decrease child abuse and improve child developmental outcomes)
• Flu shots for parents (to help protect the young children who are highest at risk for complications and hospitalization from the flu)
• Smoking cessation
• Screening for social determinants of health

Why Access to Mental Health Care

Nationally, 46.4% of adults experience mental illness at least once in their lifetime; 26.2% of adults experience mental illness annually. > 1.3 million Texas children (or 20%) have a mental health disorder. Texas has made great strides in improving funding for mental health services in the last three legislative sessions. Unfortunately, Texas continues to rank 49^thin the US for per capita for spending on mental health. And we continue to take care of patients who struggle to access mental health care.

From a DFC member and local pediatrician:“Every day I am in clinic I identify a patient with an untreated mental health concern. Unfortunately – even after I refer my patients to mental health services for further evaluation and treatment – many of my patients are either not able to access these services or the wait time is so long that the symptoms get worse and have a negative impact on my patients (in terms of relationships with friends/ family, school performance, attempts to self-medicate with street drugs, etc.).”

We therefore recommend:

1. 1. Improve access to school-based mental health services.
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We must better address mental health in our schools. Children do not feel safe at schools anymore. In addition – many children are trying to cope with trauma – from natural disasters like Hurricane Harvey, school shootings like Santa Fe, fear of deportation of a parent or loved one, bullying, etc. By addressing mental health in schools – we have an opportunity to prevent the tragedies of youth suicide and also ameliorate the negative impact mental illness has on student academic performance and behavior in schools. We recommend the following:

• Increase funding for school mental health services. The initial budget draft in the House included TEA’s proposed $12 million for school-based mental health services. We would like to see this added to the Senate budget.
• Increase access to school-based mental health providers. In Houston ISD, there is only 1 counselor for every 1,604 students (1 for 250 is recommended). We ask for more counselors AND increased access to mental health providers in school-based clinics.
• Require mental health to be included in health education curriculum across all grade levels in a developmentally appropriate manner.
• We also ask for increased training in trauma-informed practices in Texas schools to support students who experience trauma and grief.
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Pertinent legislation:

• HB 198 (Thierry): Relating to providing mental health services and mental health education to public school students at school-based health centers. Filed 11/12.
• HB 204 (Thierry): Relating to the inclusion of instruction about mental health in the required curriculum for public school students. Filed 11/12.
• HB 906 (Thompson, Senfronia): Relating to the establishment of a collaborative task force to study certain public school mental health services. Filed 1/17.
• HB 1072 (Price): Relating to mental health and substance use resources for certain school districts. Filed 1/24.
• HB 1069 (Price): Relating to consideration of the mental health of public school students in training requirements for certain school employees, curriculum requirements, counseling programs, educational programs, state and regional programs and services, and health care services for students and to mental health first aid program training and reporting regarding local mental health authority and school district personnel. Filed 1/24.
• HB 1312 (Moody): Relating to the provision of on-campus mental health services by a school district and reimbursement under Medicaid for certain services provided to eligible students. Filed 2/4.
• HB 1335 (Price): Relating to the establishment of school-based behavioral health centers by school districts and a grant program administered by the executive commissioner of the Health and Human Services Commission for the operation of those centers. Filed 2/4.
• SB 344 (Watson): Relating to the participation of campus-based mental health professionals in certain health benefit plans. Referred to Business & Commerce on 2/7.

2. 2. Improve access to mental health services and utilize more integrated behavioral health models to provide both mental and physical health care.
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DFC supports the creation of a Texas Mental Health Care Consortium. Part of the consortium’s charge would be to establish a network of comprehensive child psychiatry access centers to provide consultation services and training opportunities for pediatricians and primary care providers on a regional basis. The consortium would also seek to expand the use of telemedicine for identifying and assessing behavioral health needs and providing access to mental health care services.

DFC also supports the development of a statewide initiative to further study and address mental health using innovative means in Texas. This is truly an exciting initiative through which Texas could lead the country in optimizing mental health outcomes.

Pertinent legislation:

• HB 628 (Thierry): Relating to an acute psychiatric bed registry to list available beds for the psychiatric treatment of certain individuals. Filed 1/3.
• HB 1448 (Zerwas): Relating to the creation of the Texas Mental Health Care Consortium. Filed 2/6.
• HB 1578 (Thierry): Relating to establishing the Mental Health Crisis and Suicide Prevention Task Force. Filed 2/11.
• HB 1598 (Lambert): Relating to an initiative to increase the capacity of local mental health authorities to provide access to mental health services in certain counties. Filed 2/11.
• SB 633 (Kolkhorst): Relating to an initiative to increase the capacity of local mental health authorities to provide access to mental health services in certain counties. Filed 2/4.
• SB 10 (Nelson): Relating to the creation of the Texas Mental Health Care Consortium. Committee hearing 2/12 – Health & Human Services.
• SB 63 (Nelson): Relating to the creation of the Texas Mental Health Care Consortium. Filed 11/12.

3. 3. Utilization of telemedicine to make mental health care more accessible(discussed above).

4. 4. Maintain Graduate Medical Education funding to continue the pipeline of trainees providing mental health to future Texans.Continue to grow the loan repayment program, an evidence-based program to bring more mental health providers to the underserved Texas population.

Pertinent legislation:

• HB 955 (Thompson, Senfronia): Relating to eligibility requirements for student loan repayment assistance for certain mental health professionals. Filed 1/22.
• SB 503 (Seliger): Relating to eligibility requirements for student loan repayment assistance for certain mental health professionals. Filed 1/29.
• SB 429 (Lucio): Relating to a comprehensive plan for increasing and improving the workforce in this state to serve persons with mental health and substance use issues. Filed 1/23.

5. 5. Address the opioid crisis and all substance abuse in Texas.
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There were 1,375 deaths from opioid overdoses in Texas in 2016. From 2012 – 2015, drug overdose was the leading cause of maternal death in the first year after birth (58% due to opioids). In 2015, approximately 40% of opioid-overdose deaths occurred in young people (15-34 years). Opioid addiction costs the state of Texas over $20 billion annually ($706 per capita). Texas Medicaid claims for opioid-related emergency department visits increased by more than 40% from 2008 – 2011. Texas, like the United States as a whole, needs to further address this crisis. We therefore recommend:

• Use the Medicaid program to increase access and funding for medication-assisted treatment (MAT). Texas Medicaid covers MAT (i.e. methadone, suboxone or buprenorphine, and naltrexone) for individuals diagnosed with opioid use disorder. If Texas were to expand access to care through Medicaid, more individuals who need treatment for opioid use disorder would be able to access MAT.
  • Amongst Texans who qualify for state-funded MAT in 2016, only 30% of those on the waitlist were able to receive treatment. Only 5.8% of uninsured adults needing treatment were able to receive it through funding from the Substance Abuse Prevention & Treatment federal block grant. The average wait time for access to MAT is 68 days.
• Mandate prescriber education on pain management (5 states already require that physicians receive Continuing Medical Education on pain management).
• Require electronic medical records to directly connect with the Texas Prescription Drug Monitoring at no cost to the physician (thus decreasing the administrative burden of physician).
• Fund integrative, multidisciplinary pain management programs. Addiction to opiates and chronic pain are complex biopsychosocial issues that are optimally managed using a multifactorial approach. Texas lacks programs that approach the problem in an integrative, evidence-based manner (including promoting use of non-opioids first, stepwise approach, physical therapy, counseling and other interventions that de-emphasize medication alone for pain control).
• Specifically address opioid addiction during and after pregnancy.
• Implement primary prevention strategies targeting children in school given the increasing use in adolescents and young adults.

Pertinent legislation:

• HB 1292 (Price): Relating to statewide initiatives to improve maternal and newborn health for women with opioid use disorder. Filed 2/1.
• SB 436 (Nelson): Relating to statewide initiatives to improve maternal and newborn health for women with opioid use disorder. Filed 1/23.
• HB 1293 (Price): Relating to recommendations by local school health advisory councils regarding opioid addiction and abuse education in public schools. Filed 2/1.
• SB 435 (Nelson): Relating to recommendations by local school health advisory councils regarding opioid addiction and abuse education in public schools. Filed 1/23.

6. 6. Improve access to mental health care for women with postpartum mood disorders:
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Perinatal depression (PPD) is a serious depressive mood disorder that affects mothers during pregnancy and the year following childbirth. While there is no formal collection of PPD diagnoses across the U.S., it is estimated that 10-25% of women suffer from PPD. Beyond significant maternal distress, untreated PPD is associated with poor child health outcomes.

In 2015 – 2016, Texas recognized the importance of increasing the awareness, education, and continuity of care for women with PPD. Initiatives included the designation of May as PPD Awareness Month in tandem with a PPD outreach campaign in May 2016, as well as the HTW auto-enrollment process to close the coverage gap for vulnerable Texas women using MPW. In 2017, Texas Medicaid policy changed to allow pediatricians and family physicians to screen mothers for PPD during well-child visits and reimburse both screening and treatment costs through Children’s Medicaid (CHIP): However, there are still many barriers to identifying and treating Texas mothers with PPD. We therefore recommend:

• Extend Medicaid for Pregnant Women coverage to one-year post-childbirth (discussed above).
• Broaden coverage within HTW to cover more comprehensive care for perinatal mood disorders such as postpartum anxiety and postpartum psychosis. Postpartum anxiety is very common and affects up to 20% of women. While postpartum psychosis is rare and affects less than 1% of women, patients with postpartum psychosis can have severe symptoms such as delusions, mood swings, confused thinking, and disorganized behavior which may result in harm to themselves or their infants.
• Expand care options for patients with perinatal mood disorders.

Pertinent legislation:

• HB 253 (Farrar): Relating to a strategic plan to address postpartum depression. Filed 11/12.
• SB 307 (Watson): Relating to the Medicaid eligibility of certain women for behavioral health services after a pregnancy. Referred to Health & Human Services 2/7.

Why Maternal Morbidity

Between 2012- and 2015, 382 Texas mothers died within a year of giving birth. Causes of death included overdose, cardiac events, homicide, and suicide. Medicaid covered 52% of births in Texas in 2015, and most new mom’s Medicaid coverage ends 60 days after she delivers her baby.

Medicaid provides comprehensive care for eligible women from the time they find out they are pregnant until 60 days after delivery. When Medicaid pregnancy-related coverage ends, Texas automatically enrolls adult women into the Healthy Texas Women (HTW) program, which connects them with preventive health services, including contraceptive services, and basic primary care. HTW provides coverage to low-income women of reproductive age before pregnancy, too. But it provides little or no treatment for acute or chronic conditions, leaving women with complex medical needs, such as diabetes, substance use disorder, or postpartum depression, without coverage for specialty care.

From DFC member and local medical student: “Right after we found out that we were expecting, we immediately grappled with how we were going to do this – I was in medical school and my wife was working to both provide for our family and put me through school. She would come home from work and often leave to babysit while I stayed home studying. Money was tight, but it was worth it – we knew that this was an investment and that one day I would be able to care for the people that had inspired me to go into medicine – the vulnerable, the sick, and the afflicted. And as we went over all of the decisions that we’d need to make over the next 9 months, we came back to the same problem. Although my wife was lucky enough to still be on her parents’ insurance, she would be turning 26 soon and would therefore lose coverage. A friend told us that we would be eligible for Medicaid while my wife was pregnant, and she signed up. It was a weird feeling – I had spent the last couple of years learning about the healthcare system, and never did I hear the word Medicaid and think that my family would one day be part of the group that it covered. After receiving confirmation that Medicaid would cover my wife during her pregnancy, she left for her first appointment. She imagined walking up to the counter, presenting her Medicaid card, and immediately feeling herself placed into a box as another person too poor to take care of herself or her baby during her pregnancy. What she experienced, however, was the exact opposite. Not once did we feel like we lacked quality care, and we literally slept soundly knowing that no matter the absolute momentous changes happening both in our home and to my wife, that she and our soon-to-be-born son would be taken care of and given every chance to be healthy. She was excited that Medicaid allowed her to choose her obstetrician and she didn’t need to worry about if her doctor had admitting privileges at a hospital that would accept our insurance. And, on February 28 at 5:30 am when my wife woke up with the beginning stages of labor and we rushed to the hospital, not once did we have to stress about what bill we would have to leave unpaid and if we would have to forgo on food for hospital bills. At 8:35 pm on the last day of February, we got to hold our new, healthy son in our arms, grateful for the medical care that we were able to receive.

We remember how disappointed we were when the Medicaid coverage for my wife expired 2 months after the birth of our son. The care had been so comprehensive and of such excellent quality that we were sad to see it go, and we were back to the struggle of finding affordable health insurance that would cover any potential postpartum problems that could appear. We were lucky that although post-partum depression runs in my wife’s family, she did not develop any symptoms after her Medicaid coverage ended. We were worried that, without Medicaid coverage, should my wife need mental health services that they would be difficult for us to afford. In medical school, our lecturers constantly reminded us that just because we were learning about a disease didn’t mean that every cough meant we actually had that disease. Far from imagining myself sick, I remember reading about all of the potential problems for the mom that can appear after childbirth and immediately picturing what would happen if my wife was the recipient of those problems. My wife often talked about how she missed the peace of mind knowing that any potential, unforeseen problem would have been covered with Medicaid without having to navigate the difficult-to-understand insurance market.

We are forever grateful for the peace of mind that Medicaid afforded us during my wife’s pregnancy and delivery, and we just wish that peaceful “Medicaid honeymoon” period would have lasted just a little longer.”

To decrease maternal morbidity and mortality in Texas, we recommend:

• Optimize access to care either through accepting federal matching funds to expand Medicaid or pursue a federal demonstration waiver to increase access to comprehensive services for low-income women before, during, and after pregnancy (fund Medicaid for a full 12 months after delivery).
• Automate the transition from Medicaid to HTW for adolescents aging out of Medicaid and CHIP, and for CHIP-P enrollees to the Texas Family Planning Program.
• Increase substance use disorder treatment capacity by allocating dollars to promote and establish community-based treatment options.
• Improve access to long-acting reversible contraceptives (LARCs). Provide funding to make LARCs available immediately following delivery to women enrolled in CHIP-P. Increase teen access to contraceptive care by allowing adolescents to enroll in both CHIP and HTW (with parental consent).
• Improve data collection and analysis on women’s health to clarify understanding of the incidence of maternal mortality and to guide our e orts to reduce maternal mortality and severe maternal morbidity.

Pertinent legislation:

• SB 750 (Kolkhorst): Relating to maternal and newborn health care and the quality of services provided to women in this state under certain health care programs. Filed 2/11.

Why Ant-Human Trafficking

Human trafficking (HT) is modern-day slavery, and Texas is a hub for both international and domestic human trafficking. Texas is leading the nation in enacting policies to make it easier to go after the predators who are enslaving and exploiting our children.Now it is time for Texas to strengthen policies to 1) establish interventions that will result in primary prevention of trafficking, and 2) better help the victims of this heinous crime.

DFC has a very active Anti-Human Trafficking Committee. Over the past twelve years, we have provided education to thousands of health care providers on identifying human trafficking victims. The goal of this education is to identify victims who present to medical care – so that these victims can escape their traffickers and receive the physical and mental health care they need.Between 50-80% of human trafficking victims are seen by health care providers during their captivity. Delay in health care can lead to relapse. Current time to appropriate subspecialty care can be 2–3 months.

We therefore recommend:

1. 1. Implement primary prevention strategies in high risk youth including interventions in the foster care system.

The child welfare system plays a critical role in protecting children whose parents are unable to take care of them. While foster care placements are intended to be safe, 86% of runaway children lured into commercial sexual exploitation are from the child welfare system. Risk factors for commercial sexual exploitation include past sexual abuse by someone in the home, parental neglect or abandonment, homelessness following running away or being kicked out of the home, or homelessness following aging out of foster care. In any given year in Texas, the 24,097 children involved with child welfare services are considered at high-risk of being trafficked. Traffickers often target foster care group homes and youth homeless shelters knowing that these children have limited social and financial support, as well as traumatic experiences that can distort what they believe they can expect and deserve from the people in their lives. Traffickers often engage in a variety of tactics to establish power and control over their victims. Tactics include establishing an intimate relationship that evolves to manipulation, control and violence, forced coercion with drugs or alcohol, violence and threats to cultivate fear, grooming through online social networks, and leveraging current victims to convince their peers to become involved.

Across the last decade, the Texas Department of Family and Protective Services has been under intense scrutiny and criticism for lapses in ensuring child safety within the foster care system. During the 85th legislative session, 88 bills were introduced to legislature to address foster care system reform. Twenty-one of those bills passed and were enacted into law. While this represents a critical step forward in foster care system reform, work remains to be done to produce meaningful change and support for our most vulnerable children.

We therefore recommend:

• Fully fund the foster care system.
  • Dedicate additional funding to hire more caseworkers and improve recordkeeping.
  • Provide semiannual trafficking training for all caseworkers and foster families.
  • Support innovations within the foster care system ameliorate the risk factors for trafficking.
• Develop a Texas Runaway Intervention Project – similar to what has been done in other states. In 2006, Minnesota passed the Safe Harbor for Youth Act, which detailed three key components for a statewide primary intervention model. First, the act called for a systematic identification of adolescents who are at risk for, or are currently, commercially sexually exploited. After identification, they screen and refer at-risk youth to appropriate programs. Each individual identified is assigned to a certain program based on the associated level of risk.
  • Minnesota’s Runaway Intervention Project (RIP) is a program that includes these key components and has been well studied. RIP is a program designed to specifically help girls aged 15 years or younger who are at risk for or who have experienced sexual exploitation in Minnesota [9]. The purpose of the program is to intervene with potential runaways who are at risk and to try to stabilize them within their family of origin, if possible. The first component involves screening and referrals from the community that allow workers to identify the appropriate level of individual risk of each girl. RIP referrals generally include runaways with significant truancy from school who have not been commercially sexually exploited. The second component is a referral to the County Attorney’s Truancy Intervention Project (TIP). TIP is a program that accepts girls who are at low or moderate risk for sexual exploitation. If the screening by RIP is positive for the child to be in this category, RIP refers the girl to TIP to improve the child’s school attendance and family connectedness. The third component of the RIP intervenes for girls identified as moderate risk for sexual exploitation, running away, or any other risky behaviors. These girls are referred to the Sexual Offense Services (SOS) in Minnesota which provides empowerment support groups. The last component of the RIP refers girls who are at the highest risk of sexual exploitation and running away or have already experienced sexual exploitation to the MidWest Children’s Resource Center (MCRC) which provides intensive intervention services.
  • This program has a 96.7% overall effectiveness rate in intervening and preventing sexual exploitation with a net return of $28.9 million in value to the public budget per year of intervention. A 2016 study by the University of Texas at Austin found that in Texas’s current climate of sex trafficking, an estimated $6.5 billion is spent on the lifetime costs of providing care to the survivors of sex trafficking. The cost of implementing a runaway intervention program in Texas to prevent trafficking before it happens certainly pales in comparison to the immense cost of providing for victims once the damage is already done.
• Prevent child abuse in Texas. There are evidence-based means of systematically decreasing child abuse. One such intervention is improving access to evidence-based parenting education. We also support a statewide effort to address Adverse Childhood Experiences (ACEs) that increase the risk of trafficking during adolescence.
• Educate teachers, school leaders, and students (at a developmentally appropriate level) regarding safe relationships and trafficking.
•  

Pertinent legislation:

• HB 45 (Minjarez): Relating to creating a mentor program for foster youth. Referred to Human Services 2/11. A workgroup formed by the Legislature during the last session recommended the use of a peer support model to further enhance support for older youth.
• HB 403 (Thompson, Senfronia): Relating to training requirements for a member of the board of trustees and the superintendent of an independent school district regarding sexual abuse, human trafficking, and other maltreatment of children. Filed 11/26.
• SB 458 (Huffman): Relating to training requirements for a member of the board of trustees and the superintendent of an independent school district regarding sexual abuse, human trafficking, and other maltreatment of children. Filed 1/25.
• HB 507 (White): Relating to a task force to coordinate and make recommendations on parent engagement and education programs provided by state agencies. Filed 12/11.
• HB 822 (Parker): Relating to addressing adverse childhood experiences and developing a strategic plan to address those experiences. Filed 1/15. Using a public health framework, the bill directs state agencies to collaboratively analyze data, identify effective strategies to prevent and treat ACEs using existing programs, and recommend additional supports as needed, among other actions.
• HB 1509 (Calanni): Relating to consent instruction and instruction on the prevention of sexual abuse and sex trafficking for certain public school students. Filed 2/7.
• SB 355 (West): Relating to developing a strategic plan to ensure the provision of prevention and early intervention services complies with federal law. Referred to Health & Human Services 2/7. This bill directs the Department of Family and Protective Services to develop a strategic plan to leverage new opportunities to use federal funding to prevent child abuse and neglect and keep more children safely with their families in compliance with the Family First Prevention Services Act.

2. 2. Improve healthcare access and funding for human trafficking victims by establishing a medical home. We would also like to see a requirement that all airlines, hotel companies, and hospitals that operate in Texas develop internal protocols for addressing anti-human trafficking incidences, as well as, annual staff trainings to recognize signs of human trafficking.
3.  

Pertinent legislation:

• HB 1113 (Davis, Sarah): Relating to state contract limitations and programs for sex trafficking prevention and victim treatment. Filed 1/28.
•  

3. 3. Continue to fund and enhance the various state-led coalitions, task forces, and working groups that sustain adequate public awareness campaigns.
4.  

Pertinent legislation:

• HB 1232 (Guillen): Relating to the establishment and duties of the human trafficking prevention coordinating council. Filed 1/31.
• SB 72 (Nelson): Relating to the establishment and duties of the human trafficking prevention coordinating council. Referred to State Affairs 2/1.

Why Obesity 

Texas has a growing obesity crisis. One-third of adult Texans were obese in 2017, up from 21.7% in 2000. In the 2016-17 school year, 18.5% of Texans age 10-17 were obese, the seventh highest rate in the nation. Obesity and being overweight contribute to diabetes, hypertension, heart disease, cancer, stroke, and maternal health problems. Obesity costs Texas billions of dollars every year in health care costs and decreased work productivity.

Why do we have such a problem with obesity in Texas? There are many reasons – a combination of genes and the environment; our children are consuming increased calories (eating in front of the TV, fast food, sugar-sweetened beverages, fewer fruits and vegetables) and have less activity (less time in school PE, concerns for neighborhood safety, and more TV and video games). We also lack health education and our culture does not always value a healthy lifestyle. What makes things worse in Texas is that almost 50% of our children are living at or near poverty, and we have > 1.3 million households (18.8%) that are food insecure. Poverty and food insecurity are directly linked to increased risk of obesity.

Can we reverse this trend? Absolutely. Other states are making progress (Mississippi, Georgia – to name a couple). And DFC believes that Texas can reverse this dangerous and costly trend by implementing evidence-based policy changes that do the following:

• Increase fresh fruits and vegetables
• Increase physical activity
• Increase breastfeeding initiation, duration, and exclusivity
• Decrease sugar sweetened beverages
• Decrease consumption of calorie dense, nutrient poor foods
• Decrease TV (screen) time

We therefore recommend:

• Have districts develop a locally determined school recess policy and establish a state working group for best practice guidelines on recess
• Implement comprehensive wellness reform in Texas schools including requiring health education and increasing the time requirements for physical education.
• Reimburse health care providers for lifestyle/ obesity counseling

Pertinent legislation:

• HB 455 (Allen): Relating to policies on the recess period in public schools. Filed 12/4.
• SB 364 (Watson): Relating to policies on the recess period in public schools. Referred to Education 2/7.

Why Immunizations

Vaccines save lives. DFC supports immunization as the safest, most effective way to control and eradicate vaccine-preventable diseases in Texas. Thanks to vaccinations, many of the infectious diseases that plagued past generations—like polio, mumps, rubella, diphtheria, tetanus, and H. flu meningitis —have been nearly eradicated. But still, every year, people in Texas die or suffer from vaccine-preventable diseases.

Barriers to immunization access (including lack of insurance coverage, inadequate funding for immunization programs, and poor utilization of Texas’ immunization registry) increase the risk of outbreaks of life-threatening diseases in our communities and endanger the health of Texans and our state’s economic vitality.

In past sessions, the Texas Legislature has taken significant steps to protect Texans from vaccine-preventable diseases by ensuring college students are protected against meningitis, improving immunization uptake among health care and childcare providers, and ensuring funding for safety net programs. We can do more, however!

Now is the time for Texans to recommit to building a community free of vaccine-preventable diseases. The immunization status of individuals can affect the health of the entire community because vaccine-preventable diseases will re-emerge unless there is a protective shield of immunized individuals to prevent outbreaks. Vaccines are the most effective option for preventing and stopping the spread of infectious disease. Unfortunately, we have seen an alarming increase in nonmedical school vaccine exemptions (from ~ 2,000 in 2003-04 to ~ 57,000 in 2017-18). This could put Texas children at risk for a devastating outbreak of a vaccine-preventable illness like measles. The vast majority of Texans — including 86 percent of Republican primary voters — support strong immunization requirements for school children.

And finally, vaccinations are important for adults, too. Approximately 12,000 Texans died of influenza in the 2017-18 season, and about 75 percent of whom were 65 or older. The flu shot doesn’t provide perfect protection, but even among older people who live in long-term care facilities (where flu outbreaks are most common) the vaccine is 80-percent effective in preventing death from a flu complication.

We therefore recommend:

• Protect children in Texas by not making it easier to obtain a nonmedical school vaccine exemption (we do not want it to be more convenient to opt out of a vaccine than obtaining the vaccine, i.e. – we do not want parents to opt out of immunizations out of convenience).
• Provide rates of unvaccinated children in schools and school districts to assist parental choice.
• Increase education and access to cancer preventing vaccines such as HPV vaccine.
• Reverse 2017 legislation that prevents healthcare providers from immunization children in temporary foster care.

Pertinent legislation:

• SB 329 (Seliger): Relating to requirements for and the transparency of epidemiological reports and certain immunization exemption information and reports. (Referred to Health and Human Services on 2/7).

It is CRITICAL that we oppose legislation that would make it easier for parents to opt out of vaccines. HB 1490 (Krause) is a dangerous bill that would significantly simplify the nonmedical exemption process and stop collection of data regarding the number of children who have nonmedical exemptions. This bill would put children at risk for dangerous outbreaks of vaccine-preventable diseases.

Why Public Health Initiatives

Tobacco use is the number 1 cause of preventable disease and premature death in Texas.~28,000 Texans die from smoking every year, and Texas spends an estimated $8.8 billion in annual direct health care costs attributable to tobacco use.

Nearly 3 million Texas adults smoke cigarettes, and most smokers (95%) started prior to the age of 21. Adolescent tobacco use leads to an increased risk of nicotine addiction. Continued use causes lung cancer, coronary heart disease, diabetes, other serious and costly chronic health conditions, and an early death.

We therefore recommend that Texas:

• Raise the minimum legal age for purchasing tobacco products to 21.
• Restore state funding for tobacco prevention and control programs and eliminate funding restrictions on statewide efforts to prevent tobacco usage.
• Reduce infant exposure to secondhand smoke (as this exposure increases the risk of a number of health problems like respiratory illnesses and sudden infant death syndrome).
•  

Pertinent legislation:

• HB 252 (Farrar): Relating to increasing awareness of the dangers of exposing children to secondhand smoke. Filed 11/12.
• HB 749 (Zerwas): Relating to the distribution, possession, purchase, consumption, and receipt of cigarettes, e-cigarettes, and tobacco products. Filed 1/11.
• SB 338 (Huffman): Relating to the distribution, possession, purchase, consumption, and receipt of cigarettes, e-cigarettes, and tobacco products. Filed 1/11.

While great progress has been made on the state level to keep children safe, more work remains to optimize child safety and injury prevention.

Motor vehicle crashes are the leading killer of children older than 1 year, yet state legislative efforts to improve child passenger safety standards have remained largely stalled in recent years. Missing from many state child passenger laws are requirements for safety seat to be rear-facing seats until age 2 years.

Pertinent legislation:

• HB 448 (Turner, Chris): Relating to the creation of an offense for failing to secure certain children in a rear-facing child passenger safety seat system. Filed 12/3)

Why Immigrant and Refugee Health

Immigrant and refugee populations face numerous barriers to receiving health care services which can lead to negative health outcomes not only in their specific populations but also decreased overall health in their greater communities and wasteful economic spending in both state and county settings.

In Texas, undocumented immigrants receive primary care via either safety net hospital systems or any of the sixty-nine federally qualified health centers in the state. Due to lack of adequate sources of care, most of these patients do not receive regular care, and when they begin to present with advanced stages of a disease, they tend to utilize emergency care services. The lack of an adequate health care structure for these vulnerable populations contributes to a cycle of wasteful healthcare spending and poor health management. Other barriers this population faces include language difficulties, fear of deportation leading to fear of seeking medical care, and odd work schedules that prevent them from seeking medical care. As of 2016, 4.1 million native-born Americans residing in Texas had at least one immigrant parent – and these children frequently face many of the same barriers to accessing health care as their parents.

Amongst refugees, acculturation (i.e. the stresses of adjusting to life in a new country), is one of the chief barriers to accessing healthcare services. Isolation, stress, and strong cultural beliefs about health care practices play a role in delayed care in this population. Additional barriers to access to care in the refugee population involve inadequate transportation, lack of childcare services, time cost, financial cost, and scheduling difficulties.

Asylees also face several barriers to healthcare primarily because past trauma and conflict can lead to hesitancy in seeking care. Added to that, difficulties with navigating the American healthcare system can make these individuals less likely to seek care.

DFC strongly believes that Texas needs to address these barriers and optimize immigrant and refugee health outcomes. We therefore recommend:

• Designate hospitals and clinics as safe spaces.
• Ensure that all hospitals and emergency rooms have access to medical translation services.
• Address the healthcare worker shortage through an expedited process for credentialing individuals who completed medical training abroad.

Why LGBTQ Health

Research suggests that LGBTQ individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBT persons has been associated with high rates of mental health disorders, substance abuse, and suicide. In fact, LGBTQ youth are 2-3 times more likely to commit suicide. Recent polling shows that a solid majority (64%) of all demographic groups in Texas favor nondiscrimination laws to protect LGBTQ Texans.

Eliminating LGBTQ health disparities and enhancing efforts to improve LGBTQ health are necessary to ensure that LGBTQ individuals can lead long, healthy lives. Evidence shows that reducing health disparities results in: reductions in disease transmission and progression, improved mental and physical health, reduced health care costs, and increased life expectancy.

Pertinent legislation:

• HB 244 (Farrar): Relating to the prohibition of certain discrimination based on sexual orientation or gender identity or expression; providing an administrative penalty; creating a criminal offense. Referred to State Affairs 2/19.
• HB 254 (Bernal): Relating to the prohibition of certain discrimination based on sexual orientation or gender identity or expression; providing an administrative penalty; creating a criminal offense. Referred to State Affairs 2/19.
• SB 151 (Rodriguez): Relating to the prohibition of certain discrimination based on sexual orientation or gender identity or expression; providing an administrative penalty; creating a criminal offense. Referred to State Affairs 2/1.
• HB 85 (Gonzalez, Mary): Relating to the prosecution of the offense of indecency with a child. Referred to Criminal Jurisprudence 2/12.
• HB 517 (Israel): Relating to unprofessional conduct by mental health providers who attempt to change the sexual orientation of a child; providing penalties. Referred to Public Health 2/20.