Time to get real about tackling uninsured rate
It is a truth only grudgingly acknowledged at times, but a truth nonetheless: Elections have consequences.
Texas’ Republican leaders were abruptly reminded of that Friday, when the Biden administration announced it was rescinding an 11th-hour waiver extension issued by the Trump administration relating to the Medicaid program. The waiver has continued the flow of federal dollars to Texas to prop up hospitals that treat low-income, uninsured residents even as the GOP-led state has refused to expand Medicaid through Obamacare.
To hear Republicans such as Gov. Greg Abbott tell it, the president cruelly yanked the rug out from under some of the state’s most vulnerable Texans — while we’re still in a pandemic, no less. Biden is “deliberately betraying Texans who depend on the resources made possible through this waiver,” the governor said in a statement.
That’s a bit rich, considering that Abbott is a longtime critic of the Affordable Care Act who continues to reject some of the resources it might make available to Texans. The Biden administration is pushing to expand Medicaid to 1.27 million Texans who would be eligible for coverage under expansion and included a temporary financial incentive to do so in the coronavirus relief measure passed this year. Federal funds
already covered 90 percent of the cost of Medicaid expansion, which might explain why some Republican-led states recently signed on.
In any case, the Biden administration has every right to review the previous administration’s decisions.
“It is not just commonplace but routine that when a new administration comes in, they’re always going to be looking at last-minute actions by the last administration,” said Anne Dunkelberg of Every Texan, formerly known as the Center for Public Policy Priorities, in a Zoom summit with journalists Tuesday.
At issue is a Jan. 15 decision by the Centers for Medicare and Medicaid Services (CMS) to approve a request from Texas to extend a waiver initially granted as an alternative to Medicaid expansion under the Affordable Care Act, known as a 1115 waiver. The approval came five days before President Joe Biden’s inauguration.
The federal funds issued to Texas under the agreement support the Texas Healthcare Transformation and Quality Improvement Project, which provides some indirect support to uninsured Texans by reimbursing hospitals and other providers for uncompensated care and funding various community projects.
Texas, citing the ongoing COVID-19 pandemic, had requested that the waiver be extended without the usual public notice and comment periods. The Trump administration was sympathetic to this request and extended the waiver for 10 years. Not so fast, Biden’s team said. “Upon further review, we have determined that CMS materially erred in granting Texas’ request for an exemption from the normal public notice process,” wrote Elizabeth Richter, now the CMS acting administrator, in an eight-page letter to the Texas Health and Human Services Commission dated Friday.
The determination changes nothing in the short term. Prior to the Trump administration’s last-minute intervention, the waiver in question had already been approved through September 30, 2022. That approval remains in effect, meaning that the state now has 18 months to get its act together and resubmit its application for an extension of a waiver.
Still, state leaders, as noted, are crying foul.
“By rescinding this waiver extension, the Biden administration is obstructing health care access for vulnerable Texans and taking away crucial resources for rural hospitals in Texas,” Abbott argued.
Texas Attorney General Ken Paxton, also a Republican, alleged that Biden had “grossly betrayed those who rely on our assistance the most,” adding that he would use “every legal tool available to regain the assistance Texans need.”
Paxton, of course, is seeking to have the entire Affordable Care Act, which extended health care to millions of Americans, struck down by the U.S. Supreme Court.
Richter’s letter has revived a debate over Medicaid expansion in Texas — one that was languishing in the Legislature.
Texas is one of just 12 states that has continued to reject Medicaid expansion in the 11 years since the ACA’s passage, despite having the highest rate of uninsured adults in the country — 18.4 percent, according to the United Health Foundation.
Several Republicans have joined Democrats in calling for the Legislature to consider Medicaid expansion this year.
“A recent survey found as many as 69 percent of Texans are supportive, as this would bring over $10 billion in annual federal funds and millions more in annual programs savings,” said a bipartisan group of lawmakers in a recent call for action.
Still, Texas House Speaker Dade Phelan has expressed skepticism that Medicaid will be expanded, telling the Texas Tribune in January that the votes didn’t seem to be there. Last week’s news doesn’t necessarily change the legislative arithmetic, even if it has elevated the discussion.
“Some within the body will take the decision as an indication that the federal government is not acting in good faith, and others will view the decision as a fulcrum to advance the expansion conversation,” said Enrique Marquez, Phelan’s communications director.
Who’s not acting in good faith here, though?
Biden, a Democrat, has long been a strong supporter of the ACA, memorably remarking to President Barack Obama that its passage was a “big (expletive) deal” at a 2010 White House bill-signing ceremony where the remark was picked up by live mics.
And Biden’s enthusiasm for the ACA has remained undimmed, even as some progressives have pushed for him to embrace a more expansive single-payer program, like “Medicare for All.” He even sought to further incentivize Medicaid expansion in the American Rescue Plan Act passed earlier year, boosting the federal match rate for two years for states that decide at this point to implement the expansion.
That may seem like strongarming, to Republicans. A more fair assessment, however, is that Biden is attempting to use the leverage he now wields as president to encourage holdout states to consider a deal that would extend Medicaid coverage to more uninsured adults — including more than a million in Texas. One could argue that an additional $5 billion or so a year in federal dollars is a good deal.
In any case, the revocation of the 10-year waiver is rooted in the state’s goof; it’s hard to see how Biden is responsible for that.