Ben's Blog

For those legislators and staff who were planning on leaving the tumult in the capitol behind them, 5 p.m. Monday shocked many back to reality. The 82^nd Session had ended just as prescribed after 140 days of deliberations and debate.

But with major bills caught up in the time limit rules in the House and Senate, both houses adjourned without completing their state business.  SB 1811, which outlines the fiscal matters that make the state budget a working document, remained unresolved.  And, key legislative matters related to cost savings in Medicaid that are critical to the budget were also sidetracked by time and dispute.

Gov. Rick Perry’s proclamation issued Monday afternoon called for “an extraordinary session of the 82^nd Legislature” to start at 8 a.m. on Tuesday, May 31, to consider:

1.       “legislation relating to fiscal matters necessary for the implementation of House Bill 1 as passed by the 82^nd Legislature, Regular Session, including measures that will allow school districts to operate more efficiently”

2.      “legislation relating to healthcare cost containment, access to services through managed care, and the creation of economic and structural incentives to improve the quality of Medicaid services”

The announcement, though expected by almost everyone, still came as a shock and dampened the usual festive celebration accompanying the last day of the session. Tomorrow would be yet another day, just like the previous 140 days. The making of the sausage was not over.  There would be no vacations, no time off for staff, and no time to focus on other pursuits.

Legislators are paid a whopping $600 a month in salary, so those of more modest means are quite eager to return to their primary livelihood.   Extending their time in Austin, away from home, family, friends and job places an extraordinary burden on them, a major stimulus for them to get to work quickly and return home!

A special session can deal with only the subjects designated by the Governor.  And, each house can decide what is germane to that call. Special sessions can last no longer than 30 days. Traditionally, they move at a much faster pace than a regular session, obviously because the scope is much more focused.  Both houses still must refer bills to committees, have hearings, and follow other rules and procedures.   The Calendars Committee also still has to post the bills to be heard in the House. The Senate, however, may operate in a more relaxed fashion.

Bills introduced in a special session usually are bills that already have been heard but failed to get final approval.  The proposals receive new bill numbers and undergo additional alterations but remain aligned with the Governor’s instruction.

This is only the seventh special session to begin the day after sine die, and only the fifth in 50 years to be held in the 20-day post-session veto period. This is the 115^th special session since 1850.

The Governor also can add additional topics to this special session, or wait for the work on these issues to be completed and then call another special session. The news media already are reporting that the Governor is receiving pressure to add Texas Windstorm Insurance Agency , sanctuary cities, immigration issues, congressional redistricting and myriad other issues to his present call; on  Tuesday he added redistricting.

The Senate began the first day promptly, with eight bills in hand (someone worked throughout the night before) and referred them for consideration to the Senate Finance Committee and to the Education Committee.

Senate Finance began hearing the following this morning:

• SB 1 by Duncan. This was formerly SB 1811 and relates to fiscal matters/non-tax revenue bills containing a hybrid school finance allocation method.
• SB 2 by Ogden. This restores $34 billion to the budget bill that was contingent on the passage of SB 1811, which includes Foundation School Program payments to school districts.
• SB 5 by Huffman and Nelson. This bill will establish an Interstate Health Compact (which in turn could allow Texas to opt out of traditional Medicaid and set up its own program).
• SB 7 by Nelson. This is a Health and Human Services efficiencies bill that creates cost savings in CHIP and Medicaid.

The Education Committee took up the following:

• SB 6 by Shapiro which deals with curriculum, instructional materials allotments, and textbooks.
• SB 7 by Shapiro which is the former SB 12.  This bill provides school districts with management flexibility to save money.

In addition, there is a growing number of bills that are deemed by their authors to be relevant to the Governor’s call,  including SB 27 by Zaffirini, which calls for tuition revenue funding for university campus buildings. Of special importance to UTMB is HB 26 by Madden; this replaces HB 3459, providing for operating efficiencies in the correctional health care arena and for an offender premium charge estimated to produce about $13.5 million in revenue.

How long will the special session last? The simple answer is “until all the business is done.”  That could be a couple of weeks or more. There is a time limit of 30 days, so if the business is not finished, the Governor can call a second special session. 

Aren’t you enjoying Texas History and Government 101?

The 82nd Legislative Session has been quite a roller coaster ride — and it’s not over yet, with a special session starting today because the major fiscal matters bill needed to fund the  budget died in a Senate filibuster Sunday night.

By law, the special session can last 30 days; the Governor will determine what is “on the call” (i.e., what the Legislature is allowed to address). Some have lasted the full 30 days; others have finished in a few days, depending on the complexity of the issues in the call.   As of today, two large items are on the call:  fiscal matters needed to implement the appropriations bill, including school finance reform; and health care cost containment, managed care, and Medicaid structural and economic incentives.  

But for now, here’s an update on where things stand as the regular session ended. .

It seems like a century ago when Dr. Callender provided testimony before both the House and the Senate budget committees regarding UTMB’s remarkable resiliency and recovery from Hurricane Ike. Callender described a rapidly recovering campus, growing student enrollment and expanding clinical services, including recertification of the university’s Level 1 Trauma Center. He laid out the potential for an exciting future for the campus that many had previously thought should be moved, closed or otherwise diminished. He confirmed that the 120-year-old battle cry, “The University of Texas Stops for No Storm!” is still relevant.

And there have been plenty of storms in the 82nd Regular Legislative Session. From initial budget bills cutting UTMB funding by as much as 25%, to an audit critical of UTMB’s CMC division released in the first days of the session, to months of heated legislative debate on difficult health care issues with potentially profound impacts on patients and providers, to final hours when major revenue bills died and a special session loomed, the session was anything but smooth sailing.  

UTMB’s requests during the legislative session were modest compared to the requests of many others. The list was simple:

• Fund the Tuition Revenue Bond for construction of the Jennie Sealy Replacement Hospital that was approved in the 81st Session ($11 million)
• Permit UTMB to have continued access to the monies appropriated in the 81st Session for use related to Ike recovery and the FEMA match
• Treat our hospital’s base appropriation reductions in a manner comparable to other health-related institutions with hospitals, and
• Restructure the correctional health care contract to permit UTMB to contract directly with TDCJ, and provide a supplemental appropriation for UTMB’s CMC-related losses from FY10-11.

Achieving any of these objectives was a serious challenge given the guidelines under which the legislators were working: (1) no new taxes, (2) limited use of the Rainy Day Fund, (3) a conservative revenue estimate, and (4) a promise of “limited government/smaller government.”

The Legislature also found itself with new political forces in play. Many political pundits had predicted that the new “Tea Party” movement would have an impact on the 82nd Session, but most failed to predict just how powerful an influence this block of new legislators would have on the Legislature’s budget and policy agenda.

The appropriations process took many twists and turns, involving complicated interactions between several bills to produce savings, reform school finance and create revenue to fund the appropriations bills. The final result is a state budget that is about $15 billion less than the previous biennium, with only about 18 months of the next two years’ Medicaid being funded and public schools being $4 billion down from what the formulas would require for projected enrollment.   The Legislature openly acknowledged that it will have to fill in the FY13 Medicaid shortfall next session. All state agencies, higher education institutions and public schools took reductions.

Final appropriations for UTMB are much better than they could have been, given the circumstances. In the end, UTMB’s overall GR appropriation is a total of about $472M for next biennium, which includes $11 million for the proposed replacement hospital TRB debt service. UTMB’s hospital appropriation level was a major issue in the negotiations leading to the final total; thankfully the hospital reduction in the end was less than 15%, after being more than 25% for several months of negotiations on the bill.

In addition, UTMB’s Ike recovery funding from last session was carried forward for two more years, a critical help to UTMB due to the fact that some FEMA approvals are finalizing much later than expected. Although this funding had been appropriated last session, it was still a major step for the Legislature to give us access for two more years; they could have swept any unencumbered funds and used them for a host of other state budget needs. Even though that action would seem unlikely given the more than $1 billion in FEMA dollars these funds draw, there were several times during the negotiations when it appeared likely that UTMB would lose access to a portion of the appropriated funds. Thankfully, the Legislature’s final decision gives us full access through the coming biennium; we can continue with our Ike recovery as planned. This result was nothing short of miraculous work on the part of the Senate and House leadership and their staff.  

Financial issues and contracting issues surrounding the correctional health care contract have long been a source of concern for UTMB. Prior arrangements have resulted in all budget shortfalls being borne by UTMB until such time that the Legislature could meet and provide a supplemental appropriation to cover the amount of money UTMB had spent on offender health care. After much discussion with key leadership in the executive branch and both houses, changes to the correctional health care program will now place the financial responsibility for the program’s funding in the TDCJ budget. UTMB (and Texas Tech) will become vendors for health care services through a direct contract with TDCJ. The role of the correctional managed health care committee will be determined by TDCJ and will focus on dispute resolution, standards of care and review.

In addition to the budgetary issues related to UTMB’s future, many other issues affect our ongoing delivery of health care services. Funding for indigent care, trauma, diabetes and family planning were among the many reductions, along with reductions in Medicaid programs and rates. Higher Education Coordinating Board programs for graduate medical education and student loans were reduced. All of these affect UTMB and our fellow academic health centers.

In other areas of interest, there were no major scope of practice changes in the health care arena, except for an amendment that requires insurance companies to accept bills from chiropractors. There was no increase in scope of practice specifically for nursing or any of the allied health fields. Students were big losers in the state budget, with large reductions in student loan programs such as Texas Grants. Major reductions in funding were also seen in the women’s health care arena, especially for family planning programs.

As House Bill 1 finally left the Senate, the vote was 20-11. As House Bill 1 finally left the House, the vote was 97-53

Remember, it’s still not over.  The budget bills and major policy bills are on their way to the Governor, and he has until June 19th for vetoes.    And with the special session (possibly the first of several) starting today, anything can happen.  

As usual, stay tuned for the “rest of the story!”

As the number of days on the session calendar grows shorter, the Conference Committee members from the House and Senate finally came together to present their recommendations for all Articles in the state budget, with the exception of Article III (education). 

Of special interest to UTMB was the presentation of the budget related to correctional health care services. In Conference Committee, the amount appropriated for offender health care was $858 million (a compromise between the House and Senate’s proposals). The compromise budget specifically calls for a greater reduction in hospital funding, maintaining pharmacy funding at $51 million per year, and reducing $7 million in unit-based and mental health services for the biennium. The Texas Department of Criminal Justice (TDCJ) will ultimately be responsible for allocating inmate health care resources in a manner that will ensure constitutional compliance (federal) of services.

The Conference Committee also restructured TDCJ’s contracting process with UTMB and Texas Tech. The future role of the Correctional Health Care Committee and its staff will be determined by TDCJ. UTMB will negotiate a contract directly with TDCJ for operation of the community-based units around the state, hospital and clinical services,  and certain other core services such as pharmacy, telemedicine and electronic medical records.

It was late in the week before the House of Representatives was able to finalize SB 23 (administration of and efficiency, cost-savings, fraud prevention and funding measures for Medicaid and CHIP). This bill substantially restructures Medicaid, expands managed Medicaid, and provides for a variety of direct cuts and spending reductions amounting to $1.65 billion. A large number of amendments were attached to SB 23, which precipitated much discussion and debate. Funding for the Medicaid/CHIP program remains an estimated $4.8 billion short of the amount necessary for the biennium. 

Finally, fiscal matters bills SB 1811 (state agency appropriations and state funding mechanisms) and SB 1581(fiscal matters related to public and higher education) reached the House floor for consideration. The impasse between the House and Senate regarding revenue sources reached a resolution that seemed acceptable to executive leadership in both houses.  The compromise funding agreement for higher education came to $830 million. No agreement was reached on the funding for public education.

The “guns on campus” legislation was attached to SB 1581 as a rider. A point of order related to the germaneness of the rider on SB 1581was raised immediately and sustained. SB 1581 was sent back to the Senate for reconsideration.  This additional delay has resulted in the House deferring once again the business on Article III budgets.

The failure of SB 1581 leaves the state without a comprehensive plan for public education unless an amendment can be placed on a Senate bill immediately. Key leadership is in heavy deliberation regarding potential ways to resurrect legislation regarding public school finance.

The Conference Committee has agreed on SB1811 and approved Article III (education), with the following items relevant to UTMB:

-       10% reduction to formula-funded items (relevant to student and resident education)

-       15% reduction to the hospital and clinics’ base budget

-       25% reduction to all other special items in all health-related institutions’ budgets.

These reductions are fair when compared to the reductions at other health-related institutions.

The next step in the process is for the Conference Committee to vote out the entire state budget as soon as the printed version is available, which should be before the Memorial Day weekend. Both the House and Senate need to approve HB 1 in a formal vote before anything is official. In short, this means in theory (and politics) that some things still could change.

Currently on the horizon is the consideration of HB 4, the Supplemental Appropriations Bill. UTMB interests include the Supplemental Appropriations Request (SAR) for correctional care funding and the debt service for the Tuition Revenue Bond needed to construct the proposed Jennie Sealy Replacement Hospital and restore bed capacity to pre-Ike levels. UTMB has also requested an extension of time for the expenditure of revenue in HB 4586 (FEMA match funds) from the previous session.

It is NOT over until it is over!  “Sine die” is at midnight on Memorial Day, May 30, 2011. Anything can (and will) happen up until the moment the clock strikes midnight (and in some sessions they have unplugged the clock). 

Stay tuned.

If you want to get a real flavor for what is happening, go to:  www.house.state.tx.us  or www.senate.state.tx.us  during the time the House or Senate are in session and click on the live video stream. You will be able to follow the process and appreciate the pace and dynamics of the session.

It is hard to find the words to describe this past week in the Capitol. Unusual?  Tense?  A cliff hanger?  A nail biter! 

However you describe it, the action has been fast paced and lively. It has had everyone on the edge of their seat.

Last week the Senate passed out its version of House Bill – 1 (the budget).  The House and Senate versions of the budget still are at polar extremes. The House has proposed a lean budget as it set out to do. The Senate version identifies additional revenue sources and proposes the expenditure of more funds, especially in public education and Health and Human Services.

The House quickly took up the Senate version and began the conference process. House conferees are House Appropriations Committee Chairman Jim Pitts (R – Waxahachie), Rep. John Zerwas (R – Richmond), Rep. Sylvester Turner (D – Houston), Rep. Myra Crownover (R – Denton) and Rep. John Otto (R – Dayton).

To hold the conferees true to the conservative “no new taxes and don’t use the Rainy Day Fund” desires of the House during the conference committee process, the House adopted “motions to instruct” the conferees as follows:

• Conferees to adhere to floor amendments shifting family planning funds (Rep. Sid Miller)
• Conferees not to use any funds from Rainy Day Fund (Rep. Phil King)
• Conferees to keep amendment requiring separate legislation for fee increases (Rep. Phil King)
• Conferees to use funding in House version for Emerging Tech Fund for schools, libraries, and nursing homes (Rep. David Simpson)
• Conferees to prioritize any “found” money to public education and health and human services (Rep. Charles Perry)
• Conferees to prioritize funding for women’s health programs (Rep. Warren Chisum)

Although the motions to instruct are non-binding, they certainly reflect the mood of the House and indicate to the Senate (and all others) that the super majority in the House will likely resist giving up any of its newly found power during this 82^nd session.

On Monday morning the day began with the Senate announcing its conferees, which included Senate Finance Chairman Steve Ogden, (R – Bryan), Sen. Juan (Chuy) Hinojosa (D – McAllen), Sen. Jane Nelson (R – Flower Mound), Sen. Robert Duncan (R – Lubbock) and Sen. Tommy Williams (R – The Woodlands).

Conferees began meeting immediately and met diligently all week without reaching consensus on the very divergent budget proposals. Especially difficult to resolve are the differences in revenue proposed for public school funding and for health and human services funding. Late Friday, there was talk of a “special session” if agreement is not reached. According to precedent, the budget should be sent to the printers for formal codification by Thursday of the week (May 19, 2011). There is considerable skepticism whether or not that timeline is achievable.

This week also marked the deadline for bills to pass the House on second reading. Any bill not making the second reading by midnight Thursday meant almost certain death for the bill unless the author can successfully place it on another bill as an amendment. Most of the time, the author of a bill that has made it through the second reading will not agree to an amendment that may prevent the bill’s final passage (third reading).

So where does UTMB stand 17 days before session’s end? 

This is the most tense time of the session because others often attempt to add whole bills to existing bills still in the third reading process, which can produce unpredictable results. It is also a time that various desirable (or undesirable) items may find their way into fiscal matters bills. The House takes up fiscal matters issues on Monday or Tuesday, after letting the dust settle over the weekend while the conferees continue to try to reach some agreement on budget. 

The Tuition Revenue Bond Debt Service is in Article XI of the House budget and Article III of the Senate budget; overall it seems to have support in conference committee. Passage of this item in the budget will allow UTMB, with Board of Regents permission, to construct the Jennie Sealy Replacement Hospital.

UTMB Hospitals’ Base Funding remains a sensitive issue. The House version of the budget proposes a reduction of 25%, which would mean a $101M reduction to our hospital base budget over the biennium. We have prepared at the conferees’ request a "what if" scenario related to the impact of 25%, 15% and 10% reduction scenarios. We have also pointed out that the DSH-UPL that is generated by UTMB and placed into the state's General Revenue fund more than offsets any appropriation for our hospital base. Conferees will consider all options.

UTMB’s Post-IKE Recovery Funds ($150M from the 81^st Legislative Session) remain of concern since the appropriation expires June 19, 2011.  UTMB is working to encumber these funds before they expire and has asked that the legislature consider an extension to the time for obligation of these funds past the June 19, 2011, deadline.

Correctional Health Care proposals in the Senate version of the correctional health funding bill call for a direct contract between the universities and TDCJ, with enhanced accountability, quality assurance and financial audit. Funding in the Senate bill was increased to approximately $900M (remember that this is for the whole program including Tech and UTMB). This is still an overall decrease of about 10% from the last fiscal year. The House conferees are making efforts to increase funding from their original $700M based on the recent HHSC audit of UTMB's cost structures.

The next two weeks will be filled with continued negotiations between House and Senate to reach an acceptable budget. If that does not occur, a “summer session” is  certain.

I've written a lot about the state legislative budget process and its impact on UTMB over the past couple of months. Looking beyond our own focused interests, the Legislature is also dealing with a wide array of other issues that will certainly impact every Texan. There is much that bears watching as the session reaches its final days.

The Legislature has debated just about everything imaginable — from ultrasounds prior to elective abortions to "puppy mills" to raising the speed limit to 85 MPH to texting on your cell phone while driving. Guns-on-campus has been a very controversial piece of legislation that is currently blocked in the Senate because it lacks the necessary vote to be heard. But the Capitol has seen no shortage of gun enthusiasts calling on legislators to advocate for their right to carry on campus.  

We Texans are notorious for the preservation of our independence. So the Legislature most often reflects the mood and character of its people. If people want to drive 85 miles an hour, have a mini-armory at their side, text on the phone, chew, smoke or drink a sugar-laden soda on their way to a "puppy mill," these are matters the Legislature must consider, and the outcome may just reflect the will of the people.

Democracy is like that.

I "predicted" some things that would occupy legislators’ time as they went into this session, and I was right about some of them.

The budget process is far from being over and it has occupied more meeting time and involved more work than one can imagine. Countless hours of committee meetings, number crunching by the Legislative Budget Board, subcommittee activity, compromise and some complaints have kept members so busy that one wonders how they get anything done on all the other topics they must consider — but they do. They legislate and they appropriate.

Issues related to voter identification have certainly been dealt with quickly. New regulations will require voters to show photo IDs in order to vote. A driver’s license or other valid ID, such as a passport, will be required. Proponents cited the fact that photo IDs are required for all sorts of activities and that the same should be true for voting. Opponents point out that not everyone has a driver’s license and that procurement of a valid Texas license is difficult for some people in remote areas.

The requirement for women seeking an abortion to have an ultrasound done, view the ultrasound and wait for 24 hours prior to making a final decision about the procedure  passed the Senate in spite of vigorous opposition by a wide array of interest groups.

A bill to permit local police to establish legal immigration status during any routine contact with a person also passed, as did a request to the federal government requiring them to add a balanced budget amendment to the Constitution.

With large budget cuts looming over this 82^nd Legislative session, the potential changes regarding higher education are numerous. . Texas grants providing financial aid to students were reduced significantly. As one legislator noted, this increases the financial burden on students and their families as they seek to obtain an education, with greater impact on the more economically challenged. At the same time almost every college and university across the state has announced tuition increases to compensate in part for the loss of funding from state general revenue.

Redistricting is just now taking center stage in the House of Representatives. The Texas House of Representatives Redistricting Map was released for public view today. As expected, the map was met with immediate opposition from several groups worried about sufficient representation under the proposed districts. This rings especially true for Hispanic voters. There is no doubt that redistricting will be a source for major discussion and political compromise over the next few weeks. 

Gaming (gambling) proponents continue a wait-and-see vigil. There are only one or two bills on file and there has been no strong push to advance these bills toward full discussion on the floor of either chamber. With the deficit so large, it is easy to imagine that the Legislature would jump to gaming as a potential solution. But, the magnitude of the deficit is so great that the contribution gaming revenue would make to the budget is considered small. Nevertheless, one can continue to speculate that it will surface as a $1 billion solution in the next few weeks, and even as I write this, a bill is emerging that would place casinos in five major Texas cities and two coastal communities.

Although border security has been discussed, there has been no major new proposal on this topic. This is likely because anything that the state would do in that arena would take money, and dollars are woefully absent in this session.

Public school funding has clearly been the center of attention for discussion in both the House and the Senate. The original budgets proposed by both chambers could have resulted in a reduction in force of more than 300,000 teachers. This in turn would require teachers to have more students in their classrooms. The backlash from school boards, superintendents and teachers has been a voice that Austin legislators could not ignore. Newly found funds have been quickly diverted to public education as a first priority.

Medicaid and other programs in Health and Human Services continue to face approximately 10 percent reductions across the state with no new funding designated for increased enrollment or expansion of services in these programs. In fact, the programs are being transitioned to "managed" programs or HMO-like programs in an effort to further reduce related costs. The impact to the state's hospitals and healthcare workforce is obvious. Many physicians have already begun to exit the Medicaid program because of its insufficient reimbursement for services. Senate bills 7 and 8 by Sen. Nelson and supported by Lt. Gov. Dewhurst codify many of these changes and incentivize quality, prevention and patient education as ways to curb costs.

Something missing from the forefront of debate has been health education, health reform, scope of practice and mental health services. Loan repayment programs for health professionals have been stymied. The broadening of scope of practice for advanced practice nurses and physician assistants has not received a lot of attention. The Texas Medical Association (TMA) has lobbied against increased scope, citing the shortage of nurses in the state and the need for more front-line practicing nurses in hospitals. Meanwhile the Texas Nurses Association points to the huge shortage of primary care providers in the state and notes that advanced practice nurses could help address access to care issues. 

What to do about addressing the need for increased graduate medical education slots in Texas to keep our medical graduates in-state has received little attention. This is likely because it requires funding. 

The House budget and the Senate budget diverge in scope. The House's proposal for public schools, higher education, and health and human services is quite austere. The Senate's version of the budget is more generous but still quite lean when compared to prior budgets.

The House seeks to use $3.1 billion from the Rainy Day Fund (RDF) to pay off last year’s deficits. The Senate seeks an additional $3 billion from the Rainy Day Fund to support FY12-13 programs. Even though that takes $6 billion from the sustainability fund, it also leaves $3 billion for later use. With the price of fuel going up almost daily, some pundits predict the RDF will replenish that $6 billion by the next legislative session because it is funded, in part, by fuel taxes. One can be sure that the debate on using RDF funds will be long and loud. And, some predict that budget debate will spill over into a mid-summer special session, along with redistricting. 

The deadline for bills to move out of committee hearings, through calendars committee and on to the House or Senate floor for action is fast approaching. Less than 35 days remain in this 82nd session of the Texas Legislature. Watch the action carefully because this is when it really gets crazy!

Under the leadership of Senate Finance Chairman Steve Ogden and Vice Chairman Juan “Chuy” Hinojosa, this past week witnessed some watershed moments in the legislative process. After three months of testimony, hearings, member discussions and searches for new revenue, the Senate Finance Committee (SFC) pulled together a comprehensive state budget that recommends some $10 billion more in budget expenditures than does House Bill 1 approved two weeks ago.

The Senate’s approach to education and health and human services has resulted in a more “favorable” allocation of state funds than recommendations from the House. Yes, there are still a number of painful reductions, but fewer than those proposed in the other chamber. Ogden also called for members to address the structural deficit in the budget — an important step toward a permanent solution to recurring shortfalls.

Among the decisions affecting UTMB was the Senate’s proposal last week that funding be restored to the criminal justice health care programs, along with major restructuring of that health care contracting system. The Senate recommendations included:

-        Restoring almost $200 million of base funding to the program (from $707 million to $903 million) for the biennium. Although this is still 10 percent lower than funding in the 2011 biennium, it is a far less drastic reduction than prior recommendations.

-        The recommendation calls for letting the monies appropriated drive the amount of care delivered rather than vice versa. In other words, the health care vendors (UTMB and Texas Tech) would NOT be called upon to provide more care than the state appropriation proposed. The responsibility for the prison’s health care budget would fall squarely on the shoulders of the Texas Department of Criminal Justice, not upon the two university providers.

-        The proposal also de-funds the staffing of the Correctional Managed Health Care Committee and calls for the contracting for care to occur directly between the university providers and TDCJ.           

-        Budget allocations were recommended specifically for unit-based care, for hospital care, and for pharmacy inventory and operations.

-        TDCJ was authorized to move monies among strategies with prior Legislative Budget Board approval to fund additional services should TDCJ deem them necessary.

-        Reasonable reporting requirements related to oversight, quality, costs, utilization, acuity and other benchmarked measures were outlined.

The SFC recommendation received broad support among its members and was approved unanimously. Senator Robert Duncan told the Austin American Statesman, “We’re doing that so the care isn’t driving the budget, the budget is driving the care.”

During discussions related to university funding in Article III of the budget process, Senators Ogden and Tommy Williams offered up a provision for the approval of $11 million in FY13 funding for the debt service of the Tuition Revenue Bond approved by the 81st Legislature. This recommendation was approved in the Senate Finance Committee’s overall budget recommendation.

Last week also saw some other interesting proposals designed to allocate funding to the state’s health-related institutions (HRIs). Senator Judith Zaffirini chaired a newly formed Senate sub-committee on fiscal matters, which was charged with identifying funds for the HRIs. 

Since there were no general revenue funds available for distribution, the sub-committee proposed liquidating the Permanent Health Fund for Higher Education − the $430 million endowment from the decades-old tobacco settlement set aside for the state’s health-related institutions. The endowment produces about $45 million in revenue each biennium, which is allocated to the HRIs.  The sub-committee recommended that distribution of those funds occur on a formula basis for each of the 10 institutions. In turn, the institutions have the option of directing their portion of the funds to immediate budget needs this next biennium or placing the funds in a continuing endowment under their system’s direct management.

Senator Zaffirini opposed the recommendation because, rather than providing the institutions with new monies, it simply distributed to them revenue that had already been set aside for their use. Others joined her, citing the intent of the endowment to provide a perpetual source of revenue to the state’s HRIs. The Senate Finance Committee voted 10 to 5 to recommend the action to the full Senate.

House Appropriations Committee Chairman Jim Pitts told the media, “I don’t favor it, and I would speak against it.” He added that, “Once it’s gone, it’s gone.” Pitts did not rule out the fact that he may be persuaded otherwise.

UTMB currently receives $5 to $6 million each biennium from the endowment. If it is fully liquidated and distributed, UTMB’s portion of the proceeds using the current distribution formula would be about $47 million.  Like everything in the budget, details of this are still in flux, even if the idea is ultimately accepted in the conference committee. A number of things may change depending on decisions about how much of the fund to liquidate (all or part of it), how to distribute the proceeds, and how much flexibility each institution would have regarding use of the proceeds. 

A quick re-cap of funding for health-related institutions, with the Senate version of HB1 compared to the House version:

Both bills make substantial reductions in Medicaid, CHIP and other health care funding, but the versions differ in amounts and types of reductions. 

Next Steps

The Senate plans to complete its work with approval of the fiscal matters bills this week and pass them from the Senate Finance Committee for action by the Senate as a whole after the Easter break. Their agreements later this week have resulted in significant additions to public education ($6 billion), along with a revenue increase of $5.5 billion through fast-tracking collection of fees and taxes, eliminating various exemptions, and selling public lands not being utilized.

After the Senate presumably approves the Senate Finance Committee’s recommendations, the House and Senate budgets will move to the Conference Committee.

The Speaker and Lt. Governor will each appoint five members to a joint budget resolution committee. These deliberations will likely take members into mid- to late May. If a consensus can be reached, the conference bill goes back for concurrence to each house and if accepted in both bodies, it goes to the Governor.  The Governor can veto specific line items in the budget, veto the whole budget, or sign the budget within 20 days of its arrival on his desk indicating his concurrence. Or, he can do nothing within the 20-day veto period and  the budget will be enacted without his formal approval.

If anything in these steps prevents a budget from being enacted by the end of the session on May 30, the Governor will have to call a special session (or two . . . or three) this summer to adopt a budget before the September 1 start of the new fiscal year.

After a brief respite for the Easter break, legislators will return to a schedule of non-stop activities . . . and the House will take up discussion of redistricting!

I began the week with heartburn so bad that I thought I must be having a heart attack. It started late last weekend and progressed. After a quick check-in Monday with one of the world's most brilliant doctors, Dr. Steve Quach, he quickly decided that I had "pill esophagitis" from swallowing doxycycline (antibiotic for acne) without drinking enough water. (Instructions with the prescription are very clear on the need to drink a full 8 oz. of water with the pill.) He predicted that the pill had stuck in my esophagus and eroded it. Go figure!  By the way, why I have acne and am married to a dermatologist is a whole other story! 

Another quick check-in with my ole med school friend Dr. Marc Shabot offered phone confirmation, medication, and some relief. I returned to Galveston Tuesday morning and met Marc's endoscope (must be named "Big Bertha"), and he confirmed a quarter size erosion in my mid-esophagus. I've been chugging meds all week and am well on the road to recovery. And a lot more attentive when it comes to following the doctor’s orders on how to take my medication.

The legislature has been very busy, as legislatures should be. They have passed out emergency legislation requested by the Governor in the first 60 days and have also gotten past those thorny subjects like voter ID. This week has been consumed on the House and Senate sides with more budget issues — past, present and future!  The Senate has held hearings and met in member work groups to review their options for creating their own budget recommendations.

Remember that the state health-related institutions are treated more equitably in Senate Bill 1. The Senate has taken an approach to building a budget that addresses the burning issues of education funding and health and human services funding, and that mitigates negative impacts on existing programs. Under the skilled leadership of Senate Finance Committee Chairman Steve Ogden, members have been collegial and deliberate in trying to find realistic ways to solve long-standing problems related to the state's financing methodology.

The House began action Thursday at 0830 with the second reading of HB4, the supplemental appropriations bill. The supplemental appropriations bill called for the expenditure of $3.1 billion from the economic stabilization fund and the use of newly identified revenue and savings to cover the $4 billion shortfall in tax revenue from 2010-2011. The debate was filled with passionate pleas to avoid cuts to state programs that disadvantage the elderly, children, the disabled, schools and other public programs.

Sixty-seven amendments were offered by members to add money and programs previously reduced back to former or near-former funding. Rep. Sylvester Turner waxed eloquent in his pleas to "save our nursing homes," and Rep. Mike Villarreal pleaded his case for more money for education by reversing cuts that had been made. Suggested funding for the reinstatements would require use of more Rainy Day Funds. Discussion of the matter followed party lines and lasted for the amount of time allocated; it was then tabled by a predictable party line vote.

HB4 (Supplemental Appropriations Bill) passed the House on its second reading virtually unchanged from its introduction, with three exceptions:

·         Rep. Phil King sponsored an amendment implementing a hiring freeze for vacant state positions.

·         Rep. Drew Darby offered an amendment that reduces funding in the current biennium to the Soil and Water Conservation board.

·         Rep. Strama offered an amendment that moves unobligated funds from the Emerging Technology Fund to the Foundation School program.

All three amendments represented a “new source of revenue” and all three passed.

The final vote FOR passage of HB4 was 100 – 46.

The House then took up the debate on HB275, which relates to use of the Rainy Day Fund (RDF) to fill the gap in the current biennium budget. The debate was fierce and focused on limiting any expenditure from the RDF to just $3.1 billion. Votes followed party lines among those members present, with an occasional "stray" objection. Much like the debate of HB 4, amendments were introduced and quickly tabled after the time allocated for discussion in House Rules. Only one amendment passed, and it was Rep. Zedler's language that makes HB 275 effective ONLY if HB4 or similar legislation is enacted and becomes law, with an effective date of July 1, 2011. This is important strategic move.

House Bill 275 passed with a vote of 142 – 2 approving the use of $3.1 billion from the Rainy Day Fund during the current state biennium.

On Friday morning the House had the third and final reading of HB1 and HB275 and passed both out of the House. It’s official!  The bills now go to the Senate for review.

The House took up HB1, the 2012-2013 state budget on Friday morning; it has almost 400 amendments!  The Governor's agreement with the House Appropriations Committee has been that the Rainy Day Fund could be tapped only for the purpose of paying off the state’s debts from the current biennium and not for use in the new state budget. However, this procedure in turn frees up about $4 billion for revenue for the upcoming budget. As previously noted, this allows some restoration of funds — about $2 billion each — for public schools and health and human services.

Adding money to any one appropriation area means taking it away from another area. The pie is only so big. It can be sliced a lot of ways. But unless the pie gets bigger (through new revenue that is not currently available), there is no way to increase funding in the current budget discussion until the budget passes from the House and moves to Senate. 

You know the rest of the story. HB 1 passed from the House with only minor modifications, none of which were significant to UTMB. In spite of a “rumor” that UTMB’s disproportionate cuts in its hospital funding had been restored, that was indeed rumor. Although there are still recommendations in Article XI of the bill for restoration, there is no money. Items put into Article XI are often referred to as “the wish list” and usually die on the vine without funding.

So what happens now?

The House’s work is partially done; another phase will begin shortly.

But first, the Senate must wrap up its work and produce its version of the budget. Senator Robert Duncan has been chairing a task force of sorts to identify other sources of revenue to add about $5 billion to the budget. That search has yet to produce a final report. Some say there is just no pot of gold; some say there is no rainbow either! 

But those more optimistic individuals (like yours truly) believe in miracles. Certainly if anyone can pull a miracle off this session it will be Senator Steve Ogden.  He has had the fortitude to confront the elephant in the room and spoke last week of the ultimate need to “fix the structural deficit,” referring to the margins tax enacted in 2006 that has failed to produce revenue to replace the state tax cuts enacted that same year.

The inevitability of a special session on the budget seems to loom more depressingly on the horizon as each day passes without resolution on this budget.

What next?

Indeed! What next?

On Thursday, the Senate Subcommittee for Health-Related Institutions discussed tapping the decade-old tobacco settlement trust fund, breaking it up into allocations that would provide each health-related institution with some cash in this year’s budget. There are many positives associated with that suggestion (instant cash) — but also some pitfalls (loss of future revenue). More thought and discussion regarding this alternative are inevitable.

The Senate will make its final attempt at a budget shortly, and then the two budgets will be brought together into a joint conference committee composed of five house members and five senators for deliberation. Their impossible and unenviable task will be to become King Solomon and determine what is fair and equitable in the budget and decide that which lives and that which dies by the budget axe.

Pray for them. 

Definitions:

House Bill (HB) 1:  "The" Budget Bill that lays out the budget for the 2012-2013 biennium.

House Bill (HB) 4:  The Supplemental Appropriations Bill; Texas will finish the current biennium (2010-2011) with a deficit in excess of $4 billion. Deficits by constitutional mandate cannot carry forward; the budget must balance at the end of the year. The Comptroller is allowed to take money from the economic stabilization fund (Rainy Day Fund) and pay all bills by August 31 of the end of the biennium with or without legislative permission. HB4 gives the House's endorsement to what would have been done anyway.

House Bill (HB) 275:  Provides for use of $3.1 billion of the economic stabilization fund for balancing the budget.

The Ides of March have come and gone, and so has the midpoint of this 140-day legislative session.  The House of Representatives Appropriations Committee has worked at a feverish pace to produce HB1 and the supplemental funding bill.  These bills have been voted out of committee, gone to Calendars, and been posted for presentation on the House floor.  The bill has been scheduled for reading on the floor of the House and for debate on Friday, and maybe on Saturday, and perhaps even on Sunday!

I thought I would provide for you a “Cliff Notes” version of just where we are from the House viewpoint at this stage of the session.  Remember that changes can be made on the House floor next week.  Also remember that when the bill leaves the House, it moves into a conference committee with the Senate.  Five lucky House members will constitute that House conferees; the same number will come from the Senate.

Recognizing the financial situation Texas faces, UTMB has requested that in HB 1:

• The university's appropriations be cut by percentages no greater than other health-related institutions’ appropriations are cut, and
• The university receives Ike restoration funds appropriated or approved last session.

Tuition Revenue Bond Debt Service Funding

o    A $150 million tuition revenue bond (TRB) was passed by the 81^st Legislature. Since it was approved late in the session, and since UTMB did not need immediate funding for the facility, debt service for that TRB was not appropriated.

o    UTMB has requested approximately $13 million for TRB debt service during the second year of the next biennium ($150 million at 6% over 20 years).

o    This TRB will be used to construct a Surgical Tower connected to the existing John Sealy Hospital to restore bed capacity to pre-Ike levels and to provide operating rooms and ICU beds to support UTMB’s patient care obligations, including the Level I Trauma Center, and UTMB’s education and research programs.

o    The TRB will be matched by a grant from The Sealy & Smith Foundation of $170 million; bonds and philanthropic sources will cover the remainder of the construction costs.

o    Construction of the Surgical Tower is essential to maintaining current clinical, trauma and educational programs.

o    Funding for the TRB debt service is NOT in HB 1. It must be added to the FY 2012-2013 appropriations bill before or in conference, or be added to the FY 2011 Supplemental Appropriations bill.

UTMB’s Base Appropriations

o    During the 81^st Legislative Session, UTMB received a $48-million-per-year adjustment to its base appropriation in lieu of DSH and UPL funds, which go to the state treasury. The base appropriations adjustment helps support UTMB’s services to low-income patients and is crucial to UTMB’s operation of the Level One Trauma Center. These sorts of services are supported at other public tertiary care hospitals by DSH and UPL. 

o    UTMB has requested that the legislature treat appropriations reductions in the same manner as it does other state-funded teaching hospitals, which were reduced by only 10% in HB 1.

o    Reductions of the magnitude proposed in HB 1 (25% to UTMB’s hospital base GR funding) will likely lead to some or all of the following:

−    Reduction in services to women and children through UTMB’s Regional Maternal and Child Health Programs, which are located throughout East and Southeast Texas and in border communities,  and which last year served more than 100,000 economically disadvantaged women and children

−    Elimination of the contract to serve Central Texas mothers at Austin Women’s Hospital at Brackenridge Hospital, which delivers more than 130 infants per month and provides family planning services

−    Reduction in indigent health care services in UTMB hospitals and clinics

−    Reduction in post-graduate medical education programs and house staff

−    Reduction in available beds to support hospital admissions

−    Reduction in services and/or closure of the Level I Trauma Center

o    Preservation of UTMB’s base hospital appropriation is essential for UTMB to continue its post-hurricane recovery and maintain its clinical and educational programs. UTMB is asking the Legislature to reduce its hospital appropriation by no more than the 10% reduction applied to the other state-owned hospitals in HB 1; the final decision to be made in conference committee.

Continued access to HB 4586 funds appropriated in the 81^st Legislature for Ike Recovery

o    UTMB received $150 million in General Revenue to be used to match FEMA funds and other Hurricane Ike recovery needs.

−    The FEMA damage estimate in May 2009 was $667 million; the current revised FEMA damage estimate is $1.2 billion.

−    FEMA requires fund matches at both the 90:10 level and the 75:25 level based upon the type of repair.

−    Some damages are not covered at full cost and some are not covered at all by FEMA funds.

o    Since the hurricane, UTMB has been working around the clock with contractors and FEMA representatives to finalize the damage and mitigation cost assessment; however, due to the pace of FEMA approval, the appropriation cannot be fully spent before its expiration date. UTMB is working with the LBB and the Comptroller and will encumber much of the funding by the June 2011 expiration of the appropriation through contracts with major construction vendors.

o    Any funds unencumbered before the HB4586 June 2011 expiration will be swept.

o    UTMB seeks permission for continued access to these funds if it is unable to encumber all of the funds before the appropriation timeline expires. A potential remedy is “re”-appropriation of unencumbered funds in the HB 1 FY2012-2013 appropriations bill or in the Supplemental Appropriations Bill.

Correctional Managed Health Care Contract

o    The state has contracted with UTMB and Texas Tech since 1993 to provide medical care to inmates.

o    The major portion of correctional care services is funded through a baseline appropriation. However, both universities customarily incur care-related expenses over and above their share of that baseline appropriation. These expenses have traditionally been covered by the institutions until a supplemental appropriations request can be approved by the state.

o    As a result, UTMB and Texas Tech have had to carry substantial losses on their books until a supplemental appropriation to cover the deficit is approved; this creates a financial hardship for both university systems.

o    This process also runs counter to existing statute, which states that university funds will not be utilized for offender health care services.

o    UTMB and Texas Tech have both gone on record by disagreeing with the most recent auditor’s report:

−    Both universities believe that their health care costs and indirect costs are stated accurately and that they are consistent with community standards.

−    Both universities believe that the accounts for all monies used for salaries and contracted services in their delivery systems have been compliant with generally accepted accounting principles, as well as the provisions of the Correctional Managed Health Care Committee contract.

o    The cost of health care in the prison system continues to rise because of:

−    Medical inflation(i.e. increased costs for drugs, supplies and equipment)

−    Increasing number of older offenders who do not qualify for parole

−    Increased acuity and volume of hospitalized patients

−    Increased burden of chronic diseases

−    Increased use of pharmaceuticals

−    Increasing personnel costs

−    Expanding mental health services

−    Offender litigation

o    UTMB wants to serve as a vendor for hospital and specialty health care, pharmaceutical services, telemedicine, electronic medical records, information systems, and physicians and mid-level practitioners, fully reimbursed for these costs.

o    UTMB must be allowed to adjust the amount of care it provides to the appropriation provided and not expend university educational funds to close that gap.

o    UTMB’s reimbursement for patient care services must cover associated costs, as determined by GAAP accounting standards.

o    UTMB must obtain $51.1 million in Supplemental Appropriations in order to cover the deficits from FY2010-2011. The current Supplemental Appropriations Bill, HB-4, includes $40 million to UTMB for CMC.

o    UTMB must have a new contract with TDCJ that clearly defines roles and responsibilities, with UTMB as a vendor for offender health services sized to fit the appropriation amount.

More than 10 years ago, the Statewide Health Coordinating Council (SHCC) launched several initiatives designed to improve the method for collecting and tracking the number and demographics of health practitioners in Texas.  It is impossible to predict and address future needs without that information.

As a member of the SHCC from 1997 until 2010 and someone who chaired the council for the past 14 years, I thought the following excerpt from a recently published “Chairman’s Letter” would be of interest — particularly with health care reform on the horizon, the serious shortage and mal-distribution of doctors and other health care providers in Texas, and the state’s budgetary challenges.

Data have shown year after year that Texas is faced with two clear trends: (1) the population is growing faster than almost any other state in the U.S., and (2) the number of health care providers is NOT keeping pace with that rate of growth.

In addition there continues to be major geographic mal-distributions of health care practitioners across Texas. Border and rural areas face the greatest shortages in numbers of health professionals per 100,000 population. And, in spite of significant advances in technology, regulatory barriers have prevented the deployment of telemedicine and other technologies in medically underserved areas, whether urban or rural.

The facts are simple and sobering:

1.       Texas has a shortage of physicians in primary care and specialty care!  Although the state has increased both the number of medical schools and the size of medical school classes over the past decade, there have not been significant increases in Graduate Medical Education positions for the training of these graduates in Texas. The lack of funded GME slots results in Texas graduates going out-of-state to do their residencies. Only half of those who leave Texas to train ever return; in contrast, more than 80 percent of those who graduate from a Texas medical school and complete a Texas-based GME program will stay and practice in Texas. Until Texas makes graduate medical education its priority in health education funding, the state will continue to invest in medical students who ultimately will go elsewhere for residency and long-term practice. It simply doesn’t make good economic sense for Texas to educate physicians who will serve other states when the need here is so great.

2.      There is also a shortage of registered nurses in Texas, but there is an abundance of licensed vocational nurses. The scope of practice of LVNs has been severely restricted exacerbating the nursing shortage. Moreover, the shortages of nurse educators and graduates persist despite innovative programs funded in recent sessions by the Texas Higher Education Coordinating Board and the Legislature to support faculty salaries, fast-track programs and student scholarships. Attrition rates from nurse education programs are alarming; even more so are the attrition rates from the profession itself, in spite of significant salary increases over the past 10 years.

3.      Unfortunately, shortages aren’t limited to physicians and nurses. The workforce in all the other health professions is woefully insufficient to meet current or future demand in Texas. The well-documented shortages are most apparent in border and rural areas and include pharmacists, physical therapists, occupational therapists, physician assistants, behavioral health professionals, clinical laboratory scientists, radiology technicians, and others.

The Texas population is growing faster than any other state, with more than 400,000 people becoming new Texans every year (half by birth and half by legal immigration). The growth in the number of undocumented immigrants is unknown but thought to be quite significant. The high birth rate in Texas demands increased numbers of obstetricians, midwives, nurses, and pediatricians. The number of pediatric sub-specialists in our state is dramatically below the ratio found in  the U.S. as a whole.

At the other end of the age spectrum, there is an ever-increasing number of Texans 65 and older with remarkable longevity in spite of poor overall health status. These individuals require primary and specialty care services as well. In addition, aging Texans, like their pediatric counterparts, need a vast array of support services, as well as assistance from therapists, pharmacists, nursing care, and chronic disease management experts.

These demographic pressures are compounded by the anticipated impact of national health care reform. Millions of Texans will be added to the current Medicaid eligibility lists by 2014 and others will enter through discounted purchasing organizations. The demand for health care services could increase by as much as 25 to 30 percent in some areas of our state. This will likely overwhelm an already fragile health system.

As the demand for health care services in Texas grows daily, the question is:  How can we meet that demand now and in the future?  We must entertain new models of care that improve access. We must also employ more effective health and wellness programs, prevention programs and educational programs to improve health status. The use of technology will also demand new workforce initiatives.

Boldness and innovation in our thinking and practice may be uncomfortable for some, but they are a necessary step toward a healthier Texas. Without the willingness to change, we will find ourselves with a health system incapable of meeting the needs of any of our citizens—young or old, wealthy or impoverished, urban or rural.

In turn, the productivity of our state will be significantly and adversely affected as more and more Texans find themselves unable to work due to chronic and debilitating health conditions. Maintaining current regulatory and scope-of-practice restrictions will not serve us well. Major reforms in education, regulation, scope-of-practice determination and the use of resources MUST be priorities for our state. Simply put, the status quo is not sustainable.

Texas must embrace a serious re-prioritization of resources in health education, and that education must be interprofessional and interdisciplinary. Graduate Medical Education programs must be placed at the top of the financial priority list. We must determine scope-of-practice boundaries using evidence-based criteria and core educational competencies, with standards for quality and public welfare of paramount importance.

Licensure for the practice of medicine must NOT be compromised. Health care education must become less fragmented and include a career matrix so that professionals share broader bases of knowledge that enable them to migrate among different career paths as their interests and the needs of those they serve evolve. We must educate health professionals collaboratively so that they can practice in team-based models in the future.

Texas must align desired health outcomes with financial incentives and rewards for those practitioners demonstrating evidence-based practice and quality outcomes. Priority must be given to maintaining wellness, for prevention and education programs, and for the management of chronic disease in a manner that reduces unnecessary emergency room and hospital admissions.  

Every year that our state puts off reforming the health professional education and training process is another year that quality of and access to health services deteriorate. Inaction almost guarantees that future assessments will report increasing shortages in the health care workforce, decreased access to services and erosion in quality of life.

Improving the health of all Texans is about much more than adding a new medical or nursing school. It is about a vision for a future in which health care delivery is a shared community responsibility. It requires us to stretch our imaginations and our comfort zones to embrace new technologies and new models of medical practice.

After all, it is South by Southwest week in Austin, and there is as much to see in the session as at the annual music festival.

The House Appropriations Committee (HAC) waited for over two hours to convene to hear House Bill 1 and House Bill 274 (the budget and the supplemental budget placeholders). 

Chairman Pitts called the meeting to order and read a press release from the Governor, Comptroller and Speaker of the House stating their limited support of the use of $3.2 billion of the Rainy Day (or economic stabilization) Fund to balance the current fiscal year's budget.  The message was quite clear that there would be no use of these funds for the forthcoming fiscal year.

Why $3.2 billion? 

The Comptroller updated her revenue estimate to include an additional $300 million in sales tax revenues. Additionally, cuts in the current budget of over $800 million have been identified.  This means that original estimates of the shortfall ($4.3 billion) have been reduced by $1.1 billion.  Thus, the $3.2 billion pays all remaining obligations from FY10-11. Without supplemental debt having to come from the projected future budget, the House has in effect freed up $4.3 billion for additions to the FY12-13 budget.

Proponents of using more of the fund toward the next biennial budget quickly made their displeasure known.

The HAC lost no time in designating $2 billion to the foundation school program (which will still face a $7 billion deficit rather than $9 billion). Another $2 billion was designated to Health and Human Services to address shortfalls there (which still leaves a $6+ billion hole in those services).

In the crowded, standing-room-only hearing room were media, disabled people in wheel chairs holding yellow signs stating "our homes, not nursing homes," and hoards of others.  The crowd was restless but seemed almost resigned to the fact that the budget that was about to be voted out of committee still had some gaping holes.  Resignation was also apparent on many members’ faces.

Although there were tense moments as the Democratic members and the Republican members disagreed, the discussions were civil and filled with probing questions and even occasional puns.  The disagreements ranged from "what got us to this point?" to who is ultimately responsible for the structural deficits that some feel caused the current revenue shortfall.

House members are to be commended on their tireless work, patience, and respect for one another’s  viewpoints.  Certainly, Chairman Pitts had a difficult task of consensus building, which he achieved with praise from both parties.  His leadership and ability to listen and respond with compassion and concern is laudable.

This was not a joyful journey.  No one seemed overly thrilled with the decisions being made and no one came away feeling like they'd "won."  Discussion of the Health and Human Services budget drew quite a bit of heartfelt comment. Case load growth was not funded in the Child Protective Services budget, as well as a number of other programs for the most vulnerable.

My Grandma used to say "never put off until tomorrow that which you can do today!”  Many members adhere to this same philosophy and are seeking more lasting solutions to the problems that have placed the state in such troubled straits.  They are still awaiting that opportunity.

Representative Debbie Riddle quickly rose to point out that UTMB’s reductions were much larger than the other health-related institutions and called upon the Legislative Budget Board and subcommittee chairman for explanations.  She also requested additional consideration for the impact of the reductions on UTMB’s post-Ike recovery funding from the 81^st Session.  Representative Craig Eiland reminded the committee of the promised recovery funds and cited the adverse impact that such significant cuts to UTMB's budget would have on that recovery.  Both members received assurance from Chairman Pitts that the UTMB issues would be further reviewed and addressed in the form of actions on the House floor and/or in the joint conference committee with the Senate.

The budget that passed out of the House Appropriations Committee reduced UTMB’s health care operations (hospital) appropriation by 25 %.  The other state-funded higher education teaching hospitals’ budgets were reduced by 10 %.  Otherwise, the reductions to UTMB are the same as those for other health-related institutions.  No money was allocated to offender health care (CMC), pending further study.

In short, the overall reduction in HB-1 as it left the House Appropriations Committee leaves UTMB with an overall reduction of 21% from the FY10-11 funding level. This means $50.2 million would have to be added back to the budget for UTMB to be on par with other health-related institutions.

On a positive note, $40 million did find its way into the supplemental appropriations bill as a placeholder amount for the correctional health care shortfalls experienced by UTMB and Texas Tech thanks to the work of Representatives Taylor, Turner and Eiland.

Where do we go from here?

It’s important that we continue educating members about UTMB’s statewide role in health professions education and clinical care delivery.  Also, it is important to highlight the important role our research enterprise plays in improving health for Texans and people the world over.  The very positive economic impact on the state through UTMB’s education of health care professionals and the forthcoming construction projects associated with Hurricane Ike recovery cannot be overstated.  Friends of the university, students, and alumni should certainly be letting people know about the merits and value of our fine institution. Putting a “human face” with the issues is important for increased understanding.