After just four months on the job, Texas' new top public health bureaucrat has said he doesn't believe in Texas' high uninsurance numbers, blames good weather for Texans' ill health, and has hired an adviser who hates children's Medicaid. Welcome to the future of public health care in Texas.
The new executive commissioner of Texas' Health and Human Services Department -- the social services behemoth that's currently in the process of building a whole new Texas Women's Health Program (WHP) so it can exclude Planned Parenthood from providing contraceptives and cancer screenings to low-income Texans -- has some interesting views on the condition of public health care in his state. And by "interesting," I mean shocking. I mean shockingly ignorant. Astounding, even.
Dr. Kyle Janek is an anesthesiologist by training, but for the last 18 years has served as a Republican in the Texas Legislature and as a lobbyist for various medical organizations. Governor Rick Perry appointed him as executive commissioner of the Texas HHSC on September 1st. You might expect that in 18 years of being plugged into Texas politics and state health policy, he'd have a decent grasp on the issues facing Texans.
You'd be wrong. Because Kyle Janek doesn't believe -- despite credible, widely accepted evidence to the contrary -- that one of Texas' most pressing health problems, its high number of uninsured adults, is real. He doesn't believe that more than a quarter of Texans are uninsured, as estimated by the U.S. Census Bureau. He told a Texas Tribune reporter in early October that he believed that number to be "inflated," and then reiterated his point in an extended interview with Tribune editor Evan Smith on October 31st. (Through his press representatives, he refused an interview with RH Reality Check.) Here's his most recent take via the Tribune:
"It's not that I don't believe those numbers. I don't believe the reasoning for those numbers."
Janek's problem: he said the Census Bureau only takes a "snapshot" by asking people if they're uninsured, and doesn't ask them if they had insurance in the past or if they think they have a job lined up with insurance in the future. Janek must not be aware that for nearly 25 years, the Census Bureau's "snapshot" has shown practically the same thing: since 1987, Texas repeatedly has one of the highest, or the very highest, number of uninsured adults in the country. That rate has not been below 1987's 23 percent; it peaked at 26.8 percent in 2009 and is currently estimated at 26.2 percent.
That's a remarkably consistent snapshot of something that Janek seems to believe changes for millions of people by the day. Janek says he isn't sure why Texas "is different" when it comes to health care, but he told the Tribune it could be because the weather here is nice.
"Do we have so many people that are temporarily uninsured? Or is it the general climate of better weather and glorious place to live? Folks come here, and that attracts more folks with health care needs or disabilities?" he wondered during the interview. Surely our high uninsured numbers couldn't be due to the fact that Texas jobs generally don't provide health insurance, that Medicaid in the state is limited, that insurance rates are unregulated or that Texas has a large immigrant population, as the Washington Post reported last year. No, it's probably just the purty weather.
I called Dr. John Holcomb, a pulmonologist who chairs the Texas Medical Association's committee on Medicaid, to find out what he makes of Janek's stance. (Spoiler alert: the TMA's official position is that "Texas is the uninsured capital of the United States.") Holcomb told me that Janek's comments are "a perfect example of how Dr. Janek is not ready for prime time."
Holcomb told me that while Janek is a "very good speaker" and "very articulate," when it comes to uninsured rates in Texas, "everyone knows exactly what those numbers are." They aren't inflated. They're real. They're accepted by public health professionals all over the state, including Dr. Janet Realini, the president of unplanned pregnancy prevention group Healthy Futures of Texas. Realini has been a vocal supporter of maintaining the Medicaid Women's Health Program and a critic of the state's and the HHSC's cuts and changes to money-saving family planning programs.
"We have more uninsured, a higher precentage in Texas, than any other state," Realini told RH Reality Check. She called Janek's job "pretty tough," and said she's "glad there's a physician in that position," but says she's mainly focused on Janek's performance with regard to reproductive health care and the Texas Women's Health Program. The WHP has so far been the most highly publicized of Janek's challenges in his short few months in office, and has occasionally put him at odds with the medical community, which tends to favor the continued inclusion of Planned Parenthood in the WHP.
"I still see a great concern that we won't have enough providers throughout the state," said Realini of the new Texas WHP without Planned Parenthood; it's a concern she shares with a number of researchers and public health experts in Texas. To its credit, the HHSC under Janek relaxed rules regarding the WHP's definition of abortion "promotion" after an outcry from doctors who were afraid they'd be barred from even discussing the procedure with their WHP patients.
It was a brief moment of clarity for Janek, who has said that he believes Texas' public hospital system, and private hospitals that are reimbursed for providing indigent care, are decent solutions to Texas' (non-existent?) uninsured problem. In fact, they may have already solved the problem (which may or may not be a real problem, according to Janek). He told the Texas Tribune: "There is another system that we tend to forget, and that is the system of safety net hospitals around the state."
Who constitutes the "we" that the memory-challenged Janek is referring to is unclear: Taxpayers, who fund public hospitals through increasing property taxes, and insured people who see their premiums go up to cover emergency room care, haven't "forgotten" about the higher costs they're taking on. Uninsured people who have nowhere else to go for treatment haven't "forgotten" about public hospitals. Nobody has "forgotten" about an overburdened, expensive system that usually catches people when they're at their sickest. But Janek wants us to believe that Texas' county hospital system -- every county in the state is required to spend eight percent on its general revenue on indigent care -- is sufficient?
By that reasoning, the TMA's Dr. Holcomb told me, "That means every county in the state is already taken care of." Of course, Texans' ill health and high uninsured rate belie that.
Interestingly enough, Janek does have a solution to this non-existent problem that he doesn't believe in, and that is to widen the "safety net," not by accepting a federal Medicaid expansion or the Affordable Care Act, (which the Kaiser Foundation has found would help cash-strapped Texas cut the rate of uninsured in half in a very short amount of time for a minimal investment) but by launching more medical schools.
"One of the things i'd like to see us do is shore up those medical schools," Janek told the Texas Tribune. He said he tried to convince legislators in years past, when he served as a state representative and then senator, that medical schools were the way to go, but that he was "unsuccessful at getting [his] message across."
Texas currently has nine medical schools in largely high-population suburban or urban areas: College Station, Waco, El Paso, Fort Worth, Dallas, San Antonio, Galveston, Houston and Lubbock. These schools, and ones that Janek hopes will be founded in the future with federal funds the state may or may not be able to secure through Medicaid block grants or waivers, could be "a network that is just terrific," according to Janek, who envisions treating the schools as managed care providers.
"That is not just a safety net. They actually do become an insurer," said Janek.
For someone who says he argued on behalf of more medical schools for years, Janek takes a mighty rosy view of how easy it is to found them in Texas. Take, for example, my very deep blue city of Austin, a bastion of tax-loving hippie-dippie liberals. In November's election, we were presented with Prop 1, a five-cent medical school-funding property tax increase. It was a hard-fought victory, but the measure passed. Health care-loving people -- I'm one of them -- rejoiced. And barely two days after the election, the measure was embroiled in a lawsuit --one that was swiftly thrown out, but nonetheless: even in academic-focused Austin, where you'd expect the founding of a new medical school to be more of a cakewalk than anywhere else, it was a long and dirty fight. At the earliest, that medical school will enroll its inaugural class in 2016 -- in Austin, a city with a vibrant public service community, a county-funded reproductive health care program, and many other low-income-focused health care resources.
Whereas Texas' border area in the Rio Grande Valley, one of the neediest areas of the state when it comes to low-income health care needs, has been angling for a medical school since the 1940's. Sixty years of lobbying, negotiating and fighting, and the brandest, newest, shiniest medical school in Texas goes to ... Austin, with a $30 million per year special budget. As a consolation prize, last spring, the University of Texas System Board of Regents "reaffirmed their commitment to transitioning South Texas' regional health centers into a freestanding medical school, but without additional spending."
An Austin medical school takes a property tax increase and a dedicated multi-million dollar budget, but the Rio Grande Valley is somehow, someday going to get a medical school "without additional spending." South Texas probably is next in line for a school, but when, or where, or for how much money is unclear at this point.
"Dr. Janek's idea didn't have any fiscal note associated with it," Dr. Holcomb at the TMA told RH Reality Check. "I'm astounded that Dr. Janek would come up with that idea without the dollars to go with it."
Dr. Holcomb told RHRC that his organization has asked Janek's office for details on the fiscal realities of the medical school proposition, but has so far received nothing in response.
Why does Janek think that Texas legislators, county commissioners and other politicos are suddenly ready to funnel millions, probably billions, of dollars into medical schools?
Perhaps because he's hired a conservative think-tanker to help make that happen. Her name is Mary Katherine Stout, and for $150,000 per year, the former Perry staffer, Wal-Mart defender and far-right Texas Public Policy Foundation economics "expert" will act as a "special advisor," "involved in a number of policy and planning issues," according to HHSC spokesperson Stephanie Goodman. Goodman told RH Reality Check that Stout will be "looking at ways [Texas HHSC] can work with medical schools to support their efforts to make sure Texas has enough health professionals."
In the past, Stout has particularly focused her efforts on criticizing Medicaid and especially CHIP, the popular children's Medicaid program, which she has said is rife with luxury car-driving freeloaders and should be closed to people who are verily rolling in cash and furs, like "those making as much as $40,000 annually for a family of four." Stout's coldness is unusual even for Texas right-wingers, and her cruel preoccupation with making sure as few Texas children as possible receive needed aid borders on the bizarre. To that end, this was her 2007 proposal for fighting "The Left" in the National Review:
Perhaps we should fight their strategy with our own campaign to tell stories of success, of people working hard and making good decisions for their family, of people who made something out of nothing, or who turned something into more. Yes, send me your stories of success, of personal responsibility, and of government's depredations on a family trying to make ends meet.
These are the words of a "special advisor" on Texas public health care policy, who'll be whispering in the ear of a man who believes the state has "inflated" uninsured numbers because hey, poor people can always go walk in and get some open heart surgery at a public hospital or amorphous medical school of dubious funding origin.
For now, it's hard to say how Janek's term as executive commissioner will go -- after all, he's only been on the job four months. But he's had nearly 20 years in politics to form reasonable, fact-based opinions about the state of public health care in Texas, and if the best he can do is wonder about the weather, the forecast for this state is stormy indeed.