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.
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.
The current budget proposals fail to provide the additional $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:
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.
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 his 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:
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:
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. Withthe 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:
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:
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).
From a 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.”
From a 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:
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:
Pertinent legislation includes:
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:
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:
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:
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:
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:
We therefore recommend:
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:
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.
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:
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 49thin 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:
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:
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.
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:
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:
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:
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:
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.