Former Texas Medicaid Director Stephanie Muth led a panel discussion at the 2022 North Texas Reform State Health Policy Conference on Wednesday that focused on the impacts that changes pending federal policy will have on Texas Medicaid. Federal Public Health Emergency (PHE) funding and the state’s incentive payment program for delivery system reforms are set to expire soon.
According to the panel, Texas could opt out of up to 2 million people from Medicaid coverage at the end of PHE when the continued coverage provisions end. The discussion affirmed that collaboration and innovation would be needed to close the gaps in health coverage caused by the end of PES.
The Legislature has resisted Medicaid expansion in recent sessions despite data suggesting it would qualify as a supplement 1.7 million inhabitants with income below the Medicaid poverty line. Texas currently has the highest rate of uninsured people in the country.
Tapley said Foremost Family Health Centers, a network of Federally Qualified Health Centers (FQHCs) that serve both Medicaid and uninsured patients in low-income Dallas County communities, would be preparing for the end of the PHE by continuing to conduct their operations to the highest of standards.
“We would see anyone walking through the doors, regardless of their ability to pay,” Tapley said. “But I believe one of the ways we have to prepare is to continue to run the organization in the most compliant way, with the most comprehensive types of services, with the best people. [and] better positions and expanding our source of income primarily through insurance plans… Whenever that day comes when the pandemic is no longer designated as such, there are people who are out there right now who don’t receive no treatment.
The panel also highlighted the tension between state and federal officials over 2021 cancelation and this year’s approval of the Medicaid 1115 waiver. The current 1115 waiverwhich provides federal authority and funding for state Medicaid managed care programs, was approved as a 10-year extension of the previous waiver by the Trump administration in 2020. Some of the tensions involved the lack of Medicaid Financial Accountability Regulations (MFAR) in the waived waiver.
CMS designed the MFAR rules to make changes to how states structure provider taxes and supplemental payments in their Medicaid programs.
The non-federal portion of Medicaid funding in Texas comes from local taxes and does not go through the general appropriations bill. Muth said federal authorities are increasingly uncomfortable with the level of oversight of how the funds are used.
“Thus, while those [MFAR] the rules haven’t moved forward, I think you can expect to continue to come under scrutiny,” Muth said. “There have been promises of audits from the federal government in this area…Some federal policymakers aren’t comfortable with the number of Medicaid dollars coming out of your traditional Medicaid program. So I think we will see continued review and monitoring and some changes there. Some of them will concern transparency and fair [having] a better vision at the federal level of this source on the non-federal part.
The new waiver eliminated funding for the Delivery System Reform Incentive Payment (DSRIP) program, incentive payments to providers aimed at improving health outcomes through innovative health initiatives. The DSRIP program which aimed to reform the ACA’s delivery system will expire on November 1.
In response, the Texas Health and Human Services Commission (HHSC) has designed a series of Medicaid Supplementary and Directed Payment Programs which were endorsed by CMS earlier this year. As outlined in the new waiver, these programs are designed to direct more funding away from large hospital systems and address a range of health care issues from rural access to behavioral health.
“[The Directed Payment Program for Behavioral Health Services] provides support for a full range of services in an appropriate manner rather than direct medication prescribed by psychiatrists,” Burruss said. “I’m a big fan of necessary medications, but there are a whole range of treatments that are important for the populations we care for.
Plus unpaid care and charitable care, which is robust and relevant as opposed to [uncompensated care] for hospitals. So the waivers at all levels are moving us more and more towards the possibility of having a range of treatment programs for people. There are still gaps, but it takes us forward…I would say we are moving forward.
Metrocare Services primarily addresses mental health issues and developmental disabilities throughout Dallas County. It is also the largest provider of permanent housing assistance in Dallas.
Burruss said while the state has specific resources in place to care for people with mental health issues and developmental disabilities, there remain gaps in providing those same people with the physical health care they need. needed when problems arise.
Foremost Family Health Centers has worked closely with Parkland Health to support each other’s patients through referrals. Tapley said the lack of primary care presence in underserved communities could be addressed by expanding FQHCs in those areas. She added that health systems should target their marketing and awareness efforts to motivate people to seek primary care and see a doctor regularly.
The panel agreed that Medicaid has the potential to inspire more providers to integrate physical and behavioral health.
“A more meaningful relationship where you have a cross-information exchange, that’s how you have to do it, otherwise again, you’re wasting too much,” Burruss said of the potential vendor collaboration. “There’s not enough extra headroom for us to build across from each other and try to do it that way. So we have to work together. »
The panel also focused on labor shortages, an area of reform where members expected the next legislative session to provide additional support.
“One of the requests we always talk about [with] lawmakers is to expand the loan repayment program, so doctors who need to repay their loan [get assistance]”, Tapley said. “This [if] they are prepared to work in some of these areas, critical areas where we are located, [then] they can get a regular salary, their competitive salary and have the loans repaid. It will be a good way to attract more people not only for primary care, but also for mental health and behavioral health and nurses. Because we are [experiencing] shortage of nurses.
Burruss discussed the competitive dynamics between Texas and other states regarding the national shortage of healthcare workers.
“Don’t get me wrong, it’s a competition. We compete with all the other states and what they put into their system to attract vendors,” Burruss said. “There are very few places in the country where you can consider supplier surplus areas. So everywhere you look they are doing the same thing. We’re just trying to figure out how to persuade people to come… These gaps aren’t going to go away unless we have a workforce that can deliver the solutions.