Liveblog: Health and Human Services at The Texas Tribune Festival
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We'll be liveblogging throughout the weekend from The Texas Tribune Festival's health and human services track — which includes panels on the fight over federal health reform, whether Texas can cure cancer, what effect tort reform has had statewide, and how patient privacy is possible in the digital age.
Featured speakers include Planned Parenthood Federation of America President Cecile Richards; U.S. Rep. Michael Burgess; Texas Health and Human Services Commissioner Tom Suehs; and Doug Ulman, president and CEO of the Lance Armstrong Foundation.
Follow us here for updates from the University of Texas campus.
Liveblog
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Burgess says he tries to refer to "Obamacare" by its proper name, the Affordable Care Act. "Everyone knows what you're talking about when you say that." (Obamacare)
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Burgess says the measure effectively had to be passed to find out what's in it: "People are finding out what’s in it, and it hasn’t helped one bit."
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There are some good things about "Obamacare," Burgess said, like expanding insurance to kids on their parents' coverage until age 26, and mandating coverage for pre-existing conditions. "That was something around which there might have been some coalescing."
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Burgess: "Is Medicaid the answer? Is that the best you can do with all these Harvard educated people?"
Burgess says in Texas, which has the highest rate of the uninsured, there is "a fairly robust safety net system."
Burgess says in Texas, which has the highest rate of the uninsured, there is "a fairly robust safety net system."
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Burgess on the difference between "Romneycare" and "Obamacare:" "Does the state have the right to do that? Of course they do. Does the federal government have that same right? I would argue that they do not."
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Burgess said he asked Romney about people without Social Security numbers (i.e. illegal immigrants). Romney could ignore immigrant population with "Romneycare" because it's such a tiny population, Burgess said. Texas can't ignore it.
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Question about what happens in the courts on "Obamacare" "keeps me up at night," Burgess says. "We need to think through this as responsible policymakers."
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Burgess says "Obamacare" was created without any real public input. "It was supposed to be a transparent and open process." He says the only players were the American Medical Association, the Hospital Association, Big Pharma, Medical device manufacturers and the insurance companies.
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Burgess said there's a population that won't buy health insurance for any reason. "Why do I have to give up a significant portion of individual liberty because other people won't do the right thing?"
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Burgess says he has a health savings account, and that he thinks that's that's appropriate for most people. "Something magic happens when people spend their own money for health care."
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Testy line of questioning about the recent GOP debate where someone in the audience shouted "let him die' about a hypothetical uninsured patient.
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Burgess: "If there's an individual mandate in this country, you're not going to cover everybody."
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"When the patient controls the money they are likely to make reasonable decisions based on their own situation."
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Lack of transparency for hospital costs: "There was nothing in the affordable care act that dealt with that."
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Health and Human Services — Has Tort Reform Been Good for Health Care?
Panelists: Howard Marcus of Texas Alliance for Patient Access, Jay Harvey of Winckler & Harvey, LLP, Michael Hull of Hull Hendricks, LLP, and David Hyman of the Epstein Program in Health Law and Policy at the University of Illinois
Panelists: Howard Marcus of Texas Alliance for Patient Access, Jay Harvey of Winckler & Harvey, LLP, Michael Hull of Hull Hendricks, LLP, and David Hyman of the Epstein Program in Health Law and Policy at the University of Illinois
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Panel will debate the effects of Prop 12, which passed in 2003 by a close margin (51%-49%). The initiative limits the amount of money patients can recover from malpractice suits. It capped non-economic damages (pain and suffering) at $250,000. Some say it has helped to recruit doctors to Texas. Other say they would have come anyway due to the population boom.
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Dr. Marcus Hall says there's an upward trend since 2007 in the number of direct patient care physicians.Texas is now ranked 10th in the growth of physicians. That's up from being ranked 23rd. It takes time for tort reform to work, but it appears to have made a difference.
Law professor David Hyman says the increase is largely due to dramatic population growth. There are fewer specialists after tort reform, but when you account for population growth...there's just not much difference.
Law professor David Hyman says the increase is largely due to dramatic population growth. There are fewer specialists after tort reform, but when you account for population growth...there's just not much difference.
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Attorney Jay Harvey says liability costs in the most broad sense (reimbursements, attorneys fees, insurance premiums) was significantly less than 1 percent of the health care dollar prior to the 2003 laws. Over-utilization of health care providers causes higher costs.
Lyman on defensive medicine: If doctors have lower costs, you’d expect that to be reflected in patient bills. But it’ll have small impact. If physicians are afraid of being sued, they’ll run extra tests, etc. The theory is that if doctors don’t have to worry about the risks of being sued, they won’t run extra tests. Harvey argues that makes no sense. Doctors don't order tests without a legitimate, rational basis for the need for that test. So if there’s an unreasonable mark-up, it’s the doctor’s fault and not the plaintiffs’ fault.
Lyman on defensive medicine: If doctors have lower costs, you’d expect that to be reflected in patient bills. But it’ll have small impact. If physicians are afraid of being sued, they’ll run extra tests, etc. The theory is that if doctors don’t have to worry about the risks of being sued, they won’t run extra tests. Harvey argues that makes no sense. Doctors don't order tests without a legitimate, rational basis for the need for that test. So if there’s an unreasonable mark-up, it’s the doctor’s fault and not the plaintiffs’ fault.
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Attorney Jay Harvey: Rural communities have not been served to the level we’d hoped. So-called tort reform has not been the panacea for getting doctors into rural facilities. We’re not seeing dramatic changes. They have to have additional incentives to get them there.
Health law expert Lyman: If you want to motivate physicians to practice in those areas, tort reform is a small piece of the puzzle because it might lower costs. The trends in Texas show increase in urban areas where there are lots of uninsured as well as insured patients. If you want to broaden access to rural areas, tort reform isn’t at the top of the list of ways to make it happen.
Dr. Hall sees progress. He says 32 Texas counties that didn’t have ER doctors now have one.
Health law expert Lyman: If you want to motivate physicians to practice in those areas, tort reform is a small piece of the puzzle because it might lower costs. The trends in Texas show increase in urban areas where there are lots of uninsured as well as insured patients. If you want to broaden access to rural areas, tort reform isn’t at the top of the list of ways to make it happen.
Dr. Hall sees progress. He says 32 Texas counties that didn’t have ER doctors now have one.
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Last blog post came after an audience member pointed out health care spending hasn't changed and the uninsured/under-insured continue to struggle to access health care.
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A pre-med student asked what she can expect in five years. Harvey says those who practice within the malpractice field realize there's an imbalance between plaintiffs and defendants. The Texas Legislature will likely maintain that climate.
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Up next: Can Texas Cure Cancer? Moderated by Trib staffer Emily Ramshaw and featuring the following panelists.
Raymond N. Dubois Jr., provost and executive vice president of the University of Texas M.D. Anderson Cancer Center and a professor of cancer biology and cancer medicine.
Doug Ulman, President and CEO of the Lance Armstrong Foundation. He’s also a three-time cancer survivor and founder of the Ulman Cancer Fund for Young Adults.
Joseph S. Bailes, vice chairman of the Cancer Prevention and Research Institute of Texas, a state-established foundation that has awarded over $455 million in grants for cancer research and prevention.
Raymond N. Dubois Jr., provost and executive vice president of the University of Texas M.D. Anderson Cancer Center and a professor of cancer biology and cancer medicine.
Doug Ulman, President and CEO of the Lance Armstrong Foundation. He’s also a three-time cancer survivor and founder of the Ulman Cancer Fund for Young Adults.
Joseph S. Bailes, vice chairman of the Cancer Prevention and Research Institute of Texas, a state-established foundation that has awarded over $455 million in grants for cancer research and prevention.
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First question: Is Texas in a position not only to treat, but to cure cancer?
“We have actually cured some cancer,” said Dubois, citing the success of curing Lance Armstrong’s as an example. New treatments also “put the cancer into a more chronic-type condition where people can live with that.”'
“We have actually cured some cancer,” said Dubois, citing the success of curing Lance Armstrong’s as an example. New treatments also “put the cancer into a more chronic-type condition where people can live with that.”'
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Ulman: “Texas is leading the way in terms of recruiting top talent from around the country that are now flocking to the state to access the resources of CPRIT.”
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Question: “The cancer advances take a really long time…how do we keep the public engaged and supportive when you might not see immediate results in a two-year budget cycle?”
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The legislature fully funded the CPRIT program this legislative session, said Bailes. “Members of the legislature heard from their constituents about how important this is.” And the program has garnered attention worldwide, he said.
Dubois adds that Texas’ funding for CPRIT ranks fifth or sixth in the world in terms of available funds for research. “It’s a major impact on worldwide cancer research," he said.
Dubois adds that Texas’ funding for CPRIT ranks fifth or sixth in the world in terms of available funds for research. “It’s a major impact on worldwide cancer research," he said.
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“The slogan is research saves lives,” said Dubois. What’s happening in cancer research is similar to the discovery of antibiotics during World War I, he said, which saved hundreds of thousands of lives. The question now is how to utilize knowledge of the human genome to target the causes — and the ways to cure — cancer.
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Q: What reputation do Texas' cancer research programs have?
Ulman says people across the nation recognize M.D. Anderson as a leading cancer research center, but they don’t know some of the other institutions across the state, such as U.T. Southwestern, that also have strong research programs. “People are paying attention to Texas,” said Ulman, and “wondering who the next Nobel laureates are that are going to move to Texas.”
He said it is also important to keep talking about cancer research programs, especially during future legislative sessions, because the funding needs to stay consistent for the program to be successful. “These are not processes you can stop and start.”
Ulman says people across the nation recognize M.D. Anderson as a leading cancer research center, but they don’t know some of the other institutions across the state, such as U.T. Southwestern, that also have strong research programs. “People are paying attention to Texas,” said Ulman, and “wondering who the next Nobel laureates are that are going to move to Texas.”
He said it is also important to keep talking about cancer research programs, especially during future legislative sessions, because the funding needs to stay consistent for the program to be successful. “These are not processes you can stop and start.”
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CPRIT “will help us with jobs, it will help us with commercialization of drugs,” said Bailes. Over 100,000 Texans are diagnosed with cancer every year, which makes up almost 10 percent of diagnoses in the country.
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Ramshaw asked, what do the panelists think of the legislature’s failed attempt to pass a smoking ban this session?
Ulman’s response: “You can’t sit in the legislature…and say I’m in support of CPRIT, but not in support of smoke-free work places…people should not have to choose between making a living and health.”
Ulman’s response: “You can’t sit in the legislature…and say I’m in support of CPRIT, but not in support of smoke-free work places…people should not have to choose between making a living and health.”
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Question from the audience: How do you decide which cancers Texas is going to focus on finding the cure for?
Dubois: “It would be wise for us to think about focusing on maybe five or six particular cancers where we’re going to go all the way…If we could focus our energy in a narrower beam, clearly we’re going to have a lot more impact.”
Dubois: “It would be wise for us to think about focusing on maybe five or six particular cancers where we’re going to go all the way…If we could focus our energy in a narrower beam, clearly we’re going to have a lot more impact.”
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Audience question: ‘CPRIT sounds great, but are you considering leveraging the fact that Texas is such a pro-corporate state?’
Bailes said CPRIT funds companies that have innovative products and other sources of funding, “so commercialization is a very important part…of what CPRIT’s mission is and what CPRIT’s research efforts are. Our goal is to leverage the other funding people bring in.” He said that most grants require a 50 percent match from other funding sources.
Bailes said CPRIT funds companies that have innovative products and other sources of funding, “so commercialization is a very important part…of what CPRIT’s mission is and what CPRIT’s research efforts are. Our goal is to leverage the other funding people bring in.” He said that most grants require a 50 percent match from other funding sources.
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Dubois said CPRIT has talked to the pharmaceutical company Pfizer about partnering on programs. “They can leverage some of their funds...with the Texas CPRIT funds to go a lot further,” he said.
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Ulman said, “if we did zero additional bio-medical research we could save 60 percent of people with cancer if we just give them access to what we know works.” Educating people and ensuring they know what options are available is part of the puzzle, he said. Proving these methods work is also part of what’s necessary to continue CPRIT’s funding, he said.
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An audience member brings up a topic very near and dear to Gov. Rick Perry’s presidential campaign: Is mandating an HPV vaccine wrong?
Dubois: “We don’t typically make public policies, but we can see the benefit of some preventative effort like that.”
Dubois: “We don’t typically make public policies, but we can see the benefit of some preventative effort like that.”
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Ramshaw straight up asks the panelists, is Gov. Perry’s executive order to mandate the HPV vaccine the right thing or the wrong thing to do?
Panelists pause for a moment, laugh a bit, before answering. Ulman: “Probably not the right way to go about it, but people should have access to this vaccine, because it is a huge success story.” HPV is the number one cause of death by cancer for women in Africa, he said, and “we have the tool” to help.
Panelists pause for a moment, laugh a bit, before answering. Ulman: “Probably not the right way to go about it, but people should have access to this vaccine, because it is a huge success story.” HPV is the number one cause of death by cancer for women in Africa, he said, and “we have the tool” to help.
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Dubois: “I think the vaccine is very effective, we need to make it available to all women that want to get vaccinated…There are a lot of political issues swirling around with the presidential race…but in terms of a medical doctor, what my advice would be — clearly it’s a very effective preventative measure.”
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Audience member asks about the educational opportunities offered by cancer research programs in Texas. Dubois said M.D. Anderson has 70,000 trainees that work in some capacity at the institution. “One of the most effective programs that we’ve developed is our summer undergraduate program,” he said, in which students spend six to seven weeks working at M.D. Anderson to “see what its like to be in the clinic, be in a research lab.”
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The panelists take on healthcare reform laws:
Bailes said people need health insurance, but if reform means more people are going to be put into “financially-stressed” healthcare programs, such as Medicaid and Medicare, these programs need to “cover needed benefits for individuals with cancer.”
Dubois adds that the health care debate is usually focused on access and services. “We haven’t been talking enough about the value of the healthcare, the quality of our healthcare, and really, how we can reduce our costs,” he said.
Bailes said people need health insurance, but if reform means more people are going to be put into “financially-stressed” healthcare programs, such as Medicaid and Medicare, these programs need to “cover needed benefits for individuals with cancer.”
Dubois adds that the health care debate is usually focused on access and services. “We haven’t been talking enough about the value of the healthcare, the quality of our healthcare, and really, how we can reduce our costs,” he said.
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Audience member yelled out: “Do you go through the radiation scanner or have them pat you down?”
Panelists crack up in laughter. “You’d have to go through billions of times to get cancer,” said Bailes.
Panelists crack up in laughter. “You’d have to go through billions of times to get cancer,” said Bailes.
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The Livestrong foundation would have difficulty garnering the amount of funding for cancer research that CPRIT has, so “we focus on improving people’s lives, rather than ‘curing’ the disease,” said Ulman, emphasizing both types of programs are necessary for helping cancer patients. He added that according to the American Cancer Society, “we are saving 300 more lives today than in 1991 from cancer, but we should be saving 1,000 per day. That’s their end-all target.”
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Up next: The Texas Health and Human Services commissioner, Tom Suehs, is live at Tribune Fest to talk about Texas and the Transformation of Medicaid.
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In his introduction of Suehs, Texas Rep. Elliott Naishtat said the simplification of Medicaid, which he worked on to help increase access to health insurance for low-income children, was never fully implemented. “Texas is a conservative state, you may quote me on that, and the political will has never been there to provide the funding and resources to ensure that low income individuals have easy access to public assistance programs.”
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To give a little context, Naishtat says prior to last session, Texas politicians were talking about opting out of Medicaid. During the session, the discussion became about the need to support federal efforts to give out block grants for state Medicaid programs, as a way to contain costs and give states greater flexibility. Ultimately, “the legislature underfunded Medicaid by $4.8 billion for the next biennium,” said Naishtat.
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The proportion of Medicaid costs in the state budget is increasing rapidly, said Suehs. In 1991, Medicaid was 14 percent of the state budget. By 2001, it was 28 percent. Now, it’s even greater, he said, and the costs are only growing. “That’s crisis.”
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“It’s amazing how people misinterpret Medicaid,” said Suehs. To receive benefits, an individual must be a resident, a U.S. citizen or a qualified alien with legal permanent residency status, he said.
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Many of the uninsured in Texas could qualify for Medicaid or the Children’s Health Insurance Program, said Suehs, but they are not signed up to receive benefits. He says four major factors are contributing to the high rate of uninsured individuals: Texas’ workforce consists mostly of small employers that can’t afford to provide health insurance for employees, the average education level in Texas is a lot lower than the national average, the average age of the workforce in Texas is also a lot lower, and roughly 13 percent of that population are non-legal citizens of the state.
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“Whether you’re a U.S. citizen or not you’ll get treated at a Texas hospital,” said Suehs, but he points out that emergency medical care for individuals makes up less than 1 percent of those served by Medicaid. More than half of the program — 63 percent — are children under the age of 18 from low-income families.
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“Almost half of the Medicaid budget is spent on hospital care,” said Suehs, commenting he'll return later to the reasons why lump sum payments for hospitals are inefficient.
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Suehs: “I think the current Medicaid program cannot go on forever without some major fundamental reforms.” Cost drivers include the number of the people served and increasing utilization of medicine and technology. “I guarantee those drug advertisements change drug usage,” he said. “We pay billions of dollars in the pharmacy industry for ads, that impacts medical utilization.”
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Looking at the growth in Medicaid caseloads reveals an increasing number of newborns and children are receiving services from Medicaid. “It’s been Texas policy to try and pick up and serve as many children as possible,” said Suehs.
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Enhanced funding from the federal Affordable Care Act will not include extra funding for eligible individuals who aren’t currently enrolled in Medicaid, said Suehs. Texas will likely have to bear the burden of financing Medicaid for these individuals, said Suehs, because more people will sign up for Medicaid when the federal reform requiring all individuals to have health insurance kicks in.
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There are problems in the federal funding structure of Medicaid, said Suehs. Texas receives 6.8 percent of federal Medicaid funds, but provides 8.4 percent of the federal tax revenue for the program. Texas also has a higher rate of people living below the poverty line — 10 percent — than other states, which isn’t accounted for in the federal funding structure, he said. “We’d gain $1.7 billion,” annually, he said, if the federal government took poverty levels into account when distributing Medicaid funding.
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In terms of transforming Medicaid, Suehs said the Texas legislature set certain priorities this session, such as reducing fraud, abuse and waste in the program. “Fraud and abuse are probably as high as people say,” said Suehs.
The legislature also pursued a set of different waivers from the federal government. According to Suehs’ presentation, an FMAP waiver that is “based on a state’s relative income and its relative burden serving poor residents would more equitably allocate federal funds.” Another option is a benefits waiver, which would reduce the mandatory populations covered by Medicaid in order to save taxpayers' money.
The legislature also pursued a set of different waivers from the federal government. According to Suehs’ presentation, an FMAP waiver that is “based on a state’s relative income and its relative burden serving poor residents would more equitably allocate federal funds.” Another option is a benefits waiver, which would reduce the mandatory populations covered by Medicaid in order to save taxpayers' money.
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“We’ve got to get out of the delivery system,” said Suehs. The current structure of Medicaid “now focuses on the emergency room and the most high cost environment to treat somebody,” he said. “It’s not an easy task to ask hospitals to change.”
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“I can’t speak for Gov. Perry,” said Suehs, but he personally believes, “there’s enough money in the system, we’re just not spending it very wisely. We’re not spending it very efficient.”
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Audience member asks why would it be more efficient for hospitals to receive patient-specific funds rather than lump sums?
The lump sum payments to hospitals are based on how much the hospitals charge for services, not the actual cost of care per Medicaid patient, said Suehs. “The more efficient system is getting out of this lump sum payment so you can diversify how you make those payments,” he said. For example, more money could be directed to primary care physicians to prevent emergency medical costs.
The lump sum payments to hospitals are based on how much the hospitals charge for services, not the actual cost of care per Medicaid patient, said Suehs. “The more efficient system is getting out of this lump sum payment so you can diversify how you make those payments,” he said. For example, more money could be directed to primary care physicians to prevent emergency medical costs.
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“Rural health care in Texas…is kind of going to be a challenging one for us, I’m not sure I have all the answers,” said Suehs. Hospitals need to work on utilization of emergency room and non-emergency care, he said, which can be a problem for rural hospitals in particular, because often “they don’t have a primary care doctor or they have a limited number of primary care doctors.”
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“There’s enough money in the system,” said Suehs, again. “Before you talk about expanding government programs,” we need to work on making the current program more efficient, he said. Public-private partnerships are important to reducing costs and increasing efficiency, he said. “Government is a leverage, and that’s how I see Medicaid, as a leverage, not as the only source.”
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Day 2 of Tribune Fest, first up in Health and Human Services is Governance and Healthcare: Who Decides? Moderated by Emily Ramshaw and featuring:
Leo Linbeck III, president and CEO of Aquinas Companies and vice chairman of the Health Care Compact Alliance, which seeks to limit federal government intervention in medical care.
Spencer Berthelsen, managing director of Kelsey-Sebold Clinic, a Houston-based medical clinic and past chairman of the Texas Medical Association's Council on Legislation.
Arlene Wohlgemuth, director of the Center for Health Care Policy at the Texas Public Policy Foundation.
Charles E. Begley, professor of management policy and community health at the University of Texas School of Public Health in Houston.
Leo Linbeck III, president and CEO of Aquinas Companies and vice chairman of the Health Care Compact Alliance, which seeks to limit federal government intervention in medical care.
Spencer Berthelsen, managing director of Kelsey-Sebold Clinic, a Houston-based medical clinic and past chairman of the Texas Medical Association's Council on Legislation.
Arlene Wohlgemuth, director of the Center for Health Care Policy at the Texas Public Policy Foundation.
Charles E. Begley, professor of management policy and community health at the University of Texas School of Public Health in Houston.
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Ramshaw starts us off: “We’ve got some pretty different opinions on this panel…How much healthcare should be personal, how much should be governed on the state and federal level?
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Berthelsen said budgetary concerns must be taken into account, but in the past we’ve been able to pay for government healthcare programs. “We know that our insured model is becoming increasingly strained so we need to bring other decision makers into the process.”
Linbeck: “I run a single-payer system in my family, I being the single-payer, and I know at some point that breaks down,” noting that his four-year old daughter can't be trusted to make decisions. But on the other extreme, he said, federal decision-making of healthcare reform is not better. “The direction it's going is wrong and it needs to go the other way.”
Linbeck: “I run a single-payer system in my family, I being the single-payer, and I know at some point that breaks down,” noting that his four-year old daughter can't be trusted to make decisions. But on the other extreme, he said, federal decision-making of healthcare reform is not better. “The direction it's going is wrong and it needs to go the other way.”
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Wohlgemuth: “We are a free-market think tank,” on the side of moving back towards a individual-driven free market system. As payors, only the government and private industries are currently engaged in the process, she said. “It’s broken that relationship between consumer and provider.” Government needs to let states be the innovators, so individuals have more input on the local level. “Let Texans be a part of that process.”
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Begley: “It should be left to the individual unless there are lots of problems with the free-market system.” In terms of the policy outcome of addressing the uninsurance problem, the Affordable Care Act “has significance potential.”
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“No one wants to have people dying in the street, so there’s going to be a subsidy of some kind,” said Wohlgemuth, but the current healthcare programs do not allow people to have control over decisions about their healthcare.
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Linbeck said communities need to be motivated to solve the healthcare problem and the power to make decisions at the local level. “The disempowering of communities…is the biggest problem when we start to centralize power in Washington.”
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Berthelsen: “What we have is an efficiency and maldistribution problem. We’re not getting our bang for our buck.” The answer is finding innovative ways to control costs and coordinate better between healthcare providers, he said. Other countries, for example, use price controls to maintain lower costs. And creating Accountable Care Organizations could help doctors coordinate care better, he said.
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Concerning current policy proposals, such as the Affordable Care Act and federal waivers to transform Medicaid, Begley said, “both of those are big access improvement oriented strategies.” He said he is concerned that the discussion is not about efficiency, “how we’re going to do those payment reforms and move away from fee-for-service.” Healthcare providers are excited to receive enhanced funding to improve access to care, he said, but there are not enough incentives in these policies to encourage providers to increase efficiency in the services already provided.
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Linbeck credits President Obama for taking on the healthcare problem, which needs reform, but he said concentrating power in “massive federal bureaucracy” is not the answer. A construction worker trying to raise a family on $15 an hour shouldn’t have to give their money “to the federal government to turn around and pay for my dad’s healthcare, that is unjust on the face of it,” he said.
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Begley said if you do the math, it really would be a challenge on the local level, even on the state level, to address the problem of the uninsured without the financial help of the federal government. In “Harris County, we don’t have enough funding to provide minimal coverage…for 3.5 million people…it’s going to have to be the federal-state-local partnerships…to solve this problem.”
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Audience applauses Ramshaw's summary of the panelists' debate: 'I guess the question is how much do you trust Texas?'
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“We don’t have enough money in the system the way we’re operating today,” said Berthelsen, but we would have enough money if the system was operated more efficiently. The Affordable Care Act in the long run will be beneficial for the country, he said, because the country will have to confront the healthcare problem. “We have something that’s rolling downhill and we have to deal with it or it’s going to roll over us,” he said. The program will need to be modified over time, he said, and “it may not be until we hit 4.0 that we’ll be happy with it.”
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“There’s too much diversity for one-size fits all anything,” said Wohlgemuth, emphasizing the need for a local component.
Begley responds: “One of the things that I like about ACOs is it would be a mechanism for getting healthcare providers to share information.” (ACO = Accountable Care Organization.) “You’d have a degree of centralization,” he said, which would allow healthcare providers to compare the regional costs of healthcare. It would be easier to identify efficient providers, and how to implement those savings in regions with more expensive care, he said.
Begley responds: “One of the things that I like about ACOs is it would be a mechanism for getting healthcare providers to share information.” (ACO = Accountable Care Organization.) “You’d have a degree of centralization,” he said, which would allow healthcare providers to compare the regional costs of healthcare. It would be easier to identify efficient providers, and how to implement those savings in regions with more expensive care, he said.
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Wohlgemuth, a proponent of a free-market plan, says the Affordable Care Act is only predicted to reduce the number of uninsured by 38 percent, so “we’re still going to have a huge number of uninsured in Texas.”
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Audience member asks, how are state mandates any different from federal mandates? “Until we start to cut some of those strings in our own state, we’re immobilized waiting on Washington to let us have our money back.”
Linbeck responds: “It’s a long journey to try to devolve power back to the people…it’s not going to happen overnight.” It is wrongly presumed now that federal government should make these decisions, he said.
Linbeck responds: “It’s a long journey to try to devolve power back to the people…it’s not going to happen overnight.” It is wrongly presumed now that federal government should make these decisions, he said.
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Question: Where do you come down on the debate of whether mandating the HPV vaccine was good or bad?
Berthelsen: “I believe vaccination is the single best paradigm for prevention of disease…I’m in favor of having vaccines used to their maximum extent in a population.”
Linbeck: “A terrible abuse of power…hate to kick the guy when he’s down,” referencing Gov. Rick Perry’s current status in the presidential campaign. The question should be solved county-by-county, he said. “Let them debate it, weigh the pros and cons.”
Wohlgemuth: “Generally speaking, we’re opposed to mandating.” Vaccinating for HPV is beneficial, she said, “it is the mandate that is the problem.” The flu-shot is also beneficial, she said, but people should choose whether it is in their self-interest to get one.
Begley: The HPV vaccine is extremely cost-effective as a preventative measure, "but it is very controversial, because of the opposition to mandates.”
Berthelsen: “I believe vaccination is the single best paradigm for prevention of disease…I’m in favor of having vaccines used to their maximum extent in a population.”
Linbeck: “A terrible abuse of power…hate to kick the guy when he’s down,” referencing Gov. Rick Perry’s current status in the presidential campaign. The question should be solved county-by-county, he said. “Let them debate it, weigh the pros and cons.”
Wohlgemuth: “Generally speaking, we’re opposed to mandating.” Vaccinating for HPV is beneficial, she said, “it is the mandate that is the problem.” The flu-shot is also beneficial, she said, but people should choose whether it is in their self-interest to get one.
Begley: The HPV vaccine is extremely cost-effective as a preventative measure, "but it is very controversial, because of the opposition to mandates.”
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Up Next – Now What? Health Care After the 82nd Legislative Session
Moderated by Paul Burka, senior executive editor of Texas Monthly and featuring:
Anne Dunkelberg, associate director at the Center of Public Policy Priorities.
Rep. John Zerwas, R-Simonton, chairman of the Health and Human Services subcommittee.
Rep. Garnet Coleman, D-Houston, senior member of the House Public Health Committee.
Dianne White Delisi, former state representative, R-Temple, and senior policy adviser for Delisi Communities.
Moderated by Paul Burka, senior executive editor of Texas Monthly and featuring:
Anne Dunkelberg, associate director at the Center of Public Policy Priorities.
Rep. John Zerwas, R-Simonton, chairman of the Health and Human Services subcommittee.
Rep. Garnet Coleman, D-Houston, senior member of the House Public Health Committee.
Dianne White Delisi, former state representative, R-Temple, and senior policy adviser for Delisi Communities.
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Anne Dunkelberg starts the panel off. "One thing all of us agree on is the notion that there are reforms needed... to get costs under control."
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Dunkelberg says a lot of moderates from both sides of the aisle want to create a financing system, but that can't be done unless everyone has a ticket to ride. Texas can't ever do a decent job of reforming delivery and payment systems "unless we have almost everybody in the boat." She says Texas has a horrible record of that.
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Dunkelberg says the politics of the last legislative session meant Texas didn't take any major legislative steps toward preparing the state to implement federal health reform in 2014. "The polarized politics of the day tend to pull the dialogue away from thoughtful consideration of public policy... and into these ideological extremes."
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She says the media is tempted to follow politics and policy like football, or combat. Not by creating a space "for thoughtful development of public policy."
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Rep. Garnet Coleman, D-Houston, up next. "The Legislature this session endeavored to do the best they could with a really, really bad situation, where you had $27 billion short" in the budget, and the "word of the day is no new taxes. Not just no new taxes...but no increase in current taxes."
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Coleman says budget math is very troubling, because big cuts have accumulated, and the cuts are going to be bigger than those written in the budget.
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Coleman: "If we have to have bad policy to take care of business because we can't spend more money... I think that's a problem."
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Dianne Delisi up next: Talking about how people on the House floor will sometimes yell "WORK." "As arduous as this legislative session was... our hardest task is ahead of us." She said she thinks two "watershed moments" — the first was the passage of the Affordable Care Act, the second is the debt ceiling debate, and the appointment of 12 people to reach an agreement — have moved the debate.
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Delisi: Value for dollars, best practices, and outcomes are the same three issues in both health care and education.
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Delisi: "Because of the bills Texas still has to pay for Medicaid and for the Foundation School Program, we are going to see a serious movement toward outcome budgeting."
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Dr. Zerwas up next: He says no fireworks out of this panel, because they're friends, work together closely. He recalls that he and Coleman got rowdy during the session on the health care compact debate.
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Zerwas: What would happen if Medicaid disappeared? "What if the federal government kept racheting back the money?" "What happens if Texas has to pick up an ever-increasing amount of that?"
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On who qualifies for care: "We do have to have people get skin in the game," Zerwas said. "Everybody can pay some amount of money for their health care."
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Question from the audience about low-cost insurance options.
Zerwas: "When people have skin in the game... a health savings account... people are more discretionary buyers."
Zerwas: "When people have skin in the game... a health savings account... people are more discretionary buyers."
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Dunkelberg: Says she supports everyone having some skin in the game, but the amount of skin is very variable, especially when you're dealing with someone living on a $690/month social security check.
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Dunkelberg: "I think one of the reasons, if you sense a little bit of irritation from me, it's almost become... a political red herring. I don't think there's an opposition to having skin in the game. It's, if you're willing to put skin in the game, will you be taken care of."
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James Rohack, former AMA president, says local governments are willing to raise taxes for football stadiums, but not asked to do it for health care. He's also asking about end of life care.
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Delisi asks in the audience if people have plans for end-of-life care. About two-thirds raise their hands.
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Delisi said at the end of life, 'everything within their power, everything within the power of technology, has been used, and has reached a point where additional care to this person becomes inhumane."
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Delisi; "These end of life issues are not about the disability community. They're about someone who is terminal who cannot improve under any situation, and that further care is actually harming them."
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Up Next – Is Patient Privacy Possible in the Electronic Age?
Moderated by Sherri Greenberg, interim director of the Center for Politics and Governance at the LBJ School of Public Affairs and featuring: J. James Rohack, the former president of the American Medical Association, Nora Belcher, the executive director of Texas e-Health Alliance, Michael Stearns, President and CEO of e-MDs, and Deborah Peel, founder and chair of Patient Privacy Rights.
Moderated by Sherri Greenberg, interim director of the Center for Politics and Governance at the LBJ School of Public Affairs and featuring: J. James Rohack, the former president of the American Medical Association, Nora Belcher, the executive director of Texas e-Health Alliance, Michael Stearns, President and CEO of e-MDs, and Deborah Peel, founder and chair of Patient Privacy Rights.
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Michael Stearns says his organization is working on a process whereby you can lock sensitive info (i.e. those with HIV). The challenge is determining what's safe to block and what's NOT safe to block. It can be injurious to block certain information. It needs to be tested in a "robust environment" that includes cost, adoption rate, technology requirements, etc. "Its a very active area right now. We're at the teething stage of patient privacy."
Deborah Peel says we have no ability to control where our information flows. "It isn't flowing to the people we want it to." There are effective tech, "but we're in a dangerous space." Texas has $28 million to develop data exchanges, and it's going to happen before we have the right technology in place. The government is pushing ahead even though we have no idea how far and to how many third parties this information flows... this is very, very dangerous." People depend on not being judged to work and survive.
J. James Rohack says it's an ethical question. "Safeguarding the patients' privacy" is important, but it's not absolute. Must balance efficient delivery of care and availability of resources. The issue is can it be done in the electronic age? The answer is yes. What is the safeguard? It's the ethics, which drives the profession. Code of conduct is signed by all employees. If it's breached, they lose their job. It gives more safety to patients than the current system, in which patient records are on papers in rubber bands. Electronic records allow us to know who's been handling our records.
Nora Belcher says her constituents are very concerned about patient privacy. If consumer confidence isn't high, the system won't work. However, Texas leaders have set a high bar to protect patients. Texas approach is different because it makes everyone who comes into contact with patient health information accountable. They're regulated. There are consequences.
Deborah Peel says we have no ability to control where our information flows. "It isn't flowing to the people we want it to." There are effective tech, "but we're in a dangerous space." Texas has $28 million to develop data exchanges, and it's going to happen before we have the right technology in place. The government is pushing ahead even though we have no idea how far and to how many third parties this information flows... this is very, very dangerous." People depend on not being judged to work and survive.
J. James Rohack says it's an ethical question. "Safeguarding the patients' privacy" is important, but it's not absolute. Must balance efficient delivery of care and availability of resources. The issue is can it be done in the electronic age? The answer is yes. What is the safeguard? It's the ethics, which drives the profession. Code of conduct is signed by all employees. If it's breached, they lose their job. It gives more safety to patients than the current system, in which patient records are on papers in rubber bands. Electronic records allow us to know who's been handling our records.
Nora Belcher says her constituents are very concerned about patient privacy. If consumer confidence isn't high, the system won't work. However, Texas leaders have set a high bar to protect patients. Texas approach is different because it makes everyone who comes into contact with patient health information accountable. They're regulated. There are consequences.
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Security systems are abysmal, Deborah Peel says."Wikileaks! If the government can't protect sensitive state department information, do you think a hospital in podunk Texas is going to be able to protect your information?" The top hospitals in Texas have money and large staffs. Despite the "code of ethics," the systems don't enable doctors to protect patient information.
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Dr. Rohack says the challenge right now is that those who are paying for their health care themselves-- does that give them a different right to privacy as opposed to someone relying on the government for help? We're having this discussion because the cost of health care is high and we have an inability at the time services are provided to know exactly what's going on. An electronic health system being used at the major health facilities (such as Mayo Clinic) shows it can lead to better care at a lower cost. There is a benefit to patients to have their information aggregated to know whether they're getting the care and the medications they need.
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Belcher says breach of information is usually for purposes of identity theft. We need to crack down on that. It's a piece of the puzzle.
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Moderator Sherri Greenberg is asking panel whether electronic records will enable better care.
Rohack says there has to be trust between the patient and the doctor. The patient safety issue is the awareness of the drug interactions that are out there. Electronic records summarize medicines, possible reactions, etc. But if the trust factor isn't there, we're not going to be able to provide the care patients deserve and need.
Stearns citing VA experience. Records have helped them improve care for their patients. Getting patients immunized for pneumonia, for instance, helped to save millions.
Peel says we don't have a data map, so there's a massive difference between paper records and electronic world. With paperwork, one person handles it at a time. With e-records, you don't know how many people are accessing your information.
Rohack says there has to be trust between the patient and the doctor. The patient safety issue is the awareness of the drug interactions that are out there. Electronic records summarize medicines, possible reactions, etc. But if the trust factor isn't there, we're not going to be able to provide the care patients deserve and need.
Stearns citing VA experience. Records have helped them improve care for their patients. Getting patients immunized for pneumonia, for instance, helped to save millions.
Peel says we don't have a data map, so there's a massive difference between paper records and electronic world. With paperwork, one person handles it at a time. With e-records, you don't know how many people are accessing your information.
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Peel says insurers are selling data and that proves health records are high value data that should not be placed at risk.
Stearns says it's not a new thing. Access to those databases has been around for a long time.
Rochack says this issue is being studied.Information can be aggregated and identity information can be stripped off. That's another way to look at population health without invading privacy. "There's always been evil people out there. Always will be."
Belcher says Peel's example of using databases isn't allowed in Texas. There is regulation here. This year, the Legislature also took steps to remove the commercial value of health information.
Stearns says it's not a new thing. Access to those databases has been around for a long time.
Rochack says this issue is being studied.Information can be aggregated and identity information can be stripped off. That's another way to look at population health without invading privacy. "There's always been evil people out there. Always will be."
Belcher says Peel's example of using databases isn't allowed in Texas. There is regulation here. This year, the Legislature also took steps to remove the commercial value of health information.
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Greenberg asking panelists whether e-records will control costs and for their concluding remarks:
Dr. Stearns-- As far as cost goes, people have to invest in this or it won't take off. We need to look at privacy on a broader spectrum. It's more than health care. What privacy means for our society and within the context of health care.
Dr. Peel-- There are costs savings, but it's not totally clear or guaranteed. Saving all this data is very costly, too. Certain costs can go down and that's true, but this hasn't been fully mapped out. How do you support the cost of protecting this information? Often, it's to sell the data.
Dr. Rohack-- E-records are a tool to provide better care. Some believe it's a variant of the Internet, "a tool of Satan." But from a real standpoint, our system has shown that with appropriate safeguards, ethics and professionalism (including protecting that sacred bond between doctors and patients), we can provide better care.
Belcher-- The boundaries of social media? That's something we need to talk about as a society. She's concerned what this will do to the provider base if we DON'T help them through this transition. We won't reap any benefits if we don't support our physicians and hospitals in their efforts to transition.
Dr. Stearns-- As far as cost goes, people have to invest in this or it won't take off. We need to look at privacy on a broader spectrum. It's more than health care. What privacy means for our society and within the context of health care.
Dr. Peel-- There are costs savings, but it's not totally clear or guaranteed. Saving all this data is very costly, too. Certain costs can go down and that's true, but this hasn't been fully mapped out. How do you support the cost of protecting this information? Often, it's to sell the data.
Dr. Rohack-- E-records are a tool to provide better care. Some believe it's a variant of the Internet, "a tool of Satan." But from a real standpoint, our system has shown that with appropriate safeguards, ethics and professionalism (including protecting that sacred bond between doctors and patients), we can provide better care.
Belcher-- The boundaries of social media? That's something we need to talk about as a society. She's concerned what this will do to the provider base if we DON'T help them through this transition. We won't reap any benefits if we don't support our physicians and hospitals in their efforts to transition.
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Up Next – Winning the Next Generation: Reproductive Health in the iPhone Age
Introduction by state Rep. Donna Howard, D-Austin, and featuring Cecile Richards, president of Planned Parenthood Federation of America
Introduction by state Rep. Donna Howard, D-Austin, and featuring Cecile Richards, president of Planned Parenthood Federation of America
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State Rep. Donna Howard, D-Austin, introduced Cecile Richards, a Texas native and the daughter of former Gov. Ann Richards. Howard said the state has reduced spending on family planning services by 80 percent.
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"I think the future is on our side," Richards says. PP will play a critical role in maintaining services and building a new generation of leaders for this movement. "Women should have the right to plan their families."
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Richards: "PP medical staff across the country provide abortion care to women and we are proud to do so.."
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More than 90 percent of PP's services are preventive care, Richards said. "If the politicians in this country really wanted to do something constructive about the rate of abortion in the United States, they would be volunteering at our East Austin clinic." She said they'd be helping get women birth control and screenings, and by default preventing unplanned pregnancies.
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Richards: This year alone, PP will see 30 million people online. She said Facebook and Twitter pages for PP average 8 million visits a month.
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750,000 teenage girls get pregnant each year in the U.S., Richards says. STDs are rampant. "This generation has very real and immediate needs for health care and information." PP is developing as many state of the art tools as it can. Birth control advice, STD risks. "We are the Fandango of reproductive health care."
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Richards believes this generation is digital and demanding honest access to reproductive care.
With federal health care reform, birth control and other preventive health care will be covered with no co-pay or cost to women. Richards says there is an "unprecedented" assault against family planning underway. Nearly 300,000 women just lost access to non-abortion health care in Texas. That includes access to cancer screenings, well woman exams, etc. She was just in Waco, where PP is the only community family planning service provider for the region. Due to budget cuts, they're turning away men and women who've been relying on PP for STD testing.
Tech age represents an opportunity to change this.
With federal health care reform, birth control and other preventive health care will be covered with no co-pay or cost to women. Richards says there is an "unprecedented" assault against family planning underway. Nearly 300,000 women just lost access to non-abortion health care in Texas. That includes access to cancer screenings, well woman exams, etc. She was just in Waco, where PP is the only community family planning service provider for the region. Due to budget cuts, they're turning away men and women who've been relying on PP for STD testing.
Tech age represents an opportunity to change this.
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Richards says providing this information and access using digital platforms shows "we can decrease teen pregnancy and treat STDs." Most young people are coming to Planned Parenthood through their mobile phones. PP has responded to that demand with advanced applications that provide directions, etc.
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At one point earlier this year, Congress held the federal budget hostage because of an effort to de-fund Planned Parenthood's family planning and preventive care. Richards says House Speaker John Boehner demanded President Obama end federal funding to PP. Obama said, "It's not going to happen, John. It's not going to happen." Richards says that's why we have to have a president of the United States who cares about the health of women. She points out five Republicans in Congress voted to support PP funding.
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"We have to fight those political battles, and there are some tough ones coming," Richards says. "There's a whole new generation that's ready to take up the charge.... and they believe sexual health is a value and a right."
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During the Q&A, Richards responds to question about helping those with disabilities and cultural differences. "We have to continue to have feedback about what's working... the possibilities are endless."
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What can supporters do? Richards says local Planned Parenthood needs financial support from their communities. Register people to vote. Congress has taken focus away from jobs and targeted social issues like abortion. Voters need to know that's not the message they're sending. Social media is critical, too. 'Like' PP and post stories on their Facebook page.
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Young man at the mic is thanking Planned Parenthood for offering him health services when he was uninsured. What else aside from ideology prevents people from being informed about PP's services? Richards says social media is allowing them to take inaccuracies and misstatements, and turning them around to educate people.
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Due to legislative cuts, Richards says four Planned Parenthood health centers are closing in south Texas. (Even though they did not provide abortion services.)
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"Our job is to educate young people and voters about where people stand on these issues, regardless of party," Richards says. She hopes to have a Republican run for president someday who has the courage to stand up for women's reproductive rights. It should be a bipartisan issue.
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Man asking Cecile Richards when life begins. She responds by saying,"Women in this country have the right to birth control, even though the TX Legislature has done everything in their power to prevent them from getting it. Women have a right to decide when they want to have a child."
Another man at the mic says legislators like to say government should stay out of our lives, "and we should put that argument right back in their face."
Another man at the mic says legislators like to say government should stay out of our lives, "and we should put that argument right back in their face."
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Tanden, COO for the Center for American Progress, will give "defense of federal health reform" remarks.
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Tanden says Republicans' efforts to reform health care over time have largely mirrored Obama's federal health reform.
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Basics on ACA: Idea was to keep those happily insured covered, and set up state-based exchanges for others to shop for it. For most people, insurance would've continued to be employer-based.
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She says the insurance exchange in ACA was originally a proposal put forward by a conservative think tank.
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She says the individual mandate had a bipartisan foundation. She said Obama decided to support it because he heard from both Republicans and Democrats who thought it was the right move. "It wasn't until the end of consideration..." until governors and other officials started calling it unconstitutional.
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"Health care is different from other products." Tanden says there's no requirement that you have to get a TV, or be provided a car. There is a federal requirement that if you're facing a serious illness, you must get health care.
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She says individual mandates bring better efficiency to the system. "It's unfortunate to me that this idea that has had bipartisan roots in the past has now succumbed to political partisanship."
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The most obvious example, she said, is that Mitt Romney's health plan in Massachusetts was a model for federal health reform. "Massachusetts' health insurance system has lowered the lack of health insurance to 1 percent of the population." Costs are increasing there, she said, but not more than the national average.
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Fears that health reform legislation would bankrupt the federal government have been unfounded, Tanden says.
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Tanden: "Kids up to 26 can stay on their parents' health insurance, and that was the only group where we had insurance rates go up."
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Tanden: ACA's core promise -- that Americans won't go bankrupt because they're sick -- is still on the road to becoming reality. She says the polarization of views, the level of intensity, is receding. (Not on the campaign trail).
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Tanden: "I have the battle scars to prove it was a long partisan debate. I believe strongly as the bill is fully implemented our country will be better off for it."
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Tanden asked about public option: She says in Hillary and Obama's presidential plans, they had an option that in each of health exchanges, one option would be a public plan. "If the public plan was able to charge lower rates like Medicare... it would create a downward pressure on costs... and be a competitive pressure for insurance companies."
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Question on how she defends the bill from "socialism, death panel remarks."
Tanden acknowledges it was super-long. But she said there are so many Republican bills that are "over 1,000 words long."
Tanden acknowledges it was super-long. But she said there are so many Republican bills that are "over 1,000 words long."
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"There were various arguments within the White House about taking on every challenge that happened."
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Q: Why did they take on health care legislation over taking on, say, jobs legislation? "I've had sleepless nights wondering if we should've taken health care on..." But she reminds audience that Obama took on a stimulus bill before health care.
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Tanden: "What angered the American people about health care [reform] is... it just took too long."
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Tanden: The president and Congress should've shifted back to jobs sooner, as opposed to sticking it out with health care reform.
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Tanden said now that she's out of the administration she can say this: "It was a fundamental error to give so much oxygen to Congress."
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