Liveblog: Health & Human Services at The Texas Tribune Festival

We just launched into Texas vs. Obamacare with Texas Attorney General Greg Abbott. 

Abbott asking people to follow him on Twitter @GregAbbott_TX. "I was tweeting immediately about what was going on from the United State Supreme Court courthouse" after federal health reform ruling. 

Abbott says in order to get vote of state of Nebraska, Congress cut Nebraska a break — "publicly sanctioned bribery" from the floor of the Senate. 

"The theme you will see develop, evolve and expand... is by that time, states attorney general were emboldened to ensure we would take action against any possible legal violation that would be foisted upon this country." 

Abbott describes attorneys general filing a lawsuit one hour after Obama signed federal health reform. When they did it, he said, they were "hastily dismissed." "Pretty much every pundit in the country" said the claims they were waging had no chance. 

Criticism continued, he said, up until the day the case went to trial — which had expanded from 13 states to 26 states. "More than half the states in this country were suing their own government." 

Abbott says he knew it'd be "roller coaster" even at the time they were waiting for the U.S. Supreme Court to issue it's decision. First, Justice Roberts on U.S. Supreme Court declared anti-injunction tax law didn't apply to federal health care law because if everyone could challenge a tax law before it was taxed, they could effectively deny the federal government the revenue it needs to keep the doors open. Then, he got to the individual mandate, "the issue that dominated" the case and be the "defining constitutional moment."

Abbott says he knew the "decision was in our hands, only be to stunned two minutes later as the Justice continued reading his opinion." Abbott says Justice Roberts contradicted his earlier comments that federal health care reform wasn't a tax, by declaring it was a tax, and therefore the individual mandate was constitutional. "It was almost a Hamlet-esque like moment, to tax or not to tax," he said.

"If you engage in an activity, Congress can regulate it. If you refuse to engage in an activity, Congress cannot regulate it," said Abbott, explaining the commerce clause that allows the federal government to regulate state trade. The decision to mandate everyone purchase health insurance is "historic in its reigning in of the commerce clause."

"The takeaway the attorney generals have of this decision," says Abott is that they will be more thoroughly evaluating laws passed by Congress under the commerce clause. 

"Never before has Congress been allows to tax someone for refusing to undertake an activity," says Abbott. "Here's the bizarre thing about this decision, in order for an act of congress to be considered a tax, the primary goal of that act has to be one of raising revenue for the United States government."

On the issue of the Medicaid expansion, Abbott explains the U.S. Supreme Court's decision reflects an understanding that "states must agree to the terms of their contract," and cannot be "coerced into taking the Medicaid expansion that is ordered under Obamacare."

Abbott compares expanding Medicaid to the Hotel California, "you can check in, but you can't check out," because if Texas agrees to expand the program under federal health reform, "you're going to be stuck with it."

"Once we are in the program, we will forever be stuck by the terms of that program," even if the federal government changes the rules of the program, says Abbott. 

"States rights are alive and well and expected to be asserted going forward," says Abbott.

The legal fights aren't over says Abbott, citing forthcoming challenges to details and rules set by U.S. Health and Human Services Department coming out of federal health reform. For example, Texas' challenge on the mandate for insurers to provide contraceptive coverage for employment-based health care.

"I believe that the legislative ability and the political will exists to overturn Obamacare...if Mitt Romney is elected," says Abbott. Citing anecdotes and a study by Texas Public Policy Foundation, he said there will be more challenges to accessing health care if the law continues. 

"With a law that requires so many more people to get plugged into the federally provided health care system," you're going to find fewer providers available or willing to treat those patients, says Abbott.

Abbott says more businesses may choose not to provide employment-based healthcare, and pay penalty tax instead, as a result of federal health care reform. 

Asked about his political intentions for 2014, Abbott says, "I have my hands full..so my focus is solely on what I'm working on right now." 

If Texas accepts a contract to expand Medicaid, the federal government would have control over setting rules from the program, "preventing Texas from being able to control its own destiny," said Abbott, so the better angle is one that would give Texas flexibility. 

Student asks Abbott for advice for pre-law students, he says, "find out what is in your heart about what interests you and what you want to do." Regardless of your political affiliation, following the law will help you overcome challenges.

For the "cynics" out there, someone asks if the lawsuits Abbott has filed against the federal government are "pandering" to Tea Party activists or politicizing the Attorney General's Office. Abbott says he's needed to take action because the intrusion on states rights by Washington is "unprecedented." 

Gives example of Voter ID. Although SCOTUS approved constitutionality of Voter ID laws the year President Obama elected, a federal agency still shot down Texas' Voter ID law.

Asked about the constitutionality of Medicare, Abbott says  "Medicare...seems like it would be constitutional."

Abbott says Chief Justice Roberts "was reaching to try to find some ground upon which he could rule the law constitutional," when he ruled on the federal health care reform.

And that concludes Abbott's talk. Up next The Affordable Care Act is Constitutional. What Now? featuring four health policy experts, Anne Dunkelberg, associated director of the Center for Public Policy Priorities, Dan Stultz, president and CEO of the Texas Hospital Association, Thomas Suehs, former executive commissioner of the Texas Health and Human Services Commission, Arlene Wohlgemuth, executive director of the Center for Health Care Policy at the Texas Public Policy Foundation.

Our moderator Bill Sage, health policy expert and University of Texas professor, kicks it off by asking panelists for honest, short answers: Name one thing about health reform that all of you ought to agree about. 

Dunkelberg: We need to get the costs of health care under control. Stultz: Agrees with getting costs under control. Wohlgemuth: Health care reform is needed. Suehs: Current system is not efficient and needs to be improved.

Dunkelberg: We need to get the costs of health care under control. Stultz: Agrees with getting costs under control. Wohlgemuth: Health care reform is needed. Suehs: Current system is not efficient and needs to be improved.

What can you not believe about federal health reform? 

Suehs: That we’d expand Medicaid before reform.

Wohlgemuth: That federal government can solve the problem.

Stultz: That 26 percent of the population is uninsured and Texas might not pass legislation to change that.

Dunkelberg: That it is not a good and needed thing for the us to have an explicit system of guaranteeing financial access to standard health care.

Sage explains the Patient Protection and Affordable Care Act, says take home teaching point is that, "this federal law is extraordinarily ambitious," because it tries to do something about health insurance coverage, health care delivery and health.

PPACA uses "magic wand" to ensure insurance coverage for the uninsurable, says Sage. Asks Suehs about his thoughts on the cooperation between Texas and the federal government on setting up health insurance exchange. Suehs says state shouldn't rush to set it up, because there are many complex issues.

Dunkelberg says federal authorities are committed to giving states latitutde, and currently, only six states are prepared to set up health insurance exchange. She says, the only way Texas will get the maximum benefits from state health insurance exchange is if Texas also revamps Medicaid-eligibility. 

Wohlegemuth says there's questions over whether it's even legal for the federal government to set up a state health insurance exchange. She says, "complexity equals cost," and adding complexity to Medicaid program just adds to cost. "I'd take a step back and look at what the federal government is not doing currently in Medicare and Medicaid," she says. If the government can't control massive fraud and abuse occurring now, she questions whether the government can set up an efficient system.

Stultz says he doesn't think Texas needs to go into the exchange trying to do everything.

Suehs says best estimate, even if Medicaid is expanded, is that there will still be three million people without insurance, because we still haven't addressed some of the fundamental deficiencies of the system.

Sage explains Title II of PPACA has variety of provisions to make healthcare affordable, including expanding Medicaid. Wohlgemuth says expanding Medicaid insurance doesn't mean those patients would have access to care, because the current primary care network would not be sufficient to cover the additional enrollees and future doctors would have less incentives to go into primary care.

"This is in indictment of the Medicaid program," because already people enrolled in the current program have problems getting access to care, says Wohlgemuth, and adding three million people won't help access to care. "The system has failed."

Stultz says he disagrees with the notion Texas shouldn't expand something because you may not have the capability currently, and the state should "rise to the challenge." He says the presumption health care coverage doesn't equal access to care bothers him, because the numbers suggests that when more people have health care coverage, more people have access to primary care and fewer people end up in the emergency room.

Sage refers to the ball point pen as "the most expensive medical technology in the world," because the administrative processes of the current medical system are not efficient.

"Care is never wasted, care is never futile," says Stultz. He cites research that points to ways to reign in costs, such reducing overtreatment, failure to consolidate care, fraud and abuse.

Stultz says you can't penalize patients for going to the emergency room if we don't have available medical homes for patients to get primary care. 

Suehs brings up the pay-for-performance measures passed last legislative session, says the debate should not be on whether the state is providing health care, but how health care can be more efficient and more equally financed. 

Dunkelberg says ,"I have a little bit of fear right now," because when managed care was proposed 20 years ago, it was supposed to reward quality, but instead, it "made people richer for providing too little care." The free market hasn't made health insurance more affordable, as evidenced by the 26 percent of the population that doesn't have health insurance, says Dunkelberg. 

Wohlgemuth says the consumer can control costs, so her goal is "to reestablish the financial relationship between the patient and the provider." She agrees there's not a free market system right now, and by employing a sliding scale for payments, rather than expanding Medicaid, an all or nothing entitlement program, "that marketplace will be rejuvenated and we'll start seeing the costs go down."

Now they panel moves on to discuss how the PPACA addresses community health, such as smoking and obesity problems. 

"The deck is stacked against us," because our bodies crave salt, sugar and fat, says Dunkelberg, and with the free market, "you can make a lot of money selling foods that essentially are addictive." 

So how do you improve community health without taking away consumers' freedom?

Wohlgemuth makes an analogy, saying paying for antibiotics out of her own pocket forces her, as a consumer, to realize how important it is to follow the doctor's orders to use it until the end, so she doesn't have to come back and pay for more.

Stultz brings up the tax on cigarettes. "If you look at the damage done [by smoking], it's comparable to the diabetic model," yet we don't have any disincentives or taxes to eduate the public on reducing obesity, says Stultz. "It's phenomenal that we somehow think diabetes is going to be taken care of."

Sage asks: has the political climate become too toxic to make actual progress on health care reform? Dunkelberg: Maybe, Stutlz: Yes, Wohlgemuth: No, Suehs: No.

Medical student asks given the current political system, assuming Obama is re-elected, is there any possibility the federal and state governments could compromise on health reform? Suehs says yes, there could be compromise, but Texas leaders don't want to expand Medicaid until the performance incentives are effective.

And that's it! Coming up next: The Future of Health Care Policy. The Tribune's lovely editor, Emily Ramshaw will be moderating a discussion between Kyle Janek, executive commissioner of the Texas Health and Human Services Department and Chris Traylor, his right-hand man/chief deputy commissioner of the HHSC.

Ramshaw: What's next for Texas? Perry compared Medicaid to the Titanic last night, said he won't expand Medicaid. Where do you stand and where do you see the future of Medicaid?

Janek says "things are so dramatically off kilter right now...we don't have the choice of doing nothing, we have to do something different." Federal reform presents opportunities, but Texas will work with federal government to get more leniency, he says. Medicaid is like the Titanic, and you can't put more people on it until you change the cost curve.

Will Texas accept the $100 billion to expand Medicaid?

"The governor needs to keep the message simple," and the governor is correct to say they won't expand Medicaid as its currently proposed, says Janek. "I consider the governor to be my boss, I want to go to him and say the Feds have given us some latitude...is that enough latitude for us to now press forward?"

Traylor says the Medicaid system is not sustainable, either administratively or with the increases in expenditures throughout the program. "If we don't look at it differently, then the system itself can never, ever be sustainable," he says.

Ramshaw: How underfunded is Medicaid going in to the current legislative session?

Janek: Immediate shortfall when lawmakers come back is about $3.8 billion. That means caseload has increased, services has gone up and so the cost is more than lawmakers assumed.

25 percent of Medicaid enrollees use the majority of the assets says Traylor. That's the aged, blind and disabled population. And most of those funds are for acute care, not long-term care. If we look at the linkages of how that care is delivered, could find savings, he says. 

On the question of Medicaid fraud - have lawmakers been too hard on providers by cutting off funds? Should Texas be doing more? Janek says, "yes to both." Texas wants system that tests fraud and abuse early, such as patterns of wrongful administrative coding. And then Texas can use those techniques to find purposefully fraudulent providers, such as the orthodontists who put braces on kids, but couldn't provide medical records to prove that care was medically necessary. "The dog ate the X-Rays."

Ramshaw: The LBB has said family planning cuts will cost the state money, because there will be an increase in Medicaid births as a result. 

Janek says the new Texas Women's Health Program will save money in the same way if you provide the services and avoid births. "I'm confident our challenge is to make sure we've got that good broad network of providers," says Janek, "...so we're busy getting a robust network together."

Moving on to future efficiencies. Traylor says they've asked their "federal partners" to allow pilot program to combine Medicaid and Medicare services, so we can provide better quality of life and quality care while containing costs. 

Janek says the state needs to "come up with a new system to help deliver that care to those folks who aren't necessarily acutely sick, but they're chronically disabled," because if they were delivered good care in the first place, there'd be less additional costs, like caring for bed sores or infections. 

Janek says public hospital districts assess county taxes, therefore "uncompensated care" is actually compensated. "Uncompensated means nobody ever pays for the bill," he says. He suggests everyone who pays taxes for a public hospital district should have a card they could present to providers when they show up in the emergency room. He says, people who go to the emergency room frequently often end up in hospital clinics, which are utilized as a medical home. 

Medicaid managed care organizations are essentially a network of providers, says Janek. "We are ignoring our state-supported medical schools," which get a set amount of funding, rather than funding adjusted to the patient population they serve. "Let's give them money with a match, and the caveat is...take care of people."

"We need to both reward the medical schools to taking care of so-called uncompensated care," and foster an environment for them to produce a network of providers that we need, says Janek.

On proposals to get block grants from the federal government to run Medicaid and Medicare, Traylor says it'd be difficult with the system we have now for the state to take over those programs. Promoting consumer choice with a voucher system, might be a good alternative to what we have now, particularly if it allows us to integrate those two programs. Overall though, block grants "would give us an extraordinary opportunity," he says. 

"It's time for a fresh approach on how we do this, I don't know what it is...maybe we nee to do very innovative things like crowdsourcing," says Janek. 

How do your jobs change under a Romney or Obama presidency? "My job is to work with the tools that are given," says Janek, emphasizing there will be different challenges under each. "My challenge is to work with the hand that I'm dealt."

Regardless of who is elected, Traylor says hopefully they'll see the wisdom of giving Texas flexibility in operating health programs. 

Janek says they've had some success getting waivers from the federal government (1115 Waiver).  "I think we'll have some successes with CMS, it's a politically charged atmosphere," he says. 

Texas did not get approval for a waiver to have limitations on certain services. Janek says he'd rather have someone pay for a broken arm in some cases, because "the goal should be that no one gets bankrupt because someone in their family suffers a devastating illness."

A San Antonio physician says because other physicians in his specialty don't accept Medicaid patients, his practice has a disproportionate number and Medicaid reimbursements don't cover his costs.

Traylor responds: In September, there was a 45 percent increase for children's services and 10 percent increase for adult services."This is an area we're goign to have to strategically attack, because we know it's not completely reimbursement rates," he says, adding there needs to be a discussion with physicians on why they take Medicaid patients or why they don't.

Janek says right now, they can't change reimbursement rates depending on the proportion of provider's practice that is Medicaid patients. Usually, high-volume Medicaid practices are in underserved areas, so when reimbursement rates reduced, it does affect access to care. "What we don't want to have happen is practices close because they're so dependent upon Medicaid," says Janek.

Question on how HHSC will address acute care costs for disabled and whether the Legislature will increase attendant wages to ensure access to (less costly) home care.

"Maybe we should...pay [attendants] to take care of somebody, not for every hour or 15 min increment...but in terms of meeting their needs," says Janek, qualifying he cannot speak for the Legislature.

That concludes this session. After lunch, Family Planning: The Great Debate.

Starting soon... Emily Ramshaw will be moderating Family Planning: The Great Debate featuring Rep. Donna Howard, D-Austin, Rep. Bryan Hughes, R-Mineola, Kimberly Carter, assistant professor at the University of Texas Southwestern Austin Programs, Joe Pojman, executive director of Texas Alliance for Life.

To start things off, Ramshaw asks are contraception and abortion synonymous for the Legislature? 

"To confuse the two would just be willfully ignorant," says Carter, who clarifies that contraception prevents unintended pregnancy and thus, termination of unintended pregnancy.

"No state dollars go to pay for abortion, period," says Howard, so "that's not what this is about."  The cuts to family planning that were intended to stop abortion just cut off access to other women's health services, says Howard. 

Hughes says he agrees contraception is not the same as abortion. "The concern is about money going for abortion," he says, because if an organization that performs elective abortions receives state dollars, it frees up other funding at the organization to direct towards abortion services.

Howard says, "those that provide abortions as well as family planning services have separate operations," and there is "no evidence of shifting of funds."

Hughes says there's allegations from former Planned Parenthood employees that there has been cost shifting. It's hard to argue that cost shifting can't happen, he says.

"Just because they can, doesn't mean that it's happening," says Howard. The organizations are getting paid a fee for a service, so none of the money that was cut is having any impact on the delivery of abortions because it is a separate budget.

Pojman says the state should not give funds to organizations that provide abortions. 

"The staff at Planned Parenthood will frequently say, can I schedule you for an abortion," says Pojman. Members of the audience loudly disagree.

Carter counters that doctors should be able to talk to patients about all of their medical options, and many patients do not chose abortion. Only 1 percent of women with unintended pregnancy go forward with adoption. Abortion is "an unfortunate option, but it's an option," says Carter

Pojman says he's cheering the creation of a state-funded Texas Women's Health Program, and he's mystified by the lack of support by pro-choice community for that program. 

"We have the highest uninsured rate in the country, if we want people who do not have the means to provide their own health care to be able to be healthy productive citizens then absolutely we need to be looking at supporting family planning," says Howard, "...by investing that minimal amount of several hundred dollars, we can prevent the pregnancies that might have occurred otherwise...so it's also fiscally conservative."

Here in Texas, majority of unanticipated pregnancies are among 18 - 24 year olds, uninsured, low-income minority population, says Carter. "If we want healthy Texans...who are not going to continue to be a burden on the social welfare system," then we should champion ways to make individuals responsible for their contraception and personal health.

Hughes says he's "troubled by some things that he reads," -- not from this group -- on keeping certain populations from having children (disgruntled noise from the crowd). "I don't question where you guys are coming from at all."

Other clinics besides Planned Parenthood closed as a result of the family planning cuts and the tiered funding system implemented by the Legislature, says Howard. The Legislature could have reduced money to Planned Parenthood clinics through the Tier system without cutting total family planning funds, she says.

Hughes says they have new providers in his district as a result of the Tier system. The funding that was cut "went to pretty noble places," such as autism programs, says Hughes. 

If you compare Planned Parenthood clinics to other types of clinics and providers, they do not provide as comprehensive or quality care, says Pojman. 

Ramshaw: Is the effort to run Planned Parenthood out of business?

Hughes: If Planned Parenthood wasn't providing abortions, I wouldn't be opposed to giving Planned Parenthood family planning funding. "They're the largest abortion chain in the country, and that's why they're targeted."

Tax dollars should not be going to an organization that promotes abortion as a method of family planning, says Pojman. El Paso's Planned Parenthood clinics were shut down because of mismanagement, he says, emphasizing he does not think Planned Parenthood provides comprehensive care. 

Pojman says, in no area is Planned Parenthood the only provider and there are many other providers in the Women's Health Program. 

Carter interjects, says her entire staff at federally-qualified health center decided they could not sign up for the Texas Women's Health Program, because they would have been forced to agree to not "promote" abortion under the threat that all the facilities Medicaid funds could be taken away if violated. "I don't know who promotes abortion...what were you asking us when you said, 'do you promote abortion?'...because doctors do not promote abortion, I don't think Planned Parenthood promotes abortion," says Carter.

"As a practical matter...it's about abortion as a means of birth control," says Hughes. "No one campaigns on denying health care for women, people do campaign on standing against elective abortion."

"Nobody wants abortion to be a form of birth control," says Carter. 

If you don't want abortion, then you should be for contraception, says Carter. Everyone wants people to have healthy, happy, loving relationships, she says, but "that's some kind of utopia that we don't live in, and I talk to these people on a regular basis, these are my patients." She says some of her patients are sex slaves, some are in abusive relationships.

Ramshaw: How did we get to where we are today? When did contraception become a political football? Has the Legislature gotten more conservative?

Hughes: "Money in the state budget has made us scrutinize more closely." 

Starting in 2003 conservative members began to campaign on this issue, says Hughes, and their constituents are concerned about state funds going to abortion providers. 

Sen. Jeff Wentworth was the last Republican openly supportive of women being able to make their own decisions when it comes to health care, says Howard. "It's become politically dangerous for Republicans to be in support of women being able to make those decisions, as we just saw Sen. Wentworth lose his race." She hopes women who have trouble accessing health care realize "it does matter who you vote for."

"We really misread the issue if we look at it in terms of access to family planning for women," says Pojman, explaining if Planned Parenthood ceased providing abortions it would be acceptable for those clinics to receive state funds. 

“The cuts that were made have no impact” on the number of abortions provided by Planned Parenthood, says Howard, all we’re doing is creating a situation where women don’t’ have access to contraception. 

Howard and Hughes disagree on whether number of abortions has decreased because of increased access to contraception. 

Woman asks men on panel: “What gives you the right?” Maybe men should be required—like they are with guns—to get a license proving they’ve been trained on family planning, she suggests. “What are you willing to do to educate men?”

Hughes agrees it takes two to make a baby. "I hear what you're saying, we believe that that unborn child is a human being with rights that need to be protected," he says, but that protecting the woman is also very important. 

Increased funding in contraception "doesn't lead necessarily to irresponsible behavior," says Carter. It does lead to a decrease in uninteded pregnancy.

Howard brings up an analogy made by a recent Houston Chronicle editorial, when teaching teenagers to drive you tell them to use a seatbelt. Studies show teaching teenagers about contraception actually delays sexual intercourse, she says.

Another woman asks about the difference between pro-life and pro-birth, when many poor women chose to have abortions because they do not believe they can provide a quality life for their children, particularly given discrepancies in education and health care for indigents.

"It's hard for us to make a judgment that a child born to certain circumstances...won't have a quality of life," says Hughes. 

Carter brings up studies that show a male child born to an African American teenager is more likely to go to jail than to college. Important for the Legislature "to not abandon these people," says Carter.

Pointed question to Hughes, do you support Medicaid?

Although he's for the program, the federal government should give states that money in a block grant, says Hughes. "It's not working very well, I wish we could get that money from the Feds and have local, creative solutions."

Joe Potter, a professor at UT that is conducting a three-year study on the results of family planning cuts, asks if Howard and Hughes have noticed similar feedback to what he's received, that the cuts will have a negative fiscal impact on Texas?

Howard says yes, for example, providers have told her some clients can no longer afford to see them because they have to charge for services that were free before.

Hughes says he hasn't heard that and it hasn't been an issue in his part of rural Texas.

Question: Wouldn't it make the pro-life movement stronger if it was based more on science and less on anecdotal stories?

Hughes says, "there are actual numbers that don't lie, that are out there." As the Legislature has gotten more conservative, there has been a reduced number in abortions, he says. A woman calls out from the audience saying that's doesn't mean the two facts are correlated.

We're kicking off Is Texas' Stem Cell Policy Good For Texas, with Leigh Turner from the University of Minnesota, State Rep. Rick Hardcastle, Andrea Ferrenz, executive vice president of CellTex,and David Bales, chairman of Texans for Stem Cell Research. 

Bales: "We need private/public partnerships.... We all need to get together. We really need to have a comprehensive stem cell legislation next session." 

Hardcastle, who has multiple sclerosis, has received stem cell therapy. "We changed the law last session to make sure none of the labs were selling you sugar water." 

Hardcastle said the Texas Medical Board changed rules to protect the taxpayers, and the patients. "We are now doing adult stem cell treatments" that "the governor and I both had." 

Hardcastle said Perry's adult stem cell therapy worked out ok; his was "miraculous." 

Ferrenz, with Celltex, the lab where Hardcastle got his adult stem cells harvested. "We can separate from that small amount of fat the patient's own stem cells." 

Turner: There are multiple policies in play in Texas. There are policies about the Texas Medical Board, about stem cell banks. "Texas has a problem. It's like Florida, California, Arizona. There seems to be a number of clinics in Texas... [where] evidence indicates they are not in compliance" with federal law. 

Stem cell tourism? Turner: "There's a dual phenomenon taking place." He said there are Texans crossing over into Mexico and getting access to stem cell procedures. "There's a Texan who passed away after receiving a stem cell treatment in Mexico."

Hardcastle says there's no reason some form of stem cell tourism couldn't happen in Texas — that the industry couldn't take off here — but that it should all be regulated and safe. "We want to make sure that the efficacy has some line there... so that we don't get into a Mexico problem."   He says every lab he "knows of... they're concerned with the same efficacy I am."

Ferrenz: "What's key for regulators... is to really look at the product, at what is going on in every individual circumstance."

Bales: Says he often hears from people who have had family members paralyzed in accidents, wondering if they should get stem cell treatments. He suggests they seek data, seek studies. "Be veyr careful, make sure you know what you're getting into, and that it works." 

Turner wrote a letter to the FDA about CellTex. "When it comes to CellTex, the reason I wrote to the FDA is that this looks to me like a clear example of a company that isn't in compliance with federal law." 

Ferrenz: Says Turner made a lot of allegations based on misinterpretation of the law. 

Ferrenz responding to Turner's allegations: "I feel like I'm doing a Food and Drug 101 class."

Ferrenz: Back in April we had two FDA inspectors come visit us. "They stayed with us for two weeks. They looked at literally everything we do... One of the things they saw was that cells go to physicians." "We've shown them, through dialogues, through materials, that we fall into ... this category that says we don't have to go through a pre-approval process."

Hardcastle: Goal is "to make sure the patients get what they're paying for." 

If someone feels like a therapy works miracles, and another feels like it does nothing, how do you judge? Hardcastle: "All of it is some degree of your chance of it working compared to the chance of it not working on someone else." 

Turner: "I worry about exploitation of hope" for desperate patients.  

Turner: "The question is, what are people consenting to? What are they being told?"

Ferrenz: "Patients have rights. If they have decided they want this therapy they have the right to do that so long as it does not contravene the law." 

Hardcastle: "I promised I wasn't going to get in a fight with Leigh." 

"We all go for the best we can get of what we think will work, and what our doctor thinks will work... We do a good job of regulating doctors in Texas, we now do a good job of regulating labs in Texas."

Turner: "Give them an appropriately designed clinical trial context. Don't charge them for something that hasn't been established."

Turner: "When someone is charged $25,000, $30,000... it's not something that's been established in any kind of meaningful way." 

Turner says he's concerned any U.S. company (i.e. CellTex) would partner with the Korean RNLBio due to its past controversies.

Ferrenz to Turner: "You throw out a lot of false information, actually." 

Ferrenz: "There are literally decades of research" on stem cells. 

UT's Bill Sage suggests that CellTex "should only get paid" if the therapy works. 

Hardcastle asked about MD Anderson's "moon shot" program - designed to cure 8 forms of cancer. He says being stuck in research is an endless process. 

Bob Kafka from ADAPT - "many people don't wake up every morning saying, 'oh my God, are you going to cure me."

"If there was a stem cell that would make a person without a disability, I'd probably say yes... You set a tone of inferiority." 

Hardcastle: As I see it the issue changes every time the Legislature meets in Texas. Ten years ago when I was diagnosed, the debate was embryonic vs. umbilical cord. "The question then becomes, are we protecting the citizens. Will that change? Every two years." 

Hardcastle says he's MS seems to be "in a permanent break" as a result of his stem cell therapy. 

And now, the final panel of the day: An 83rd Legislative Session Preview. The Tribune's executive editor Ross Ramsey will be moderating the discussion between Rep. Garnett Coleman, D-Houston, Sen. Bob Deuell, R-Greenville, Rep. John Zerwas, R-Simonton and Sen. Royce West, D-Dallas. 

Ramsey says the main thing he wants them to hit is federal health care: How does it impact Texas and how does it play here specifically, under President Romney or President Obama?

Coleman says it's hard to take things away from people, so Romney is already backtracking on which provisions he would undo. On option of extending Medicaid to adults, Coleman says the states and federal government both have power, so they'll have to come to some agreement. He thinks compromise will come through some sort of waiver.

West says he's uncertain of what will happen exactly because of the stances Gov. Perry has announced he'll take on the health insurance exchange and Medicaid expansion (that he won't do either). When you look at the number of uninsured, Texas has the highest rate of any state, he says, and he's certain of where Obama stands - everyone should have health care - and he thinks Texas should be involved.

Most Texans, regardless of whether they're Democrats or Republicans, are in favor of having young adults on their parents' health plans until age 26, says West, alluding to a provision in the federal health reform that's already taken effect.

Deuell says he believes in Medicaid and Medicare, but what he keeps trying to get people to understand is having health insurance and having access to health care are two different things. "Only 31 percent of physicians in Texas take new Medicaid patients," he says. As a family physician, he says he treats Medicaid patients that he cannot find specialty physicians to treat. "Being on a government program does not necessarily mean you're going to get health care."

Deuell says doesn't think expanding Medicaid to able-bodied adults is a good idea, but that decision will be left to the Legislature.

Commenting on how the federal government is "broke," Deuell says "usually what the federal government does is cut provider rates."

"Come on now, provider rates are set by the state of Texas," Coleman loudly interjects.

"You set the rate and that's the reality of it," says Coleman. If doctors aren't accepting medicaid patients, it's because the financiers in the Legislature set the rates to low. 

"We're going to pay for it one way or another," says West.

"You're talking to someone who advocated for raising the rates," says Deuell.

Zerwas says they didn't want to destroy the safety net, so they tried to keep provider reimbursement rates level. "The hospitals really took it in the pants," he says, commenting the hospitals took more cuts. "I'm not saying I like it necessarily, I do think its one of the things we have to try to figure out if we're going to sustain this program and sustain the safety net of providers," says Zerwas.

Ramsey: What does Texas have to do differently starting in January?

Zerwas: Goes back to the presidential question. No matter who is elected, he doesn't think children with pre-existing conditions should be denied health insurance coverage.

West: Romney has said he'll repeal that.

But Coleman points out Romney won't rescind coverage for young adults under 26 because the public is in favor of it.

"His running mate is for block granting all of it, and his running mate's plan is the plan that Romney would push forward even if you kept the preexisting stuff for children and the insurance until 26," says Coleman.

Ramsey asks what's the practicality of taking block grants?

Zerwas says, "it's like the dog that finally catches the car, what do you actually do with it?" Texas would have to focus on expected outcomes it wants to achieve, he says, and ultimately, decide how Texas is going to manage the program once they get funds. Also Texas should set up an exchange so the consumer can go to one place to understand what they're buying.

Deuell says they could design an exchange system - even though the Legislature got discouraged last session - that's more patient centered. SCOTUS said this law is constitutional, not that it's good policy, says Deuell.

Coleman says, "regardless of who is elected, the bill is in place and we have to meet the benchmarks." More than likely, "we'll be going down the road of implementing the Affordable Care Act... We also have to deal with the reality of the world...I think we can come together to make some real progress, even on the Medicaid expansion," he says.

On Gov. Perry's request for a block grant to managed Medicaid - will that happen?

Zerwas says, it's a possibility the federal government would say yes. "It does put upon us the burden to make sure we do it and we do it right," he says. 

On working with federal government on the 1115 Waiver, Deuell says, "we need to prove we can make that work." The problem with Texas is there's so many different needs and health care systems across the state, just because of geography, he says. 

"Essentially it's a cut," says Coleman of the block grant strategy. "20 years later we'll have the same dollars that we have today and that won't be enough." That'll end the "entitlement" issue that Republicans like Romney and Ryan bring up, he says, because there simply won't be enough funding. "If somebody believes, anyone believes...that the federal government is going to send us a block grant of $189 billion, they're just not going to do it." 

Deuell brings up the seeming success of implementing the 1115 Waiver, so far.

On the 1115 Waiver, Coleman says there's been agreement between Gov. Perry, President Obama and within Texas counties on carrying it out on the administrative level. Under the waiver there are benchmarks so that CMS has to agree to everything moving forward, not like the block grant, which would allow Texas to do whatever they want for five years.

Zerwas says they're talking about compensation based on quality, and patients having "skin in the game" so they'll make better decisions for their health care.

Ramsey brings up the Texas Women's Health Program, does the state land its WHP in a place that allows most women eligible for those services to actually receive those services?

The state is planning to fund the TWHP through the Medicaid expansion, says West, but Gov. Perry has said he won't expand Medicaid. 

Deuell says, "should government provide family planning?...Probably not." Although the answer is really no, the answer becomes yes because of the number of unplanned pregnancies that result if the government doesn't, he says. He cites facts that most births are to Medicaid enrollees. "There's an inherent conflict of interest," in allowing providers that perform abortion to receive family planning money, he says. "There is a network out of there of non-abortion affiliates that can provide care."

Zerwas says, "the money is there, the money can be found," to fund the Texas Women's Health Program. "The consequence of them not having access to family planning services results in unwanted pregnancies that go to term," which is how he'd want to see it as a pro-life person, says Zerwas. But he says there needs to be an adequate network of providers.

West questions again - where do we get the money? Is it coming out of general revenue?

Coleman brings up the "gag rule" on by providers in the TWHP, which says they cannot discuss abortion, says that ultimately discourages providers from participating. "What Republicans have said time and time again is they want people to have the choice of provider for the healthcare that they need...and now, people are advocating to cut out that same choice of provider, but it's not just Planned Parenthood it's a bunch of providers out there," says Coleman.

Asked if local counties could go forward with a Medicaid expansion, lawmakers say generally, yes, but there could be unintended consequences. Deuell for example says low-income people with employment-based insurane might switch to Medicaid, which would disrupt the market.

Questioner brings up Insurance Com. Eleanor Kitzman's decision to rescind balance billing rules on health insurers. Deuell says he agrees that's decision was wrong and he's following up on it.

Ken Janda who runs Community Health Choice says they have a network of providers in Houston and rural areas around Houston that take Medicaid patients - wants to correct assertion that Medicaid does not provide access to care.

"I'm very happy to hear what you're telling me, but it's not true all over the state," Deuell says. His personal experience is specialty physicians he refers patients to don't necessarily want to deny Medicaid patients, but "just as human beings, they can only see so many people." 

"The issue is overall we have too many uninsured people," says Coleman. 

"Able-bodied adult," who works for minimum wage says she can't find a health insurance plan that doesn't have high deductible - 40 percent of her salary. Asks Deuell where how he thinks she should find coverage.

Deuell says there's federal legislation proposed by vice-presidential candidate Ryan that would give people like her rebates to purchase private insurance. "It's recognizing that health insurance is expensive," he says. Doesn't want to bring up the word "voucher," but says it would allow patient choice.

West says that legislation gives money on the back end and doesn't ensure people can actually afford the care they need.

And that concludes our day. Goodbye!

Kolkhorst: "Still arguing over the $700 billion that was cut or maybe saved" from Medicaid -- Republicans say one thing on the campaign trail, Democrats say another. 

On federal health reform: "There's an old saying with women that you can't be half pregnant. We're kind of half pregnant thanks to Justice Roberts." 

She says the Affordable Care Act's foundation was the expansion of Medicaid — but the Supreme Court ruled states didn't have to do it. 

She said the spiraling cost of health care now has broad interest — largely because it's cutting into other services, it's crowding it out.  

Kolkhorst said it's been a "push and pull, ying and yang" about the cost of health care — the right sometimes is afraid of seeming heartless, the left wants to provide non-stop services. 

"The concern that I have is, you cannot talk about health care... if you're not talking about what the cost is. And that is driven mostly because we have this very large debt."

"If I have a thing for next session it's going to be about innovating."

"There's a number of states now that are really asking CMS... for some flexibility in the Medicaid program." 

She said some criticized her for carrying the Health Care Compact, but now seven states have passed it. 

"No matter who wins the next election... I do believe that both administrations will begin to reach out to states more with flexibility." 

She says she backs Perry on the statement not to expand Medicaid. 

"When we move forward toward the 2013 session we will have a better feel for the political landscape." 

If Obama is elected "we will continue to speak with CMS about flexibility." Possibility about expanding Medicaid must be tied to flexibility, she said -- not closing the door on the expansion.  

"Why would anyone in the health care business not want a block grant?" She said Medicaid and Medicare are pretty much an "open check." When you get a block grant, you have to fit in a box. 

"When I see Congress really wrestling... about what to do with health care I see fear in their eyes." She said they're farther away from the people who are living with these realities in their home states.

On Tom Suehs, Billy Millwee's departure from HHSC: "Some have called it kind of a brain drain at HHSC."

Many of us have discussed "is Kyle [Janek] crazy" for wanting to step into the new role. Says he's up for it. "His ideas and his enthusiasm, it's refreshing." 

Traylor has "been all around that agency, brings some real stability back to that position as well." 

"Obviously CMS has tapped the breaks with us a little bit. We're at a stalemate right now. We'll work it out after November." 

She says no matter who wins, she'll be reaching out to make waivers work. 

On Medicaid fraud -- "the F word." 

"I have to tell you that we're not even talking about overutilization right now. We're really talking about the word 'fraud.'" 

"People rob our tax dollars and nothing really happens to them." 

"You'll hear a whole lot about the pay chase model..." She said the state made mistakes with its approval model for orthodontia. 

"CMS... was paying for roughly our match, 60-40, and they are saying they want their money." 

Corporate practice of dentistry — "there are large hedge funds that are buying up dental practices" -- and they specialize in Medicaid kids. 

"I do think our dental board needs to be strengthened." 

Managed care in places like the Valley — "there's great pain" and it will be reevaluated during the session. 

On the 1115 waiver: "What amazes me is how many people, how many entities are chasing these dollars. It is really amazing. When you have that much money, kind of this gold rush, you're going to create a lot of entities that become dependent." She worries they'll be too dependent on government money, and might make the system less efficient. 

Some county governments are just now realizing their tax dollars are funding health care in other communities. "We need to look at it in a very fair manner... making sure we're making a system that is based on equity." 

The health care exchange called for by federal health reform: "I'm interested in the federal debate right now on what the feds will set up in their exchange. Is that enforceable if you don't set up your own state exchange? Some of this will be settled by the election. If Obama is reelected we'll have to make some decisions very quickly." 

Women's Health: "As of Oct. 31 things will change in Texas. The debate is who delivers women's health. I believe as we move forward we will see even more providers enter that." 

With Planned Parenthood not being involved, "in every one of my rural counties I have multiple providers of women's heatlh. In the small county of Lavaca, we have 7 providers in that county. Almost in every little town there. We are going to give women a different way to seek that service that we provide." 

The "food freedom movement," with Eddie Rodriguez. Efforts to oversee legislation around locally sourced, sustainable food. "What amazes me about this movement is all the people against it." She said she had to fight DSHS "tooth and nail," with font sizes, non smearable ink. "Now we see cities using their ordinance powers to keep people from being able to bake goods and sell them from their homes." Says Rodriguez is working on a lot of urban farming issues. 

Kolkhorst asked how the Lege will work with so many first-termers and new members: "The freshman group is coalescing, and they're coalescing very quickly." 

Freshmen "have a chance to figure out that they have a lot of votes" — they can be a powerful block if they choose to be. "It is going to be baptism by fire. The budget is looking better, but the whole adage, is there ever enough..." Plus the Medicaid months that weren't paid for. 

As far as Medicaid expansion and possibilities for flexibility: To make changes to long term care, to co-pays. "When you talk to physicians, one of the things they're hesitant in taking more Medicaid is that they don't show up for their appointments... They really don't like the entitlement mentality that they're seeing." 

What she didn't agree with most in federal health reform was the ratcheting down of health savings accounts. 

"I believe a system we have to look toward, when I talk about consumer driven, is more transparency in the system. We really need to understand the costs." 

The idea of making the poor more responsible for their health care and its costs. 

"I'm really insulted when people go, 'they can't handle it.'"

On Medicaid expansion, "I have to see what happens in the November election."

"If Romney wins, we have to see what Congress does. I have asked some, 'will they really repeal it?'"

"If Obama wins I do believe that we as Texans will have to survey the landscape." 

Not sure Texas will figure out Medicaid expansion issue this session.