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BY MICHAEL E. SPEER, MD, TMA PRESIDENT Medicaid in Texas is broken. I am sure some of you will agree with that statement more strongly than others. Medicaid plays a vital role for mil- lions of low-income Texans. But I doubt I can find many Texas physicians who would argue that our Medicaid system does a good job of providing health care for Texas’ poorest citizens. That’s one of the reasons why I wasn’t terribly surprised

when Gov. Rick Perry announced that Texas will not partici- pate in the expansion of Medicaid to single adults. Setting the politics aside, just for a moment, let’s look at the facts in front of us. First, there’s no question about the need. One in four Tex- ans younger than 65 today have no health insurance coverage. Hospitals and physicians are required to treat patients in emer- gency situations under EMTALA. Insured patients, state and local taxpayers, and the hospitals and physicians who provide the care share the cost. Our recent survey results, released the same day Governor

Perry rejected the Medicaid expansion, further document the problem. The share of Texas physicians who say they accept all new Medicaid patients has fallen from 42 percent in 2010 to 31 percent today; that’s less than half the 67 percent who reported they would take all new Medicaid patients in 2000. If health system reform were to increase the number of pa- tients covered by private insurers and Medicaid, one in five doctors (and one in 10 primary care physicians) say they can- not serve any more patients than they do today. More than half of physicians report their practice could take more privately insured patients, but not more Medicaid patients. Physicians increasingly are forced out of the Medicaid pro- gram because the payment does not cover the cost of provid- ing the care. As Texas physicians, we are deeply concerned about our most vulnerable patients. We don’t want a faulty system to force us to close our doors to them. But that’s what is happening. If doctors can’t participate because of the system, then Medicaid is broken. You cannot fix a bro- ken system simply by making it bigger. We have to make it different. Let’s look at the political realities for


a moment. Whether you agree with his decision or his rationale, the governor was extremely clear and pointed in his announcement. His anti-Washington, states-rights rhetoric was consistent with

20 TEXAS MEDICINE September 2012

the message he has delivered for years. I don’t see him budg- ing on his opposition to expanding Medicaid. What about the November elections? We can say with a fair

degree of certainty that the voters will elect a Texas Legislature that’s even more conservative than the one we had in 2011. I don’t see us ending up with a House or Senate that would push back on the governor on this issue. Meanwhile, if President Obama wins reelection, the Repub- lican majority in Texas will likely continue to rally around the governor’s push to protect constitutional sovereignty for Texas. If Mitt Romney wins, we can expect a full-scale attack on the Patient Protection and Affordable Care Act. But we still have patients to care for. They’re still showing up in the emergency departments sicker than they would oth- erwise be. We need to build a system that will work so poor Texans, often with multiple health problems, can see their doc- tors when they need care. Texas needs to fund the system so that Texas physicians can take care of those patients.

I do not know what that system looks like … yet. But I do know we need to fix it so doctors come back. We need to win realistic payment rates, we need to reduce the stifling state bureaucracy, and we need to eliminate the fraud-and-abuse witch hunts.

I also know we have plenty of very smart men and women

who are TMA members, who serve on the boards and commit- tees of the Texas Medical Association and our state specialty societies. We have plenty of bright and capable staff members who understand the politics and the economics. Let’s be cre- ative about this. We have just about four months until the Texas Legislature

convenes in January 2013. We must have a workable plan … something that will work for our patients and our practices and something that will fit the political exigencies of the time … ready to present by then. By the time you read this, TMA will have convened a Physi- cians’ Medicaid Congress to devise that plan. There has to be a better way, and I’m determined to find it.

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