March 2, 2015 President Barack Obama The White House 1600 Avenue, NW. Washington, DC 20500 Dear Mr. President: The Texas Medicaid program has grown from 11% of the state budget in 1987 to 29% in 2015, and caseloads have skyrocketed from 2.1 million individuals in 2002 to an expected 4.3 million by 2017. This trajectory is clearly unsustainable. Moreover, the state's Medicaid program continues to crowd out funding necessary to support other crucial needs such as education, transportation infrastructure, and the development of reliable and sustainable water resources. This untenable situation has been further exacerbated by the impacts of the federal Patient Protection and Affordable Care Act (ACA). Since its passage and implementation, the ACA has imposed excessive federal requirements on our state that are projected to cost over a billion dollars. In addition to the signi?cant number of individuals expected to enter the Texas Medicaid program due to ACA mandates unrelated to Medicaid expansion, this fundamentally ?awed law has forced Texas to navigate an ever-growing and ever?changing array of rules and regulations. Despite the legal and ?scal uncertainty of the law, some in our state, and many in Washington DC, continue to call for an expansion of Medicaid. However, our focus as a state must be centered on ways to control costs in our existing Medicaid program in order to ensure the long- term sustainability of the program designed to care for our state's most vulnerable citizens -- the elderly, the disabled, pregnant women, and children. Texas has already implemented numerous strategies to contain costs in the Medicaid program, including the implementation of managed care and other cost containment initiatives, which have saved taxpayers hundreds of millions of dollars in recent years. In addition, the Texas Healthcare TranSformation and Quality Improvement Program 1115 Waiver has allowed the state to transform health care delivery systems and test innovative new care models to improve access to care while lowering costs. However, the federal government's continued refusal to grant our state more autonomy over our own Medicaid program leaves us with an unsustainable cost growth trajectory and frustrating, in?exible mandates that prevent effective program management. We implore you to allow the state of Texas more ?exibility within our current Medicaid program to allow us to design a program that is stable and sustainable for Texans. Speci?cally, we seek to implement the following, at a minimum, to more effectively manage the Medicaid program: 0 personal accountability requirements, including cost-sharing, missed appointment fees, and health savings accounts; tailored bene?t packages; work requirements for able-bodied adults; reduced administrative burdens for providers; asset testing as part of eligibility criteria; reinstatement of the active renewal process; customized certi?cation periods; exemption from the ACA health insurance issuer fee; exemption from ACA maintenance of effort requirements; and exemption from hospital presumptive eligibility. The Texas Medicaid program is a national leader in innovation and cost containment, but the state must have the ?exibility it needs to manage its own program. We have proven ourselves to be reliable stewards of state and federal funds. We look forward to your response so that we may continue to provide the appropriate care for our state?s most vulnerable citizens, while designing a sustainable program that is accountable to taxpayers. Sincerely, a? 4M 3 1 Lieutenant Governor Dan Patrick Senator Charles Schwertner, MD Chair, Senate Committee on Health and Human Services (Egg Senator Paul Bettencourt Senator Konni Burton Senator Donna Campbell, MD any? ?rm Senator Brandon Creighton Senator Kevin Eltife Senator Craig Estes Senator Bob Hall 1 7 ,z i. Senator Don Huf?nes gm?? Senator Lois Kolkhorst Senator Robert Nichols Senator Van Taylor Senator Troy Fraser Senator Joan Huffman Senator Jane Nelson Senator Charles Perry 47774 Senator Larry Taylor