PaladinSG’s instructions were clear and specific:  Conduct a series interviews built around three specific questions designed to solicit the respondents’ views on the future of indigent health care and the role of TIHCA in indigent health care in the coming years.  The final question was intended to ascertain the respondents’ views regarding which programmatic areas that TIHCA should focus its efforts (given its members limited time and resources).  Each interview was intended to last no more than fifteen minutes.

 

THE PROCESS

In response to the instructions, PaladinSG developed the following three questions:

1.)               Looking out over the next three or so years, what do you see the future for the provision of indigent health care in Texas?

 

2.)               Looking out over the next three or so years, what do you see as the role of the TIHCA in the provision of indigent health care?

 

3.)               I am now going to read you a list of four categories of programs that TIHCA could undertake over the next two years.  I understand that these categories are not necessarily mutually exclusive and I also understand that the organization probably should, and likely will, undertake programs that fall into each of these programs.  I also understand that many programs that TIHCA can and will undertake could be construed as falling into more than one category.  My objective here is to determine which of these categories represents the area where you feel the organization should put the greatest effort.

The categories are:

·                     Technical assistance

·                     Developing relevancy

·                     Membership development

·                     Membership satisfaction

 

Each of the above questions is intended to solicit “top-of-mind” answers from the respondents.  Top-of-mind responses are generally thought to be more indicative of an individual’s true feelings about an issue.  While “considered” or “thought out” answers are typically more articulate they also can be distorted by a respondent’s natural tendency to want to give the interviewer a “correct” or more acceptable answer.

It should be noted that, while the first two questions are rather straightforward and easy to understand, the third question is a bit more complicated.  In the third question a series of “false dichotomies” are purposefully established.  Upon examination it is clear that the components of the proffered list are not mutually exclusive and that each could easily be construed to be a part of at least one, or more, of the others.  For instance, “Technical Assistance” could easily be part of “Developing Relevancy” which could be argued is part of “Member Satisfaction” which is a primary component of “Membership Development.”

The third question was intended to cause the respondent to focus on a specific area or category of programs that most closely aligned with their vision of where the organization should expend its efforts in the intermediate term.  For instance, should the respondent answer that they thought that TIHCA should focus on technical assistance over membership development, it would not mean that membership development programs were unimportant or should be abandoned, it simply means that the individual prefers the organization to focus its main efforts on assisting its members with technical issues.

 

THE RESULTS

Over the course of the two day annual conference all board members but one (who declined to participate in the process) were interviewed.  Interviews were held at the convenience of the respondent and took place during breaks between sessions and after hours.  Interviews tended to last longer than the proscribed fifteen minutes (some considerably longer) and, owing to their informal nature, tended to cover a wider-range of indigent health care topics than those embodied in the questions.

Since the interviews were informal there was no attempt to perform quantitative analysis on the results.  The following are simply “consensus” positions and are presented as either a “general consensus” or as a “secondary consensus.”

To rise to the level of “general consensus” a topic or issue needed to have been mentioned or alluded to by at least seven of the respondents.  A “secondary consensus” is a topic or issue that represents a component of a general consensus topic or issues about which five or more respondents generally agreed.

During the course of each interview, it was not uncommon for other indigent health care related topics or issues to be discussed.  Some of those same topics or issues were discussed by multiple respondents, however, because there was no consensus opinion discernable among enough of the participants, those topics are not part of the findings.

Also, since the interviews were conducted in private, there is no attempt to identify opinions or views held with any particular board member.

 

 

 

 

 

 

QUESTION # 1

Looking out over the next three or so years, what do you see the future for the provision of indigent health care in Texas?

The very clear, if unsurprising, general consensus among the respondents was that the provision of indigent health care in the State of Texas would undergo noticeable change in the foreseeable future.

While each individual respondent had a slightly different take on the nature and scope of those changes, there was no disagreement to the proposition that change would come.

Within this “general consensus” there were some narrower areas around which a consensus was clearly discernable.  To wit:

1.)               The demand for indigent health care services will increase.

 

Within this secondary consensus three sources of increased demand were mentioned, or alluded to, at least three or more times:

 

·                     Economic conditions -  Several of the respondents believed that the general economic health of the country and the state was trending downward and will result in an increase in the numbers of both the unemployed and employed-but-uninsured.  The growth in these two categories will necessarily result in increased demands on the state’s overall indigent health care system.  While it was acknowledged that some regions, and sub-regions, will be hit worse than others, it was generally accepted that all of the state’s indigent health care programs would see at least some level of increase in economically-driven demand.

 

·                     Growth in population -  Respondents all agreed that the population in Texas would continue to grow.  Only two of the respondents mentioned the root causes of that growth (in-migration and in-population birth rates) so it is difficult to determine what consensus might exist as to the causes of the expected growth.  However, it can easily be assumed that each of the respondents would be willing to accept both components as contributory.

 

Also, there was no verbalized consensus regarding whether or not there would be an implicit change in existing demographic trends as currently experienced (in other words, whether or not the growth trends in the state would shift toward the less affluent).  However, it should be noted that a shift in the demographics of the upward trend would represent a fundamental long-term change that could be viewed as outside the timeframe of the question.

 

The above caveats notwithstanding, the respondents anticipate that the growth in the state’s population will necessarily bring growth in demand for indigent health care services.

 

·                     State-mandated expansion in eligibility criteria -  While there was certainly no expressed unanimity on this component, it did receive several mentions as a potential factor in the expected growth in indigent health care service demand.

 

Among the respondents that mentioned or alluded to this component, there was a general recognition that the eligibility requirements are subject to political pressures and the forthcoming biennial legislative session may fall in the middle of an economic downturn.  If that turns out to be the case then the normal pressures on legislators to expand eligibility criteria (particularly for county programs) may very well be greater than the pressure (brought by county commissioners) to keep them the same.

 

2.)               The cost of providing health care services in general will continue to increase.

 

It is a fact that the cost of health care has been trending precipitously upward for as long as most people can remember.  The respondents do not see, or at least did not verbalize, a reason to believe that the trend would abate anytime soon.

 

Within this secondary consensus about rising health care cost there were two areas where the respondents seem to have a high-level of agreement

 

·                     Current trends in health care cost will have both political and operational impacts on indigent health care in the state -  The rising cost of health care creates both a political and operational issue for indigent health care.

 

As a political issue, rising health care cost puts pressure on the politicians to take action.  As with many politically driven actions, policies made under public pressure can have consequences that are unforeseen and contrary to intent.  While it is not possible to accurately predict if, when and what action policymakers at the state and local level may take with regard to the rising cost of health care, it is very likely that indigent health care programs will feel some level of impact.

 

As an operational issue, increasing cost of health care directly impacts indigent programs.  There can be little argument that the provision of indigent health care is, at the local level, considered by policymakers and the public alike to be an unfunded mandate pushed down from the state to the local taxpayers.  As such, the programs tend to be viewed as necessary but unwanted burdens that do not warrant funding beyond the most minimal amount.  It tends to be true that appeals to policymakers for increases in funding aimed at meeting rising cost are usually made with limited or no success.  That fact leads to the second point of agreement:

 

·                     Increasing cost will put pressure on indigent health care programs to be more efficient -  As mentioned above, funding for local indigent health care programs tends to be somewhat “sticky” (tends to remain at the same nominal level with little regard to cost pressure).  The respondents largely agree that the pressure from rising health care costs taken, when weighed against “sticky” funding, will likely cause most medium to large local programs to be increasingly vigilant for ways become more efficient to avoid cutting services.

 

3.)      The Federal Government will offer no help in the near-term.

It is fair to say that respondents offered a mixed bag of assessments of what role the Federal Government will play in indigent health care over the next three years.  There was, however, a general consensus that, notwithstanding any potential outcome of the 2008 national elections, there would be no substantive help for indigent health care coming out of Washington.

Since it was not even slightly germane to the task at hand, there was no attempt on the part of interviewer to determine the political leanings or affiliation of any of the individual respondents.  However, given the number of respondents it would be reasonable to assume that there was representation from several political points of view.  That the case, it is even more noteworthy that none of the respondents expressed any strong belief that the Federal Government would be able to craft a national program that would insure appropriate health care to the indigent.  That apparent lack of faith in the Federal Government to meet indigent health care needs was even more pronounced when put into the three year time frame being discussed.

It is clearly outside the scope of this report to determine why the respondents believed as they do about help coming from the Feds, however, at least one respondent voiced their feeling that – again without regard to the outcome of the national elections – it will be politically impossible to get a workable solution through the resulting political storm.

 

4.)      The State will continue to reduce its technical assistance to local programs.

As with the Federal Government discussed above, respondents held a variety of opinions of the actual role that the State Government would play in the provision of indigent health care over the next three or so years.  However, there can be little doubt that a consensus of respondents believe that the State will continue to reduce its efforts to provide technical assistance to local programs.  Respondents seemed to agree that the reduction in ancillary services and oversight from state regulators that have been brought on by political and budgetary pressures will continue and that without outside intervention by others (such as the TIHCA itself) local programs will be left to fend for themselves.

 

QUESTION #2

Looking out over the next three or so years, what do you see as the role of the TIHCA in the provision of indigent health care?

Responses to this question were slightly less unsurprising than the answer to the first question … but only slightly.  There were in fact two points of consensus that rise to the level of “general” each of which is discussed below.

General Consensus #1 –

As to the appropriate role of TIHCA in the provision of indigent health care, the first general consensus was undeniable: TIHCA should not be involved in advocating for any particular policy or regulation.

The respondents seemed to feel very strongly that individual programs should be welcomed to advocate for their own best interests, however, since TIHCA is made up of a number of different organizations that covered the gamut of types of Chapter 61 entities, the interest of one program – or even one type of program – would not necessarily be parallel one with the other.  For that reason it would be inappropriate for an organization comprised of various interests to advocate for one to the detriment of the other.

It is worth noting that the expressed “no advocacy” consensus is consistent with that preclusion as alluded to in the TIHCA’s mission statement.  At the time of the founding of the organization, it was felt that individual indigent health care programs would find it difficult to join the organization if it did not specifically renounce advocacy as one of its missions.

General Consensus #2 –

For the most part, respondents were in equal accord with regard to the second general consensus on question number two.

The respondents evidenced strong agreement with the proposition that the appropriate role of TIHCA was to provide a forum for inter-program communication and mutual technical assistance.  Again falling back on the organization’s purpose as originally presented in the Mission Statement, respondents seemed committed to the continuance of the Annual Conference as an opportunity for representatives from the various member indigent health care programs to congregate toward the purpose of learning about issues and sharing possible solutions.

It is worth noting that the respondents also evidenced strong, though not unanimous, support for the development of TIHCA programs aimed at providing technical assistance to members.

 

QUESTION #3

I am now going to read you a list of four categories of programs that TIHCA could undertake over the next two years.  I understand that these categories are not necessarily mutually exclusive and I also understand that the organization probably should, and likely will, undertake programs that fall into each of these programs.  I also understand that many programs that TIHCA can and will undertake could be construed as falling into more than one category.  My objective here is to determine which of these categories represents the area where you feel the organization should put the greatest effort.

The categories are:

·                       Technical assistance

·                       Developing relevancy

·                       Membership development

·                       Membership satisfaction

 

 

This overly long question was intended to determine the respondent’s top-of-mind belief as to the most appropriate category of programs into which TIHCA should put most of its efforts.  The question was not intended to develop a rank order (although a rank ordering did develop during the interviews) nor to suggest that the organization should focus the entirety of its efforts toward category or another.

 

While questions such as this will sometimes cause confused answers, there was no confusion nor was there substantive disagreement inherent in the responses.  With regard to the four options offered above an overwhelming consensus developed around developing programs that provide technical assistance to the members.

 

It should be noted, there was also very strong support for programs that helped the organization bring in members as well as programs that help garner membership satisfaction, however, it was generally agreed that a strong commitment to technical assistance would work to promote both.

 

 

ANOTHER ISSUE

 

During an interview early in the process an issue arose that merited follow up and inclusion in this report.

 

It was the original intent of these interviews to develop a working understanding of the feelings of TIHCA Board Members regarding certain topics to act as a basis for the development of a strategic plan for the coming two years.  There were preliminary plans for a board workshop of similar character to the one held in 2006.  However, one of the holdover board members expressed significant objections to that plan.  The board member also reported that others had the same objections.

 

That objection prompted an expansion of the discussion points with other respondents.  The objective was to determine how the various board members felt about the process used in the 2006 planning workshop as well as their feelings about going forward with another similar exercise.

 

Although each board member was asked about whether or not they would participate in a 2008 planning workshop, only those who actually participated in 2006 were asked to give input on that meeting.

 

In keeping with the theme of this report, the outcome of those discussions yielded the following points of consensus:

 

1.)               Some level of strategic planning involving a board workshop is definitely warranted for 2008;

2.)               Any board planning workshop should be configured differently than the one in 2006;

3.)               The 2006 workshop tried to do accomplish too many objectives;

4.)               The plans that were developed during the workshop grossly overreached the organization’s ability to accomplish them; and

5.)               Those plans that were within the reach of the organization suffered from a lack of follow through.