Q&A: Sen. Nathan Johnson on the session, the interim and health policy

Sen. Nathan Johnson represents the north Dallas County area. He is in his first term, having won a seat in 2018 as a Democrat that had been held for three decades by Republicans. I sat down with him following our Convening Panel meeting ahead of our 2019 North Texas State of Reform Health Policy Conference. This conversation has been edited for clarity and length.

DJ: How was your first session? What did you think of serving in the legislature?

NJ: I thought it was terrific. I’m hopeful that in addition to some of the successes we had, in addition to mitigating some of the damage that would have otherwise been done, we were able to start or advance conversations on important topics that, although we didn’t get those resolved this session, we’re on the road to getting them resolved in the next session, or even the session after. I’m really looking across a 4-year time frame and we’re in the first half of year one in the four-year time frame.


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DJ: Is the reality of the calendar such that your caucus colleagues who are up for election next year, are they already thinking about re-election, now that the session is over, and the primary is about 8 months away?

NJ: They started thinking about re-election the day after the last election. We all do to some extent. It’s unavoidable. You can’t help but be aware that the actions you take will be remembered, and if you want to want to be influential (that, after all, is the point), you have to be present. Now, I try not to conduct myself with the next election in mind. And the vast majority of the time, everybody else does too.

The session was dotted occasionally with legislation that had nothing to do with state policy, bills that were, alas, nothing more than fodder for the next election. Trying to get you to vote the wrong way, trying to get you to take the bait, or trying to get little nuggets for themselves to take home to their base and yell hoorah.

So yes, some legislation is designed with the next election in mind.


DJ: Would you view mental health as a bi-partisan win from this session or is there too much left on the table?

NJ:  It’s a bi-partisan win. I don’t like the word ‘win’, though, because it suggests the game is over. The game’s not over. But it was definitely bi-partisan progress.

Part of that is because behavioral health is one of those areas of long-standing social concern that has more recently met with a recognition of economic concern. Recognition, that by providing better access to mental health services, we not only make people’s lives better, we make them less reliant on other state services and therefore we are lowering our costs by investing in that particular area. I’m hoping that’s a model for how Texas can start looking at health care altogether.

I’m hoping behavioral health is just the pilot for what’s to come in health policy.


DJ: I think when you look at behavioral health, there is a lot of data and evidence that shows the importance of treating behavioral health as part of one’s overall health. How do you see data and evidence playing into the Medicaid expansion conversation?

NJ: When expansion was first introduced, it was theoretical and more political than it was analytical. We are now five years into expansion with 36 states that have expanded Medicaid. And there are actual results on what works, and what works with a wide range of variation of implementations across various states.

So, we’re able to examine the model of expansion overall. Is this program cost effective? Is it improving people’s lives and quality of care? And the answer is unequivocally yes to all of these questions.

But, in addition, we have the ability to look at specific methods of implementation. We can choose from their shortcomings, from their advantages, and choose from among those what will work best for us here in Texas.

We have a wealth of data in front of us. Some of that data makes its way into the hands of economists and analysts, like the Perryman Group.  Five years ago they had to make their best guess, but they’re now able to update their projections with data. And, their analysis demonstrates that Medicaid expansion will actually pay for itself.

It’s not that there aren’t problems. And, Texans are always hesitant to embrace anything from the federal government. But, I think the data shows that this program is making a meaningful difference in the lives of people and businesses, and Texans appreciate that.


DJ: How do you as a citizen-legislator try to dig in on complex health policy subject areas, like driving more accountability in the managed care health care system? How do you get your hands around difficult content areas?

NJ: As a legislator, you have to find experts in the area, and consult with them. I’ve been a senator for 5 months. And I’ve developed relationships with people I rely on and I’m working to expand that across a range of perspectives.

I do think that even its critics recognize that the managed care structure holds great promise, but that we have to make sure we get it right. And, I think it’s clear we have work to do.

Every player in this seems to be convinced that this is a good, basic structure; it’s just a question of how to administer it properly. In this session, I believe we provided better oversight and enforcement of managed care plans, and I think that was necessary.


DJ: You know, some legislators have shared with me that ‘Forget what you’ve heard. The enemy isn’t the other party. It’s the other chamber.’ Is that an accurate assessment of Texas legislative politics?

NJ: No and yes.

Generally, we all want to pass good laws, and we are dependent on one another in each chamber. We cross back and forth to make sure we have someone that can carry legislation we care about in each chamber.

But sometimes there was a surprising degree of competition between the two chambers, probably more than there should have been, perhaps less respect than there should have been for the work we’re all trying to do.

Sometimes good legislation died because of competition between the two chambers. Sometimes pride of authorship got in the way of passage, or the pride of the body got in the way.


DJ: We hosted Rep. Sarah Davis, a Texas Republican from Houston, as part of our conference in Austin this year. She would say that language matters a lot in health care policy, like talking about “extending” benefits rather than “expanding.” What do you think about the nuanced way language might be used in health policy?

NJ: You know, I observed that incumbents are afraid of the term “expansion,” much more than I am. And I think that’s because they have had to experience of the political backlash of the 2014 mindset and attitudes, and they’re afraid to run into that again. But I don’t think were in that 2014 mindset any longer.

I mean, it’s still there, but I don’t think you’re going to fool the public by calling it the Longhorn Plan or the Texas Way. For a long time, people hoped that would help. But, I don’t think that’s meaningful or helpful. The data is clear. The data supports the logic of expansion.

Let’s stop playing games and picking words. I think the public is smarter than we give them credit for. If you’re trying to package an apple and call it an orange, they’re going to know the difference.


DJ: What are you most interested in working on in this interim period?

NJ: I want to improve health, increase access to healthcare, and decrease costs and dependency. Medicaid expansion is one of the primary mechanisms, and so is one of the primary things I want to get done in the next session. There are a number of other mechanisms for lowering costs and increasing access in health care. I think you can make the case for a high-risk reinsurance pool, for example. I think that would have a meaningful impact.

Here’s the thing: I think we need to cover more people at a lower cost.

Everything that is in the State of Reform conference coming up in Dallas in September is subject matter that I need to be very familiar with, and I hope to learn from everyone who is there.