Former Texas Medicaid Director Stephanie Muth led a panel discussion at the 2022 North Texas State of Reform Health Policy Conference on Wednesday that focused on the impacts that pending federal policy changes will have on Texas Medicaid. Federal funding for the public health emergency (PHE) and the state’s incentive payment program for delivery system reforms are scheduled to expire soon.
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Muth, now the head of her own health and human services consulting firm, was joined by Joyce Tapley, CEO of Foremost Family Health Centers, and John Burruss, MD, CEO of Metrocare Services during the panel.
According to the panel, Texas could disenroll up to 2 million people from Medicaid coverage at the end of the PHE when continuous coverage provisions end. The discussion affirmed that collaboration and innovation would be necessary to address health coverage gaps caused by the end of PHE.
The legislature has resisted expanding Medicaid over its most recent sessions despite data suggesting doing so would qualify an additional 1.7 million residents with incomes below the poverty line for Medicaid. 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 (FQHC) that serve both Medicaid and uninsured patients in low-income communities in Dallas County, would prepare for the end of PHE by continuing to conduct their operations to the highest of standards.
“We’d see anybody who walks through the doors regardless of their ability to pay,” Tapley said. “But I believe that one of the ways that we need to prepare ourselves is to continue to run the organization in the most compliant way, with the most comprehensive types of services, with the best folks [and] best positions and expand our revenue stream through primarily insurance plans … Whenever that day comes, when the pandemic is no longer designated as such, there are people that are out there right now that aren’t getting care.”
The panel also highlighted the tension between state and federal authorities over the 2021 rescission and this year’s approval of the Medicaid 1115 waiver. The current 1115 waiver, which provides federal authority and funding to the state’s Medicaid managed care programs, was approved as a 10-year extension to the previous waiver by the Trump Administration in 2020. Some of the tensions were around the absence of Medicaid Fiscal Accountability Regulation (MFAR) rules in the rescinded waiver.
CMS designed MFAR rules to make changes to how states structure provider taxes and supplemental payments in their Medicaid programs.
The non-federal share of Medicaid funding in Texas is coming from local tax dollars and does not flow through the general appropriations bill. Muth said there has been increasing discomfort by federal authorities with the level of oversight over how funds are being utilized.
“So while those [MFAR] rules did not move forward, I think you can expect to continue to see some scrutiny,” Muth said. “There’s been some promise of audits from the federal government in this area … There’s a lack of comfort from some federal policymakers with how many Medicaid dollars flow outside of your traditional Medicaid program. So I do think we will see continued scrutiny and oversight and some changes there. Some of it will be around transparency and just [having] a better view at the federal level of this source of the non-federal share.”
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 that aimed to reform the delivery system for the ACA will expire on November 1st.
In response, the Texas Health and Human Services Commission (HHSC) designed a series of Medicaid supplemental and directed payment programs that were approved by CMS earlier this year. As outlined in the new waiver, these programs are designed to direct more of the funds outside of the 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] brings support for a full array of services in a manner that is suitable rather than straight medications prescribed by the psychiatrists, ” Burruss said. “I’m a big fan of medication that’s necessary, but there’s a whole array of treatments that are important for the populations we take care of.
Plus the uncompensated care and charity care, which is robust and relevant as opposed to [uncompensated care] for hospitals. So the waivers across the board take us further and further towards being able to have an array of treatment programs for people. There’s still gaps, but it is moving us down the road … I would say we’re making progress.”
Metrocare Services primarily treats mental health conditions and intellectual disabilities throughout Dallas County. It is also the largest provider of permanent housing support in Dallas.
Burruss said that while the state has implemented specific resources to take care of people with mental health issues and intellectual disabilities, there remain gaps to getting those same individuals the physical health care they need when problems arise.
Foremost Family Health Centers has been working 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 into these areas. She added that health systems should target their marketing and outreach efforts to motivate people to seek out primary care and be seen by a physician regularly.
The panel agreed that Medicaid has the potential to incentivize more providers to integrate physical and behavioral health.
“A more meaningful relationship where you have cross-referral information exchange, that’s the way you have to do it, or else again, you’re wasting too much,” Burruss said of the potential collaboration between providers. “There’s not enough extra margin for us to build across the street from each other and try to do it that way. So we have to work collaboratively.”
The panel also focused on the workforce shortage, an area of reform where members were looking to the next legislative session for additional support.
“One of the requests that we are always talking about [with] legislators is to actually expand on the loan repayment program, so that those doctors who need to pay off their loan [get assistance],” Tapley said. “That [if] they’re willing to work in some of these areas, critical areas where we are located, [then] they can get paid regular salary, their competitive salary, and have the loans paid. That will be a good way to bring in more people not only for primary care but even for mental health and behavioral health and nurses. Because we are [experiencing] shortages of nurses.”
Burruss discussed the competitive dynamic between Texas and other states concerning the nationwide health workforce shortage.
“Make no mistake, this is a competition. We are competing with every other state and what they put into their system in order to lure the providers,” Burruss said. “There are very few places in the country you can consider provider surplus areas. So everywhere you look, they’re doing the same thing. We are just trying to figure out how to persuade people to come … These gaps are not going to go away unless we have a workforce that can deliver the solutions.”