NurseWeek: Difference of Opinion: Judge rules Texas Medicaid program failing children; state disagrees

Difference of opinion
Judge rules Texas Medicaid program failing children; state disagrees

By Melissa Gaskill
October 2, 2000
Photo: Artville

A federal judge ordered the state in August to remedy problems in outreach, transportation and education within its Medicaid program.


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A federal judge says Texas is failing to provide for 1.5 million low-income children under its Medicaid program. The attorney general and governor say Texas has made significant strides in reaching this population with health care services.

Add to this mix Gov. George W. Bush’s presidential campaign, a race in which the barbs already are flying over children’s health care, and the disagreement starts to look pretty big.

It began with a 1993 class action lawsuit accusing the state of not providing adequate services to children under Medicaid. San Antonio attorney Susan Zinn, who represented the plaintiffs in that suit, said, "I had been talking with families about their children’s health and many didn’t have any idea at all what Medicaid was supposed to cover or how it could help their children. We wanted to do something about that."

As a result of the lawsuit, the state agreed in 1996 to take remedial action. In August, senior U.S. District Judge William Wayne Justice ruled that problems remained with nine of those actions, including outreach, transportation and education. He ordered the state to remedy the problems by Oct. 13.

Texas Attorney General John Cornyn filed a notice of appeal and his office is in the process of creating the appeal brief, which will take at least three months, according to spokeswoman Andrea Horton.

After evaluating what the state would have to do to respond to the court order, the attorney general’s office filed for a stay Sept. 22, which will postpone the October deadline. Regardless, the Texas Legislature will likely consider a number of measures relating to Medicaid in its next session, beginning in January.

In filing the appeal, Cornyn said the ruling ignored significant strides made by the state. "Texas spends more money on outreach than any other state in the nation and has doubled the participation rate since 1993," he said.

The $15 million outreach effort budget is the largest in the country. According to the state, Medicaid enrollees are contacted on average three times a year to encourage use of benefits.

Zinn acknowledges that the state has made improvements since 1993, but said it is not enough. For example, while Cornyn’s office reports that spending on the medical transportation program has increased 300 percent since 1973, and utilization has risen from 743,000 trips to more than 2.5 million annually, Zinn calls the program one of the best-kept secrets in the state.

"One of the most common reasons Medicaid patients miss an appointment is that they don’t have a ride," she said.

The judge also found that Texas is not doing a good job of training health care workers about how Medicaid works, Zinn said.

The Texas Nurses Association began working with the state Department of Health in 1995 to educate nurses and physician assistants. In May, the association responded to a new request for proposals by the state. The organization has been awarded a $1.3 million grant for additional education programs.

Executive Director Claire Jordan said the association will work with schools of medicine, dentistry, pharmacy and nursing to align curricula with the requirements for well-child care, a major program under Texas Health Steps, the state’s Medicaid program. The association also will establish a Web site, with a focus on acquainting health professionals with culturally competent care, an area that Judge Justice ordered the state to work on.

All this was occurring almost simultaneously with the court ruling, according to Jordan.

The Bush campaign says the ruling ignores key facts, and spokesman Ray Sullivan points out that it is based on a case filed before Bush took office.

"Under Gov. Bush, Texas has increased health care funding by billions of dollars, passed a landmark Children’s Health Insurance Program, and passed some of the best and most effective patient protection laws in the country. Texas is doing a better job than the nation as a whole when it comes to providing health and dental care to children enrolled in Medicaid."

Texas’ Children’s Health Insurance Program (CHIP) is aimed at children of working parents who don’t qualify for Medicaid but cannot afford insurance.

That the motion to enforce addresses only nine of the original remedial actions demonstrates, Sullivan said, recognition of Texas’ compliance with the other provisions, which he numbers at 148. The problems with those nine, he said, largely come down to the health department and the plaintiff having different interpretations of the requirements.

The Gore campaign points out that Bush fought efforts to expand CHIP coverage, and that Texas ranks 49th among the states in providing health care to kids.

"While Gov. Bush brags on television, 600,000 kids in his state are going without health care because of his negligence," Gore spokesman Douglas Hattaway said.