FREDERICKSBURG — At a January candidate forum, the six Republican contenders for outgoing state Sen. Troy Fraser’s seat were asked how the Legislature could improve access to health care in this sprawling, rural district that reaches from Abilene to the northwest suburbs of Austin.
The first five candidates to speak — two doctors, a surgical nurse, a hospital owner, and a former city councilman — each thanked the moderator for the question before answering in detail. Then came Jon Cobb, a rancher and owner of a construction company.
“This is a little unfair,” Cobb quipped. “I’m expecting a concrete question and a cattle question next."
The scene highlighted an oddity of this race in a Republican primary cycle dominated by talk of illegal immigration and national security: four of the six candidates have ties to the health care industry.
Like Republicans across the state and much of the country, all six of the GOP candidates running for Senate District 24 have voiced opposition to President Obama’s signature health law, the Affordable Care Act. They also all support the state maintaining its opposition to expanding Medicaid coverage, despite a long-standing offer by the federal government to cover most of the extra costs for expanding coverage to more low-income Texans.
Yet some of the candidates have also embraced health policy positions that are not coming up in most other Republican primaries this year, like increasing Medicaid payments to doctors, stabilizing cash-strapped rural hospitals and improving health care access in underserved areas.
During last year's legislative session, lobbyists for primary care doctors urged lawmakers to back a nearly $1 billion budget boost aimed at paying them more for treating patients in Medicaid, the federal-state health insurance program for the poor and disabled. That funding ultimately died during negotiations with budget writers in the Senate.
At least three of the candidates — Dawn Buckingham and Brent Mayes, both doctors, and state Rep. Susan King, a surgical nurse — said they would try again to raise those payments.
Buckingham, an eye surgeon from Travis County, said she would find the money to raise payments to health care providers who see Medicaid patients by cutting funding from the Texas Health and Human Services Commission, which administers the program.
“What we need to do is significantly shrink the size of government in those areas and get more of the dollars going directly to the people who need them and to the providers providing that care,” she said.
Mayes, a retired radiologist from Fredricksburg, said he would fight the Texas Medical Association, the physician lobby group, to require health care providers to be more transparent about their pricing. That, he said, would increase competition and reduce costs.
He also voiced support for “fully funding” Medicaid payments to doctors, “if we can find money,” he said.
“I can’t imagine having a sick child that I can’t afford to take to the doctor,” Mayes told the Fredericksburg forum. “We need to take care of the least among us.”
King, an Abilene Republican who has served in the Texas House since 2007, said she opposed Medicaid expansion for fiscal reasons, “even though many of my friends who are in family practice felt like it was important.”
But she said improving Medicaid payouts to primary care doctors was “important because every day, more and more people are leaving, taking Medicaid patients because they cannot make money.”
King’s husband Austin King, a physician, is a former president of the Texas Medical Association. The association recently made a rare dual endorsement in the race, backing both King and Buckingham, who has also held leadership roles at TMA.
Even Cobb, who joked about his lack of connection to health care field, gave a detailed answer about how his plan would seek to draw down more federal funds for rural hospitals that treat poor patients by passing laws to create Local Provider Participation Funds, a mechanism to allow hospitals to be reimbursed for the uncompensated care they provide through a $29 billion funding pool known as the 1115 waiver, which is set to expire this year.
Texas is currently negotiating with the Obama administration to try to extend that pool of money, which could be in jeopardy given the state's refusal to expand Medicaid against the federal government’s wishes.
“These hospitals are faced with indigent care, and these counties are burdened,” Cobb said. “We have to help our hospitals in any way we can, so I think the Local Provider Participation Fund is a much better answer than expanding Medicaid.”
Cobb also said he supported using technology to improve access to health care in the rural district. He said 70 percent of the district lacked high-speed Internet, and that improving digital access could help connect rural patients to doctors via telemedicine.
Ryan Downton, who said he had experience operating rural hospitals as the owner of Little River Health Care, disputed the notion that local hospitals couldn't survive without Texas expanding Medicaid coverage.
“I’m tired of hearing rural hospitals can’t make it because they need more federal funds,” he said. “We can make it. We have made it.”
But he conceded that rural hospitals in Texas are "struggling" and said the Legislature "cannot decrease funding for rural hospitals."
"Doctors and hospitals lose money on Medicaid patients," he said. "We have to at least pay the amounts of those current rates."
Reed Williams, a former San Antonio city councilman, gave the shortest answer.
"No on expansion," he said. "Yes on following our obligations."
He said he wanted to “contract” the federal-state health insurance program, rather than expand it, by getting people off the Medicaid rolls.
Disclosure: The Texas Medical Association is a corporate sponsor of the Texas Tribune. A complete list of Tribune donors and sponsors can be viewed here.