The fact that the Obama administration approved Texas' request for a waiver from federal Medicaid rules was itself a surprise.
With a Republican governor bad-mouthing all things federal even before he launched his presidential campaign in August, political watchers speculated that approval for Texas to expand Medicaid managed care while creating funding pools to finance healthcare delivery improvement programs was unlikely.Under managed care, the state pays a set monthly fee to a health plan to provide care for Medicaid recipients, who select primary doctors from the plan's network. Federal rules, however, reduce the funds to hospitals under the Medicaid Upper Payment Limit in states that expand their managed care program.Under the five-year waiver granted in December, Texas will continue to receive Medicaid UPL money while increasing the number of Texans moving into managed care.Texas needs that money, especially after the Legislature made deep cuts in Medicaid during last year's session, including an 8 percent cut in payments to hospitals.Under the waiver, the state will move almost 1 million additional Medicaid enrollees into privately run managed care while still receiving billions in federal matching funds for hospitals.But how hospitals receive those supplemental payments under the plan created by the Texas Health and Human Services Commission will change. The federal funds will go into a pool for Regional Healthcare Partnerships.For the hospitals to dip into that pool, they will have to cooperate with the anchor hospitals that supervise the funds to increase primary care access and health quality.The waiver's changes to hospital funding will affect more than 300 hospitals that currently receive supplemental payments under the state plan."If they're not willing to provide care for the potential Medicaid eligibles or the indigent, they're not going to be in the plan, nor should they be in the plan," Executive Commissioner for Texas Health and Human Services Tom Suehs said in a Dec. 15 Kaiser Health News report.As helpful as it would be to remove politics from healthcare delivery, some hospitals may not receive as much money as they used to, and that will likely prompt some administrators to look for help from elected officials.If state lawmakers are wise, they will follow the obligatory "dang those feds" response with an "I'm sorry, but there's nothing I can do about it." The system has to change if there's going to be greater efficiency and accountability.The waiver represents what state officials have been demanding -- local solutions to healthcare challenges. And one of the challenges this new approach hopes to mitigate is the number of Medicaid patients using hospital emergency rooms as their primary care providers.Rural counties without public hospitals have a dearth of community clinics that can serve as medical homes to low-income and indigent residents. Tarrant County taxpayers can't deny how many out-of-county patients are showing up in the John Peter Smith emergency department for non-life-threatening illnesses or injuries.Under the waiver, JPS Health Network, the anchor hospital receiving the federal funds in this region, needs to partner with private hospitals and healthcare providers in surrounding counties to create medical homes/clinics for their residents.The Texas healthcare system needs to be ready to serve the newly insured individuals who will enroll in Medicaid or federally subsidized insurance starting this year under current federal law. Greater demands on the state's healthcare system are coming. The waiver savings will allow Texas providers to be creative and collaborative in developing a delivery system that will meet those demands for major coverage expansion.Have more to add? News tip? Tell us
