Liveblog: Health Care at The Texas Tribune Festival

Rocha opens by asking about last session’s increased funding for mental health programs. “Tell us about what was being talked about in the Legislature at that time,” Rocha says. Huffman says unfortunate timing with the Newtown tragedy “really brought us thinking about what can we do in Texas to address these issues.”

Lakey said DSHS has been able to address waiting lists, substance abuse and homelessness as three main accomplishments of that increased funding. “There really has been a number of programs that are having a significant impact over the past year,” Lakey said. Garcia speaks to the intersection of jail system and mental health system. “People who are mentally ill who are in jail are in jail because they’re sick, not because they’re bad people,” Garcia said.”

Luce said early intervention is important. Relying on emergency room treatment, he said, “doesn’t make sense economically, it doesn’t make sense for the person.” Solomon, speaking on mental health issues faced by veterans, said prevention and early detection programs have had a positive impact — and are “really empowering.”

“We’re looking for outcomes,” Garcia said. “There are many people in our facility who don’t need to be there.” Huffman, speaking about the jail diversion program, said people coming from emergency rooms were being targeted to have a case worker to help them “navigate life.” “All the things that we take for granted that we can do for ourselves, some of these people have issues so they can’t do it,” she said. But the biggest hurdle so far, she added, is housing, because federal and state regulations make the system difficult to navigate.

“We now need to get this discussion on a higher level on how to deal with this in the future,” Luce said. Garcia agreed, calling the costs of untreated mental health conditions “very onerous” to local communities. Lakey, asked about the state’s 10-year mental health plan, talked about the need to modernize the state’s mental health infrastructure. The inpatient system, he said, was designed “for where Texas was 75 years ago.” “What I would like to see is people being able to get care in the community where they live,” he said.

Solomon said there is now “so much stigma” associated with VA care for veterans that many were choosing not to seek mental health care. “The suicide rate for veterans is absolutely unacceptable,” he said. Luce, agreeing, spoke again to the need for early intervention. “We’re finally getting to the situation where we’re dealing with the emergencies, but how much better would it be if we could prevent somebody from needing a bed someday?”

Garcia said children are a crucial demographic to discussions about mental health care. Lakey, asked about the Speak Your Mind program, spoke about the state’s efforts to reach out to children with information about mental health care. “We need to do much, much more, but it is a good first step in trying to address the stigma and trying to reach out to kids,” he said. Huffman, on reaching out to children, said, “I think we’re still struggling about how to do this best.” “We’re going to have to come together and coordinate our efforts,” she said.

Garcia said there remained a “sense of urgency” despite increased mental health funding last session. “We’ve got to get the state moving in an immediate direction now, otherwise you’re going to have so many different initiative statewide that it’s going to be an incredible challenge to corral that.” Huffman said taking care of the mentally ill is both “the morally and the fiscally right thing to do.”

The first audience question is about insurance coverage for mental health care. Luce mentioned the tenet of the Affordable Care Act that requires parity for mental and physical health care. “That is not occurring, in my judgment,” Luce said.

The second audience question, for Lakey, is about Federally Qualified Health Centers: “Are there plans to put mental health plans within those clinics, and what would those services look like?” Lakey said that there have been “good examples” of FQHCs hiring mental health professionals, but that “we’ve got to get better at integrating those systems.”

The next audience question is about the kind of training police officers are given for emergency situations involving the mentally ill. Garcia said the crisis intervention response teams and mental health units are given special training for those events. But, he cautioned, any time law enforcement is brought into a mental health crisis, “there’s a great opportunity for something to go wrong.”

First question, from Ornstein: “Now that we’re into the actual implementation stage, how is that actually playing out?” Burgess said there is still a lack of information and transparency from the Obama administration on how things are. On Medicaid expansion, he said, “I think the states that have been somewhat circumspect are correct.” The problem, he said, is that “there is no actual money there to give to the states.” Schwertner also expressed opposition to the federal health law. “In general, I think Obamacare has overpromised and under-delivered,” he said. On Medicaid expansion, he added that it merited “honest discussion,” but that “expanding Medicaid in its current form is a nonstarter for Texas.”

Davis said a common theme since the rollout of the Affordable Care Act is “complete uncertainty,” citing the many legal challenges to the law. Coleman said the largely partisan divide over Obamacare “is a big opportunity to sit down and see where we agree” regarding a potential “Texas solution” to Medicaid expansion. “If we don’t do anything to fix what we’ve learned, that’s a tragedy,” he said.

Assuming no Medicaid expansion, Orsntein asks, “What is Texas going to do about that population?” Schwertner said, “We’re already doing things,” including the 1115 waiver and Medicaid managed care programs. He further cited Oregon study that found, despite Medicaid expansion, there were more emergency room visits. Janek said the uninsured rate doesn’t necessarily reflect rate of care. “We should not confuse who has an insurance card in their pocket with who is getting care,” he said.

Coleman disagreed with Janek, saying people who have health insurance enjoy certainty. “The best way to get treated is through a model that uses primary care first,” he said. Davis said Texas wants to work with the federal government “to try to find some solutions as long as we have the flexibility.”

Janek said he wanted to “dispel the myth” that if a person doesn’t have health insurance, he or she can only get care in the emergency room. He mentioned the 1115 waiver’s uncompensated care pool and the role of clinics in treating the uninsured. “There are more ways to provide more care to folks with or without insurance than ever before,” he said.

Burgess compared the Affordable Care Act to a bunch of bureaucrats gathering in “a small, windowless room” — “that’s been the problem,” he said.

Burgess suggests federal reforms that allow people to buy health coverage with pre-tax money, and to make all plans HSA-compatible.

“I think you cannot deny that that’s true — that we are not fully funding Medicaid,” Davis said. “But I think the cost drivers behind health care are on path to outpace what we spend on education.”

First question, for Janek, is whether HHSC is “setting up for failure” the ACA, citing the regulations put on federal navigators. “What is the purpose of these regulations?” Janek said that’s a question for the Texas Department of Insurance. Coleman called the rules “a barrier to having navigators.”

Second audience question, for Schwertner, is “how can we make the ACA work for Texas,” given that it is law? Schwertner said Medicaid expansion “is not the right path for Texas in its current form.”

An audience member asked why the state didn’t set up its own exchange. Davis said it was clear that Gov. Rick Perry would have vetoed a bill to that effect. 

Final audience question is why Texas is setting such low rates for Medicaid providers. Janek conceded the rates are not good, but said, “I have a certain number of dollars to provide for a certain number of people… We’re required to set actuarial sound numbers.”

On the changing landscape of medical education, Giroir says that the current medical education system has served us extremely well. But he added that the state is entering a new era that requires combination of disciplines. Medical schools are likely to implement more of this in their curriculum, Giroir said. Johnston agrees and said using increased access to information through technology is key to better medical education and patient care.

Podolsky said there is “competition in values,” explaining that the key principle of medicine used to be autonomy but working as a team plays a much bigger role today. Mitchell adds that working together should also lead to breaking down the “silos” that different medical fields operate in at the state’s universities.

Conversation shifts to community support for medical education. Watson, who helped spearhead efforts to fund UT’s new medical school, said people can get behind financially supporting the creation of a medical school when the need for increased medical services exists. 

Panelists now discussing the challenges of keeping medical school graduates in Texas and its growing population. Mitchel said Texas benefits from affordable medical education, but it needs to find a way to not lose doctors to other states. Podolsky suggests that this could be accomplished by creating more efficient pipelines that help medical students find residencies in the state.

Watson says Texas hospitals are helping by increasing the number of residency slots, but the hospitals need financial help from the state and federal government. While the state has taken steps to help, he says more can be done.

The panelists are now discussing the troubles primary care faces in Texas. Johnston said the “fee for service” system is primarily affecting primary care physicians who are getting less time with their patients, and this trend could be discouraging students to become primary care doctors. Mitchell said medical schools need to find a way to support those students who express interest in becoming primary care physicians, considering the shortage of doctors the state faces.

Moving to funding mechanisms for medical education, Girior says Texas medical schools need to find methods to financially help medical students so that student debt doesn’t keep them from pursuing primary care. Johnston says medical schools must embrace innovative care models that drive funding, including collaboration with hospitals.

Watson adds state lawmakers will have a surplus in the state’s coffers to work with during the next legislative session. This presents an opportunity to “restore and enhance what we need to do in terms of medical education,” he said.

Johnston is now giving an update on the construction of UT’s new Dell Medical School, which includes three buildings and a hospital. He said construction is set to be completed in the spring of 2016 and the first class will begin their degrees that summer.

The first question from the crowd is about the lack the female representation among medical school leadership. Johnston said the leaders of medical programs need to find ways to accommodate family bearing and acknowledge that underlying bias that exists in the workplace.

In response to question about why Texas schools don’t rank among the medical schools that most produce primary care physicians, Mitchell said the financial disincentives tied to primary care play a role. Podolsky and Giroir acknowledged that the state’s medical schools are facing a shortage in producing primary care physicians but agree that they’re actively working on this.

Final audience question is about the responsibility of medical schools to maintain physicians in clinical care. The panelists agree that they can play a bigger role in this. Johnston says schools that are partially funded by the community must think about this mandate. 

Discussion begins with the future of House Bill 2, which is being challenged in federal court. Alvarado said she hopes it will be ruled unconstitutional because new requirements lead to more unsafe abortions. White calls HB2 a victory because it increases the safety standards of abortions, specifically in cases of emergencies.

King, who owns an ambulatory surgical center, says she disagrees with the provision of HB 2 that require abortion facilities to meet the same standards as ambulatory surgical centers. She said the provision “might be too much” because it is a “tremendous regulatory addition” that comes with additional expenses.

White responds to Dukes’ comment by arguing that women who have not had abortions don’t have the same understanding about the psychological effects the procedure can have on women. Dukes then said that she has had an abortion.

Discussing the cuts the Texas Legislature made to family planning financing in 2011, Deuell says he opposed those and hopes that lawmakers returning to the Capitol in January “address the reality” of the state of women’s health care. Alvarado says Texas’ financing of women’s health “falls short” from an economical and fiscal responsibility standpoint, comparing the price of unwanted pregnancies to the cost of contraception. Dukes reiterates that the cuts were intended to eliminate abortion in the state because the cuts targeted Planned Parenthood, whose affiliates who do not perform abortions were prohibited from receiving state funds.

Looking forward to the upcoming legislative session, Ramshaw asks White if she is prewriting legislative on women’s health. White says she would like to pursue “tighter restrictions” for parental consent of minors obtaining abortions.

Alvarado says HB2 is the most harmful legislation to women in Texas history, adding that she doesn't see the need for the far-reaching legislation. "People complain about over-regulation," Alvarado said. "But when it comes to women's health, for some, you can't get enough regulation and enough government inside a woman's uterus."