The prospects for Medicaid expansion in Texas

After yesterday's first-hand experience, I would have to say that the prognosis is guarded. Here's what happened the day before yesterday's lunchtime march and rally at the Capitol.

The House GOP Caucus met in a closed door session Monday in which they decided overwhelmingly to reject Medicaid expansion as proposed under the Affordable Care Act. After a meeting that sounded a bit like a pep rally –- with lots of cheering happening behind the closed doors –- Caucus Chairman Rep. Brandon Creighton emerged to say they would stand with Gov. Perry and hold the line on Medicaid expansion.

So into the valley of death rode the six hundred thousand some number in between.

Keep in mind that there are Republicans in key positions in the Lege who appear to be looking for a way toward -- and not away from -- Medicaid expansion. It's just those efforts might be a Trojan Horse in order to deflect the criticism from their intransigence.

Some leaders, including State Senator Tommy Williams, a Republican and chairman of the Senate Finance Committee, have insisted that the state needs flexibility to administer a “Texas solution,” like requiring co-pays and deductibles for Medicaid recipients and enrollment in private or employer plans if available. 

Slicing more skin off the necks of poor people to throw into the game is, frankly, a non-starter. They have already given enough of their lives -- children, seniors, and those below the poverty threshold. We are already at the blood-out-of-a-turnip stage in Texas.

-- Many working, low-income Texans aren't offered healthcare coverage through their jobs, and many more simply don't get paid enough to purchase it. (Forget for a moment the unemployed, the underemployed, and the under-self-employed.) These are the crisis situations: people who put off doctor visits because they cannot afford them, and then go to the emergency room when their health takes a turn for the worse.

-- Large majorities of Texans polled say they want Texas to accept the federal dollars for Medicaid.

-- Then there are the personal stories. For example: my father, 86 84, who had a good job all his working life and then a comfortable retirement, is at medium-to-end-stage dementia and has essentially outlived his assets. So it's humiliating enough for seniors like him who find themselves at the prospect of spending the very end of their lives on the government dole (when they are even capable of understanding that). But because health care providers are refusing new Medicaid patients -- in large part because the state pays its Medicaid bills very slowly -- people like him are falling straight from middle class all the way through the shredded safety net.

And people like him have no advocates. My dad can't write a letter or an e-mail; can't make a phone call, can't go to a townhall meeting to speak to his state rep, can't march at a rally. You know what's even worse about his situation, though? If he lived in Arizona, or New Jersey, or Florida, he would be getting covered. Because their conservative governors can see the benefits of expanding Medicaid. Not our governor, though.

I find empathy, however, to be somewhat fungible among Texas Republicans. So a straight appeal to the financials is what we are left with, and it's a good thing those arguments are pretty solid.

-- Medicaid expansion is free to Texas for the first three years, and after that pays the state at a 9:1 ratio. The net expense for Texas over ten years is $15 billion, and for that investment the state receives $90 billion in federal revenue.

-- It's our tax dollars we are getting back. We have already paid for it, and if Rick Perry remains obstinate about not taking it, then the money will just go elsewhere. This is some powerful stupid even for the governor, folks.

-- The annual Medicaid funds are enough to cover an additional 13,839 nurses and 5,131 family doctors in Harris County alone. Almost a billion dollars -- $935.25 million to be precise -- is greater Houston's share of the pie. And -- this is for the conservatives, now -- additional savings can be recognized from reduced property-tax-supported spending on the uninsured for emergency care, mental health, public health, and so on. (These numbers come from CPPP's Anne Dunkleburg. I'll add some links to this post later.)

So after the rally we targeted a few of those Republicans who have a lick of sense and a somewhat open mind; one was Rep. John Zerwas of Fort Bend County, who sits on the House Appropriations committee and serves as chair of the Health and Human Services subcommittee. His aide, Cameron Cocke, met with our group of six and indicated that the representative sees that Medicaid expansion is "something that is eventually going to have to happen". We shared our personal stories, made a call to action, left behind some of the research, and all felt that the messages we delivered were heard.

Wish I could say the same for Speaker Straus, who has a phalanx of policy advisors and gatekeepers in a separate sprawling office on the first floor of the Capitol (the old Purchasing Agent's office). We did not meet with anyone except the women guarding the front, and were only able to secure the card of the Speaker's policy analyst for healthcare issues, Jennifer Deegan. At least it wasn't the waste of time that some of our group endured at the hands of Sarah Davis' staff, though. Dozens of other legislators got visits from the hundreds of activists who made the day trip from Houston, Dallas, and elsewhere.

So while Medicaid expansion remains viable as of this posting, I am -- a word I am using a lot lately, made up specially for occasions like these -- skeptimistic that the Lege will do much about it in this session unless Rick Perry's fever breaks. The pressure is working, however; they are getting deluged with calls, letters and e-mail from both sides of the issue (so they say).

Kicking the can down the road would be more than a little unfortunate for millions of Texans, some of whom will probably die as a result of this recalcitrance. This is your state government in action -- or better expressed, inaction.

Kuffner, Stace, EOW, Juanita Jean, and of course Progress Texas all have more to say on the subject. Update: And also the Texas Observer.

The clock is ticking. The federal government will only provide its generous 100 percent match (later shrinking to 90 percent) through 2016. It’s late in the game for Texas to draft an entirely new waiver application and program, and Perry already rejected setting up a state exchange like the one Arkansas will use.

We could know a whole lot more about where Texas is heading later this week. House Appropriations Jim Pitts (R-Waxahachie) announced today that his committee will discuss Medicaid expansion Friday.

Update (3/7): This qualifies as both discouraging and a example of the disgraceful lack of leadership on this issue. I don't believe that is unintentional, either.

In an interview with the San Antonio Express-News, Straus said he and other Republicans have made it clear they oppose expansion of Medicaid as the program now stands.

“But I think it's time that we said more than that. It's time that we put forth a good-faith effort to find a Texas solution,” he said.

“We need to move beyond the word 'no' to something that the administration might entertain,” Straus said. “There are no winners if nothing is agreed to. We have a very large state, a significant population of uninsured people ... and I think it could be an opportune time to put some proposals on the table that could be supported by Texas leadership.”

Yes, Texas cries out for leadership. It's a crying-ass shame we can't expect any from the governor or the House speaker. These grandiose remarks consist of nothing but excusing failure in advance. Prove me wrong, Mr. Speaker.