Off with their heads?

Dear friend –

The storm shut us all into our homes for a week (after a year of pandemic semi-isolation, no less). For millions it imposed sustained freezing cold and darkness, even lack of water, along with all the awful consequences. When the power finally came back and the artic dome at last left us to thaw, indoor water pipes burst, flooding homes and buildings, adding to the financial, physical, and emotional toll. It was the 4th-worst Texas winter storm on record.

It’s tempting to call for heads to roll. We want someone to blame for all this. But beware rolling heads, for in our overzealous search for personal fault we will almost certainly miss the larger, structural and systemic causes of failure and loss. And that leads to mistakes we can’t afford.

Which brings me back to those pipes. Why did they burst? Because they weren’t designed to accommodate or withstand subfreezing indoor temperatures. What happened with our energy system is sort of like what happened to the pipes: it wasn’t able to function in the conditions that it wasn’t designed to operate in.

Last week the House and Senate convened hearings to investigate what went wrong. For 14 hours on Thursday and 10 hours on Friday, my Senate Business & Commerce committee colleagues and I questioned witnesses from the panoply of players in the energy supply sector – ERCOT, PUC, RRC, TDUs, REPs, and other acronyms, as well as industry executives, advocates and scientists.

We have a great deal of work ahead. Much remains to be analyzed and explored. But the hearings made abundantly clear that sole blame cannot rightly be placed on a few individuals at ERCOT or the PUC or elsewhere. That’s dangerously simplistic. I’ll be working on the harder questions.

TXMedX

This morning I released a new video, Cutting Through the Fog, in which I use animated drawings and a white board (and a little dry ice) to explain the math and the benefits of Medicaid expansion. The 10-minute video offers an entertaining look at how Medicaid expansion works for Texas, and calls upon all Texans – Republican, Democrat, urban, and rural – to learn the facts and advocate for immediate expansion. “We absolutely have to cut through the partisan fog. It’s time to get this done.”

Click here to watch the 30-second trailer, or click the image to view the full video. 

The 87th Texas Legislature

Dear friend –

We’re now two weeks into the 87th Texas Legislative Session. The Capitol is abuzz with excitement, and maybe with a bit of intrigue, too. Possibilities abound.

What’s new: My team and I begin this new year in a new Capitol office, and with a new set of committee assignments. The Lieutenant Governor appointed me to serve as Vice-Chair of the Senate Committee on Administration, and on Business and Commerce, Jurisprudence, the Senate Special Committee on Redistricting, and Water, Agriculture, and Rural Affairs. These are weighty assignments, and I embrace them eagerly and with high aspirations.  

What’s continuing: My work in the healthcare space, meanwhile, will continue unabated. I have filed several healthcare bills already, none larger or more important than the quest to forge a bipartisan agreement to bring to Texas expanded Medicaid coverage under the Affordable Care Act. Please take a moment to read the Policy Spotlight: “Live Well Texas Program”, below.

Top response from my January 19th Town Hall: “I had no idea state government did so much.” Missed it? Curious? You can watch the whole show here. Warning: I talk too fast. There was a lot to cover.

Podcast fans: Jason Whitely and Jason Wheeler brought me onto their smart and entertaining show Y’all-itics last week, for a quick look at a few of the big items looming ahead for the session – the state budget, the startling scope and scale of benefits from Medicaid expansion, schools and property tax, marijuana, partisanship, and more. Catch the segment here, or for a quick sense of the show, listen to this 1-minute clip.

Want to follow state politics in real time? You can watch committee hearings as well as Senate and House floor proceedings, and even track legislation in progress, at https://capitol.texas.gov/.

Policy Spotlight: The Live Well Texas Program

The opportunity. We can bring health insurance to an estimated million Texans while adding $2.5 billion dollars to state general revenue without raising taxes. At the same time we can provide support to rural and urban health systems, stabilize family finances, improve public health, decrease ER visits, relieve pressure on local property taxes, improve racial equity, encourage employment and create jobs.

All this results from expanding health insurance coverage under the Affordable Care Act. But despite the benefits, ACA expansion still faces significant obstacles in Texas – political, practical, and philosophical. To overcome these obstacles, we’ll have to address long-standing and valid conservative concerns, while still meeting the challenge to broadly expand access to healthcare. That’s the aim of my Senate Bill 117, the “Live Well Texas” program.

The Live Well Texas program is neither traditional Medicaid nor traditional Medicaid expansion. In fact, it’s a waiver of substantial elements of traditional Medicaid requirements. The program draws down federal Medicaid dollars to provide coverage to the ACA “expansion” population (non-elderly, non-disabled, non-pregnant adults age 19-64 who earn less than 138% of the federal poverty level), but gives Texas substantially more control and discretion over how we administer and spend those funds, over how we work with providers, payers, and participants. Importantly, the program incorporates approaches that have proven effective in other states with Republican leadership. As with other comprehensive bills, SB 117 also provides a flexible framework within which legislators can change, add, subtract, re-shape, and refine the various elements and operations of coverage expansion.

What about the money? We’re good on the money. Because it draws down federal Medicaid dollars at a federal-state match rate of $90-$10 (instead of $60-$40 under standard Medicaid), a Texas ACA expansion generates more in savings and revenue ($1.4B) than it introduces in new costs ($1.3B). See, among other sources, An Open Letter to Elected Officials, November 9, 2020 by Ray Perryman, Laura Dague, Randy Fritz, and Vivian Ho: “[T]he probable net static fiscal impact of implementing a federally funded expansion in Texas would be positive and in the range of $75 million to $125 million during the 2022-2023 Biennium.”

And that’s just the static component. Economic stimulus from an additional $11B in federal funding is expected to generate additional dynamic state revenue of $2.5B, and local revenue of $2.0B – in just the first fiscal biennium.

Finally, if – as virtually all other expansion states have done – Texas were to implement any kind of provider or plan assessments, fees, or taxes, the resulting revenue would be available for other state needs.

$90-$10 or failure. The money math only works with a $90-$10 federal-state match. Calls for “alternatives” to ACA expansion propose exceedingly narrow, incremental, but politically attractive programs. They cover a small fraction of the expansion population, generally draw funding at $60-$40, and depend on local property taxes. The money math doesn’t work, and they’ll get a negative “fiscal note”, which in the Legislature means they impose net cost to the state budget, which in turn means that they won’t become law. In practical effect, then, there are only two options: $90-$10 or failure.

Does expansion mean less efficiency in government? No. The present structure of healthcare assistance programs is fragmented, comprising a large and complex patchwork and featuring inconsistencies and contradictions and leaving large gaps. To an appreciable extent, ACA expansion can streamline processes and consolidate operations, resulting in greater, not lower, government efficiency.

An overview of Live Well Texas. Some key elements of the plan include:

• Health savings accounts. Participants are enrolled in a high deductible health plan. The state initially funds the account in an amount equal to the (high) deductible or, in the case of the plan option for advanced benefits, in the deductible amount minus the amount the participant will be expected to contribute to their own health savings account. For low-wage workers, the participant’s contribution may be funded by the participant’s employer (incentivizing both employment and employer participation) or by charitable organizations (calling upon and enabling the participation of the community).

• Provider participation incentive: raises Medicaid reimbursement rates to parity with Medicare rates. Higher reimbursement rates correlate to higher provider participation.

• Utilizes Texas’ existing MCO model, including value-based payment systems.

• Creates incentives for healthy behavior modifications. Insurers (MCOs) can reward participants for healthy behavior modifications, like smoking cessation and chronic disease management, by making extra contributions to their HSA accounts.

• Medicaid residency and citizenship requirements apply to plan eligibility.

• Encourages and facilitates employment. The plan refers unemployed and under-employed participants to work-search and job-training programs provided by the state. Participants who do secure employment and then, as a result of their additional income become ineligible for the program, may continue to draw upon their HSA account funds while they obtain new insurance, thus eliminating what otherwise might be a disincentive for seeking employment.

• Simplifies eligibility. Uses a single, consolidated application process for all state health benefit programs, including current Medicaid and the Live Well Texas program. Once an applicant is determined to be eligible, eligibility continues for 12 months.

• Continuity of enrollment, and maximum federal funding for pregnant women, parents and caregivers. To the extent standard Medicaid for pregnant women might (now or in the future) provide benefits beyond what the Live Well Texas program offers them, women who become eligible for traditional Medicaid by virtue of pregnancy will receive all standard Medicaid benefits in addition to their benefits under their plan. The program treats parents and caregivers likewise. This ensures that participants receive all benefits that the state has specifically designed for pregnant women and caretakers. At the same time it incentivizes them to remain enrolled in the Live Well Texas program, which for the state means federal funding at $90-$10 instead of $60-$40 (or other less favorable rate) under traditional Medicaid.

• Self-destruct: if the federal government were to decrease the $90-$10 match rate, the program ends.

Expansion under the ACA is stable. With 38 states having opted to expand under the ACA, representing 228 million people and 53 million expansion enrollees, we can expect that Congress will preserve it, just as Congress continues to provide funding for transportation and education.

More to do. Coverage expansion under the Live Well Texas program (or other ACA $90-$10 expansion model) comprises only part of the exciting range of healthcare initiatives being pursued at this moment. Some will advance this session (pushing for a few of my own), and some will have to wait for other legislative sessions. But ACA coverage expansion is by far the most comprehensive, powerful, and economically advantageous measure available to Texas.

Weight for it

Strange that the Senate still files bills on paper. Eleven legal-size copies of every bill. E-filing would be more convenient, of course; and then there’s all that wood pulp… But I must admit there’s something satisfying in signing real paper, with a real pen, and carrying a heavy stack to be filed – a sort of physical sense of the weight of our work.

The heaviest lift (sorry) was SB 117, the “Live Well Texas Program”, a non-partisan bill to expand health insurance coverage in Texas by drawing down federal Medicaid dollars at a 9:1 ratio (video excerpt of the announcement here). It’s expected to result in insurance coverage and healthcare for a million Texans, while preserving state control and generating positive net revenue for the state budget. On the lighter side (by weight), I also filed bills addressing criminal justice, taxation, business and the environment, good government and effective democracy, impediments to social progress, and a wide range of health initiatives.

If you’d like to know more about the legislation I’ve filed so far, please see my early-filing press announcement here. We’ll be exploring these and other matters of importance to the coming legislative session at my Virtual Town Hall on Tuesday, January 19 at 7:00 p.m.  Click here to receive a link to attend.

Thankfully the election is at last over (yes it really is over). We can concentrate on why we have elections, which is to make good policy. This SNJ Journal volume’s Policy Spotlight looks at one of the policy areas that holds great promise for bipartisan effort: criminal justice reform. Please read the full discussion below.

As always, thank you for reading, and for being engaged in state politics. 

Around the District:

Texas Woman’s University, Texas A&M Commerce, and the Dallas County Community College system all shared inspiring news about expanding the services they offer to the many Texans who seek to better their knowledge, skills, and prospects. With the increasing demand for higher education, the visits were especially timely.

The State of Reform Leadership Series invited me to serve as the opening day keynote speaker, for a conference in which leaders in health care discussed and debated some of the most important health policy issues we face today. Click the image below to watch the video.

The Hope Supply Company is a DFW-area non-profit that serves as a clearinghouse for donated supplies, assisting the entities who are providing care to individuals who need it most. Due to the COVID-19 pandemic, they’ve seen a 300% increase in the need for diapers. In response, my staff and I held a diaper drive for the many families in need. We’re still accepting donations, so if you’d like to participate, you can order something from our Wish List or email us at District16.Johnson@senate.texas.gov to schedule a supply drop-off.

Every ten years, the Texas Legislature redraws our state’s electoral maps based on our recent U.S. Census data in a process we call “redistricting” (known less fondly as “gerrymandering”). The 2021 redistricting process is already underway in the Texas Legislature. As part of that process, the Senate Committee on Redistricting has invited the public to submit comments and attach documents for the senators to review and consider before they begin drawing the new maps. If you’d like to submit thoughts, observations, or other information related to the redistricting process, please do so here.

Policy Spotlight: Watching the Detectives

Investing in investigations may be the next step towards a better criminal justice system.

In the mid-1960s crime in the United States rose at a shocking rate. Murders doubled while violent crime overall tripled. Property crime of all types – larceny, burglary, auto theft — became commonplace. It would take 30 years to subside.

Responding to the demands of (understandably) fearful citizens, lawmakers made what were, in hindsight, a pair of catastrophic errors.

First, they ratcheted up criminal penalties across-the-board. Second, police departments and courts emphasized prosecution of small-time drug users and dealers, imposing harsh criminal penalties for non-violent activity. To accommodate all the shift, America built one of the largest systems of incarceration in modern history. Over two million Americans remain incarcerated in 2020. 

Crime began to drop dramatically in the 1990s and now sits at half of its peak. Does mass incarceration – notwithstanding all the injustice and social destruction and budget-breaking costs it imposed – get the credit? It’s important to ask the question, but the answer is No. Modern studies indicate that only a small fraction – perhaps 10% (see, e.g., this study by the Brennan Center) – of the decline in crime is attributable to mass incarceration. The rest owes to myriad other factors that have nothing to do with harsh penalties and inequitable application of the law. They include higher employment rates and rising personal income, declining alcohol consumption, and an aging population. Consider also the increasing academic interest in and support for the “lead-crime hypothesis” (as in leaded gasoline), which is that the damage to intelligence, self-control, and sociability resulting from childhood lead exposure has a causal link to 30-50% of the 30-year crime wave. (The environment is important, folks. Interesting and chilling article here.)

For its meager benefits, mass incarceration has imposed immense social and fiscal costs.

• Direct costs add up to $182 billion annually, according to the Prison Policy Initiative.

• Permanent criminal records have reduced the total male employment rate by 1.5-1.7%, causing $57-$65bn in annual lost economic output, according to CEPR.

• Kids with an incarcerated parent are twice as likely to become homeless and far more likely to have social, academic, and behavioral problems.

• Prisons reinforce rather than rehabilitate criminal tendencies. Texas’ state jail system, originally intended as rehabilitative alternative to prison, actually has higher recidivism rates for those released. (TCJC study)

• The damage of misguided crime policy has fallen disproportionately upon communities of color, exacerbating the enduring problems of racial inequity.

• Surveys in high-crime areas show low trust in police (Urban Institute). This trust has been destroyed by drug enforcement and other punitive laws and practices. Without trust, residents and police can’t – and demonstrably haven’t been able to – work together to reduce crime.

I’m working on legislation to roll back some of our most counterproductive, unjust, and often cruel criminal laws and penalties, including laws regarding state jail parole, cannabis concentrates, automatic license suspension, and marijuana possession.

But though undoing bad policy is important, crime prevention remains the primary goal of the criminal justice system. We need more good policy on preventing crime. The U.S. Department of Justice concludes that the certainty of being caught and punished has vastly more deterrent power than the severity of punishment. So, we can best deter crimes by solving crimes.

In 2019 Texas solved or “cleared” only 58.7% of murders, 23.3% of reported rapes, 18.4% of robberies, 39.6% of assaults; and 8.5% of burglaries, 14.1% of thefts, 10.9% of motor vehicle thefts. Neither the police nor the public are, or should be, satisfied with this. To solve more crimes law enforcement needs (1) resources, and (2) time. Pursuing non-threatening activity subtracts from both.

By correcting the policy mistakes of the past – those policies that distract police and command their resources, that drag down communities and families, that even raise levels of crime – we can make available additional resources and time for law enforcement to more effectively protect people and property. It’s beyond the scope of this Policy Spotlight to prescribe measures for local law enforcement. But it’s fitting to observe that thoughtful, objective crafting of state policy can facilitate more just and effective law enforcement, along with the great social benefits it would bestow to all of us.