Pandemic adds to Medicaid debate

GOP legislators face reckoning as state’s uninsured rate spikes

Texas Republicans have long resisted expanding Medicaid under the Affordable Care Act, unswayed by the promise of billions in new federal aid for a state perennially ranked last in health coverage. But last fall, with their state House majority on the line and the uninsured rate climbing again amid the pandemic, conservative support seemed to be building.

On the campaign trail, Rep. Angie Chen Button, R-Richardson, said she was newly open to expanding the public insurance program under limited conditions. Rep. Morgan Meyer, R-Dallas, expressed support for a broader expansion than he had previously. Rep. Lyle Larson, RSan Antonio, tweeted that lawmakers should “seriously consider accessing federal Medicaid funding” in the next legislative session.

“This is money we’re sending to the federal government and not getting back,” he wrote.

With the session now underway, the party is facing a reckoning on the issue. All but a dozen states, including Texas, have expanded Medicaid since President Barack Obama’s signature health care law passed in 2010. It is broadly popular in Texas, according to polls. And Republicans in swing districts have come under increasing pressure from voters to address the state’s ballooning uninsured rate, which was at 18.4 percent before the pandemic, or

about 5.2 million people.

House Republicans have yet to file any bills, though lawmakers said work is happening behind the scenes on a measure that could satisfy the GOP majority. Staffers for Button, Meyer and Larson either did not respond to messages or said they were unavailable to comment.

Finding widespread approval will be tough, and proponents lost a key leverage point this month when the outgoing Trump administration extended part of a waiver that helps Texas hospitals cover uncompensated care. While the move does not expand health coverage, it does ensure that emergency care is reimbursed for struggling hospital systems that treat low-income patients.

“The 1115 waiver was never meant to be a permanent fix,” said Sarah Davis, a former Republican state representative who favors expansion. “It was really supposed to be kind of like a bridge, because we were assuming — or the government was assuming — that the state would be expanding Medicaid.”

In the Senate, Republicans are likely to oppose any expansion bills. The upper chamber has blocked past attempts and killed legislation last session that sought even a narrow expansion, for new moms. A Senate committee omitted the option entirely in a report last year on ways to lower the state’s uninsured rate.

Critics have chiefly raised concerns about the long-term costs.

Gov. Greg Abbott also holds veto power and appears set on reestablishing his conservative credentials coming out of the pandemic and heading into next year’s gubernatorial re-election. Abbott, whose spokeswoman did not respond to a request for comment, has been under fire from some fellow Republicans for mandating masks and other emergency health measures.

“He doesn’t want to be a governor that expands Medicaid,” said Matt Mackowiak, a Republican strategist in Austin.

Abbott has outlined two health care priorities for legislators so far: increasing access to telehealth and enhancing protections for people with preexisting conditions. Neither addresses the coverage gap — the nearly 800,000 Texans who are below the federal poverty line and have no insurance options.

‘Revenue neutral’

In Texas, Medicaid is currently limited to mostly children, pregnant women, people with disabilities and low-income seniors. Under expansion, it would extend to adults making up to 138 percent of the poverty line, about $17,600 for an individual and $36,200 for a family of four.

More than a fifth of the 5.2 million Texans who were uninsured pre-pandemic would be eligible if the program was expanded, without accounting for the 1.6 million more Texans who lost work-related health care in the economic fallout of COVID-19.

House Speaker Dade Phelan, R-Beaumont, told the Texas Tribune that he was open to discussion about a conservative approach to expansion. His spokesman this week pointed to the 1115 waiver as having provided some relief, but said the speaker remains open as long as any proposals are “revenue neutral.” Under Medicaid expansion, the state is required to contribute 10 percent of the costs.

In some Republican states that have supported Medicaid expansion, lawmakers added provisions such as work requirements and copays. While some of those tweaks have been challenged in courts, Democrats in the House said they are open to any ideas that draw down some of the expansion money, even if it’s sold as something else.

It ‘makes sense’

“I know that some are anathema to saying Medicaid expansion,” Rep. Donna Howard, D-Austin. “I don’t care what you call it — you want to call it leveraging federal dollars, that’s great.”

“We’ve got to find a way to expand the health care accessibility and coverage of all of those Texans who have lost their jobs,” she said. “Or are the working poor who don’t have coverage and need that in order to be able to be productive, to continue their jobs and help us restore our economy.”

Democrats have also floated the idea of putting the issue directly before voters through a constitutional amendment, which could take some of the partisan pressure off of individual Republicans.

Critics of expansion, including the Texas Public Policy Foundation, warn that Medicaid is already broken, with too many administrative burdens and too few providers who accept the state’s reimbursement rate, which is among the lowest in the country. The conservative think tank instead supports targeted approaches to increasing access to low-income health clinics and primary care doctors.

“We’ve got to stop conflating terms,” said David Balat, a health policy expert for the foundation. “Health insurance is not health care.”

Most of the research on Medicaid expansion so far has found improvements in coverage, financial security for those covered, some health outcomes and economic benefits for states and providers, according to the Kaiser Family Foundation. A report last month from the Perryman Group estimated that the state would net $1.95 for every dollar it invests in expansion through new tax revenue. That would be $2.5 billion to the state and $2 billion to local governments over the coming biennium.

“Texas could alleviate a substantial portion of this problem by expanding health insurance coverage using available federal funds while reaping notable economic and fiscal gains in the process,” Ray Perryman wrote in an oped announcing the findings. “It just makes sense.”