Long struggle ahead for Medicaid Expansion Advocates in Texas

Health care advocates and business groups, whose efforts failed to move Gov. Rick Perry and the Texas legislature to expand the state’s Medicaid population under the Affordable Care Act, are digging in for a protracted struggle that might extend until 2015 or beyond.

Had Medicaid expansion been enacted during the legislative session that ended last week, individuals earning between 100 and 138 percent of the federal poverty level (an individual earning up to roughly $15,000, or, for a family of four, up to $31,000) would have been eligible for Medicaid health coverage beginning in 2014. The federal government would have paid the entire cost of Texas’s expansion for the first three years through 2016, and 90 percent in years thereafter.

Texas’s Tea Party-driven political leadership shunned an estimated $100 billion over time, money that would have assisted in providing health insurance to an additional one million Texans, according to the state’s Health and Human Service Commission, at a proportionately small cost to the state.

“When the Children’s Health Insurance Program (CHIP) first got approved as a federal program, Texas didn’t take it, but we kept on working and working, and finally they did take it,” said Rev. Vincent Fana, Community Projects Facilitator for Texans Together Education Fund, Inc., a civic and community advocacy organization based in Houston that serves the city and its metropolitan area, where about a third of the state’s 3 million African Americans reside.

“So we need to use our efforts on CHIP as the model, in terms of how to get Medicaid expansion. We need to educate people about what it was the [federal] government was trying to bring in and who opposed it.”

Given that the Texas legislature meets every other year, Medicaid expansion won’t come up again for consideration until 2015, unless public pressure persuades Perry to moderate his position. He could call legislators back to Austin for a special session to consider the issue, as he has already done this year on redistricting. Such sessions are typically used by governors only to promote legislation they support, and Perry’s opposition to Obamacare has been unwavering.

Texas leads the country in the highest rate of those without health insurance – 26 percent out of a total population of 26 million. And of the 6 million residents who are uninsured, 58 percent – or 3.6 million – are Latino, including 1.3 million children under age 18.

Juan Flores, executive director of the San Antonio-based La Fe Policy Research and Education Center, notes that the Latino community has scored some success in reducing the total percentage of uninsured Latino children from 26 percent to 19 percent. He credits the drop to increased enrollment in the state’s CHIP program. Yet, coverage of Latino children still lags behind Whites and African Americans, where the uninsured rates have fallen to 10 percent.

Flores said that Texas has historically moved very slowly on health and human service issues, with low per capita investment compared to other states, a trend he blames for perpetuating a longstanding pattern of marginalizing the state’s Latino community.

Bruce Lesley, President of First Focus, a Washington DC-based research and advocacy organization promoting children and family issues, fears the Texas decision means that many parents will now assume their kids don’t qualify for any federal health care assistance and therefore may be less inclined to seek out services. “Texas doesn’t do a fabulous job on outreach,” the Texas native explained. “There are a large number of kids in Texas who are eligible for assistance but not enrolled.”

Rev. Fana agrees that people need to be pro-active about determining their eligibility. “One aspect of our campaign is to put together a basic outline of all the things that the ACA brings to people even without Medicaid expansion,” he says, ticking off free mammograms, colonoscopies, blood testing, glucose and diabetes testing. “But nobody knows about that down here.”

Fana said advocacy groups will encourage those who qualify for federally subsidized health insurance to enroll in the state’s health insurance exchange, which is scheduled to begin operating Oct. 1 but has yet to be set up by the federal government. (Texas opted not to establish its own exchange.)

Nonprofit advocacy organizations are not alone in clamoring for Medicaid expansion. Eva DeLuna Castro, Senior Budget Analyst at Texas’s Center for Public Policy Priorities, says Medicaid expansion “had enormous support from chambers of commerce, from local, county, and city governments,” which were anxious to avoid increasing property taxes to cover the uncompensated costs of emergency room care for the uninsured. Including charity care, that cost was $5.4 billion in 2011, according to a Texas Hospital Association survey.

Then, too, the decision not to expand Medicaid means that those between 100 percent and 138 percent of the federal poverty level, who are currently uninsured, will now be funneled into the state insurance exchange but at a higher cost to businesses, according to a new report by tax preparation company Jackson Hewitt.

DeLuna Castro explained that without Medicaid coverage, companies that employ more than 50 individuals but do not provide health insurance could face between $299 million and $448 million each year in penalties paid to the federal government just to cover employees who earn between 100 percent and 138 percent of the FPL. They now qualify for sliding-scale premium help in the exchange, but had the state opted for Medicaid expansion, they would have been covered by that and no penalties would be owed.

For Anne Dunkelberg, Associate Director of the Center for Public Policy Priorities, that people above the poverty line will be eligible for sliding-scale taxpayer subsidies while those below the poverty line will now get nothing is one of the gross inequities resulting from the state’s rejection of Medicaid expansion. She and other advocates like Lesley of First Focus believe the issue will resonate with people.

Flores is reserved about Medicaid expansion’s short-term prospects. Like DeLuna Castro and other observers, he noted that hospitals and the medical establishments have teamed with businesses and local jurisdictions to make the case, but he said the political dynamics are now worse than ever.

“The governor, the Speaker of the House, the lieutenant governor, the attorney general, almost a supermajority of legislators in the House and Senate oppose the ACA altogether and certainly oppose Medicaid expansion,” Flores observed.

Dunkelberg, whose organization supported Medicaid expansion, says no one in the health advocacy community is throwing in the towel. “I think it’s going to take continued pressure from the vast majority of Texans who favor Medicaid expansion – a higher level of engagement.”

In a poll conducted for the American Cancer Society earlier this year, 85 percent of the state’s African Americans and 73 percent of its Latinos supported accepting federal money to bring more Texans into Medicaid coverage, as contrasted with 47 percent of its white residents. Overall, 58 percent of Texans favor taking federal money, but that sentiment hasn’t translated into sufficient political power to force the issue.

Rev. Fana, again referring to the advocacy community’s prolonged courtship of the state before CHIP was embraced, understands the relatively sluggish pace of change and the political battles ahead. “Unfortunately, that’s going to have to be the Texas way.”