Monday, July 2, 2012

Texas and the Future of Health Reform in America

Richard Reece, MD

A few days ago I received a handsome 64-page brochure from the Texas Medical Association. Its title was Healthy Vision 2020: Caring for Patients in a Time of Change.

Among other things, the brochure says Texas is the fastest growing state. Its population is expected to boom from 25 million to 40 million in 2040. It leads the nation in employment growth. It is desperately short of physicians. Nearly 6 million of its baby boomers will become eligible for Medicare. Of its citizens, 6.5 million lack insurance. In 2010, it spent $23 billion on Medicaid, yet it pays doctors only 50 percent of commercial payments, and many of its physicians can no longer afford to treat Medicaid patients. I will not be surprised if Texas is among the first of the states to opt out of federal funds for expanding Medicaid.

Texas physicians and their medical association impress me. Its physicians are tough, resilient, independent, and powerful politically and economically. Its medical association persuaded the Texas legislature to pass tort reform in 2003, which brought 24,600 new physicians into the state.

Yet Texas has fewer physicians per capita than the national average in 36 of 40 medical specialties. Texas is a prime example of a looming and inevitable political crisis: lack of access to physician services by Medicaid and Medicare patients as demand for medical services boom and more physicians drop out of these programs due to reimbursements so low physicians cannot sustain their practice.

Access to financing through the Patient Protection and Affordable Care Act is not the same as access to physicians. Indeed, what good is “universal coverage” without doctors to evaluate and treat patients? The brochure notes that spikes in numbers of physician assistants (+132 percent), advanced practice nurses (+114 percent), and registered nurses (+44 percent) over the last decade will not fill the physician shortage gap.

In spite of these problems, Texas may be what the future will look like in the United States. Texas has a robust, friendly, and inviting business climate. It is drawing Californians to Texas in droves. It is an energy-rich state.

Three-fourths of its physicians are from other states. Small wonder. Texas has no state income tax. Its cost of living is low. It is an unabashed proponent of physician entrepreneurship and innovation. It favors physician ownership and investment in hospitals. It insists on physician autonomy from corporations and meddlesome insurers. It is a potent economic force. In 2009, physician offices contributed $39.4 billion in direct and indirect wages and employee benefits. On average each physician supported $924,413 in total wages and benefits.

Texas physicians are a powerful economic and political force. They are critical of federal regulations that impede their practices, increase their expenses, slow productivity, and stifle innovation. They are aware of what has happened in Massachusetts: Long waits to see doctors; shortages of primary care physicians; the highest premiums in the land; and a sharp increase in ER patients.

For more information on how the Texas Medical Association and its 46.000 physicians see the future, go to or call (512) 370-1300.

Dr. Reece is a pathologist, author, editor, and speaker. He is the author of the blog, Medinnovation: Where Health Reform, Medical Innovation, and Physician Practices Meet.

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