Senate Health & Human Services met on March 17 to take up a number of bills. In order, this report covers SB 199 (Nelson), SB 73 (Powell), SB 672 (Buckingham), SB 809 (Kolkhorst), and SB 827 (Kolkhorst). All bills covered in this report were voted out at the end of the hearing.

This report is intended to give you an overview and highlight of the discussions on 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 from End of Hearing

  • CSSB 64 voted out 7-0, not on local due to fiscal note
  • CSSB 199 voted out 7-0 to local & uncontested
  • SB 224 voted out 7-0 to full Senate
  • SB 284 voted out 7-0 to full Senate
  • SB 383 voted out 7-0 to full Senate, amendments expected on floor
  • CSSB 672 voted out 7-0 to full Senate
  • CSSB 827 voted out 7-0 to full Senate
  • SB 863 voted out 7-0 to full Senate

Opening Comments

  • Kolkhorst – Will not be voting out any bills today with fiscal notes; will need amendments for these, there are many great health care bills that have small fiscal notes

Bills on Agenda

SB 199 (Nelson) Relating to automated external defibrillators.

  • CS laid out
  • Repeals provisions to align with current AED tech, clarifies role of physicians, updates current reqs to ensure there are no disincentives for having AEDs ready
  • Hall – Does this do anything to increase liability of businesses?
    • Nelson – No, will protect them

Justin Bragiel, Texas Hotel & Lodging Association – For

  • Modern AEDs are incredibly easy to use, guide user through the process
  • Hotel industry has high turnover, training on every aspect of operations is a challenge; SB 199 allows us to place more AEDs without fear of liabilities
  • Kolkhorst – How expensive are these?
    • Can be quite pricey, roughly $1,000 a unit
    • Nelson – Costco has them for $800

SB 199 left pending, public testimony to be taken later

SB 73 (Powell) Relating to providing access to local health departments and certain health service regional offices under Medicaid.

  • Local health departments participated extensively in 1115 waivers, but are not listed as a provider type for Medicaid purposes
  • Amends Human Resources code to create separate provider type for local health departments, health services regional offices
  • Passed committee and Senate last session, but died on calendar in the House
  • CS applies provisions to local health entities, includes public health districts
  • DSHS and HHSC have a $1 million fiscal note, exploring whether adding Nelson amendment or removing health services regional offices will eliminate fiscal note
  • Kolkhorst – Bill didn’t have fiscal note last session, my understanding is it is attached to DSHS & regional offices billing

Stephen Williams, Houston Health Department – For

  • Great work being done through 1115 waivers in the Houston area, challenges exist to receiving reimbursement; hopes that SB 73 will be first step in MCOs being more intentional in contracting with local health departments
  • Recognizing local health departments as a provider type would allow local health departments to access reimbursement, wouldn’t cost state money
  • Campbell – We are working on the fiscal note? Important bill & fiscal notes cause issues
    • Kolkhorst – Yes, Sen. Powell is looking at this, could be the DSHS regional offices
  • Kolkhorst – Can you give us info on what you do? You are not looking to become a clinic?
    • Under old practice we billed Medicaid directly for immunization, family planning, etc.
    • Asking to be paid for services provided to Medicaid patients
    • Also supporting 1115 proposals from HHSC
  • Kolkhorst – In family planning, you don’t do anything like abortions do you?
    • No

Robert Kirkpatrick, Milam County health Department – For

  • Barriers from not being a provider type are very interesting, saw increased approval timelines for clinics under Medicaid
  • Milam County lost its only hospital in 2018, health department needed to provide more services
  • Additional revenue would help augment GR funds provided by the county
  • Kolkhorst – Providing services you don’t get reimbursed for, so cost goes to local taxpayer?
    • Yes

SB 199 left pending, public testimony to be taken later

SB 672 (Buckingham) Relating to Medicaid coverage of certain collaborative care management services.

  • CS laid out, Lege Council version of the filed billed with no substantive changes
  • Allows for use of collaborative care model for mental health in Medicaid, integrates physical and mental care under coordination of primary care provider
  • Kolkhorst – This would allow primary care to put together a team to address these issues?
    • Yes, would include psychiatric professional, new version also incorporates behavioral health specialist who tracks and monitors outcomes

Andy Keller, Meadows Mental Health Policy Institute – For

  • Highlights importance of early identification and improved outcomes from tracking and monitoring behavioral health issues; associates this idea with tracking and monitoring for cardiology
  • Better mental health helps to drive down mortality and morbidity, much less expensive to address these issues early on; no fiscal note
  • CDC has shown we have tremendous increase in mental health issues due to COVID

Dr. Carol Alter, Baylor Scott & White – For

  • Have always known that these issues present early and have implications on other outcomes, but now able to pursue collaborative concepts
  • Planning to implement collaborative care model across primary care practices
  • Many are reporting increased stress due to COVID, part of why Baylor Scott & White decided to do this now
  • Over 30% of patients in program have seen depression symptoms remit, typically much lower
  • Medicaid coverage is critical, these patients have greatest mental and physical care needs, collaborative care plays critical role
  • Kolkhorst – So Baylor Scott & White have already started this model and seen good results?
    • Yes, have seen increased referrals from primary care and substantial decrease in depressive symptoms
  • Kolkhorst – So the bill would set up reimbursement?
    • Yes, addresses a gap in need for Medicaid population
  • Kolkhorst – Do we have enough mental health and behavioral health providers?
    • Reason model has been so successful is that it’s scalable, using a behavioral health care manager does the bulk of the lift and can devote time to support, psychiatrist role is supportive and need far less direct psychology and psychiatry services
    • Doesn’t put burden on mental health workforce in the same way other programs might
  • Kolkhorst – Spoke previously to a psychiatrist about difficulties and extended timeline for referral to psychiatric services

SB 672 left pending, public testimony to be taken later

SB 809 (Kolkhorst) Relating to health care provider reporting of federal money received for the coronavirus disease public health emergency.

  • CS laid out
  • Requires health care providers to report federal COVID relief on a monthly basis; purpose is to understand how these funds have flowed to providers
  • Extraordinary that many funds did not hit the state budget in any way
  • CS adds req for public health provider covers the retroactive effective timeline of the CARES Act
  • Not asking to vote this out today, trying to address concerns from stakeholders, not looking for reports on PPE, not looking to wrap in physicians, etc.

SB 809 left pending, public testimony to be taken later

SB 827 (Kolkhorst) Relating to pricing of and health benefit plan cost-sharing requirements for prescription insulin.

  • CS laid out
  • Looking at other states and prior administration’s efforts to reign in out-of-pocket cost;
  • Pro free market until it fails, when the market is not really free and is opaque
  • 16 other states have considered legislation like this
  • Purpose is to make insulin more affordable; economic toll of pandemic has left many without insulin, copay cap could & would help alleviate burdens
  • Insulin has not changed since introduction, but price has increased
  • Have a couple counterparts in the House who are anxious to receive this bill
  • Campbell – If you don’t have insulin over a long period of time, it starts affecting other organs; this also costs patients and people of Texas in the long run to treat these additional conditions

Veronica De La Garza, American Diabetes Association – For

  • Legislation capping insulin copays have passed in 14 states, under President Trump’s administration CMS announced most seniors would be able to get plans with caps
  • People with diabetes are facing a crisis, insulin prices have increased drastically while formulary for insulin has not changed; cost to produce vials is roughly $4-$6

Dr. Carol Howe, TCU – For

  • Shares experiences of patients with diabetes whose control of condition has worsened due to lack of insulin supply
  • Kolkhorst – Have costs gone up appreciably to produce insulins?
    • People are stating that 3 Pharma companies’ costs have not gone up, my understanding is that there are lots of middlemen in the way driving up the cost
  • Kolkhorst – Out of pocket expense is the issue

Melissa Denny, Self – For

  • Shares experience as mother of child with type 1 diabetes, insulin is critical to quality of life, but very expensive
  • Kolkhorst – How much have you seen cost rise for increase and has there been any change to the insulin?
    • We’ve seen cost increases, because of policies and agreements between insurance and suppliers the type used frequently changes; causes condition management problems
    • Was at $100/month initially, now doing high deductible because it would be $20k without
  • Kolkhorst – Stories and response from people all over Texas has been significant

SB 827 left pending, public testimony to be taken later

Public Testimony

John Hawkins, Texas Hospital Association – On SB 809

  • Generally support intent of the bill, want to be as transparent as possible with COVID funding
  • Timing issue on how funds are calculated in lost revenue, no final guidance from CMS and deadline has been pushed back
  • Also asking for language that HHSC rely as much as possible on data already reported to fed HHS
  • Kolkhorst – Trying to get some understanding on fund usage and next steps; don’t want double reporting
  • Kolkhorst – Highlights difficult time for hospitals during elective surgeries prohibition
    • Lost revenue piece is the most significant, this is where we need clear guidance on what is allowable and what is not

Amanda Fredriksen, AARP – For SB 809

  • Transparency is particularly important when considering the pandemic
  • Residency quality of care was a problem before the pandemic, infection control was the most frequently cited issue during the pandemic
  • Highlights funding through feds; nursing facilities had roughly $1.5 billion available, $1.2 million per facility, and facilities saw a bump in Medicaid rate, QIPP was bumped up to $1.1 billion
  • Needs to be transparency on how money is being used
  • Kolkhorst – Looking at stats, roughly 1,200 facilities; is the $1.5 billion inclusive of assisted living?
    • No, data is tracked from CMS’ website with state-by-state tables
  • Kolkhorst – Stumbled upon this, not easy to find

Dr. Vance Ginn, Texas Public Policy Foundation – For SB 809

  • Great measure to provide more transparency of COVID dollars, important to understand how dollars are being spent
  • Recommends expanding this to any pandemic and providing information online for the public

Blake Hudson, AARP – On SB 827

  • Applaud efforts to help with insulin costs, have concerns that we’re missing the root cause
  • Have given insulin manufacturers a free pass on price, capping copay continues to do this; should study cost increases, evidence points to companies choosing to raise cost continually without checks
  • Perry – So the insulin market has bypassed generic production, are you working on this at a federal level to push for generics?
    • Yes, issues like evergreening and patents
    • Also things we can do at a state level, California passed a ban on delaying generics coming to market by paying those companies

Sheila Hemphill, Texas Right to Know – For SB 827

  • Important to look into high prices for drugs like insulin
  • Highlights possibility of psychiatric conditions being due to rapid hypoglycemia, should look at root causes of juvenile psychiatric issues
  • Should also look at charges for testing strips

Dawn White, Self – For SB 827

  • Shares experience as nurse and mother of child with type 1 diabetes; initially saw charges of $500/month for insulin, prices have varied widely since
  • Have heard from many families concerning high insulin costs, much higher than production costs
  • Kolkhorst – What are families doing when they can’t afford expenses?
    • Heard from some that they had to rely on others donating their insulin
  • Kolkhorst – So many other tools needed aside from the insulin

Reva Verma, Self – For SB 827

  • Shares experience of type 1 diabetes diagnosis, constant need to monitor disease and take insulin to control; ones small business that was forced to move to low deductible plan

Bill Hammond, Texas Employers for Insurance Reform – Against SB 827

  • Uncontrolled insulin prices are unconscionable, 3 companies increasing prices year over year
  • HB 827 would affect many small businesses in Texas, would cause increased premiums for small businesses
  • Kolkhorst – There’s going to be some momentum on price increases, both Trump and Biden administration pursued this; right about the 3 companies, long term plan at work

Jason Baxter, Texas Association of Health Plans – Against SB 827

  • Appreciates highlighting need for increased access to insulin
  • Copay caps would cause premium increases for Texans, do nothing to limit what is actually charged for the drug, allow price to rise without oversight
  • Copay caps give drugs manufacturers even more power to set prices
  • Legislation should focus on populations with high out of pocket costs, incl. uninsured; should help lower price of insulin without shifting costs onto employers
  • Copay caps do nothing to address issues of manufacturer patent games and unjustified price hikes, high prices are the product of drug manufacturers taking advantage of a broken market
  • TAHP opposes mandates, esp. contract mandates, that undermine market
  • Kolkhorst – Kentucky study showed a .1% premium increase per month per member; right now we’re making people negotiate with manufacturers when they have no leverage
  • Kolkhorst – Not a PBM lover, all for transparency in health care, if we had transparency, we wouldn’t need this bill; trying to move discussion back to people who can actually negotiate
  • Kolkhorst – Nothing to justify price increases, need to correct market sometimes; if we make insulin affordable we will see less ER visits, less comorbidity
  • Perry – Working on an amendment for the generic dodgers trying to give AG some teeth; cognizant of both sides of the issue
  • Perry – I don’t know that this is the perfect solution, but these steps could raise it to the level of putting pressure on manufacturers; will get somewhere, may not be the end game, but will move conversation
  • Perry – Look forward to working with you, have heard you’re a generic dodger; will work on an amendment that works for Sen. Kolkhorst
  • Campbell – What are health care plans doing to look at lowering premiums for individuals and small businesses? Big elephant in the room is premiums, not entirely due to physician fees or medication
    • Because there is no generic equivalent of insulin it reduces ability to negotiate decent price; addressing root cause of insulin prices is the main thing we can do to reduce cost
  • Campbell – Appreciates that in relation to this bill, but also concerned in a broader context; plans have a responsibility to bring down charges, considering profits made
  • Perry – Asks for future contact on the generic avenue
  • Hall – Bothered by the greed of the pharmaceutical companies, need to balance protecting people and free markets; this isn’t the end, when companies put us in this position by restricting the market we owe it to people to step in
  • Hall – Have concern about unintended consequence that this could harm those uninsured, need to do more than this to protect people
  • Kolkhorst – There are times when you need to shake the market & Texas is big enough to move the needle; free market doesn’t exist when it’s opaque and there’s a third party payer, need to get it back into balance; not going to bring a lot of these bills to the floor, trying for a long game
  • Kolkhorst – Need to get to the bottom of why Americans pay more than others for the same drugs
  • Perry – Health care system is a long way from the free market system, we’ve seen benefits, but this is the policy challenge of allowing as much freedom as possible, but still keep people healthy

Vote Outs

  • CSSB 64 voted out 7-0, not on local due to fiscal note
  • CSSB 199 voted out 7-0 to local & uncontested
  • SB 224 voted out 7-0 to full Senate
  • SB 284 voted out 7-0 to full Senate
  • SB 383 voted out 7-0 to full Senate, amendments expected on floor
  • CSSB 672 voted out 7-0 to full Senate
  • CSSB 827 voted out 7-0 to full Senate
  • SB 863 voted out 7-0 to full Senate