Opinion: Texas has an opportunity to expand health insurance coverage

In the Houston Chronicle, EHF's Elena Marks writes that whether expanding coverage comes about through Medicaid or a Texas-specific alternative by another name, whether through counties or the ACA marketplace, it’s time to NOW to act.

Elena Marks
By Elena Marks, EHF’s president and CEO

This post originally appeared in the opinion section of the Houston Chronicle

For approximately one-quarter of uninsured Texans, there has been a solution that state leaders could have adopted since 2014 — Medicaid expansion under the Affordable Care Act. While the state’s political leaders still refuse to embrace this straight-forward solution, there’s a new opportunity for coverage expansion in Texas.

Texas has the highest number (more than 5 million) and largest percentage (18.4 percent) of residents without health insurance. The problems caused by these high numbers are well-documented. Uninsured Texans who lack access to basic preventive and primary care have poorer health outcomes. Then, there’s the unsustainable financial pressure on health care providers and the shifting of costs of providing health care for the uninsured, often in expensive hospital settings, to those with insurance.

The political gymnastics underway to address this ongoing problem are reaching new heights.

First, there is a growing groundswell of support for expanding health coverage. Polling data shows that Texans’ support of coverage expansion has grown year over year, to 69 percent in 2020. For these reasons, just over half of Texas House members, including Democrats and some Republicans, signed on to a bill this year called “Live Well Texas” that would have required Texas to expand coverage through a 1115 Medicaid waiver. Despite this level of support, legislative leadership did not give a hearing to the bill.

For a decade now, Texas has been operating under a Medicaid 1115 waiver that was designed to prepare the health care delivery system for the influx of new patients who would become insured as the ACA was fully implemented in 2014. The waiver included funding for system innovation and a pool of funds to cover the costs of providing care to uninsured Texans, whose numbers were expected to decrease over time as more became insured. Next month, Texas will be applying to the Biden administration to extend the 1115 waiver.

This month, the Texas Health and Human Services Commission held hearings to obtain public input on the Medicaid 1115 waiver application. Dozens of speakers across Texas participated and advocated for the state’s application to include coverage expansion. I was one of the participants in a more than four-hour hearing on June 15 in which dozens of speakers advocated for the state to include coverage expansion as part of the waiver application. Those advocates included representatives of hospitals and clinics, physician organizations, the faith community, the disabilities community and regular Texans who want their leaders to allow their fellow Texans to obtain health insurance.

Second, congressional leaders and the Biden administration are intent on ensuring that Americans living in Texas and the other remaining 11 states that have not expanded Medicaid can obtain affordable health insurance. New incentives in the American Rescue Plan Act have made clear that Medicaid expansion is affordable for Texas. In addition, Texas Rep. Lloyd Doggett, chair of the House Ways and Means Health Subcommittee, has filed the COVER Now Act. If enacted, this bill would enable local governments to work directly with the federal government to expand Medicaid coverage locally even if their state declined to participate. Across Texas, county taxpayers provide billions of dollars through property taxes to support the costs of health care for uninsured residents who would be covered by Medicaid expansion. For this reason, many county leaders, Republican and Democrat alike, have advocated for Medicaid expansion. Other proposals under discussion at the federal level include allowing the lowest-income Americans in the non-expansion states to obtain subsidized coverage through the ACA’s marketplace. Because coverage expansion is a priority for the Biden administration and Center for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure, we should expect to see more innovative ideas about how to solve the problems that Texans in the “coverage gap” continue to face.

Third, after the recent U.S. Supreme Court decision upholding the Affordable Care Act for a third time, by a larger margin than in the prior two cases, it is clear the ACA is here to stay. It’s time for all of us, including Texas’ leadership, to accept this reality and do what we can within its framework to cover more Texans. Our leaders will have the chance to do that in the upcoming months as they work with the Biden administration to craft a new Medicaid 1115 waiver. Together, they can craft a Texas-specific coverage solution that will bring more than 1 million Texans affordable health insurance and protect our safety-net providers at the same time. These are complementary solutions to a Texas-sized problem.

Necessity is the mother of invention, the old saying goes. We’re beyond the point of necessity. Whether expanding coverage comes about through Medicaid or a Texas-specific alternative by another name, whether through counties or the ACA marketplace, it’s time to turn to invention.