Abbott: Health waiver move is ‘betrayal’

Texas Republicans have been swift to condemn the Biden administration for rescinding early approval of a multibillion dollar Medicaid program that would help fund emergency care for the state’s booming uninsured population through 2030.

Gov. Greg Abbott said the federal government was “deliberately betraying Texans.”

Attorney General Ken Paxton vowed to “use every legal tool available to regain the assistance Texans need.”

But the decision federal health officials announced Friday could end up being one of the biggest steps yet to extend government health coverage to low-income people in Texas since the Affordable Care Act, according to health advocates and political observers. That’s true even if it doesn’t spur immediate change.

“The Biden administration has all the cards here,” said Brandon Rottinghaus, who teaches political science at the University of Houston. “They aren’t playing nice anymore with health care expansion. They’ve got the money,

so they have the leverage.”

Pressure is also coming from inside the state. On Tuesday, a group of more than 150 organizations, including chambers of commerce, trade associations and local officials signed a letter calling on lawmakers to “support increased health coverage for Texans.”

“We specifically support a coverage initiative that is bipartisan, funded through available federal dollars, structured to be neutral for the state’s budget, and designed to meet Texas’ specific needs, values and circumstances,” it said.

The letter notably did not include the Texas Hospital Association, which criticized Friday’s decision. It has supported expanded coverage in the past.

For years, Texas has depended on the federal aid to prop up hospitals that treat low-income, uninsured Texans. When the funding, part of what’s called an 1115 waiver, was first approved in 2011, the Affordable Care Act had just become law and it was expected that Texas would eventually include many of those uninsured people into an expanded Medicaid pool. Over time, the need for 1115 assistance would drop.

But the U.S. Supreme Court later overturned the law’s requirement that states expand the safety net coverage, which would apply today to more than 1 million lowincome Texans. Republicans in the state have declined to voluntarily comply in the years since, arguing in part that there’s no need as long as the 1115 money flows.

Carrot and stick

With that now in question come September of next year, when the existing waiver ends, a state that has long opposed Medicaid expansion will have to at least begin negotiating with an administration that favors it and is growing impatient.

“This is classic carrot-and-stick federalism,” Rottinghaus said.

The carrot came earlier this year when Congress and the Democratic-led administration agreed to give billions in extra funding to holdout states, including Texas, if they expanded Medicaid.

But with the Texas legislative session entering its final weeks and even bipartisan expansion bills foundering in committee, the window for any legislative response is closing. A spokesman for House Speaker Dade Phelan, R-Beaumont, declined to comment on how the reversal by the Biden administration impacts whether he will allow debate on the issue before the term ends.

Earlier this year, he said he would if the proposal was budget neutral and didn’t lock the state into future commitments.

Neither Abbott’s nor Paxton’s offices responded to requests for comment.

Abbott, who has been outspoken against Medicaid expansion in the past, faces a contentious primary next year as he runs for reelection and is pushing a slate of conservative policy goals in the leadup. If the governor were forced to take unilateral action on the issue, it would likely come between the primary and the general election, according to Rottinghaus, when he could use it to appeal to more moderate voters.

Public likes expansion

More than two-thirds of Texans support Medicaid expansion, according to the most recent polling.

“Governor Abbott’s going to be a tough spot to have to either take the deal, which has been sweetened or to not take the deal, which might be very costly for Texas in terms of health, but also in terms of funding,” Rottinghaus said.

Health care advocates have been quick to downplay Friday’s announcement, saying there is still plenty of time for the state to apply again for the waiver before next year. Texas was originally approved for the extension as part of a flurry of eleventh-hour orders by Trump health officials. In doing so, it allowed the state to forgo the normal comment period.

“I think of it in terms of, Texas didn’t follow the rules, and now it’s being told to follow the rules,” said Elena Marks, president of Episcopal Health Foundation in Houston. “It’s not being told, ‘you can’t have an uncompensated care pool.’ In fact, we need an uncompensated care pool, we ought to have one. But we have to follow the rules.”