This week the Texas Senate Committee on Health and Human Services, chaired by Senator Charles Schwertner, released its interim report. The report summarizing its review of key issues over the past year and provides recommendations for the next legislative session.
We were pleased to see the report address the importance of providing organizational stability and greater support for staff at CPS; continuing the legislature’s recent focus on mental health; improving access and continuity of care in women’s health program; and other priorities.
The report includes a letter from Democratic Committee members expressing concern about some Sunset recommendation on CPS, the risk of limiting access to women’s health services through future changes to those programs, and the importance of accepting Texas’ share of new Medicaid funding to close the Coverage Gap. The letter notes that a health care committee appointed by Governor Perry recently urged state leaders to develop a Texas alternative to Medicaid expansion.
We encourage you to take a look at the full report, but in the meantime, here are a few areas that caught our eye in each of the sections of the report.
Interim Charge 1: Child Protective Services
The section on CPS reviewed the recent child deaths in foster care, summarized the several reports on CPS from the last year, and reinforced the importance of strengthening CPS and foster care during the upcoming session.
In addition to the noting the importance of providing greater support to CPS staff, the Committee echoed others’ concerns that a series of changes in the agency in recent years have distracted staff from their core mission. While the report is silent on the Sunset Commission recommendation regarding consolidation of DFPS with other health and human services agencies into a single mega-agency, the Committee’s call for organizational stability at CPS appears to contradict the consolidation recommendation:
The CPS division within DFPS has undergone significant changes over the past decade, due to statutory changes as well as internally-driven initiatives and policies. This has distracted from their core mission of ensuring the safety of children and has prevented the agency from establishing a solid foundation based on sound management structure and a strategic vision.
The Committee concluded:
The importance of this mission must not be buried under an inordinate amount of policies, programs, procedures and paperwork. CPS' focus should be squarely on creating a functioning management and organizational structure, reinventing the culture of the agency, and growing and supporting the caseworkers who are on the frontlines every day. The Committee fully supports and endorses the recommendations adopted by the Sunset Advisory Commission at their August 13th, decision meeting, which aim to improve child safety and caseworker retention, and strengthen the overall management structure of the agency.
Interim Charge 2: Mental Health and Substance Abuse
The Senate Committee outlined the significance of mental health and substance abuse issues for the whole state:
All Texans have been impacted by mental illness or substance abuse to some degree -- through a personal experience, as a taxpayer who supports the county jails, state psychiatric hospitals, and hospital Emergency Rooms (ERs) that often provide treatment to those dealing with behavioral health issues, or simply as a witness to the preventable tragedies that have become all too common in recent years. Failure to recognize the importance of behavioral health prevention and treatment results in lost productivity, lower quality of life for those who suffer with behavioral health conditions and their families, and unnecessary and costly expenditures in our ERs, state hospitals, and criminal justice system.
The Committee members also made clear that they will build on last session’s mental health focus and continue to prioritize the issue during the next legislative session:
Despite the progress that has been made through this increased funding and heightened awareness and interest, there is still significant work to do to ensure a cohesive and effective behavioral health system.
One of the Committee’s recommendations is to improve coordination:
There must be greater coordination and collaboration across programs and agencies that relate to mental health or substance abuse, leadership to facilitate such coordination, and structural changes to elevate behavioral health within the broader health and human services enterprise. Additionally, the behavioral health landscape in Texas must be carefully evaluated in light of the investments made last session to determine where gaps remain and what can be improved upon.
It also called for increasing the profile of relevant programs in the state’s organizational structure:
Mental health and substance abuse programs should be elevated from their current status as a division within the Department of State Health Services to a more highly visible position within the Health and Human Services Enterprise that will ensure adequate leadership and accountability.
We were pleased to see that Committee members recommended greater emphasis on training school personnel to support students with mental health needs, although the recommendation doesn’t address the barriers teachers face in taking advantage of the current mental health first aid training opportunities. Those barriers include schools’ reluctance to hire substitute teachers so educators may attend trainings. The Committee’s recommendation, which was unfortunately the only one to address mental health prevention and early intervention, reads:
Expand Mental Health First Aid to include additional school personnel. In addition to educators, school personnel such as counselors, school nurses, teacher's aides, school bus drivers, principals, assistant principals, and school resource officers have frequent contact with students and should have the opportunity to receive Mental Health First Aid training.
Interim Charge 3: Women’s Health
The Committee called for continued efforts to improve access to women’s health care and family planning:
Moving forward, the state should focus on three areas to ensure continuity of care and expanded access:
- Outreach and education to ensure women and providers are aware of the availability of services;
- Streamlining programs to make them easier for clients and providers to navigate; and
- Expanding access to the most effective forms of contraceptives.
The report also backs consolidation of women’s health programs, an idea we believe needs to be explored further to ensure it does not disrupt services that have gone through significant changes and cuts in recent years. The Committee recommended:
Consolidate women's health programs at one state agency
The state's three major women's health programs, TWHP, EPHC and DSHS Family Planning, should all be housed at HHSC, and should be consolidated in a manner that ensures continuity of care and does not reduce access to services. Administrative elements of these programs, such as client eligibility determination, provider education, program accountability, and client outreach, should be streamlined as much as possible to make navigation of women's health programs easier for women and providers.
We were pleased to see the Committee recommend greater attention to gaps in family planning coverage:
Reduce gaps in family planning coverage
After a woman who is Medicaid-eligible delivers her child, she may only receive postpartum services, including contraception, for 60 days. In the Perinatal Children's Health Insurance Program (CHIP), a woman receives two postpartum visits, which typically do not include contraceptive coverage. Lags in coverage present the opportunity for unintended pregnancies to occur in the period after delivery of a child. This also presents an issue of not sufficiently spacing births, which can present health problems for the mother and child. HHSC should determine the how to ensure eligible women are able to enroll in women's health programs prior to losing Medicaid or CHIP Perinatal eligibility.
The Committee also called for expanding access to Long Acting Reversible Contraception (LARCs), with greater detail available in the report.
Interim Charge 4: Alternatives to the Affordable Care Act
The report outlines who is uninsured in Texas, including those in the coverage gap:
The remainder of Texas' uninsured individuals are those who fall between the state's current Medicaid eligibility level and 100% FPL, when they become eligible for subsidies to purchase private health insurance through the marketplace. There are one million Texans who fall into this coverage gap, accounting for 4.1% of the state's total population.
The report describes the health programs currently available to uninsured Texans. In doing so, however, the report highlights – perhaps inadvertently – the inadequacies of this patchwork of services. The list ranges from services that provide important but very limited services to a narrow slice of the population, such as the Women’s Health Program, and more "comprehensive” programs that still fall short of providing preventive care, ongoing care for serious conditions such as cancer, and other important services:
By the same token, being uninsured does not necessarily equate to a lack of options for receiving health care. In addition to charity care provided by thousands of Texas healthcare providers, and emergency care required by federal law, there are numerous programs and healthcare settings which provide services to the uninsured. This includes Federally Qualified Health Centers, County Indigent Programs, Local Health Departments, health-related institutions, and multiple state-funded programs at DSHS such as women's health programs and mental health and substance abuse programs.
The report says state leaders plan to continue to take an inventory of these services through the spring of next year to inform its decision on health coverage:
The state must accurately account for the programs and services listed above in order to determine where need still exists. To this end, HHSC has identified 8,166 providers who may offer reduced-cost or free healthcare services to low-income, uninsured Texans using a survey of community-based organizations, local government, and non-profit organizations. The next phase of the survey, anticipated to be completed in spring 2015, will examine how many uninsured individuals these providers serve, the range of services provided, eligibility requirements, and the cost to clients for services, including any cost-sharing requirements or other payment arrangements. The results of this survey will help the Legislature better assess where outstanding need exists and how to best address those needs.
While the report opposes an expansion of traditional Medicaid, it does not address the option of developing an alternative market-based Texas plan to use new Medicaid funding to close the coverage gap for low-wage workers. The Committee did issue the following recommendations, with greater detail provided in the report:
Texas should encourage congressional action to operate Medicaid as a block grant program and should simultaneously continue to pursue a waiver from the Centers for Medicare and Medicaid Services (CMS) to allow the state increased flexibility in the operation of our Medicaid program.
Support successful programs and entities that have local buy-in and include local funding sources.
Interim Charge 5: Temporary Assistance for Needy Families
In describing the state’s TANF program, the cash assistance program, the report underscores – again, perhaps inadvertently – the tiny size of the program. Annual spending on cash assistance is about $27 million, compared to an annual state budget of about $100 billion:
Texas received approximately $495 million in TANF Block Grant funding in Fiscal Year 2014, about $26.8 million, or 5.4%, of which was allocated for TANF cash assistance.
The Committee notes the many limitations put on the program in Texas, ultimately concluding that even more restrictions are in order:
Overall, Texas has taken advantage of the flexibilities afforded to states by PRWORA [the 1996 welfare reform law] and has designed a TANF program that is accountable to taxpayers and truly serves only the neediest families in the state who are using the program as a temporary safety net to allow them to achieve self-sufficiency. However, there are some additional steps lawmakers should consider pursuing to further improve the integrity of the program, particularly among adults in child-only cases.
We believe the legislature must ensure that any TANF policies that are pursued don't ultimately harm families and their ability to get by when hit by hard times.
Interim Charge 6: Prescription Drug Abuse
In the section on prescription drug abuse, we were pleased to see the attention placed on support for pregnant women:
Texas should seek to build upon successful programs and policies to continue to reduce abuse of prescription pain medication in Texas and increase services, education, and outreach to address the growing problem of prescription drug abuse among pregnant women.
The Committee went on to explain the importance of supporting these women:
Neonatal Abstinence Syndrome (NAS) occurs when newborns experience sudden withdrawal symptoms at birth after being exposed to prescription drugs in the womb. The incidence of NAS has increased significantly in recent years. The number of Texas babies born on the Medicaid program with NAS increased by 18% from Fiscal Year 2011 to Fiscal Year 2013. A baby born with NAS has an average inpatient hospital cost of over $31,000, compared to $12,000 for a baby born without NAS. More importantly, the symptoms of NAS such as tremors, seizures, vomiting, and hyperactive reflexes are painful and debilitating for infants and can last for up to six weeks. Longer term impacts can result from low birth weight and related developmental delays. Texas should take steps to reduce the rate of NAS in Texas by enhancing outreach and education for providers and pregnant women and targeting interventions to support pregnant women with opioid addictions.
The report does not connect the dots back to the need for expanded health coverage for women before they get pregnant, but includes the following recommendation:
Enhance services, education, and outreach to communities and providers in order to reduce the prevalence of and treat the symptoms of NAS.
Interim Charge 7: Implementation of 83rd Legislation
Finally, the report includes a review of significant health and human services legislation passed during the last legislative. It includes the following conclusion, with additional details in the report:
Overall, the implementation of these major pieces of legislation--Senate Bill 7, Senate Bill 8, House Bill 3201, and Senate Bill 149-- has gone smoothly. However, the Legislature and this Committee must continue to closely monitor ongoing implementation efforts and ensure the successful implementation of provisions that have not yet gone in to effect, particularly those that will impact vulnerable citizens, such as those with IDD and those residing in nursing facilities. There are also some additional steps that can be taken to further fulfill the legislative intent of these initiatives.