Interesting Pursuit

Given the limited pot of money, unavailability of the Rainy Day Fund, and significant growth in the number of people needing state services, balancing the budget may seem impossible at times.  However, we have 181 dedicated Legislators and their staff working around the clock to accomplish this difficult task while ensuring the continued health and well-being of Texans.

 

So what happens?

 

Without an increase in the current revenue pool from taxes, the only real option is to increase available revenue by reducing or eliminating current expenditures.  To do that, the Legislature will need to develop a prioritized list, with the goal of preserving essential public services while reducing or eliminating those public services deemed less essential.  This would mean reducing or eliminating the expenditures the less essential programs require.  Overall, it is not too different from the process a family goes through when the household income declines.

  

For Texas, the scenario could look something like this:

 

Start by focusing on services that require most of the state's resources (excluding business/economic growth and development expenditures):

 

·     Health and Human Services Commission (HHS): Maintain existing programs that serve the state's most fragile and vulnerable populations by reducing benefits, lowering reimbursement to providers, and limiting eligibility (assumes no growth in programs)

  

·     Public Safety/Prisons: Maintain “Texas Tough on Crime” policies by keeping the large and growing offender population behind bars but reducing costs associated with infrastructure and maintenance (such as staffing, food, health care, and diversion and rehabilitation programs)

 

·     Education: Reduce state-subsidized programs/services and shift more of the responsibility for education to local communities and families

 

Higher education is particularly vulnerable in this scenario because many view it as a luxury — a personal choice and responsibility — rather than a public good or investment.  What this view doesn’t take into account is the future economic benefit of higher education to the state.  A well-educated workforce is the prime attractor for business growth and development.  Lack of education is one of the key drivers for poverty, crime, and poor health.

 

The Senate and the House face the same challenges.  But each chamber has different priorities.

 

So where do they go from here?

 

Most likely to conference. (For further study, check out Budget 101: A Guide to the Budget Process in Texas at http://www.senate.state.tx.us/SRC/pdf/Budget_101-2011.pdf.)

 

And what will that mean?

  

Both legislative bodies may elect to pass out HB1 and SB1 with little modification from the original bills as filed.  Since there are substantial differences in the two budget bills, the Speaker of the House and the Lieutenant Governor (who leads the proceedings in the Senate) would then appoint a Joint Conference Committee to hammer out a budget that is acceptable to both chambers.  The Conference Committee would also work to ensure that the budget they submit will be acceptable to the Governor.

 

What might that look like?

 

No one really knows, but it could go something like this:

 

Remember that about $4.3 billion of the available revenue for the next biennial budget will have to go toward a supplemental appropriation (which covers emergencies or other needs not covered in the regular appropriations act; in this case, budget shortfalls from the last biennium).  That would reduce the available revenue pool from about $76 billion to $72 billion.  At that point, the Conference Committee might recommend that $4.3 billion be taken from the Rainy Day Fund and used to fund the supplemental appropriation.

 

This scenario would add $4.3 billion to the funds available for appropriation by the Legislature, which would permit our senators and representatives to rethink some of their current reductions.

 

Might that happen?

 

It’s impossible to predict exactly what will happen over the next few weeks, but as the Legislature gets deeper and deeper into the tough decisions that establish budget priorities, there is more talk in both chambers and among both parties about tapping the Rainy Day Fund.  Stay tuned for ongoing developments in the challenging, high-stakes and oh-so-important process of balancing the state’s budget.  

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Correctional Health 101

Keeping pace with the rush of hearings, committee meetings, and sub-committee meetings, the UTMB team met with TDCJ, TYC, and other stakeholder groups for hearings before the House Appropriations Sub-Committee. The House Subcommittee on Corrections is charged with holding hearings on HB-1 funding recommendations for all correctional health care initiatives over the next biennium. 

Let me begin by saying that UTMB has no intention turning its back on the state’s prison health care system. The university is proud of its Correctional Managed Care program and the 3,000 men and women who work day in and day out to ensure that offenders have access to health care. And, UTMB officials look forward to working with state leadership and others toward a contract that makes sense for all stakeholders.  

Now, back to the sub-committee meeting.  UTMB President Callender, William (Bill) Elger, executive vice president for business and finance, and Dr. Owen Murray, vice president for offender health services, addressed a number of questions resulting from the recent State Auditor’s report on UTMB’s Correctional Managed Care (CMC) operations.  In a nutshell, the report had raised questions about: the rate UTMB charges to provide offender care; certain salary adjustments; how UTMB allocates direct and shared costs; charges that appeared unrelated to direct patient care; and the structure of the program as a division within the university.

Mr. Elger took the opportunity to explain how UTMB sets its rates for offender care, noting that the charge for CMC patients is 81 percent less than its allowable rates for regular Medicare patients.  He assured the sub-committee members that UTMB did not use any CMC funds to provide performance-based incentives to eligible employees, and confirmed that offender burials, autopsy services, and meals for security officers guarding patients in off-site hospitals are allowable expenses under the current UTMB-TDCJ contract.  Finally, he clarified that the indirect costs in question had actually been approved in 2006, and noted that UTMB has reduced those costs from $16 million to $8 million over the past four years.

In fact, cost savings initiatives — such as the use of electronic health records and telemedicine, 340B Pharmacy pricing, pharmacy automation and medication reclamation, evidence-based treatment guidelines, and chronic diseases management clinics — have kept the cost of offender care in Texas ($9.88 per offender per day in fiscal year 2010) among the lowest in the nation.  This, combined with excellent health outcomes, has established this state as the place others come to learn how to deliver high-quality, cost-effective, evidence-based correctional health care.

Unfortunately, UTMB can no longer afford to cover the funding shortfall for prison health care while waiting for a supplemental appropriation.  Doing so requires UTMB to tap into general university revenues, which pulls essential funding away from its academic and clinical programs.  

The dialogue continues as we move on to a hearing before the Senate Finance Committee that will focus on a thorough discussion of correctional health care in its entirety.  Clearly a lot of people are now focused on the important task of demystifying a very complex issue and working toward a solution that will benefit all.

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Fast Afoot

The pace is fast and frantic here at the Capitol.

The Senate has worked feverishly on the Governor’s “emergency” legislation agenda and so far has passed legislation on voter identification, the requirement of sonograms prior to abortions, sanctuary cities, and other items.

The Senate has begun hearings related to SB 1 (the Senate base budget).  Health and Human Services, the Texas Department of Criminal Justice and the state’s university systems have all had a chance to make their appeals related to proposed budget reductions. 

Some strategists feel that the proposed reductions are the only way to satisfy the constitutional requirement of a balanced budget.  Others feel that the called-for reductions may place the state further behind in public education, higher education and programs designed to diminish poverty.

UTMB has presented on the anticipated impact of Senate Bill 1 on the future of the University of Texas Medical Branch.  President David Callender thanked the senators for their support during the 81st session.  He respectfully asked them to please honor the promises that they made during the last session to help UTMB recover from Hurricane Ike by funding the Tuition Revenue Bond (TRB). The TRB will require $13 million for debt service for the building of the proposed Jennie Sealy Replacement Hospital after this session.  Dr. Callender also discussed the adverse impact of reductions to UTMB’s base funding.  He explained how the reductions could result in a cutback of clinical services at UTMB hospitals, including the closing of the Level 1 Trauma Center.  Also pointed out was the harmful impact to graduate medical education programs and other selected services throughout the institution.  The impact to education and research programs would be just as detrimental, with UTMB having to place its future growth and expansion of these programs on indefinite hold.

The president asked for fair treatment of UTMB comparable with other state medical schools and consideration for UTMB to meet its mission-specific programs related to education, research and health care.  All are at risk with the proposed large budget reductions.

Next Dr. Callender testified before the House Appropriations Subcommittee on Higher Education chaired by Representative Hochberg.  Chairman Hochberg, along with members Diane Patrick, Myra Crownover, Mike Villarreal and others, were joined by guest members Craig Eiland and Larry Taylor as Dr. Callender discussed the negative impacts of the budget reductions in HB1 (the House base budget).  HB1 proposes reductions of up to 25% in the UTMB hospital budget and eliminates a host of other programs that provide direct service to the poor and underserved, resident and student education programs, and key state health initiatives such as the Stark Diabetes education programs.

During the brief break in the proceedings, Dr. Callender found himself in visits with three senators and several other legislative staff members, and with Lt. Governor David Dewhurst discussing topics ranging from reconstruction of the campus to diversity and student test scores.

The days start at 7 a.m. and most often are busy past 9 or 10 at night.  But there is much work to be done before mid-March. There is that looming March 11 deadline for filing legislative bills.  The legislative bills must accomplish the allocation of the state’s precious dollars as well as providing the means for the state agencies, educational bodies and professionals to change their business practices as called for by the new budget.  Without a doubt these are adverse times but in adversity there lies opportunity.

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Precipitation in Austin

The precipitation in Austin has been intense here of late.  With the introduction of the Legislative Budget Board’s budget guidance, the filing of the House’s budget in HB-1 and the Senate’s budget in SB-1, and now the introduction of the Governor’s Budget it seems to be “Raining Budgets.” And of course there have been plenty of reactions to those budget proposals, like that of UT System Chancellor Francisco Cigarroa and other university chancellors and presidents in testimony to the Senate Finance Committee. 

House Committees were appointed mid-week.  The House Appropriations Committee, under the direction of State Representative Jim Pitts as Chairman and Vice Chairman Sylvester Turner, began its first meeting mere hours after members were named.  They convened at 7 a.m. the next day to hear testimony from the executive directors of the state’s prison system, the Health and Human Services Commission, and the Foundation Schools program.

 

These “big three” account for over 51 percent of the state’s expenditures. As Tom Suehs, executive Director of HHSC, pointed out in his prepared testimony, the choices are difficult. Mr. Suehs is challenged with the daunting task of providing services to the state’s most fragile and marginalized citizens, from the very young to the elderly, from the reasonably healthy to the most severely disabled. Services to the mentally ill, the mentally challenged, the disabled, the frail elderly, ill neonates and Texans with TB, HIV and other diseases — all are facing “priorities” (another word for reductions).

It is understandable that people are anxious about what tomorrow may bring. With the presentation of so many different budgets and impact statements, it is easy to get confused as to where we are in the process.

We are currently in the information-gathering and planning phase of the political process, in which the legislators write the state budget and the laws that govern the budget in action. Right now there is a lot of analysis going on as the legislators work to have a shared understanding of just how the state budget dollars are used and what kind of return on investment the state gets for the dollars. Having a clear perspective of how the people of Texas are served by and benefit from these dollars is vital. Developing this perspective is the focus of the various committee and sub-committee hearings that are currently under way. And it is hard work.

For instance, the prison system accounts for roughly $5 billion in expenditures. Surely a budget of this magnitude can be reduced significantly. But making cuts is not as easy as one might think. The U.S. Supreme Court has set the standards for offender care and those constitutional standards must be followed if Texas is to avoid paying a high price for non-compliance—such as lawsuits or even the possibility of federal supervision of its prisons. And this budget includes many of the programs designed to save money by increasing rehabilitation and decreasing recidivism. Corrections Committee Chairmen Jerry Madden in the House and Criminal Justice Chairman John Whitmire in the Senate have worked for years to establish one of the most outstanding offender diversion and rehabilitation programs in the nation, for which both were named outstanding legislators of the year in 2010 by Governing Magazine. Their modest investment in offender rehabilitation through drug and alcohol treatment in community programs has saved the state hundreds of millions of dollars by keeping these individuals OUT of prison and decreasing future offenses. Should these programs be cut to save money? To do so would be throwing the baby out with the bath water. But what does one cut in order to achieve the necessary savings? The choices are difficult, indeed, and they play out in countless areas of the state budget:  education, health care, public safety, transportation, parks, social services, and on and on.  Close a park, save a school? Close a college program, save another? Setting priorities is hard work. And determining just who should set the priorities is a major part of the task.

The next few weeks will be filled with long hours, an infusion of vast amounts of testimony and information, and unsettling stories of what lies ahead. The challenge is to make sense of this incredible collection of data, facts and speculation and prepare for the next stage of the political process—decision-making. Texas Senators and Representatives are eager to understand the priorities and concerns of their constituents. Now is the time for citizens to let their voices be heard on the issues that impact them the most.

The forecast for the decision-making phase is complex, thorny, hazardous and humbling. Too soon the time will come when attention must shift from information-gathering to settling on priorities, finalizing those difficult choices and allocating resources dollars. And part of this decision-making process must include appropriate legislation that enables agencies, institutions and professionals to put into action that which has been decided and funded.

There is much at stake for the future of Texas. It is important that we not get confused and that we not give up. This is the time to be clear of our mission and vision for the future. This is the time when we come together to build a Bridge Over Troubled Waters.

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The Big Chill

There was definitely a big chill in the air as Tom Seuhs, Executive Commissioner of the state’s Health and Human Services Commission, presented his services budget to the Senate Finance Committee. Suehs’ agency is so complex and diverse that its budget rivals the budget of most smaller states in the U.S.  With everything from Maternal and Child Health to the Department of Aging and Disability Services (DADS), Suehs is constantly faced with trying to please (or appease) a variety of constituents and special interest groups.  His scope of services must provide health care and social services for Texans from “cradle to grave” while dealing with limited state resources and ever-changing federal and state regulations.  His job is not one that most people actively seek out.  In spite of the difficulties, the commissioner is an excellent leader who has approached his budget with a pledge to keep reduction of services to the barest minimums possible.  You can view the Department of State Health Services Presentation to the Senate Finance Committee at this link http://www.hhsc.state.tx.us/news/presentations/2011/Finance-Committee-0211.pdf.

In spite of the freezing weather, some observers claim there has been a bit of a thaw in the frozen Rainy Day Fund option.  Or the perceived thaw might have been steam rising from some of the testimony and extended discussions among members as the reality of the impact of budget limitations became more apparent.  It is painfully clear with every passing day that the spending reductions required by the established parameters* will have far reaching consequences.

Politics is like that, isn’t it?  There is always a bridge to build between campaign promises and the reality of the legislation-making process. Our legislators are held accountable by their constituents for the political positions that got them elected.  At the same time neither the legislator nor the constituent wants to be the one to “kick granny out of the old folks home,” raise college tuition to levels the average family can’t afford, overcrowd classrooms by requiring teachers to teach as many as 40 students at a time, or let convicted criminals go free to bring down prison costs.

There are more chilly days ahead.  The committee work is intensifying with heavy schedules of proceedings, analysis, negotiations and decision-making.  It’s hard.  You Can’t Always Get What You Want.

*No new taxes, no Rainy Day Fund, stay with comptroller’s projected revenue

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Following the Bouncing Ball

As the budget deliberations progress in Austin, there are some provisions that we need to monitor closely because of their potential impact to UTMB:

General revenue base funding was reduced as follows:

  • 10% reductions for formula funding for all the state’s health-related institutions
  • 25% reduction for UTMB’s hospital and “special items” such as home dialysis, Area Health Education Centers, institutional enhancement, primary care and indigent care

No Tuition Revenue Bond debt service was included in the budget for any institution; one of UTMB’s priorities this session is securing TRB debt service funding toward the proposed surgical care tower to replace the current Jennie Sealy Hospital.

30% reduction in funding for the JAMP (Joint Admission Medical Program), which has aided UTMB in recruiting a diverse student body

Elimination of funding for

  • Primary Care Residency Education
  • Family Practice Residency Support
  • Preceptorship Support
  • Professional Nursing Shortage Reduction Program
  • Physician Education Loan Repayment Program

Changes to Correctional Manage Care

  • Elimination of the Correctional Manage Health Care Committee
  • Direct contracting for health care delivery systems with TDCJ
  • Reduction of the current funding by $226 million, or 24%
  • Reduction of funding for Texas Youth Commission services by 23% ($8.3 million)
  • Setting hospital charges to base Medicaid rates

No continuation of funding for the Department of State Health Services UT Diabetes Outreach program

$90 million of the previously appropriated “Ike Recovery Fund” would be lapsed and would  require repeat special appropriation (UNLESS the university can encumber the money through contracts for campus construction prior to June 13, 2011)

The state budgeting process involves detailed considerations, debate and negotiation. We all need to be engaged in the process every step of the way. The evolution and final outcomes of the 2012-2013 biennium budget will have an important impact on UTMB’s future.

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Grandmother’s Insight

My grandmother used to say “Be careful what you ask for — because you just might get it!”

I imagine that is what many people are thinking at this moment. It is pretty easy to speak in political parables and tell other people what they ought to do, but to walk the talk is a bit harder. 

It is time to stop for a moment and critically assess just what the state government does that is worth continuing and what it does that can be eliminated. That is exactly what the proposed 2012-13 budget is intended to do. It is a starting point for everyone. It calls for a time of reflection, for setting priorities, and for serious thought about future impact.       

In House Bill 1 (HB1), total proposed spending for the state in the 2012-13 biennium is $156.4 billion. This is a reduction of $31.1 billion, or a 16.6% reduction from the 2010-2011 level. The recommended state general revenue spending is $79.3 billion, an overall reduction of 10.4 percent. Furthermore, to pay for the deficit accumulated from the prior year before reductions were ordered, another $4.3 billion must be subtracted from available funds.

The proposed budget does not include growth in population or expansion of services. There are no incremental funds allocated to address an increased number of students in schools, increased numbers of enrollees in state programs such as Medicaid, or other related growth in state services and programs. Reductions vary from one section to another of the state budget, which is divided into “Articles”. Health and Human Services direct service programs related to Department of State Health Services, Department of Aging and Disability Services, Mental Health Services, and others are reduced heavily. Provider payments in the Medicaid program have a significant reduction of 10%.

The State’s higher education institutions and public education programs, already suffering from disproportionate reductions in prior months, have also been targeted for additional cuts. Formula funding for higher education and medical schools is reduced by 10 percent and special items were reduced by 25 to 40 percent. Some institutions and programs are eliminated entirely.

Senate Bill 1 (SB1) reflects parallel treatment of most agencies but cuts less deeply into higher education and special items such as hospitals.

Both bills offer up large reductions in funding for the state’s correctional managed health care programs with reductions ranging from 14% to 36% in funding categories.

One has to remember that HB1 and SB1 are both STARTING POINTS. There will be much debate and much discussion about the proposed budget reductions. The Senate and the House will attempt to establish priorities for funding through consensus. Programs with value and with strong return on investment will most likely be the ones that experience fewer final budget reductions.

For the next few months, there will be daily discourse in Austin and over the state. Public input is essential and highly desirable.

And as Grandmother used to say, “You’ll sit a long time with your mouth open before a roasted chicken will fly in.” If there’s a problem, try to fix it. We are all part of the solution.

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Swearing in Austin!

There’s been a lot of it in Austin over the past couple of weeks.

First, the state watched as the Governor and Lt. Governor were “sworn” into office on the Capitol steps.  The inauguration events were scaled down this year as compared to prior events in deference to the economic issues facing the state.

The next “swearing” began just hours later when members of the House and the public got their first look at the Legislative Budget Board’s recommendations regarding the revenues and interventions for the budget. 

Then the real “swearing” reached fever pitch when the Legislative Budget Board’s Recommended House Bill 1 was published and everyone got a good look at the impact of the proposed budget (994 pages of detail).  Chairman Pitts (House Appropriations Committee) presided over a one-and-a-half -hour explanation of the proposed budget’s evolution to House members.  Not surprisingly, the program reductions and eliminations that would be required with passage of HB1 gave members of both parties indigestion.  

The “swearing” continued when the Legislative Budget Board’s Recommended SB1 was published five days later (997 pages of detail). The enormity of the task of crafting the Texas 2012-2013 biennium budget is now a very sobering reality.

The “rules” or guidelines set out by the executive branches of Texas Government and the Legislative Budget Board members were plain and simple:

  1. Build a budget with NO NEW TAXES!
  2. Build a budget that DOES NOT utilize any of the “Rainy Day Fund!”
  3. Build a budget that “lives within the state’s revenue forecast!”
  4. Build a budget that focuses on “less government!”

And, that they did!  You can access both HB1 and SB1 at www.lbb.state.tx.us .  They are worth review.  You can also refresh your knowledge of the Texas Legislative Process with the aid of a summary process chart found at www.tlc.state.tx.us/gtli/legproc/diagram.html.

Lt. Gov. David Dewhurst appointed senators to committees late Friday afternoon.

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Doom and Gloom Galore! But hope still alive for a balanced budget!

The 82nd Legislative session got off to a somewhat gloomy start Tuesday.  After the budget projections issued on Monday by the Comptroller, the mood was not exactly bright.  As the reality sets in upon everyone, the work yet to be done in the next 139 days seems overwhelming.  Yet there was optimism among the members of both houses and affirmation of a desire to work out reasonable solutions to the economic issues that plague all states across the nation.

Rep. Joe Straus getting sworn in as Speaker of the House

The House re-elected Speaker Joe Straus of San Antonio to preside over the session after other candidates withdrew their names from consideration with a recorded vote of 132 to 15.

In his address to the House, Straus said, “I’ll do my best to empower members so that they can do what is right for their constituents and the people of Texas. I know that in recent weeks, members of the House have withstood threats, harassment and attempts at intimidation because of the fair and respectful way in which you want this House to operate. Division, threats of retribution, attacks on people’s religious beliefs, distortions of people’s records, have no place in this House.”

Straus said that the legislature should seek to “rebuild trust by the way we treat others,” to set high ethical standards and to make Texas government live within its means.  He challenged the House to a “spirit of boldness” and reminded everyone that “men who exist get overrun by those who act.”

Galveston County’s own State Representative Larry Taylor guided the state GOP House caucus toward a peaceful resolution of conflicting opinions in the Speaker’s race as well as a number of other issues.  As chairman of the House Republican Caucus, Taylor manages much of the “behind the scenes” work for the majority party.  His quiet but firm hand provides a strong leadership presence that many fail to appreciate unless they are intimately involved in the process.

Meanwhile, in the Senate Chamber, Senator Steve Ogden was elected by his colleagues as the President Pro Tem of the Senate.  Speaking about the budget challenge Ogden said, “We can get the job done.  It will not be easy.  It will not be painless.  But we can do it.”  Ogden also mentioned public education funding and the state’s Medicaid program, saying, “It is impossible to balance the budget without making cuts …”  Ogden implied that both public school funding and entitlement programs were both in need of major legislative reform efforts.

Governor Rick Perry issued an executive order for the Legislature to take priority action on sanctuary cities and personal property rights (eminent domain).  Legislation on these items would have to occur within the first 30 days of the session.

Over the next week both houses will confirm their rules for operations, committee assignments will be made, and a version of the proposed budget will be released by the House and by the Senate.  Bills will be filed, hearings will be scheduled, and the process will move forward at an alarmingly fast pace.

UTMB has its legislative agenda focused on four primary goals for the 82nd session:

(1)  Maintenance of UTMB’s base General Revenue (GR) to support operations of its clinical programs and schools

(2)  Continued access to the $150 million Ike Recovery funds appropriated in the 81st Session for campus recovery

(3)  Debt service for the $150 million Tuition Revenue Bond passed in the 81st Session for the construction of the proposed Jennie Sealy Replacement Tower, and

(4)  A revised contract for Correctional Health Care Services which limits UTMB’s financial losses in that program

UTMB will also focus on the health care regulatory items that impact delivery of care to patients, the funding of state Medicaid programs, health professions workforce initiatives, and a host of related health care reform topics.

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The Dawning of the 82nd Legislative Session

The 82nd Legislature officially convenes itself for the next 140 days to conduct the people’s business today.  If the past 23 hours of political intrigue is any indication, the session will hold plenty of surprises and intrigue.  Texas Comptroller Susan Combs delivered a revenue estimate that took even the stout of heart by surprise predicting as much as $26.8 billion deficit.  A variety of pundits have weighed in over the day as the estimate undergoes additional analysis with some suggesting that the “real” number may be as low as $14 or 16 billion while others say Combs may be optimistic and the deficit may be even greater.  It all really depends on just how much money the state wants to spend and “on what” that money is spent. 
 
To add to the political drama, former Congressman Tom Delay had his day in court and earned himself 3 years with the feds; this time not in the House office building but another federally run facility.  Of course, that opinion will be appealed and delayed (no pun intended) for as long as possible.
 
And before the day was over, Galveston County’s own Larry Taylor conducted the poll of the GOP caucus and as the sun set it appeared that Speaker Joe Straus had more than enough notes to easily be reelected to his position as Speaker of the House.
 
What a day!
 
Now the 82nd Legislature will get down to business.  On the top of their agenda, of course, is finding a way to balance the state’s budget (which is constitutionally required).  And, it is likely that initial discussions will include “no new taxes” and that the much talked about Rainy Day Fund will be left out of play for as long as possible (which the expectation of it being needed in the 83rd session).  Expect a stark budget to emerge … perhaps a skeleton designed to maintain only the most basic requirements for operation of the state.
 
On the crowded agenda will also be congressional redistricting with Texas gaining four new seats in the US congress.  Drawing all those new lines will take some time and result in a minimal amount of horse trading since the Texas House has 101 members — and absolute majority.  Expect no controversy (if you live in a dream world).
 
Save room on the plate for a few more items of interest:  funding for public education, funding for higher education, funding for health and human services, health care services such as SCHIP and Medicaid, criminal justice and its correctional health care programs, border security, immigration, voter ID, scope of practice in medicine  …. to name just a few.  
 
As the football bowl games wind down the real “play off” will be occurring in the Texas legislature as our elected officials make decisions that will determine the fate of our state over the next several decades.  In health care education, we know that the stakes are high.  Maintaining the absolute best quality of education is a task that requires constant and strategic investment; it does not happen by chance.  Educating and retraining health care professionals to practice in Texas is also no trivial task.  We must invest in increasing our state health professions school graduates, and we must also increase the investment in graduate medical education in Texas.  All of that takes money. 
 
Choices will be made.  Let’s hope they are focused on the future.

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