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House Health Care Reform met on March 30 to discuss the following bills: HB 2873 (Howard), CSHB 3317 (Frank), HB 700 (Oliverson), and HB 1575 (Hull). HB 1692 (Frank et al.) was on the agenda but was not discussed by request of the author. Part one of the hearing can be found here and part two can be found here.

This report is intended to give you an overview and highlight the various topics taken up. It is not a verbatim transcript of the discussions but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

Vote Outs

CSHB 25 (Talarico) 7-0

CSHB 711 (Frank) 7-0

HB 999 (Price) 7-0

HB 2180 (Harris) 6-1

CSHB 2556 (Oliverson) 7-0

 

Today’s Agenda

HB 2873 (Howard) Relating to a strategic plan for improving maternal health, including the consolidation and repeal of certain planning and reporting requirements.

  • Howard – Bill laid out, really is a simple bill; consolidates number of reports into one report

 

HB 2873 left pending

 

CSHB 3317 (Frank) Relating to the operation and financing of the federally qualified health center primary care access program to provide primary care access to persons in this state.

  • Frank – Puts two different entities/models to improve access to healthcare primary care and FQHC; is not insurance, but many are lacking necessary primary care

 

Jana Eubank, ED Texas Association of Community Health Centers – For

  • 1 out of every 4 working-age Texans are uninsured for a variety of reasons
  • Uninsured adults to do typically show up for preventative care or wait to receive care on acute issues; is linked to workforce absentee issues and expensive uncompensated care
  • Pilot program would be for uninsured working adults working at small businesses to receive primary care through primary care and FQHC
  • Would be a monthly fee based on bundle of services
  • Howard – Similar to tri-care? State, employer, and employee making contributions
    • Correct
  • Howard – Screen for those who could get subsidies/Medicaid and this is for those who do not qualify for either of these?
    • Correct; focuses on the working poor who are not in that coverage gap
    • Believe this would get people to show up more for primary/preventative care
  • Morales – If we expanded Medicaid would it have any effect reducing premium for these folks?
    • Is possible; this is about people who would not qualify
    • Are supportive of Medicaid expansion, just is not related to this
  • Harless – How many people did community care see last year?
    • 7m of all different ages
  • Frank – 1 in 4 working do not have insurance?
    • Is about working-age
  • Walle – Are not reinventing the wheel with this?
    • Correct – advocate this be housed at TDI as they are familiar with this
  • Walle – Bill is not prescriptive on the cost of the package?
    • Are not as there are a range of services to be determined
  • Walle – Asks about FQHCs and the pilot program
    • Would work closely with the businesses to see who would want to participate
  • Walle – Have invested in this; what is the normal cost for the average person who does not have insurance?
    • If they are insured, we bill insurance; if uninsured use a sliding fee scale based on income level
    • Every board at FQHCs determine what that sliding scale looks like

 

Frank, in closing

  • Left it open-ended for FQHCs and since it is a pilot program

 

HB 3317 left pending

 

HB 700 (Oliverson) Relating to creation of the Texas Health Insurance Exchange.

  • Oliverson – Deals with a section of ACA federal code every state can create their own health care exchange; 20 other states have done this
  • Know how to do this efficiently and how to avoid mistakes done in the past
  • ACA is here to stay; Texas has second highest enrollment in the ACA with 2.4m enrolled; first is Florida
  • Exchange is currently working well in the state; many Texans find meaningful care through this
  • Way ACA is structured, whoever runs the exchange runs the entire care design
  • Will have greater flexibility, innovation, and competition within the exchange
  • Are significant savings to be made running our own exchange; some states have used these to provide additional benefits/services
  • Propose we look to the one group who are having the hardest time finding healthcare are small businesses less than 100 employees
  • Employers would have additional state support
  • This is not a new concept, like ICHRA in the Trump Administration
  • Is the single biggest thing we could do to drive costs down
  • This is about Medicaid expansion; would not allow for Medicaid expansion
  • Howard – What flexibilities are you thinking about?
    • Witnesses could speak more to that
    • Is a lot of innovation with the gig economy; health insurance under ACA and Medicaid/Medicare is 20th century thinking
    • Could be simple as changing paperwork requirements to doing something electronically
    • Innovation does not mean lessening coverage; coverage options are set by the ACA
  • Walle – Actuarial analysis on transitioning to our own exchange?
    • Nothing needs to be invented; has been done many times; have people to speak to that
    • Some states have done it well and others have not
    • If this bill were to pass, would be a multi-year process; no one would be enrolled until about late 2025
    • Requires notification with the federal government and an agency-to-agency handoff
  • Walle – Notes the state did not initially step in to make their own exchange; millions are getting a benefit currently and concerned about upending something that is working well
    • Have commitment that is not the direction we intend to go
    • Are concerns to work through, but increase in enrollment due to this bill will have a positive effect by enhancing the risk pool and bringing cost down

 

Cheryl Gardner, States Work and Self – For

  • Are a non-profit facilitating state-led market-based HC reform
  • Have worked with Arkansas, Utah, and Deloitte, among others
  • Under ACA all states must provide access/pay for operation of exchange
  • Cost for using the federal exchange has increased
  • User fee previously $126m this year $436m; pay more for federal exchange than anyone else besides Florida; California pays less for their state exchange
  • Private sector technology to power state exchange is getting better/cheaper
  • 1m have transitioned from federal exchanges to state exchanges
  • Savings to Texas would be immense between $140-$200m a year; with extra funds could have a subsidy for lower-income uninsured, risk-adjustment, decision support, etc.
  • Oliverson – Speak to your experience on the transition from federal to state
    • Would take 18-24 months and federal law says stakeholders need to be involved
    • Are best practices
  • Howard – What would this cost?
    • $230m to $290m includes technology, outreach; includes in my estimate three times what the federal government spends on outreach
  • Howard – Would cost more than the savings?
    • Are decisions that drive those costs; $140-$200m is net savings
  • Howard – Would be a quasi-state agency?
    • Are different models for this; Pennsylvania’s model gives stakeholders most comfort
    • Is half connected to agency and other half not for profit; not run by the state agency
  • Walle – Asks about savings; how will that translate to customers
    • Are paying for decade old tech and contracts structured several years ago
    • Are currently subsidizing exchanges in less populous states
  • Walle – Is not about limiting types of services?
    • Correct – 10 categories of coverage you have to have; could add condition-specific plans
    • Federal exchange does not do this as they are trying to serve 25/26 states
  • Frank – Who are the stakeholders getting together to decide
    • Carriers, brokers, advocates who represent particular populations
  • Frank – Some states went back to the federal government
    • Kentucky did, but eventually went back to their state exchange; a couple states were not successful
  • Morales – Have you consulted anyone as big as the size of Texas?
    • Have consulted with Georgia who has a significant ACA population
  • Morales – Realized savings to the state in Georgia?
    • Are scheduled to launch this fall; see significant savings in their budget
  • Morales – How many employees/small businesses would qualify?
    • Can get that to you
  • Morales – Federal exit fee?
    • No
  • Morales – No time limit to notify the federal government?
    • Ask for a declaration letter; is generally 20 months in advance
  • Morales – Asks about cost/model
    • All systems out there are scalable; will may more than those with fewer population
    • Per enrollee costs between $90-$140
  • Morales – What state agency would be in charge?
    • Medicaid department and TDI, but would sit outside of state government
    • Outside of state government typically has a greater amount of savings; is a bid out even within the government
  • Morales – How did you estimate savings for state?
    • Looked at three most recently transitions; estimated cost scaled to Texas
  • Morales – 1m off the federal exchange?
    • Are those than transitioned to a federal exchange to a state exchange
  • Morales – If we had more people enrolled, could spread out costs?
    • Violates federal law to charge a fee just to those on the exchange, gets charged to carriers
  • Morales – What is the issue with expanding Medicaid?
    • Is completely separate; Idaho expanded, Georgia has not
  • Howard – Of the states that have done their own exchange, how many have expanded Medicaid?
    • Most of them have; only overlap is moving people off of commercial coverage and on to state Medicaid roles
  • Howard – Not subject to state purchasing requirements? Typically want these requirements
    • Is a best practice as state procurement takes a long time
    • Oversight by the board appointed by governor’s office and state legislature
  • Howard – Bill says speaker of the house makes suggestions while governor and lt. governor make appointments?
    • Oliverson – Will speak with you on that

 

Randy Pate, State Works and Self – Neutral

  • Previously worked under CMS during the Trump Administration
  • States who have moved to their own exchanges are from both political parties; are just a technology platform
  • States need flexibility and to forge their own paths tailored to their own people
  • Approved 7 states to establish their own exchanges; provided them with new technical resources and expertise
  • Should establish their own state exchange for cost savings/efficiency/to cover more people
  • Frank – Assuming we can do this with cooperation with HHSC for less than the federal fee
  • Frank – What control over our decision making will we actually have; seems like no matter what are still paying extra due to federal rules
    • Does not solve every problem in the insurance market, but key flexibilities include how plans are displayed as federal gov is pushing standardized health plans
    • Would control user fee, open enrollment period, special enrollment period, network adequacy
  • Frank – Is your organization a potential vendor?
    • No
  • Morales – Net savings of $250m are annual?
    • Yes

 

Heather Korbulic, Get Insured – For

  • Software vendor for state-based exchange; worked with Nevada during their exchange transition
  • Have successfully transitioned nearly 1m people onto state platforms and support 3m enrollees
  • Have worked with Pennsylvania, New Jersey, Nevada, Minnesota, Washington, Virginia, and Georgia, California, among others
  • Have received positive feedback from enrollees on state exchanges
  • Savings are significant and can be used by at the state’s discretion; opportunity to drive down costs
  • Price – What were the most significant savings realized?
    • Nevada saved 50% of what we were spending on healthcare.gov; dollars kept in state for employees/vendors
  • Howard – California’s savings? Would like to see specifics on this
    • Were able to leverage size of state to drive scalable technology less expensive and found efficiencies with call center costs
    • Use a lot of money they would otherwise use to drive state innovation
  • Morales – Estimate of how many employees we would have to hire for us?
    • Depends on what the state prioritizes; Nevada ran the leanest exchange in the country
  • Morales – Confident Texas would see similar savings like 50%?
    • Have 100% successful rate of applications transitioned into our platform
    • Georgia will see a 50% savings rate
  • Morales – Think Texas would see similar savings even though our population is larger
    • Yes

 

Annie Spilman, National Federation of Independent Businesses – For

  • Support this bill as many small businesses cannot currently afford health insurance
  • Oliverson – Small businesses cannot keep employees because of this?
    • Yes; only so much small businesses can handle

 

Stacey Pogue, Every Texan – Against

  • Concerned this will disrupt those who are currently enrolled in the program; coverage is currently affordable and is crucial
  • Under the bill this is not anchored in clearly defined coverage goals among other concerns
  • Federal waiver section is untested by other states that could restructure coverage/subsidies and would be a big change
  • Frank – What concerns do you have specifically
    • Policy goals are not clear in the bill which includes flexibilities
  • Frank – Of 2.4m average amount they pay is what?
    • 60% pay $10 or less per month
  • Frank – Why are there people not taking advantage of the subsidies?
    • Lack of awareness of the subsidies
  • Oliverson – Your organization has supported ACA over other things previously, why not this bill?
    • Supportive of its goals, but language in bill is broad
  • Oliverson – If new market entrants want to start, want to give them flexibility
    • Bill as filed is skeletal; needs guardrails and clarity
  • Howard – Have
  • Oliverson – Share some of these concerns Howard is talking about
  • Oliverson – State versus the federal government on coverage mandates is 3 to 1
    • Makes sense as state coverage mandates are more granular than federal mandates

 

Charles Miller, Texas 2036 – Neutral

  • State based exchange is a concept that has a lot of potential
  • Thanks for the work on legislation that had a great impact on Texas’ rate review
  • Have heard frustrations of lack of awareness to subsidies; are branding issues with the ACA
  • Heard feedback from the 1332 wavier; could see potential benefits like makings sure website is easier to operate and stop spam calling
  • In order for an exchange to do these things need direction, mission and objectives in the bill like making enrollment easier, specialize outreach, etc.
  • Harless – Asks about concerns
    • Less concerned about the technical feasibility, recommend specific goals added to bill
  • Frank – Enhanced direct enrollment?
    • Broker service or third-party website to do this enrollment; is easier and more consumer friendly

 

Adrienne Lloyd, Children’s Defense Fund – Against

  • Why would the state begin this undertaking when there is such financial risk and potential cost
  • The only way we are going to reach those who are uninsured is to expand Medicaid
  • Would bring in $10b in federal tax dollars we send away every year

 

Robert Miller, Government Solutions Softheon – For

  • Speaks in favor of the bill; will enable small business to afford and choose coverage to meet their employee’s needs; can be a tool to retain employees
  • ICHRAs should be considered as a part of the state exchange
  • Oliverson – Company is one of the entities that sets up and runs these exchanges; how much business do you do in other states
    • Work with Massachusetts and Connecticut on the health plan side
  • Oliverson – Communicating with federal government, state, insurance, and consumer; software is already ready to go?
    • Correct; vendors have configurations based on policy
  • Oliverson – Only company in the marketplace? Is a robust industry
    • Are many; market has matured since 2013
  • Oliverson and Miller discuss changes that could be made to the user experience
  • Howard – Written testimony says it costs $292m a year; and then would result $143.8m after implementation?
    • Some states have pushed fees back to when they start taking user fees; will get that information your way

 

Blake Hudson, Texas Association of Health Plans – Neutral

  • Want to make sure we do not go backwards; only had 8 plans operating in the state previously and now have 15
  • Have worked to improve competition in this market
  • Are 28 counties with no insurer when not long ago we had 100
  • Are neutral, will need to write rules for TDI to enforce the ACA
  • Frank – What has caused the huge increase? That is a part of the conversation we have not talked about
    • Frank and Hudson discuss increased subsidies
  • Oliverson – Want to work with you on this; thoughts section in bill where board of directors will be two members from the health insurance industry as voting board members
    • Way its written allows those formerly in the industry; would want someone who is currently in it
  • Oliverson – Wanted to make sure industry has a seat at the table
  • Walle – ACA market rules Texas does not enforce
    • Those bills have not passed in previous section
  • Frank – Data you provided is on individual market not grouped?

 

Shannon Maroney, National Association of Insurance – For

  • Formerly Texas Association of Health Underwriters; support this bill
  • Is a national narrowing of plans; believe bill as drafted has clear goals
  • Currently only 1.1k are enrolled in 3-share

 

Jennifer Webb, Self – Against

  • Health insurance agent in Plano
  • Support bill, but this needs to happen in in 2026-2027
  • ICHRA’s do not work in Texas and SHERPA fees do not get paid by the consumer
  • State should not rush this implementation; cannot do this by 1-1-2025
  • Needs to be quasi-state agency in charge; cannot have TDI or HHS doing this

 

Oliverson, in closing

  • This is not a small bill; recognize this is a big project and addresses problems of affordability with small businesses
  • Are working with a broad stakeholder group to ensure we do not mess this up
  • This will be a slow process to set up and want to ensure this is done right
  • Every additional person added to the risk pool is a benefit
  • Howard – Fiscal note on this?
    • Is a rider in the budget for the component that has to be paid up front; a result of the required actuarial analysis for CMS; less than a couple million
    • Other part will be paid for as a part of the user fee
  • Howard – User fees can be collected before the program begins?
    • Have heard people say that, cannot say for sure
    • Been told this study cost is really the only upfront the state has to pay

 

HB 700 left pending

 

HB 1692 (Frank et al.) Relating to facility fees charged by certain health care providers; providing an administrative penalty.

  • Chair Harless – Will not be hearing this bill today at the author’s request

 

HB 1575 (Hull) Relating to improving health outcomes for certain recipients and enrollees under certain state health benefits programs, through improved program administration.

  • Hull – Low-income pregnant women face many challenges to address basic needs which can result in medical issues
  • Bill addresses these issues through screenings in Medicaid Managed Care; case managers will then to better connect them with existing local resources
  • HHSC develop a set of standardized questions concerning nutrition, housing, and transportation
  • Is an important step of aggregating this kind of information
  • A2A providers only included for the purposes of this kind of screening
  • MCO can handle or refer to existing CPW program; can provide services if gone through provider training
  • Gives plans ability to bring on additional providers to help pregnant women with non-medical services
  • Addresses nursing/provider shortage and is done with the women’s informed consent; can with
  • Allows Doulas to be a regular Medicaid provider type as long as they have a national certification approved by HHSC
  • In FY 21 high risk pregnancies under Medicaid cost the state $776m; 3-24%
  • Fiscal note is $4m based on IT costs and reporting alternatives to abortion
  • Howard – Bill is well thought out and needed
  • Howard – Why were the two chosen to do the screening? Want to make sure we are inclusive of non-Medicaid women’s healthcare services
    • Are already doing screenings within the MCOs and alternatives to abortion providers
    • Would be happy to talk about that
  • Howard – Data will be protected?
    • Yes; have put guardrails to ensure she knows what she is consenting to and at any point she can revoke her consent

 

Tiffany Inglis, Elevance Health – For

  • Maternal mortality rates have risen to 1.2k women last year
  • Medical drivers of health are so important, but so are non-medical drivers of health
  • Study notes addressing these non-medical drivers of health result in 52% reduction in c-sections and reduction in postpartum depression and lower in-patient and ER admissions
  • Most doulas are limited to those who can afford them, can increase access to them
  • Frank – Of 1.2k what are the top three causes?
    • Non-black women is suicide/overdose for black women is cardiovascular causes of death
  • Frank – Look at family living situation?
    • Is a social vulnerability factor; think about distance to delivery hospital, housing security, English as same language, safe/supportive home
    • Majority of Medicaid moms are single and non-married
  • Frank – We do not talk about them living alone, do not know why not?
    • Do not think we can impact that; is more about educating people and having support structures for people
  • Howard – In our study leading causes for our maternal morbidity and mortality obstetric hemorrhage followed by mental health conditions, violence, etc.
  • Walle – Bill is reimbursements for doula services using existing programs like Medicaid
    • Correct; doula services are non-medical and done in partnership with doctors
  • Walle – Supportive of expanding services to pregnant women; especially in educating what doulas actually do
    • Doulas can improve outcomes for all pregnant groups

 

Yajaira Ruiz, Bexar County Health Collaborative – For

  • Have worked with women in many assistance programs; research shows women who participate in these community health programs are more likely to have health birth outcomes
  • Program in another state received a 236% ROI for related programs
  • Walle and Ruiz discuss community health worker training requirements
  • Walle – How are you funded?
    • Are a non-profit

 

Manuel Prado, Libre Initiative – For

  • Did not testify

 

Heather Allison, Fund Texas Choice – Against

  • Speaks against the bill
  • Support the goal of the bill, but do not want anti-abortion centers asking/collecting data with no oversight of guardrails to protect their information

 

Stephanie Stephens, HHSC – Resource

  • Howard – Why are Medicaid and HUA programs specifically listed? Want to word to be inclusive of all possible helpful programs so I can discuss this with the author
    • Agency can look into if there are other programs that would be suited
  • Howard – Information being collected is private and cannot be used to identify individuals?
    • Yes, is protected health information

 

Hull, in closing

  • This is specific to non-clinical; does not apply to medical information
  • Want to standardize A2A’s reporting and aggregate information
  • Any training a community health worker has to do, this bill is about additional training concerning informed consent
  • Case management providers reimbursed by MCOs

 

HB 1575 left pending