1.5M Texans could get Medicaid in bill
More Republicans in state House expressing support for legislation that would expand it
Health care advocates remain hopeful that Texas lawmakers will coalesce this session around expanding Medicaid, even as the political tide has shifted toward more partisan legislative goals and the fallout from last month’s deadly power outages.
Republicans in particular have begun lining up behind a Democratic-led bill that would draw down billions in new federal Medicaid dollars, but with key compromises including work and health incentives for recipients, better physician reimbursement rates and a commitment to end the coverage if it loses the state money or the federal government stops funding nearly all of it.
Seven Republican House members have signed their names to the lower chamber’s version of the bill, HB 3781, and its primary authors, Rep. Julie Johnson of Carrollton and Sen. Nathan Johnson of Dallas, say several more have expressed support privately.
“A lot of the concerns that Republicans have expressed in the past have been addressed in this bill,” Rep. Johnson said, adding that about 20 additional conservatives House members have told her they will vote for the bill. Republicans control the House by 16 seats.
The bill, modeled after initiatives in Indiana and other red states, would offer coverage to adults between ages 18 and 65 and who make up to 138 percent of the federal poverty line, or about 1.5 million Texans. Those living above the poverty line — $26,500 for a family of four — would need to contribute a fraction of their annual income to a health savings account; those living below it would be subject to small copays for non-emergency care.
The idea is not only to extend coverage to hundreds of thousands of currently uninsured people, but to also put them on a path toward securing their own insurance. Texas has long had the highest uninsured rate in the country — at 18.4 percent before the pandemic, which is about 5.2 million people.
“It makes good business and economic sense, as well as health care sense,” said Rep. Steve Allison, a San Antonio Republican and joint author. “I think we can find a way forward.”
Texas is one of a dozen states
that have declined to expand Medicaid under the 2010 Affordable Care Act. House Republicans last tried in 2013 and faced a blockade by then-gov. Rick Perry, who insisted there were too many problems in the state's existing Medicaid program to add even more people to it.
HB 3781 and its Senate companion, SB 117, try to address those complaints by increasing physician reimbursements rates, which advocates hope will attract more doctors to participate in the program.
“Many physicians just cannot afford to take on patients with this kind of coverage, unless it is improved a bit,” said Dr. Diana Fite, an emergency room doctor and the president of the Texas Medical Association, which supports the bill.
The measure still faces an uphill climb, especially in the Senate and the governor's mansion, where there has long been opposition to anything remotely resembling Medicaid expansion.
Legislative Republicans and Gov. Greg Abbott are especially focused this session on conservative policy goals, including new voting and abortion restrictions and penalties for cities were police budgets decline.
Sen. Johnson, who filed the original bill months ago, said he has been in talks with Republicans in the upper chamber who could get behind it.
“In order to pass any form of coverage expansion in Texas, it has to be something where a conservative, credentialed Republican can say, ‘This is consistent with my values,'” Johnson said. “We are not going to win on this issue by scolding the other side morally or on fiscal terms or anything. We're going to have to be able to say, together, this works for everybody.”
A lawyer and first-term senator, Johnson said he has been tinkering on a bipartisan fix to the expansion impasse since the last session, in 2019. Earlier this month, he launched a folksy explainer video on Youtube, where he goes over the fiscal mechanics of expansion and why it will be a net positive to the state budget.
That builds largely off the work of the Perryman Group, which estimated in December that the state would net about $2.5 billion over the next biennium from new tax revenue through improved health outcomes and a more resilient workforce under Medicaid expansion. Local governments would also see a projected tax boost.
“This is economic stimulus, which creates general revenue,” Sen. Johnson said.
Sweetening the deal, states that expand Medicaid this year stand to receive additional federal dollars for their existing Medicaid population under the $1.9 trillion rescue package passed earlier this month by Congress and signed by President Joe Biden. Expansion advocates estimate that would bring in at least $3 billion in extra revenue over the next biennium.
In Texas, Medicaid is currently limited mostly to children, pregnant women, people with disabilities and low-income seniors. For those covered under expansion, the federal government pays 90 percent of the cost.
A 2017 review by the data firm Mathematica of early research on states that use health savings accounts for their Medicaid expansion populations found that while many recipients paid into their accounts, many also were unaware of how they worked or that different kinds of care were covered at different rates. In Indiana, for example, nearly all recipients surveyed incorrectly believed the cost of preventative care would be deducted from their accounts.
“A big lesson from other states would be that getting beneficiaries aware of and engaged with the accounts can be a challenge,” said Laura Dague, an associate professor at Texas A&M'S Bush School of Government and Public Service.