Why Texas Republicans still oppose Medicaid expansion

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One afternoon in April 2021, state Sen. Nathan Johnson sprinted by the Texas Capitol constructing, decided to achieve the House chamber in time to see historical past made. For the primary time for the reason that Affordable Care Act was handed in 2010, the complete Texas House was going to vote on a proposal to broaden Medicaid, this system that gives well being care to America’s poorest.

Eighteen percent of Texans don’t have medical insurance — the best fee within the nation — and Johnson had already filed 5 items of laws that session to make use of Medicaid expansion to get as many as 1.2 million of these individuals insured.

To him, the method made sense. The federal authorities would decide up 90% of the price. Research confirmed that by rejecting Medicaid expansion, Texas was turning its again on greater than $5 billion in federal cash yearly.

All of Johnson’s payments have been probably useless that session, doomed by opposition from Republicans whose hostility towards the Affordable Care Act goes again to 2013, when then-Gov. Rick Perry referred to as it a “criminal act.” But as he ran to the House chamber that day, Johnson clung to a faint hope that this new effort would succeed. Nine Republicans had not too long ago signed onto a House model of his final expansion invoice, suggesting that cracks have been forming within the GOP entrance.

If Republicans have been in search of a solution to broaden Medicaid on their very own phrases, this bare-bones amendment to a House funds invoice could possibly be it.

Introduced by Houston Democrat Garnet Coleman, it merely directed state well being officers to reap the benefits of all of the federal Medicaid {dollars} out there to increase protection to low-income Texans. Since it didn’t specify what expansion needed to appear like, Republicans may design a program that allowed them to take the cash on their very own phrases. They may body it not as a legacy of the Obama administration, however as a commonsense, Texas-style plan to guard sufferers and suppliers.

An analogous personalized method had labored in different crimson states, and Johnson thought it would work in his, too. His personal Medicaid payments had tried to do one thing comparable.

“It was sort of an offering, in a way,” the first-term senator from the Dallas space instructed Public Health Watch. It “really made it easy for Republicans. ‘Take this and make it yours … Just go do it however you want to.’”

Johnson listened nervously from the again of the chamber that day as Coleman and different Democrats implored lawmakers to just accept the federal cash.

Giovanni Capriglione, a five-term consultant from Southlake, a suburb of Dallas, was the one Republican who spoke. “I think you know where you stand on this issue,” he instructed his fellow celebration members. “I would ask you to vote no.”

The debate lasted simply 20 minutes.

Coleman’s modification failed, 80 to 68. Only one Republican, Lyle Larson, a consultant from the San Antonio space, voted in favor.

Johnson felt sick as he walked out of the chamber that day.

As a Democrat, he was accustomed to seeing his payments blocked within the Republican-dominated legislature. But this loss felt totally different.

Of the 9 Republicans who had supported a House model of Johnson’s current expansion invoice, solely Larson had voted for Coleman’s modification. Public Health Watch reached out to all 9, however solely Larson responded.

Anne Dunkelberg, who has studied Texas well being coverage for many years as an analyst with the progressive nonprofit Every Texan, mentioned it’s an open secret that many Republicans privately acknowledge expansion is an efficient deal for the state. But she mentioned they’re terrified of publicly breaking with their celebration’s leaders: Gov. Greg Abbott and Lt. Gov. Dan Patrick.

Anything associated to Medicaid expansion is “DOA with Abbott and Patrick,” Dunkelberg mentioned. “There’s a very strict set of marching orders and they have nothing to do with analysis of potential impacts and facts.”

Both Abbott and Patrick have made opposition to the Affordable Care Act and Medicaid expansion a part of their political personas.

When Abbott was the state’s lawyer basic in 2010, he drew nationwide consideration by submitting a lawsuit to get the ACA thrown out. After he turned governor, he led one other lawsuit to overturn the well being care regulation.

Patrick, who beforehand served as a state senator, has an analogous observe report.

“You know, one of the best things we did in the Senate, when I was a senator … we did not expand Medicaid,” Patrick said throughout his 2018 reelection marketing campaign.

Abbott and Patrick are each hoping to carry onto their seats this month. Their campaigns haven’t emphasised their opposition to Medicaid expansion, maybe as a result of a 2020 poll discovered that 69% of Texans help it.

Abbott’s Democratic challenger, Beto O’Rourke, is promising to broaden Medicaid, however he’s behind within the polls. “Literally, Greg Abbott is the only person in this state standing in the way of connecting more than a million of our fellow Texans with health care,” O’Rourke instructed Public Health Watch.

Public Health Watch despatched a number of emails to Abbott and Patrick asking for his or her present positions on Medicaid expansion or for every other plans they’ve to shut the state’s well being care hole.

Patrick didn’t reply. Abbott despatched a press release citing value as a cause for his opposition. He described Medicaid expansion as “a tax increase waiting to happen.”

“The best way to get health care insurance is through an employer,” Abbott mentioned. “Since I was re-elected, Texas has added more new jobs than any other state … Medicaid was created to serve the most vulnerable, not able-bodied adults who can and should get health care through an employer.”

But discovering a job that provides well being advantages isn’t all that simple in Texas.

Less than half the state’s private-sector corporations provide medical insurance, based on the most recent federal data. Among companies with 50 staff or much less, that quantity falls to under 25%.

* * *

Texas Republicans hardly ever discuss their opposition to Medicaid expansion today, however a 32-year-old assume tank—the Texas Public Policy Foundation—proudly promotes their place any probability it will get. In January, Abbott thanked the muse publicly for serving to him go his political agenda final yr.

The basis is linked to among the state’s main conservative donors. According to its tax filings, it took in additional than $17 million in 2020.

The basis’s web site is crammed with hyperlinks to its personal articles and stories opposing Medicaid expansion, lots of them written by David Balat, a former hospital administrator who directs the muse’s Right on Healthcare initiative. The basis additionally holds events throughout Texas, lots of them hosted by native chapters of its Liberty Leadership Council, a program geared toward individuals ages 21 to 40.

Adrian Shelley, director of the Texas workplace of Public Citizen, a client advocacy group, mentioned conservative lawmakers usually depend upon the muse to teach them on difficult coverage subjects.

“It’s extremely influential,” Shelley mentioned. “Its priorities become the priorities of very influential conservative members of state leadership.”

Larson, the lone Republican to vote for the House expansion proposal, mentioned the muse floods GOP lawmakers with emails and truth sheets telling them the way to vote. “It’s 50% bullshit and 50% information they twisted,” he mentioned. “It doesn’t allow you to have a candid conversation like they’ve had in those other red states about forgoing those federal dollars.”

The basis lists “stopping Medicaid expansion” amongst its 2021 legislative “victories.”

On the day the House voted on Coleman’s modification, the muse’s then-CEO, Kevin Roberts, launched a statement describing Medicaid as a “sinking ship.” Expansion would “bust” the state funds, he mentioned, and “hurt everyone involved.” Roberts is now president of the conservative Heritage Foundation, one of the vital outstanding assume tanks in Washington, D.C., and a longtime opponent of the ACA and Medicaid expansion.

Research from states the place Medicaid has been expanded present it has had little impact on state budgets.

The Waco-based Perryman Group, which focuses on financial analysis and evaluation, estimates that for each $1 Texas spent to broaden Medicaid, $1.78 would come again within the type of state income, with most of it going to native governments. Expansion may additionally decrease the taxes that Texans now pay to native hospital districts to cowl look after the uninsured.

Ray Perryman, the agency’s CEO and president, thinks Texas Republicans’ opposition is fueled by one easy truth: They are afraid to help any coverage related to former President Barack Obama.

“It’s really unfortunate, because nobody’s sitting back and just looking at the numbers and looking at the reality of the situation on the ground or listening to their constituents for that matter,” he mentioned.

Medicaid expansion was one of many ACA’s key protection provisions when it handed in 2010. But after a 2012 U.S. Supreme Court choice, that requirement turned an choice, leaving the choice to broaden within the arms of state legislators.

The result’s that within the 12 states that still reject expansion, greater than 2 million individuals have fallen right into a protection hole, that means they make an excessive amount of cash to qualify for state Medicaid and too little to get subsidies within the ACA market. A third of these individuals stay in Texas, whose Medicaid program is so restrictive that folks in a household of three are denied protection in the event that they earn greater than $4,000 a yr.

* * *

In October, about 50 individuals, lots of them college students, gathered on the University of the Incarnate Word in San Antonio for one in every of almost a dozen occasions the Texas Public Policy Foundation held that month. This one targeted on methods to deal with the excessive value of well being care. Participants received a free lunch and heard a panel dialogue moderated by Balat.

The audio system lauded options like value transparency instruments and first care subscriptions, which usually cost sufferers a month-to-month charge for a sure set of providers. The preparations aren’t thought-about insurance coverage and state insurance coverage regulators don’t have any oversight.

One panelist referenced a 2013 Oregon research that conservatives have lengthy cited as proof that Medicaid expansion doesn’t lead to higher well being outcomes. But the Oregon research didn’t look at ACA Medicaid expansion, which didn’t go into impact till 2014.

Research performed in expansion states since then reveals the coverage change is associated with higher entry to care and elevated monetary stability for rural hospitals by lowering uninsured visits. Texas leads the nation in rural hospital closures.

Balat insists that increasing Medicaid gained’t enhance Texas’ well being care entry hole. “Coverage isn’t care,” he mentioned, referring to the truth that in Texas, as in lots of states, Medicaid sufferers usually have bother discovering medical doctors who will settle for the general public insurance coverage.

A report launched final yr, based mostly on 2017 knowledge, discovered that solely about 65% of Texas medical doctors settle for Medicaid sufferers, primarily as a result of the state reimburses them at a lot decrease charges than non-public insurers do. According to the Texas Medical Association, state lawmakers haven’t handed a significant, across-the-board replace to the Medicaid doctor charge schedule for the reason that late Nineteen Nineties.

Asked if the muse would help elevating the reimbursement charges, Balat mentioned he doesn’t have sufficient analysis to take a place. He mentioned the muse will, nevertheless, proceed opposing Medicaid expansion within the subsequent legislative session, which begins in January.

* * *

The first efforts to go expansion in Texas started in 2013 because the Affordable Care Act was going into impact. A Republican state consultant from Richmond, John Zerwas, tried to hammer out a Texas-style version that included concepts common with conservatives, like ensuring it was cost-neutral to the state.

Observers thought Zerwas’ invoice had an opportunity. So did Zerwas, a doctor. But it died in committee. The Texas Public Policy Foundation was the lone group to testify towards it.

“People on the pay scale above me made the decision,” Zerwas said at the time.

Zerwas is now government vice chancellor for well being affairs on the University of Texas System. He mentioned he by no means fearful about shedding his House seat over his Medicaid stance — he didn’t assume it was a dealbreaker for his constituents. But he suspects Republican politicians in different components of the state concern that main voters will boot them out of workplace in the event that they break with celebration leaders on Medicaid expansion.

“If there is something equally as cost-effective that doesn’t have a direct line to Obamacare, I’m all for that,” Zerwas mentioned. “But there’s not.”

Eight years later, in 2021, one other Texas Republican tried to deliver dwelling these federal expansion {dollars}. Lyle Larson, the only real Republican who voted for Garnet Coleman’s expansion proposal within the House final yr, tried to place expansion on the poll so the general public may weigh in. His legislation died in committee, too.

Larson, a longtime fixture in San Antonio politics, entered the Texas House in 2010 as a self-described “Reagan Republican.” He has a status for refusing to toe celebration strains — one thing that landed him on the incorrect aspect of GOP leaders over time. When Larson ran for reelection in 2018, Abbott endorsed his main opponent, Chris Fails, who dubbed Larson “Liberal Lyle.” But Larson gained handily.

Larson is retiring in January after six phrases in workplace, not due to strain from his personal celebration, he mentioned, however as a result of he believes no elected state official ought to serve greater than 12 years, a problem he repeatedly tried to advance within the legislature.

When it involves Medicaid expansion, he mentioned, his celebration has a “bunker mentality,” terrified of alienating a governor with presidential aspirations who has constructed a profession off opposing the ACA.

Public opinion doesn’t appear to make a distinction. During the final legislative session, almost 200 Texas organizations — together with the Texas Medical Association and native chambers of commerce — despatched a letter to Republican leaders urging them to broaden well being protection for low-wage adults. It didn’t matter, Larson mentioned.

“We’re just locked into listening to a few voices that don’t provide one bit of health care,” he mentioned.

Texas’ resistance to expansion has turn out to be the butt of jokes in neighboring GOP states, Larson mentioned. Republican lawmakers in bright-red Arkansas, which passed a conservative method to Medicaid expansion in 2013, inform him they “sort of laugh at Texas.” After expansion, their state’s uninsured fee dropped greater than 10 percentage points inside two years.

“They’re saying, ‘Why are you passing up on those [federal] dollars? It makes no sense,’” Larson mentioned.

* * *

Johnson, the Democratic senator who watched the House kill Rep. Coleman’s expansion proposal final yr, isn’t deterred by the string of failures he and others have registered over time. And he isn’t afraid of a combat.

A lawyer by coaching, Johnson has made expansion a precedence since 2018 when he defeated incumbent Don Huffines — then thought-about one of the vital conservative Republicans in Texas. So simply weeks after Coleman’s proposal was defeated, Johnson gave it another shot and launched an analogous version within the Senate.

It failed, too. Every Republican voted no. But it was a small step ahead. For the primary time, the complete Texas Senate had voted on a invoice to broaden Medicaid.

“I think before it was sort of like it’s just this distant place we’re trying to get to,” Johnson instructed Public Health Watch. “I think we’re there. We’ve just run into a wall. That’s the shift. We’ve got to the wall now.”

Johnson is up for reelection this month. On his marketing campaign website he describes Medicaid expansion because the “single most powerful policy tool available to Texas” to enhance public well being. If he wins, he plans to introduce one other expansion invoice in 2023.

He doesn’t count on Abbott or Patrick to vary their minds about expansion anytime quickly, however he has hope. “Notice how quiet they’ve been on the subject for the last two or three years,” he mentioned.

In the meantime, he’ll maintain having one-on-one conversations together with his Republican colleagues about Medicaid expansion.

“I think Republicans would love a way to do it, and I’m going to look for a way that helps them.”

This story is a part of “The Holdouts,” a reporting collaborative targeted on the 12 states which have but to broaden Medicaid, which the Affordable Care Act approved in 2010. The collaborative is a mission of Public Health Watch and is supported by grants from The Commonwealth Fund and the T.L.L. Temple Foundation. The contents of this text don’t essentially replicate the views of T.L.L. Temple Foundation or any director, officer or worker thereof.

Disclosure: Every Texan, the Texas Medical Association, the Texas Public Policy Foundation and the University of Texas System have been monetary supporters of The Texas Tribune, a nonprofit, nonpartisan news group that’s funded partially by donations from members, foundations and company sponsors. Financial supporters play no function within the Tribune’s journalism. Find a whole list of them here.