Is Texas the Model for Good Health Care Policy?

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Health care affects every single American. Republicans and Democrats argue over the best way to provide the essential service to the population.

But in Texas, a sweeping series of health care reform bills was able to make their way through the state Legislature. And it was done on a bipartisan basis.

Dave Balat, director of the Right on Healthcare initiative at the Texas Public Policy Foundation, was instrumental in getting that legislation passed.

“When it comes to good health care bills, there really shouldn’t be a left and right divide,” Balat says. “It should be about what’s best for patients.”

Balat hopes he can spread these bills across the nation.

“These [bills] are designed for communities,” he says. “They aren’t by any means Texas-specific. And I’m working with a number of states already to try to export these ideas and give them the support that they need to implement exactly what has been done.”

Balat joins “The Daily Signal Podcast” to discuss how his organization helped get these policies passed, and how other states can use Texas as a model.

We also cover these stories:

  • The U.S. enters a recession.
  • Sen. Joe Manchin, D-W.V., makes a deal with Senate Majority Leader Chuck Schumer, D-N.Y., on a tax-and-spend bill.
  • Justice Clarence Thomas will not be teaching his constitutional law class at Georgetown Law after student backlash.

Listen to the podcast below or read the lightly edited transcript:

Doug Blair: My guest today is David Balat, director of the Right on Healthcare initiative at the Texas Public Policy Foundation. David, welcome to the show.

David Balat: Good morning.

Blair: It’s great to have you with us. And we’re going to talk about health care today.

So, you have been instrumental in getting some really solid health care legislation passed at the state level in Texas. And this legislation sort of focuses on increasing Texans’ access to health care, improving those health care outcomes, and then making care more accessible and more affordable. So how does the legislation that you guys worked on do this?

Balat: Well, we did a number of things and a lot of credit goes to the membership in the Legislature, in the Senate and the House, and as well as the governor.

Probably the price transparency bill was the most consequential. Yeah. We saw what happened under President [Donald] Trump with the executive order that had hospitals disclose their pricing. We saw the fight, we expected the fight. We ended up winning in court, but we still didn’t see any compliance because the penalties were not significant enough.

So we knew at that point that we needed to do more at the state level and we certainly did that.

In a session that was so divided where we even saw Democrats get in a plane and end up in D.C., we saw incredible unity when it came to these efforts and these bills that came across on health care. Price transparency, for instance, we had 100% unanimous votes in support of those bills in every committee and in every chamber.

Blair: So it sounds like this was something that just, they needed to get the process through. It almost wasn’t even a right, left divide. It was just, nobody had proposed it.

Balat: Honestly, when it comes to good health care bills, there really shouldn’t be a left and right divide. It should be about what’s best for patients.

And that’s a lot of what we talk about in Right on Healthcare, is what’s best for patients. How do we make health care more affordable, more accessible, and how do we fix the safety net?

A lot of this effort that came about to improve health care and the initiative that came out of the House was the Healthy Families, Healthy Texas package. Those were bills of things that we could be for because, historically, as you know, conservatives and Republicans have been great about shutting things down and being opposed to things, but we needed to be in favor of things.

Why? Because we were pushing back on Medicaid expansion. And many people on the right were getting weary of being opposed to it and not having a solution.

So that’s what we gave them. We gave them a solution, but one of the categories of solutions had to be, how do we fix the existing Medicaid program so that it works for those for whom the program was intended?

Blair: One of those bills that you’re talking about here is House Bill 290, which streamlined the eligibility process for children to get coverage under Medicaid and then allow them to continue receiving coverage for up to a year after their eligibility expires.

Sort of playing devil’s advocate here, are children one of those groups that Medicaid was designed for? Because as you mentioned, conservatives are sort of wary of, like, expanding Medicaid as opposed to just eliminating it.

Balat: Correct. Yeah. No, it’s absolutely pregnant moms, the disabled, the elderly, and of course, children. That’s what Medicaid was designed for.

Blair: OK. So it’s a positive then that we were able to expand Medicaid into this category.

Balat: Correct. Because many of those populations don’t have—Texas is a big state. There are a lot of rural communities and they don’t have the ability always to keep up. And so for them to come on and then come off those roles because they missed an email or a text or a call is easy to do.

So having that continuous eligibility up to a year, and I think it’s actually six months is what we did, it keeps them on the roles so that we’re able to check their eligibility once that time period has ended. I think, prior to that, it was every three months and now it’s every six.

Blair: Speaking of those sort of vulnerable populations, there was another bill, House Bill 18, that reduces the cost of prescription medications for uninsured Texans. Now, I guess, to start out, how does that work? Is that more of that price transparency thing? Or how did the process work so that more Texans—

Balat: That’s actually a really innovative bill. It was proposed and championed by Dr. Tom Oliverson, who’s the head of the insurance committee in the House.

And the way that works is it relied on some of the ARPA funds that were coming from the federal government and having a fund there available so that when patients—and this benefit was only for uninsured patients in Texas.

So, we talked about how everybody was looking to expand Medicaid to help the uninsured, which it doesn’t because the supply of physicians and providers was not going to increase, which meant it was effectively going to crowd out the people who were vulnerable. So this was a drug program for people who were uninsured.

And so they could go in and buy medication for the after-rebate cost, which insulin would be $35, something to that effect. The state would make up the difference and then the PBM for the state would then refund the rebate right back into the state of Texas fund.

Blair: Is this a more effective way of reducing the cost of health care than to get these people insured?

Balat: I think we need to look at as many options as possible. That’s absolutely a great way of helping uninsured folks be able to afford and purchase the drugs that they need, whether they’re chronic or acute in nature.

But yes, no insurance, one of the things that was a big part of our messaging was coverage isn’t care. Having an insurance card does not mean that you have health care and we have got to stop conflating those two terms.

It’s important that we recognize having that shiny pretty card in our wallet does not mean that we have access. And that’s especially true as we’ve seen for Medicaid patients, because it’s so difficult to get in to go see the doctor. It’s so difficult to get in to get the care that you need, that where do they end up? They go to the ER.

Blair: OK. One of the other bills that we are looking at here as sort of this slate of packages is House Bill 133, which focused on maternal health and mortality.

You mentioned that pregnant moms are an at risk group. So given the aftermath of the decision to overturn Roe v. Wade, we’re going to expect probably more mothers to give birth here. What other programs should we be looking at at the state levels to improve maternal health?

Balat: Well, I think that’s something to focus on. I think we need to look at prenatal care and improve upon, again, access to doctors because so few physicians take new Medicaid patients.

I think the numbers in Texas, and I don’t know how this tracks in other states, but we have about 60% or just under 60% of physicians that are enrolled as Medicaid providers, but only 30% to 35% accept new Medicaid patients.

Why do so many people enroll, but don’t take Medicaid patients? It’s because they probably see Medicare patients that have Medicaid supplement. So it’s really there for their Medicare patients, but they don’t take new Medicaid patients.

So we have a third of physicians that take new Medicaid patients and a fraction of them are primary care and a fraction of them are OB-GYN. So we need to be able to provide additional avenues for these women to get prenatal care so that they can have the healthiest pregnancy that they possibly can with an outcome of a healthy child.

Blair: It seems like this bill or this slate of bills sort of expanded access to Texans every which way. One of them also expanded access for telemedicine. Telemedicine, obviously, kind of came into full force during the pandemic when it was very difficult to go and see somebody in person. How did the bill address those barriers to telemedicine and what were some of those barriers in the first place?

Balat: Well, there was a lot of opposition by a number of groups that there was a concern about telemedicine, whether the physician or medical professional on the other end of the line was meeting the same standards as the physicians in Texas, were the requirements substantively equivalent. That was one of the concerns.

Another was it really, there was a concern about turf. A lot of physicians here didn’t want to see their patients go see someone else, and it’s much easier and much more efficient to do that.

So, COVID eliminated a lot of those oppositions, and it’s a good thing. Now, are there concerns still moving forward about how best to use telemedicine? Absolutely. But I think overall it’s become more a part of a fabric of how we can consume health care and that’ll continue to be refined.

Blair: We’ve talked a lot about bills that made sense in Texas. And as you mentioned, Texas is a big state. It’s got considerations that maybe other states don’t have. Are these proposals something that you think would transfer well to, say, a Louisiana or a Minnesota, something like that?

Balat: Yeah. These are designed for communities. They aren’t by any means Texas-specific. And I’m working with a number of states already to try to export these ideas and give them the support that they need to implement exactly what has been done.

Blair: Are we seeing any states in particular that are really taking to that or that we might start to see these types of policies evolve?

Balat: Well, Montana did a lot with direct primary care. They’re looking at transparency for their next coming session. Wisconsin is looking at hospital price transparency, and also looking at prior authorization reform that we had in Texas.

And that has actually just been adopted by Dr. Michael Burgess at the federal level as well. He’s introduced a gold card program for prior authorization. So Texas has really taken the lead on that issue. And we’re seeing a number of efforts follow in the wake.

Blair: So we’ll have, probably, people who are going to disagree that the state is the best way to do this. They’ll say things like, “Medicare for all,” or, “The federal government should be in charge.” What is the counter to that?

Balat: Again, it goes back to what I was saying earlier about Medicare is insurance.

The one thing that I always tell people is that when you hear your politician say anything about health care, and predominantly at the federal level, when they say the word health care, I want that to trigger something in your mind. I want that to cause you to think and ask and question, are they talking about health care or are they talking about health insurance? Nine times out of 10, they’re talking about health insurance. And we have to make that distinction.

We hear all the time that health care is a fundamental right. When you have a right, you can’t compel the work of another for you to have a right. And that’s exactly what “Medicare for All” and people who are saying that health care is a fundamental right are saying. They’re saying they have to provide me services. They have to give me medical care. And that’s just not the way that it works.

They’ll often say, “Well, look at Canada.” Well, yeah, let’s look at Canada. I would love to have that discussion because you know what? They have extraordinary wait time. Some things they do well, but a lot of things they don’t, because if you need surgery, it could be a very long time.

If you’re in the U.K. and you need hip surgery and you’re 75, you may not be approved for it. And in fact, they just recently said, if you’re elderly and you have cataracts, you might get one repaired because they just don’t have the bandwidth for everything else.

There are invariably going to be procedures and policies that ration care in a government-run health care system.

Blair: Does that mean that the federal government has no role in the health care debate?

Balat: Preferably.

Blair: Fair enough. I guess. Yeah. Because the question then becomes, is the state the sort of excellent way, the best way to provide that care or do we even go even lower, do we go to sort of localities for providing this sort of service?

Balat: Health care is personal, not partisan. It’s not something done by governments. It’s done. What is health care at it’s most basic level? It’s the relationship between doctor and patient. Right? That’s as local as it gets.

So it’s important that we recognize where it happens, where it occurs, and how do we amplify or strengthen that relationship rather than drive wedges between it, which is exactly what’s happened.

Used to be your doctor used to look at you and put their hands on you rather than face a corner, tapping on a computer. I’ve many physician friends and I’ve told them, “Unfortunately, the policies of both government and insurance have made you overpaid, glorified date-entry clerks. And it’s unfortunate.”

Blair: I’m sure they responded positively to that.

Balat: It’s usually a nod and say, “Yeah.”

Blair: Interesting. … That raises this question, do doctors have any particular insights on, like, what would be the most effective way to start caring for their patients more intimately?

Balat: Well, let’s look at what’s working. We’re seeing a lot of surge in direct primary care and other forms of direct care.

Direct primary care is a subscription-based relationship with the patient and the doctor. It’s both clinical in its direct relationship, but it’s also financial. The payment is coming from the patient. I utilize it myself. And there are oftentimes when I say, “Doc, this exam has been about an hour long. I got to go.” As opposed to, “We’ve been here for four minutes and I’ve got to go see my next patient.”

The nice thing about that model is that physicians get to practice medicine. And right now, in this insurance centric model that we have—and I hesitate to even call what we have today health care—it’s a sick care model. It’s reactive in nature. The coding, how everything is functioning, it’s all based on a chief complaint and a diagnosis.

Whereas a direct care model is focused on preventative and proactive care. Most of the clientele for that model happens to be chronic disease patients because they get the time to ask the questions and think about how they can best control and improve upon what it is that they deal with on a day-to-day basis.

Blair: Maybe focus more on that ounce of prevention than the pound of cure.

Balat: Yeah. It’s real health care.

Blair: Interesting. Well, that was David Balat, director of the Right on Healthcare initiative at the Texas Public Policy Foundation. David, thank you so much for your time.

Balat: It’s been great. Thank you.

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