Lieutenant Governor David Dewhurst’s sincere effort to overhaul state Medicaid to save taxpayers money and improve health care for the poor has become the best jibe of the session, mirthfully described in Capitol hallway whispers as “Dewbamacare.” That may be nothing more than a joking reference to the federal Patient Protection and Affordable Care Act, derided by conservatives as Obamacare. But political reality suggests something else: The moniker is designed to kill Dewhurst’s package. The fact that a single word can define a piece of Medicaid legislation shows what a quagmire health care is for lawmakers. Politicians who enter the swamp can see their careers die there; those who are fortunate enough to emerge victorious only do so with a fresh set of scars. But, in Texas, both conservatives and liberals can claim to be right on health care for the poor. It is a shame that a quarter of the state’s population is without health insurance and often relies on the emergency room as the primary care physician. But it is also an inescapable fact that Medicaid is breaking the bank, growing at a faster pace than state tax revenues. Care for children and shuttered nursing homes captured most of the media attention as House Republicans cut $3.8 billion out of the reimbursement rates for physicians and health care facilities. In the heartstrings versus purse-strings debate, fiscal conservatives pitted medical care for the poor against raising taxes on average family budgets in tough economic times. If the American health care system has feet of clay, Medicaid is a major part of that weak foundation. That’s because the stability of Medicaid’s affects everyone who uses the health care system or purchases health insurance. After passage of the federal health care reform law, many conservatives called for pulling Texas out of the Medicaid system. Health and Human Services Executive Commissioner Tom Suehs brought that talk to a halt in December with a report that said withdrawing from the system would pull $68 billion out of the state’s economy without relieving the state of its obligation to provide indigent health care – or let Texas taxpayers off the hook for paying for Medicaid in other states. That ended the debate immediately. Still, the cuts to Medicaid in the current budget would an impact on the Texas economy. If nursing homes close, where will you put momma even if you can afford to pay? If reimbursements are lowered for hospitals, won’t they pass the costs on to paying patients, insurance companies, and hospital district taxpayers? A state budget cut can become a hidden tax for you in the form of higher health insurance premiums. The Center for Public Policy Priorities calculated, on a county by county basis, how state payments to health care providers would change under HB 1. Bexar County, for example, would lose $298 million. Dallas County, $331 million. And Harris County, $574 million. Those are grim numbers as well. But absent of the state’s ability to pull out of Medicaid, the emphasis has shifted to reform to find cost savings. That brings us back to Dewhurst, who supports Senate Bills 7 and 8, by Senator Jane Nelson. A key component of the package would exempt doctors, pharmacists, and hospitals from state and federal anti-trust laws if they form collaboratives to improve health care outcomes and lower costs. The legislation also would push the state toward paying for healthy outcomes rather than paying a fee for individual tests and procedures. Doctors initially objected to the “health care collaboratives” because they worried that hospitals would get the upper hand in dictating medical care. After all, a physician’s oath is to the patient, not the bookkeeper. They also noted a similarity to “accountable care organizations” in the federal health care law, hence the nickname Dewbamacare, a stinging epithet for a politician looking at a run for U.S. Senate. Calling me from his car between Houston and Austin, Dewhurst explained that there are no similarities between SB 7 and SB 8 and the federal law. Dewhurst said the package uses free-market principles to allow doctors and hospitals to form their own collaboratives and decide how to run them. He said the federal law pushes them into a similar arrangement but operates under strict guidelines. “Folks like you and me ought to be interested in bills like Senate Bills 7 and 8 and other options for improving the health care of Texans and Americans while lowering the costs, because if we don’t, we’ll be drowning in a tsunami of debt,” Dewhurst said. Doctors recently signed onto the legislation after language was added to put them on an equal footing with hospitals in collaborative operations. The package now has support ranging from the liberal Center for Public Policy Priorities to the Texas Conservative Coalition. Dewhurst pushed a similar package through a unanimous Senate in 2009, but it died among the bills killed in the House fight over voter identification. Federal law and regulations handcuff states on how they can restructure Medicaid. But while some like Dewhurst want to make improvements within the current system, others are for throwing it out in favor of a new paradigm. Congressional Republicans this week captured the front pages across the country with proposals to reduce Medicaid spending by eliminating funding formulas to give the states block grants instead. State Representative Garnet Coleman (D-Houston) supports the Dewhurst package as well as the new federal health care law. Coleman told me he believes most major overhaul proposals really are an effort to cut funding and benefits in the guise of savings. Medicaid is not busting the state budget, he said; it just looks like that because the Legislature frequently under-funds it and then has to pass emergency spending bills to balance the budget. Sitting amid the glass-encased cotton bowls that celebrate Texas rural past in the Capitol’s agriculture museum, House Public Health Chair Lois Kolkhorst (R-Brenham) explained to me why she believes the future of Texas Medicaid rests with throwing the current system out and starting over to design a new one. Kolkhorst has sponsored bills to authorize an interstate health compact commission and to seek federal Medicaid block grants so Texas can subsidize health insurance purchases by the individual Medicaid clients. Her plan is similar to one proposed by the Texas Public Policy Foundation. “I, for one, thank President Obama for opening the conversation. He’s the one that has finally opened the box and said we’re going to go down this road,” Kolkhorst told me. “Then everybody said: ‘THIS IS NOT THE ROAD WE WANT TO GO DOWN!’ Okay, if you don’t want to go down that road and you fear government intrusion and a one-payer system that is unaffordable, then walk down this road to come up with solutions, because doing nothing is not the solution.” TPPF health care policy expert Arlene Wohlgemuth said conservatives need to look for alternatives to the current system because even if the national health care law is repealed, Medicaid spending would grow by about $10 billion in the 2014-15 budget cycle. “A lot of conservatives think if we just get rid of Obamacare our problems are solved. Our point is it is not solved,” Wohlgemuth told me. “Does Obamacare make it worse? Absolutely. But we’re not in a happy place without it.” Jesus said the poor shall always be with us. So too, apparently, will be the debate on how to give them health care. BY R.G. RATCLIFFE
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