Becca Aaronson, The Texas Tribune, Author at �鶹Ů�� Health News

Local Governments In Texas Pursue Marketplace Signups

Becca Aaronson, The Texas Tribune — Mon, 27 Jan 2014 09:15:00 +0000

This story was produced in partnership with

HOUSTON — To coordinate education and outreach efforts associated with the Affordable Care Act, the Houston Department of Health and Human Services is taking an approach that mirrors how the Federal Emergency Management Agency might react to a catastrophe.

The Enroll Gulf Coast initiative has set up an “incident command structure” to synchronize the activities of 13 organizations in Harris and 12 nearby counties.�� An “intelligence committee” created heat maps showing the ZIP codes with the region’s highest number of uninsured residents and “access” points, like community centers and libraries, to connect with people in those neighborhoods. Meanwhile, an “operations committee” uses that information to host canvassing and health insurance enrollment events in targeted neighborhoods. The groups also share an online dashboard to input data and track their coordinated enrollment efforts in real time.

“The number of uninsured people that we have here in Harris County, 1.1 million, yeah, that’s a public health emergency,” said Ben Hernandez, deputy assistant director for the Houston Department of Health and Human Services. “That’s why it’s easy for us to say, ‘Let’s treat it like we’d treat a hurricane.'”��

While no one believed carrying out the Affordable Care Act in Texas would be easy, a series of additional obstacles has impeded efforts to help the 6.2 million uninsured Texans find health coverage. The launch of the federal marketplace, healthcare.gov, was a technical disaster. The state’s Republican leadership, saying Medicaid is broken, has refused to expand the program for impoverished adults. And last week, the Texas Department of Insurance��that added further training and other requirements for the navigators hired and trained by recipients of federal grants to help people enroll in the health marketplace.

Still, government officials and community-based organizations are working together to incorporate new rules, maximize their resources and educate uninsured Texans on how to take advantage of the federal law.��

Will Velazquez, a project coordinator for Bexar County’s Department of Community Resources, is working to unite health care and nonprofit entities in San Antonio to educate the community about the law. “We basically said, ‘How can we serve the community as a whole?’” he said.��

Twice a week, the county reserves 16 computers at��, the digital library in San Antonio, and brings in navigators and certified application counselors from five local organizations to assist people with enrollment.

“I need health care right now, so I’m anxious to get in there and see how that’s going to work for me,” said Lisa Guerrero, a part-time clerk in the Bexar County constable office, who visited BiblioTech recently for assistance.

Guerrero��has been uninsured for nine years. During that time, she relied on community-health clinics that offer sliding-scale prices for low-income residents.

It can be difficult for low-income families like hers to navigate the health system, because those clinics’ wait times for an appointment with a specialist can range from four to six months, and scheduling follow-up appointments with the same doctor can be nearly impossible.��Guerrero��said she shared diabetes and blood pressure medication with her father, because appointments are too costly.

“It’s kind of ridiculous that we have to jump through so many hoops to get cough medicine, to get diabetes meds, to get a check-up or a Pap smear,” she said.

Of the 6.2 million uninsured Texans, 28 percent would qualify for tax credits to help them purchase private health plans on the federal marketplace, and 14 percent would qualify for Medicaid coverage, according to the��(KHN is an editorially independent program of the foundation).

In addition, more than one million Texas adults —��17 percent of the state’s uninsured population — fall into a coverage gap, according to the��Kaiser Family Foundation, because the state declined to expand Medicaid to include adults below the federal poverty threshold.

So far, only 118,532 Texans have selected a health plan on the federal marketplace.

�ҴǱ�.��has said expanding Texas’ Medicaid program would cause taxes to “skyrocket” and crush the state’s economy “under the weight of oppressive Medicaid costs.”

In September, he��Texas Department of Insurance to enact additional regulations on federal navigators. The regulations were necessary to protect consumers, he said, because the navigators handle sensitive information, such as Social Security numbers, and the federal guidelines were insufficient.

The insurance department issued the regulations Tuesday, requiring federal navigators to undergo background checks and receive an additional 20 hours of state-specific training. Navigators must register with the insurance department by March 1, and complete the additional training by May 1, the end of the six-month enrollment period for the federal marketplace.

“Obamacare presents enough problems for Texans without the risk of a convicted felon handling their personal information,” U.S. Sen.��, R-Texas, said in a statement. “These are basic requirements for screening individuals hired with taxpayer money to handle sensitive consumer information.”

The federal Department of Health and Human Services awarded $11 million to organizations in Texas to hire and train navigators. They are required to receive 20 to 30 hours of training under federal law.

The United Way of Tarrant County received the largest grant, $5.8 million, and has distributed the money to 17 organizations around the state. There are 165 navigators in that consortium, including 13 hired by the city of Houston. To expand its efforts, Hernandez said the Houston health department has trained 90 city employees to become navigators and expanded their job responsibilities.

The Houston health department is also working with government entities and community-based organizations in Dallas, El Paso, Austin and the Rio Grande Valley to extend Enroll Gulf Coast’s strategy across the state, Hernandez said.

Tim McKinney, the chief executive of United Way of Tarrant County, said navigators within their consortium had conducted 10,000 one-on-one information sessions with Texans, and enrolled 914 people in health plans, as of Dec. 31.��

“The primary mission of a navigator — it’s really not to enroll, it’s to educate and inform,” he said.

Democrats and some health care advocates are critical of the new state rules, saying they are intended to obstruct navigators’ work by adding additional costs and training requirements during the final weeks of the six-month enrollment period.

“It’s really difficult to say that it’s not a politically motivated stunt,” said Tiffany Hogue, statewide campaign coordinator for Texas Organizing Project, political advocacy group for low-income Texans that is working with government entities in Dallas, San Antonio and the Rio Grande Valley to educate Texans on the their insurance options..

The insurance department has said that “unrelated political considerations would be an inappropriate basis for the rules,” and that its intent is to broaden the pool of qualified navigators.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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New Providers Face Obstacles in Texas Women’s Health Program

Becca Aaronson, The Texas Tribune — Thu, 09 Jan 2014 12:57:08 +0000

This story was produced in partnership with

Since ousting Planned Parenthood clinics from the Women’s Health Program, which provides cancer screening, well-woman exams and contraception for low-income women,��Texas leaders have made a concerted effort to recruit physician groups to fill the void.��

They also widened the services covered, adding testing and some limited treatment for sexually transmitted diseases.��

But unlike specialty family planning clinics, physician groups generally don’t receive additional government funding to help low-income women access services not expressly covered by the program — and that��has created obstacles for both providers and patients.

“Physicians cannot afford to really embrace the Texas Women’s Health Program patient,” said Fran Hagerty, CEO of the Women’s Health and Family Planning Association of Texas, “because they end up getting stuck, again, with the responsibility for the full patient care where there’s no funding available to them for that.”

In 2011, under pressure from Republican leaders, state health officials began enforcing a provision lawmakers wrote to exclude Planned Parenthood and any clinics with organizational ties to abortion providers from the Women’s Health Program. At the time, Planned Parenthood clinics provided 40 percent of the program’s services and often subsidized services not expressly covered by it.

To replace Planned Parenthood, the state recruited new providers, the majority of which are physician groups, to participate in the reimagined program. But unlike many reproductive health clinics, which qualify for additional federal family planning grants, physician groups generally don’t have the public financing to pay for services that aren’t covered by the state program. While physician groups can absorb some of these additional costs, in most cases a patient must pay out of pocket for additional services or find an alternative provider that receives federal subsidies, which can delay care.

Emma Moreno, assistant manager at Valley Women’s Specialists, a physician group in Weslaco that participates in the Women’s Health Program, said the program covers Pap smears, for example, but if a patient tests positive for the human papillomavirus and needs further treatment, that care isn’t covered.��
��

“If you’re going to provide a program or a service, provide the full service and not just half of it,” said Moreno, whose physician group still encourages women who may be eligible to apply for the state program.

Valley Women’s Specialists offers a variety of payment plans and refers patients to other clinics for treatment if they can’t pay. For some conditions that aren’t covered by the program, such as yeast infections, the physician will provide the treatment free of charge.

The physician “just loses out on it, but he’s not going to leave the patient untreated,” Moreno said.

Stephanie Goodman, a spokeswoman for the Health and Human Services Commission, said the agency is looking into these concerns. HHSC recently hired a women’s health coordinator who will be working with providers to improve the referral process for patients who need additional services from a federally qualified health center or rural health clinic, she said.

“We’ve always had to work with our providers to take care of other needs a woman might have,” she said in an email. “Now that we have many new providers in the program, we need to make sure they know about the resources that exist to help women with other health issues.”

To be eligible for the Women’s Health Program, a woman must have an income at or below 185 percent of the federal poverty threshold, or less than $1,800 a month for an individual. The original Women’s Health Program, which was jointly funded by the state and the federal government, was an offshoot of Medicaid. The federal government discontinued its $9-to-$1 match for the program in January 2012. That followed the state’s exclusion of Planned Parenthood clinics, despite the fact that those clinics were already prohibited from performing abortions because they accepted taxpayer dollars.

The Texas Women’s Health Program is nearly identical to the former Medicaid program in scope, though it now covers STD testing and some routine treatment, and is run entirely with state funding — $35.6 million a year.��

In the first six months of the state-run program, enrollment and claims for services dropped significantly.

“While these numbers were collected before we added increased funding [for] women’s health in the last legislative session, they are exactly the type of data we will be carefully reviewing in the months ahead,” state Sen. Jane Nelson, R-Flower Mound, the chairwoman of the Senate Health and Human Services Committee, said in an email to The Texas Tribune last month. “It is important that we make sure the dollars we invested are providing meaningful preventive health services for the women of Texas.”

Hagerty said the Women’s Health Program was originally designed to be one piece in a patchwork quilt of family planning funding. Federally qualified health centers and family planning clinics that receive additional grants, such as the federal Title X grants that her organization manages, are better equipped to serve patients participating in the program, she said, because they have additional resources to provide services that aren’t covered.

By excluding Planned Parenthood, formerly the biggest provider in the program, a drop in claims was inevitable, she said.��

“Someone needs to come to their senses and lift that ban,” Hagerty said. “But that’s political and until the political winds change that’s not going to happen.”

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Claims Drop After Texas Takes Over Women’s Health Program

Becca Aaronson, The Texas Tribune — Fri, 13 Dec 2013 10:24:04 +0000

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To stop Planned Parenthood clinics from receiving public financing, Texas’ Republican leaders gambled that the state could operate a contraception and cancer-screening program for low-income women without tens of millions of federal dollars.

But with the exclusion of roughly 40 Planned Parenthood clinics, none of which performed abortions, from the program in 2013, records show claims for birth control and wellness exams dropped, as did enrollment numbers.

State health officials relaunched the Medicaid Women’s Health Program as the Texas Woman’s Health Program in January after the federal government discontinued its $9-to-$1 match for the program — a decision the Obama administration made when state lawmakers began enforcing rules they said excluded clinics even loosely affiliated with abortion providers from receiving taxpayer dollars. (By law, none of the providers in the program performed abortions.)

The new state-financed program got off to a rocky start. In some parts of Texas, the state’s health agency struggled to find providers to replace Planned Parenthood clinics, which provided 40 percent of Women’s Health Program services in 2012.

“There can still be some pockets where we don’t have a provider and we did before,” Texas Health and Human Services Commissioner Kyle Janek said. “Planned Parenthood may have been the only game in that area.”

During the first six months of 2013, there were 38 percent fewer reimbursement claims for birth control than there were during the first six months of 2012, according to a Texas Tribune analysis of data provided by the Texas Health and Human Services Commission. The number of wellness exams, meanwhile, decreased by 23 percent. Program enrollment figures have also declined, down from 127,000 in January 2012 to 110,900 in May, the most recent month available.

Cecile Richards, president of the Planned Parenthood Federation of America and daughter of the late Texas Gov. Ann Richards, called the figures “troubling.”

“Despite all the promises from state officials that women’s health care needs would be met,” she said, “it’s clear they aren’t.”

But Janek argued that the claims numbers are misleading. He said the birth control distributed by the program has not declined as much as initial claims data suggest, because the majority of providers who replaced Planned Parenthood clinics are physician groups that direct patients to pharmacies for prescriptions, rather than distributing it onsite like family planning clinics. The program’s pharmacy data for 2013 is not complete, and the state could not provide additional information on how many birth control prescriptions were filled.

“We think when you add all those up for birth control, both those delivered at the pharmacy and those given by the provider’s office, we’ve got an increase, not a decrease,” Janek said.

Women’s Health Program claims for long-acting, reversible birth control methods like intra-uterine devices and hormonal implants, which must be inserted by the provider onsite, declined by 17 percent in the same time period. Janek said that was the result of the state not paying providers enough to cover the procedure, something health officials have rectified by raising reimbursement rates for copper IUDs by $200 and hormonal implants by $75.

“We’ve changed that, so I expect the second six months and thereafter will tell a different story,” he said.

Janek said that while he is happy with the state-run program’s progress, he would not be satisfied “until we do better.” The state is conducting targeted outreach to encourage more women to enroll in the program; health officials say when they sent mailers in October and November to women whose families were registered for other state programs, enrollment promptly increased by more than 9,000 women.

While Republican state leaders work to improve capacity in the state-run program, many family planning clinics have struggled. Seventy-six family planning clinics closed after the 2011 legislative session, when Republican lawmakers with Planned Parenthood in their crosshairs cut two-thirds of the state’s family planning budget, set up a tiered system to shift remaining dollars away from reproductive health clinics and ousted Planned Parenthood and other clinics from the Women’s Health Program.

Haven Health Clinic in Amarillo, for example, the only family planning clinic that serves the 26 counties in the Texas Panhandle, saw a 20 percent decrease in Women’s Health Program patients between 2012 and 2013.

“We’re struggling now, but we’d be out of business if the program closed completely, which would be devastating for this part of the state,” said Carolina Cogdill, Haven’s chief executive officer.

Republican lawmakers attempted to mitigate the damage they had done to Texas’ family planning infrastructure in the 2013 legislative session by passing the largest financial package for women’s health in state history. Texas’ 2014-15 budget includes $71 million to operate the Texas Women’s Health Program, $100 million to expand a primary care program to serve an additional 170,000 women, and $43 million to replace family planning grants the federal government used to award to the state health agency — but has now given to another organization.

But women’s health advocates remain concerned that the damage wrought in 2011 cannot easily be undone.

“The Texas Women’s Health Program has great potential, but it has not taken off in private practice yet,” said Dr. Janet Realini, chair of the Texas Women’s Healthcare Coalition, which represents 39 medical trade associations and advocacy groups. “The providers who were doing most of that work have been either excluded or damaged by the cuts.”

Although some providers say a decline in Women’s Health Program patients has put them in financial distress, others have easily absorbed new patients who previously received services from Planned Parenthood.

Parkland Health and Hospital System in the Dallas area received 212 phone calls in January from former Planned Parenthood patients looking for a new Women’s Health Program provider, said Paula Turicchi, Parkland’s senior vice president for women and infants specialty health. So far in 2013, Parkland clinics have served 9,180 patients in the program, compared with 8,655 in 2012.

“We definitely saw a greater impact around those locations where Planned Parenthood had been a provider,” Turicchi said.

After the 2011 budget cuts, Parkland’s annual family planning financing dropped to $2.1 million from $7.4 million, and it instituted a $25 co-payment for low-income family planning patients who used to be fully subsidized. Turicchi said 42 of 420 patients who canceled appointments in February 2012 because they couldn’t afford the co-payment later returned pregnant.

Parkland recently received $4.8 million through the state’s newly expanded primary health care program to increase services for impoverished women in 2014.

“That’s going to go a long way in providing even more health care services to patients,” Turicchi said, adding that the program covers far more than just family planning.

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Texas Doctors, Hospitals Don’t Know If They’re In Or Out Of Obamacare Plans

Becca Aaronson, The Texas Tribune — Mon, 21 Oct 2013 09:47:14 +0000

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As consumers weigh coverage options available in the newly launched federal health insurance marketplace, three of the largest medical associations in Texas have raised concerns about the uncertainty of provider networks offered by health plans in the marketplace.

The Affordable Care Act requires most people to carry health insurance beginning in 2014. While some states received federal financing to set up a state-run health insurance marketplace, Texas chose to participate in the federal marketplace, which offers dozens of health plans and sliding-scale tax credits to help poor individuals and families in Texas purchase coverage. Since the marketplace on Oct. 1, technical glitches have plagued the federal website and made it difficult for consumers to create accounts and compare health plans.

The Texas Medical Association, Texas Hospital Association and Texas Academy of Family Physicians said many physicians and hospitals have also been unable to determine which health plans offered in the marketplace include them in their provider networks.

“Physicians, they just want to know who’s walking through their door and what kind of coverage they’re going to have,” said Lee Spangler, vice president of medical economics at the Texas Medical Association. “They’d like that uncertainty to be settled.”

Many insurance companies participating in the marketplace have created health plans with provider networks based on existing contracts with physicians and hospitals, and did not contact those providers to sign new contracts or ask if they were willing to participate in the new health plans, according to the associations. As a result, many providers do not know which of the health plans offered in the marketplace will pay them for services.

Spangler explained that many physicians sign contracts that allow insurance companies to include the physician in the provider network for any of their health plans. Often, the insurer is not required to notify the physician which of the health plan networks include the physician.

Physicians may not be able to offer alternatives that would be less costly for the patient, if they are unfamiliar with the patient’s health plan network, said Spangler. Furthermore, health plans from the marketplace could present financial obstacles for physicians, because those health plans are required to have a 90-day grace period for policyholders that do not pay their monthly premiums on time. While other health plans would cut off coverage if a patient did not pay their bill on time, the health plans offered in the marketplace would still indicate the patient was covered during that grace period, and retroactively revoke payments to the physician for treatment provided during that time. In those situations, the doctor would be forced to seek payment from the patient for services already provided.

Lance Lunsford, a spokesman for the Texas Hospital Association, said the association has also received inquiries, mostly from small and rural hospitals, on why some hospitals haven’t been contacted to participate in the health plans offered in the federal marketplace and how those hospitals can determine whether they’re already participating through their existing contracts with insurers. The hospitals have the same concerns as doctors, said Lunsford, adding that the hospitals want to be included in the plans.

, one of the largest cancer treatment groups in the state, has chosen not to participate in any health plans offered in the marketplace because “there are many unknowns related to how the Health Insurance Market Place will cover cancer treatment,” according to a statement by the organization. “These details will impact our ability to provide patients with the latest and most effective treatments, so it is imperative that we are fully informed before a decision is made,” the organization further stated, while also indicating that it would re-evaluate its decision not to participate once more information was available.

Not all of the health plans in the marketplace are based on existing contracts between providers and insurers. For example, some insurance companies participating in the federal marketplace have signed new contracts with specific providers to create HMOs with “skinny networks.” Those plans have fewer participating providers but lower monthly premium costs.

All of the health plans in the marketplace are required to maintain provider networks that have sufficient numbers and types of providers to ensure all health services are available in a reasonable time period, according to federal officials at the Health and Human Services Department.

The uncertainty of the provider networks also creates a hardship for consumers, many of whom consider whether their current doctor is covered before purchasing a health plan. On average, Texans have 54 health plans in the marketplace to choose from, all of which have varying monthly premiums, deductibles and provider networks.

Before a consumer can view specific information on the provider networks of health plans offered in the federal marketplace, consumers must create an account on healthcare.gov and apply for coverage. The website does not have a tool to search for specific providers to determine which health plans they’re participating in. Federal officials said that consumers could click a link associated with each health plan to review the provider network, but the Tribune was unable to access that feature because of glitches on the federal website that made it difficult to create an account.

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Advocates Target Latinos in ACA Enrollment Outreach

Becca Aaronson, The Texas Tribune — Tue, 15 Oct 2013 14:42:27 +0000

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Though they make up roughly a third of the state’s population, Latinos account for nearly two-thirds of the more than 6 million Texans without health insurance. As a result, proponents of the Affordable Care Act in Texas are specifically targeting Latinos in their efforts to enroll people in a federal insurance marketplace aimed at helping the uninsured find coverage.

But in the two weeks since the marketplace opened, health care advocates across the state have encountered common obstacles getting Latinos registered, including limited access to computers and a lack of email addresses. Advocates are developing community-based strategies to overcome these obstacles, and to ensure that Latinos do not miss out on insurance options available through the Affordable Care Act, which requires most people to carry coverage beginning in 2014.

One strategy is reliance on promotoras — health counselors, often women, who provide education on health coverage options in Spanish-speaking communities.

“Just being bilingual isn’t enough,” said Frank Rodriguez, executive director and founder of the Latino Healthcare Forum, which hopes to use promotoras to reach more than 50,000 uninsured people in the Austin area over the next six months. “What we’re doing is recruiting people from the community that know the norms and the customs of the people.”

Angelica Noyola, one Austin community activist hired as a promotora by the Latino Healthcare Forum, said that when she asks her neighbors about the Affordable Care Act, she hears many false rumors: that anyone who works for a small company will be laid off, that the federal government will put people in jail who don’t have health insurance.

“There’s so much incorrect information out there,” she said. “It’s quite scary to a lot of individuals.”

The online marketplace the federal government launched on Oct. 1 offers dozens of health plans and sliding-scale tax credits to help poor individuals and families purchase coverage. Latinos account for roughly 1.7 million of the 2.8 million Texans estimated to be eligible for such tax credits, according to the La Fe Policy Research and Education Center in San Antonio. There are also tax penalties for not purchasing health insurance.

Rodriguez said there are two daunting aspects of the federal marketplace for Latinos. He said it is particularly difficult for Latinos to address the questions on taxes and projected income required to sign up for coverage. And he added that many Latinos are hesitant to commit to a major spending decision like health insurance.

“Affordability is a really subjective term for Latinos,” Rodriguez said. That is why his organization’s campaign to get them enrolled in the marketplace is relying on terms like “security” instead, he said.

Noyola said that many Latinos in Texas are living paycheck to paycheck, but that when it “comes to health and each other, they pull together.” She said many stand to benefit from the health plans offered in the marketplace, because they will be financially protected and have access to preventive health services.

While some uninsured Latinos seek out assistance organically, Rodriguez said that in his experience, most will need to be contacted five to seven times — by way of a phone call, a flyer or a sit-down conversation — to get them to enroll in the federal marketplace.

“The Latino community likes to have that face-to-face conversation when they’re buying something as important as health care,” said Arturo Aguila, an organizer for Border Interfaith in El Paso, which has created a similar community-based strategy to educate uninsured Latinos on federal health reform. With the help of local rabbis, priests and pastors, Border Interfaith has already held seven events to educate nearly 500 people on the Affordable Care Act.

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People Without Email Addresses Face Difficulty Enrolling In Exchanges

Becca Aaronson, The Texas Tribune — Wed, 02 Oct 2013 12:17:45 +0000

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Down in South Texas, health care providers are reporting an unusual problem with the federal marketplace: Many patients don’t have email addresses and, therefore, can’t sign up online.

The Brownsville Community Health Center had 50 people show up on Tuesday ready to sign up for health coverage — many even brought pay stubs and income documentation — but not a single one of them had an email address.

“If you don’t include an email address, they won’t let you through,” said Christela Gomez, the special projects coordinator and lead certification application counselor at the center. Although the center considered helping people sign up for an email account, Gomez said many weren’t comfortable with the idea because they did not have a computer to access the email address later. “Quite a few didn’t even know what an email address was,” she added.

The center’s certified application counselors helped the patients fill out paper applications, but they’ll have to wait for a written response from the federal government to find out whether additional documentation is needed or whether those applicants qualify for tax credits.

Some of the questions on the paper application were difficult for patients to answer, said Gomez. One man who came in to receive assistance finding health coverage currently works as a truck driver, she said. He earns 30 cents per mile, and his income can range from $50 to $100 a week.

“We didn’t really know how to fill in the income part with him,” she said, adding, “We kind of just wrote it in on the side, his situation.”

Paula Gomez, the executive director of the center, said her patients are mostly adults who are too young to qualify for Medicare. Although most of her patients have jobs, pay taxes and want to cooperate with the health care system, there are extenuating circumstances like language barriers that make it difficult.

“I’m sure there are pockets like ours all over the country,” Gomez said. She added that the federal government should be more flexible and consider the different situations people are facing across the country. “They think in terms of everything that’s going on in Washington, D.C., but they don’t look at the reality of the rest of the world in the United States,” she said.

Ongoing technical difficulties on the new federal health insurance marketplace’s website have created road blocks for Texans trying to sign up and review coverage options under the Affordable Care Act.

“We keep getting kicked off the network, but we’ve screened some patients,” said José Camacho, executive director of the Texas Association of Community Health Centers. “People, from what we can gather at the centers, are quite excited.”

Although Tuesday marks the beginning of a six-month enrollment period, Camacho said many Texans have already shown up at federally qualified health centers to receive assistance applying for coverage in the exchange. He described one woman who has a master’s degree but recently started a job that doesn’t offer health benefits coming to Lone Star Circle of Care in Georgetown seeking help. Unfortunately, glitches on the federal website prevented the certified application counselors at the center from helping the woman create an account and begin exploring her health plan options.

“With any new product launch, there are going to be glitches as things unfold,” Marilyn Tavenner, a federal administrator for the Centers for Medicare and Medicaid Services, said on a media conference call. She said that 2.8 million people have visited the federal marketplace since midnight, and more than 81,000 calls have been placed to their call center. “This is Day 1 of a process. We’re in a marathon, not a sprint, and we need your help,” she added.

Although the federal marketplace will eventually be able to determine whether an applicant is eligible for state programs like Medicaid and the Children’s Health Insurance Program, the Texas Health and Human Services Commission, which oversees those programs, said the federal website isn’t yet able to send applicants’ information directly to those plans. The agency is encouraging people who think they may be eligible for those programs to apply directly on the state website, .

“This federal glitch could lead to delays in children getting health coverage,” Dr. Kyle Janek, executive commissioner of HHSC, said in a statement. “We’ve let workers in our offices around the state know about this issue so they can make sure families have accurate information.”

Sixty-seven federally qualified health centers that are members of TACHC collectively received $10 million to provide outreach, in-reach and enrollment assistance. So far, they’ve trained 230 certified application counselors. Some centers, such as Su Clinica Familiar in Harlingen and Brownsville, recently received certification and will finish training additional counselors in the coming weeks.

After signing himself up on HealthCare.gov around 8:30 a.m. on Tuesday, Carl Dahlquist, a certified application counselor and the outreach and enrollment supervisor at the Gulf Coast Health Center in Port Arthur, couldn’t get back into the system.

“We had a lot more come in today than we’ve had in the last several weeks because today was Oct. 1,” said Dahlquist.

While most people wanted some advice and literature to take home and consider, Dahlquist said he used old-fashioned pen and paper to determine the eligibility status of one man. Although the man didn’t qualify for coverage in the federal marketplace, Dahlquist said he was eligible for Texas Medicaid’s program for the elderly and disabled. Ironically, Dahlquist said the state’s website was also down.

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Census: More Than 850,000 Texas Kids Lack Health Coverage

Becca Aaronson, The Texas Tribune — Fri, 20 Sep 2013 09:29:34 +0000

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Texas continued to have the highest rate of people without health insurance in 2012 at 24.6 percent, or more than 6 million residents, according to the Current Population Survey estimates released by the U.S. Census Bureau this week.

Texas also has the largest number of children without health insurance and the highest rate of poor adults without health insurance, according to 2012 American Community Survey estimates.

More than 852,000 Texas children lacked health insurance in 2012, according to the ACS estimates, which are taken from a random sampling of households throughout the year. California, which has 2.2 million more children than Texas, had the second-highest number of uninsured children at 717,000.

Texas also had the highest rate of adults making below 138 percent of the federal poverty threshold — lower than $15,415 for an individual or $26,344 for a family of three — who lack insurance, at 55 percent. Those people would have qualified for Medicaid coverage if the state had chosen to expand eligibility under the federal Affordable Care Act.

“There is just an awful lot of people priced out of the [health insurance] market in Texas because of our Wild West regulatory approach on the rate side,” said Anne Dunkelberg, associate director of the left-leaning Center for Public Policy Priorities.

She attributed the high rate of uninsured to the lack of regulations governing Texas’ individual and large employer health insurance markets, the exclusion of most poor parents and all other adults from the state’s Medicaid program, and the lack of employer-sponsored coverage in many of Texas’ predominant industries, such as agriculture, food service and construction, among other factors.

“I think that we have an unhealthy obsession with the uninsured rate in Texas,” said John Davidson, health policy analyst at the conservative Texas Public Policy Foundation. “It distracts us from the much more important question of health care for the indigent population. Insurance and care are not the same things.”

Alternative health care models, such as programs that offer sliding-scale payment rates for low-income people, can contain costs without reducing access to care, he said. For example, he cited the CareLink program run by the University Health System in Bexar County, which provides payment plans and sliding-scale rates for families who make less than 300 percent of the federal poverty level.

“Being on an insurance plan doesn’t mean you have good health care or you have access to health care,” Davidson said. “I think this is most obvious when you look at our Medicaid program,” which he said has “terrible problems with access to care.”

The ACS estimates that 1.6 million adults with incomes below 138 percent of the federal poverty threshold had insurance in 2012, while 2 million were uninsured.

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Little Evidence to Back Texas Abortion Law, According To Official Records

Becca Aaronson, The Texas Tribune — Mon, 16 Sep 2013 15:54:53 +0000

This story was produced in partnership with

In their successful push this summer for strict new regulations on abortion facilities and the doctors performing them, proponents of the Texas legislation said it was needed because conditions at existing facilities made it unsafe for women seeking to terminate pregnancies.

But a Texas Tribune review of state inspection records for 36 abortion clinics from the year preceding the lawmakers’ vote turned up little evidence to suggest the facilities were putting patients in imminent danger. State auditors identified 19 regulatory violations that they said presented a risk to patient safety at six abortion clinics that are not ambulatory surgical centers in Texas. None was severe enough to warrant financial penalties, according to the Department of State Health Services, which deemed the facilities’ corrective action plans sufficient to protect patients.

And between 2008 and 2013, the Texas Medical Board, which regulates the state’s physicians, took action against just three doctors who performed abortions — all of them for administrative infractions that did not involve criminal practices or late-term abortions.

“The point of this legislation was to make abortion inaccessible. It wasn’t about safety,” said Amy Hagstrom Miller, chief executive officer of Whole Woman’s Health, which operates four abortion clinics and an ambulatory surgical center in Texas. “Because there is no safety problem around abortion in Texas.”

Abortion opponents vehemently disagree. They say the fact that more clinics and doctors have not been penalized only signals the need for tougher restrictions. They successfully convinced state lawmakers of that during the last legislative session: Beginning Oct. 29, Texas will ban all abortions after 20 weeks gestation and require abortion facilities to have a physician with active admitting privileges at a hospital within 30 miles. A year from now, additional rules will take effect requiring abortion facilities to meet the structural guidelines for ambulatory surgical centers — which include wider hallways and pre-operative and post-operative waiting rooms.

Emily Horne, a lobbyist for the anti-abortion group Texas Right to Life, said the conditions auditors found in the last year could have easily led to women getting sick or injured, and that it is a “lower standard of care” if inspectors “find these problems and do nothing about them.”

“The clinics need to be safer,” she said. “You can’t advocate for more abortion that is unsafe.”

Among the violations auditors found at the facilities, which get surprise inspections annually, were expired or unlabeled medicine, and instances in which medical staff failed to follow proper infection control procedures. In one case, auditors found that a sterilization machine was not working properly and that nurses were not trained to recognize the problem. On another occasion, auditors reported that a patient with a bleeding complication was transferred to a hospital in a private car instead of by ambulance.

Most of the violations auditors found were at a Whole Woman’s Health facility in Beaumont, which took immediate steps to remedy the problems and had its correction plan accepted by the state.

(Use our to review the inspection records for each facility.)

A health department spokeswoman could not say any of the violations were linked to patient complications, citing confidentiality rules.

But state health officials have not shied away from making Texas abortion facilities pay for their shortcomings. In 2010, they levied a $119,000 fine against Planned Parenthood Trust of South Texas for failing to acquire licenses for three facilities that began prescribing abortion-inducing drugs in 2005.

Planned Parenthood spokeswoman Mara Posada said the organization was under the impression that it did not have to obtain licenses for those facilities because surgical abortions were not performed there — and the organization did have a license for the facility that offered them.

The state also levied several smaller fines — ranging from $200 to $500 — against clinics that failed to post their licensure numbers on their websites, misreported the age of gestation or failed to return a corrective action plan on time, among other violations.

Although most of state’s recent inspection findings point to administrative errors as opposed to medical ones, abortion opponents have not been deterred.

One group, Operation Rescue, of performing illegal, late-term abortions as recently as 2011. Harris County officials and the Department of State Health Services are still investigating those allegations, but previous inspection reports have revealed no violations that presented a safety risk.

Abortion rights advocates say that even if the investigation uncovers wrongdoing, the doctor was operating an ambulatory surgical center that would have met the requirements of the new law. They and medical experts argue that the new regulations will lead to the closure of the majority of the state’s legal abortion providers, resulting in more women seeking out dangerous, illegal options.

Since January, nine abortion clinics have shut their doors and another facility has stopped performing abortions. Two of those that closed were Planned Parenthood clinics that operated until this month; state auditors found no violations at those two clinics in their last inspections. Only six of the state’s remaining 38 abortion facilities currently meet the structural requirements of ambulatory surgical centers, and it is unclear how many have a physician with hospital admitting privileges.

Hagstrom Miller said that under the new law, abortion facilities will be forced to meet even higher standards than ambulatory surgical centers. They will still be inspected annually, while ambulatory surgical centers are only inspected every three years. And doctors at abortion facilities will be required to have active hospital admitting privileges, while ambulatory surgical centers must only have a patient-transfer agreement with a hospital.

“It’s going to increase the danger for women,” she said, “because they’re not going to be able to get safe abortion close to their homes.”

Horne said the ambulatory surgical center requirements, which also include more medical staff hours, would ensure that abortion facilities are “more equipped to deal with an emergency evacuation if it’s needed.”

Requiring doctors to have active hospital privileges would guarantee that their credentials are peer-reviewed, she added, and improve oversight of abortion procedures and continuity of care for patients who experience complications.

“The goal of the bill is to improve patient safety for the woman and the child,” Horne said.

Between 2000 and 2010, five women died in Texas from abortion-related complications; the most recent death occurred in 2008. More than 865,300 abortions were performed during that time period, making Texas’ abortion-related death rate, 0.57 deaths per 100,000 abortions, slightly lower than the national abortion death rate of 0.7 per 100,000.

Abortion rights advocates say that is 14 times lower than the risk associated with carrying a pregnancy to term; opponents argue that every abortion comes with a terrible cost, the death of a baby.

During his research on the impact of Texas’ 2011 family planning financing cuts, Dr. Daniel Grossman, a principal investigator on the University of Texas at Austin’s Texas Public Policy Evaluation Project, said he found no evidence that Texas’ licensed abortion facilities had unsafe conditions. The one safety issue he has identified is the practice of abortion self-induction — where women without easy access to abortion clinics try to terminate the pregnancy themselves.

“This additional burden is just going to be too much for some women,” Grossman said. “I think it’s very, very likely that abortion self-induction is going to go up and that’s definitely going to be bad for women’s health.”

Seven percent of women whom the researchers surveyed at abortion facilities in Texas attempted self-induction before going to the abortion facility. That rate was higher, 12 percent, in cities along the Texas-Mexico border. In comparison, a 2010 research published in the American Journal of Obstetrics & Gynecology found 1.2 percent of women surveyed at abortion clinics nationally tried to self-induce an abortion.

The researchers identified 76 family planning clinics that closed since 2011 because of lost state financing, and 45 percent of women surveyed at abortion facilities said they were unable to access their contraception of choice in the three months before becoming pregnant.

“These abortion restrictions are going into place at a time when the whole family planning safety net really has been completely dismantled,” said Grossman. “In the middle of that, now women are going to find it harder and harder to access abortion.”

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Texas Outbreaks Make a Case for Vaccinations

Becca Aaronson, The Texas Tribune — Tue, 10 Sep 2013 06:13:55 +0000

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A measles outbreak in a vaccination-wary North Texas megachurch and soaring rates of whooping cough across the state are drawing renewed calls for immunization legislation, which some lawmakers and medical professionals argue would help the state prevent public health crises.

“Sometimes we as a society are not going to be convinced of something that makes sense unless we experience a loss,” said Dr. Jason Terk, a pediatrician who serves on the Texas Medical Association’s council on legislation.

For at least a decade, the association has called on lawmakers to change the consent process for the state’s immunization registry, ImmTrac, to opt-out from opt-in to encourage retention of more records, reduce operating costs and protect more Texans against preventable diseases.��

But conservative Republicans have consistently rejected the legislation, saying that it does not adequately protect patients’ privacy or liberty.

ImmTrac should remain a consent-based system, said state Rep. Stephanie Klick, R-Fort Worth, who voted against the legislation in this year’s session, because the state is handling patients’ private medical records.

“That way if something were to happen, they might have some clue that there had been a compromise to their privacy,” she said.

Although 95 percent of Texans informed of the registry choose to participate, many do not know it exists, Terk said.

The MMR vaccine has nearly eradicated measles in the United States, but a persistent myth linking the vaccine to autism has led some communities to resist vaccination. For example, Texas has seen a rise over the last five years — to 0.57 percent from 0.23 percent — in parents seeking exemptions for children from immunizations required to attend public school.

In Tarrant County, an unvaccinated man contracted measles abroad and spread the disease to 20 people at Eagle Mountain International Church who had not been vaccinated or had not received a second dose of the MMR vaccine, as recommended. A senior pastor, Terri Copeland Pearsons, has voiced concerns about vaccines. (On its website, the church insists that it is not “anti-vaccination.”)

The Department of State Health Services also issued a health alert this month to promote whooping cough vaccinations. As the effectiveness of that vaccine wanes over time, outbreaks occur every few years when a population becomes vulnerable again. There have been 2,000 diagnosed cases of whooping cough so far this year in Texas, and two infants too young to be vaccinated have died.��

“This is extremely concerning,” Dr. Lisa Cornelius, the department’s infectious diseases medical officer, said in a statement. “If cases continue to be diagnosed at the current rate, we will see the most Texas cases since the 1950s.”

Russell Jones, chief epidemiologist at the Tarrant County health department, said his first response to reports of a vaccine-preventable disease would be to check ImmTrac to determine whether the person was properly immunized.

If vaccination records are robust in a particular community, “you get a sense of how well your immunization programs are doing,” he said, adding, “It’s going to take a while longer before it’s really complete and can tell us a lot.”

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Despite Additional Dollars, Texas Doc Shortage Is Hard to Fix

Becca Aaronson, The Texas Tribune — Fri, 23 Aug 2013 08:58:00 +0000

This story was produced in partnership with

Texas lawmakers invested millions of additional dollars in the 2013 legislative session to address a looming physician shortage. Voters and university regents have rubber-stamped plans to open two new medical schools, in Austin and the Rio Grande Valley. But those moves have not placated the medical community, which remains concerned that Texas has no long-term solution to produce enough physicians, particularly in primary care, to support the surging population.

“Nobody wants to see this pendulum swing, where there’s money for this biennium and no money the next biennium,” said Dr. David Wright, chairman of the Texas Medical Association’s education committee. “There has to be a better, more stabilized funding mechanism for all of this.”

Texas taxpayers already spend $168,000 educating each of the state’s medical students. For graduated medical students, the state will pay $32.8 million to finance nearly 6,500 medical residency positions in 2014-15.

But beginning in 2014, there will be more graduating medical students in Texas than first-year residency slots available in the state, according to a 2012 report by the Texas Higher Education Coordinating Board.

“If they are forced to do their residency training outside of Texas because we don’t have enough slots, they take that investment with them,” said state Sen. , R-Flower Mound. Nelson filed legislation in the last session to offset that trend by devoting $16 million to expand residency opportunities for graduating medical students at Texas facilities.

The majority of that financing — $12.4 million — will be used to create new first-year residency positions in Texas or fill existing slots that are empty for financial reasons. Nelson’s legislation also sets aside $1.9 million in planning grants to help hospitals that do not have accredited residency programs evaluate what it would take to establish them. There is another $2.1 million in incentives for medical schools to encourage students to go into primary care.

“The message is out to any residency program out there that if you want to grow, you can grow,” said Stacey Silverman, interim assistant commissioner of the Higher Education Coordinating Board, which is charged with distributing the grants. “It’s not a finish line by any standard, but it is an excellent first step, and it gets Texas on the road to solving the physician shortage.”

The nation as a whole is facing a physician shortage. The Association of American Medical Colleges estimates that the United States will have a shortfall of 90,000 physicians within the next decade. The need will be particularly acute in Texas, which in 2010 had 165 physicians per 100,000 people, compared with the national average of 220.

The number of Texas primary care physicians — whose services prevent patients from developing more costly and harmful conditions — is particularly low. Texas does not have enough primary care doctors in 126 of its 254 counties, according to the United States Department of Health and Human Services, which sets a threshold of one for every 3,000 residents. The majority of those counties are rural.

The state’s new grants will mostly benefit hospitals looking to start residency programs from scratch, said Dr. Thomas Blackwell, associate dean of graduate medical education at the University of Texas Medical Branch in Galveston. He said the financing was not enough to encourage most teaching hospitals, including his own, to expand their programs.

“It’s not enough, because remember, it only pays for the first year,” he said. “So who is going to pay for the other years?”

Residency programs last three to eight years, depending on the specialty. The state’s first-year residency grants will provide up to $65,000 per trainee, covering each first-year resident’s salary. But factoring in other costs, like supervisors’ salaries and the expense of extra tests and procedures ordered by doctors-in-training, each position costs about $100,000 to $150,000 a year, Blackwell said.

“You don’t do graduate medical education to make money. Our members are mission-driven,” said Maureen Milligan, president and chief executive of Teaching Hospitals of Texas. Although teaching hospitals come with prestige, advanced medical technology and, in some cases, better health outcomes for patients, Milligan said most residency programs operated at a financial loss for the hospital.

“The challenge is going to be how do you identify new hospitals or other providers that would be willing to get into” graduate medical education, she said.

Most residencies are in urban areas, which have established institutions large enough to support the programs. In addition to the financial burden, rural hospitals often do not have enough patients to ensure residents of performing enough procedures to become accredited. As a result, the state’s rural regions have become increasingly underserved, as doctors are more likely to practice in areas similar to those in which they trained.

While some teaching hospitals encourage residents to team with physicians or clinics in rural areas, Wright said the state should explore expanding residency opportunities to those communities. Silverman said the coordinating board was open to awarding planning grants for hospitals to explore creating networks between providers in rural areas and whether that would provide adequate training opportunity. Ultimately, national accrediting agencies will have to determine whether those networks are sufficient.

While lawmakers may have made progress in the last legislative session addressing the physician shortage, medical providers say the Legislature must still establish consistent, sustainable financing for residency programs. And, they argue, it may need to set up programs with incentives for doctors to train in the specialties needed most.

Wright and Blackwell said Texas should encourage more physicians to go into primary care in rural areas by expanding the loan repayment program, which offers some debt relief to doctors who do so.

“While I understand the concerns of hospitals, I believe that this session they saw the Legislature make funding residency programs a top priority,” Nelson said, “and should trust that we understand how important it is to continue funding them in the future.”

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