It’s been a bad, bad month for Obamacare. And that may be just what Texas needs.
We’ve been at loggerheads with the feds since health reform was enacted four years ago, and the state is paying a price. Texas rejected billions in federal dollars to extend Medicaid coverage to low-income residents. And the governor did little to encourage buying private insurance in the new health exchange.
So the state with the most to gain — nearly 1 in 3 working-age Texans have no health insurance — has gained much less than its peers.
Why would anything change now?
“Sometimes you just need more time to see how things are going and then you have better clarity about where you want to go,” said Dr. Steven Berkowitz, chairman of the Texas Institute of Health Care Quality and Efficiency.
It’s clear now, he said, that Texas should expand health coverage with federal dollars — but with a program tailored to the state.
The agency reached that conclusion this month, and while it’s not groundbreaking, the endorsement carries extra weight. The agency’s mission is to identify and promote ways to improve health care and contain costs. And its 15 members — led by doctors, nurses and hospital executives — were appointed by Gov. Rick Perry, a staunch opponent of the Affordable Care Act.
Perry exits the stage in January, when Gov.-elect Greg Abbott takes over. While Abbott campaigned against federal health reform, advocates are hoping for a more open, pragmatic attitude.
They note that Abbott appointed Carlos Cascos to be secretary of state. Cascos, a Republican judge from Cameron County, had supported Medicaid expansion, saying the issue was important enough to defy party leaders in Austin.
The Texas Association of Business has put Medicaid expansion among its legislative priorities for 2015. And the Texas Hospital Association has launched a major initiative for the same goal; it’s called the Texas Way, and it has the support of health providers and many large chambers of commerce.
Health care expansion in Texas isn’t just an either-or proposition, Berkowitz said — as in either embrace Obamacare or do nothing.
“There’s a third choice,” he said. “We can come up with a more innovative way to do it.”
The Texas agency proposes using Medicaid dollars to buy private insurance. It suggests a list of conservative features: co-pays, monthly premiums, flexible spending accounts, incentives for healthy behaviors (such as quitting smoking) and maybe a requirement for job training.
Advocates tout the need for patient accountability and personal responsibility. That can mean using family docs instead of the emergency room and paying a share of the costs. It’s all designed to make a government program less of an entitlement.
Again, these ideas are not new. Almost two years ago, during the Legislature, some lawmakers began pushing a so-called Texas solution. It died after Perry threatened to veto any workaround for Obamacare.
In the meantime, Arkansas, Michigan, Pennsylvania and Iowa have won approval for Medicaid expansions that include conservative elements. Indiana’s proposal, which has monthly contributions and a work referral requirement, has been under review since August. Its governor said several other states could follow if its plan is approved, according to The Wall Street Journal.
Maybe President Barack Obama will be more accommodating because Obamacare must be desperate for a win. Democrats were thumped in the midterm elections, with Obama and his signature law a frequent target. That week, the Supreme Court said it would hear a challenge over subsidies, which could wreck the financial scheme.
Then a video surfaced of Jon Gruber, an adviser on the health law, citing “the stupidity of the American voter.”
How all this alters the fight over health care remains to be seen. In 2012, the Supreme Court upheld most of the law and Obama was re-elected. Rather than take that as a signal to move ahead, Perry and many other Republicans dug in deeper.
The costs are significant. Texas is giving up about $6 billion in annual federal funding at the same time that hospitals are being squeezed by cuts in the health law. Providers agreed to reductions, expecting that many more residents would have insurance.
Tenet Healthcare, a Dallas hospital company, has operations in states that expanded Medicaid and some that didn’t, including Texas. Tenet reported a 59 percent drop in admissions of uninsured patients in states that expanded.
Despite strong results, its stock price has declined amid new fears about the law. Executives said it won’t be repealed, only tweaked or fixed. Imagine Texas being part of the fix.
“We’re all for it, but I just don’t see it happening,” said Bill Hammond, CEO of the Texas Association of Business.
Politics will get in the way again, he predicted. But Devon Herrick of the National Center for Policy Analysis isn’t so sure.
“The landscape has changed,” he said, and state experiments have everyone’s attention.
Texas just has to step up and play.