Thursday, July 24, 2014

The Role of Prevention and Population Health in the Texas 1115 Medicaid Waiver — Part II

by Jeffrey Levin, MD, MSPH; Daniel Deslatte, MPA; Joseph Woelkers, MEd; and Kirk Calhoun, MD

from The Center for Rural Community Health
at The University of Texas Health Northeast

Read Part I here.

The following invited remarks were prepared for the Code Red Task Force deliberations as it updates its recommendations. The comments were delivered on June 18, 2014 in Dallas, Texas. They are presented here as the second of a brief two-part series.

Status of the Waiver Relative to Code Red, Future Extension, and Expansion of Medicaid

As we approach the close of Demonstration Year (DY) 3 of the 1115 Waiver, and with an eye for a prevention framework as just described, we are only now beginning to see how many project initiatives may begin to fulfill several of the key recommendations of Code Red 2012. (Code Red, 2012)

However, our health care system is characterized by enormous inertia.  Implementation of health information technologies and exchange systems is highly dynamic and suffers from various states of evolution, sophistication, and obstacles to integration due to their proprietary nature. Establishing accurate and representative baselines in DY3 with real, but modest improvements in milestones and targets will barely have begun by the end of this Waiver cycle in 2016. Clearly, an extension of Waiver funding for those projects that have achieved metrics and begun to demonstrate early success would prove essential to sustaining improvements while more fully integrating transformative measures into successful delivery systems.

As the largest single source of health insurance coverage in the United States, Medicaid expansion in Texas would also more readily ensure sustainability of successful demonstration initiatives by further increasing the capacity of these projects to meet the needs of patients who presently fall below 138 percent of the current federal poverty level. In particular, said expansion would not only allow Texas and its taxpayers the opportunity to garner substantial additional federal funds for this purpose, but would also help to encourage primary and secondary prevention. Moreover, as strides are made to reduce inappropriate emergency department utilization as well as hospital readmissions, Medicaid expansion would allow building momentum in this new direction. (Crowley and Golden, 2014; Garber and Collins, 2014; Hamilton, 2013; Ryan and Mushlin, 2014)

A Brief Word About Workforce

Raimer presented health care workforce requirements on behalf of Code Red.  (Raimer, 2011) Among a wide range of professional shortages were included primary care physicians, the behavioral health disciplines, dental health providers, and public health workers. The Demonstration Waiver, while helping to build capacity in a number of these areas through traditional educational means, has also emphasized the importance of innovative approaches to workforce development as a means of building capacity for preventive intervention, such as through community health worker and navigation activities, as well as integration of much-needed services such as behavioral health at multiple levels. On a larger scale, building programs for public health at both the undergraduate and graduate level is needed, particularly in rural communities, as well as more aggressive integration of public health service delivery into undergraduate and post-graduate medical education.

In summary, extension of Waiver funding, expansion of Medicaid, and targeted workforce development in Texas can serve effectively to promote health through prevention, while reducing morbidity, mortality, and cost.


Code Red. (2012). Code red: The critical condition of health in Texas, 2012.  Available and last accessed on June 8, 2014, at:

Crowley R A and Golden W. (2014). Health policy basics: Medicaid expansion.  Ann Intern Med;160:423-425.

Garber T. and Collins SR. (2014). The Affordable Care Act’s Medicaid expansion: Alternative state approaches. The Commonwealth Fund Blog, March 28, 2014.

Hamilton B. (2013). Smart, affordable and fair: Why Texas should extend Medicaid coverage to low-income adults. Consulting report prepared for Texas Impact and Methodist Healthcare Ministries of South Texas, Inc.

Raime, BG. (2011). Health professions workforce: The health of Texas.  Presentation given at Health of Texas Workshop, available at:

Ryan AM and Mushlin AI.  (2014).The Affordable Care Act’s payment reforms and the future of hospitals. Ann Intern Med;160:729-730.

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