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A Tale of Two (or Three) States

Kayhan Parsi, JD, PhD

I recently learned that my home state of Texas has refused to participate in Medicaid expansion that is part and parcel of the Affordable Care Act. When I first heard this news on NPR, I nearly gasped in disbelief.  Gov. Perry and the Texas legislature will walk away from $100 billion of federal money to help the state’s poor, elderly and disabled.  Wade Goodwyn, the NPR reporter for this piece, went so far as to state that “Texas Republicans have moved steadily to the right — to where the very concept of public health insurance of any kind is looked at through narrowed eyes.”  The public perception of Medicaid is that it primarily covers the poorest of the poor adults.  In fact, children account for Medicaid’s largest percentage of enrollees (47%) and the largest amount of spending goes to the blind and disabled (44%).  Yet any expansion of Medicaid in the service of Obamacare is viewed as an expansion for the undeserving poor.  Texas has the distinct status of having one of the worst safety nets for the poor. Unfortunately, this latest move by the Texas State legislature and the Texas governor undermines an already weakened system.

Governor Perry’s move should be contrasted with Florida Governor Rick Scott. Rick Scott was equally vehement in his opposition to the Affordable Care Act. Yet after the 2012 election, Gov. Scott saw the handwriting on the wall. He changed course on his earlier opposition to the Medicaid expansion and stated that “I cannot in good conscious deny access to Floridians who need healthcare.” Scott is not alone.  Even Arizona Governor Jan Brewer, an ardent opponent to the Affordable Care Act, has dug in her heels in support of Medicaid expansion.

Accepting and even embracing Medicaid expansion seems like a no-brainer.   Hospitals and physicians have a legal and ethical obligation to treat the poor.  Yet many of these patients lack private health insurance or state-run health insurance such as Medicaid.  What happens when hospitals treat patients without health insurance? Many hospitals will provide charity care, either because they have a religious mission to do so or because they are public entities and treating the poor is part of their mandate.  Every dollar that could pay for some of this otherwise uncompensated care is sorely needed.   These costs are ultimately eaten by hospitals that are already stretched thin because of the demands of EMTALA and their own ethical missions.

Two of the largest health care professional associations in Texas, the Texas Medical Association and the Texas Hospital Association, both back Medicaid expansion.   The Texas governor and state legislature’s decision to refuse to expand Medicaid has galvanized a variety of strange bedfellows, including “business interests, the medical profession and religious branches, as well as activist organizations and unions” all of whom have demonstrated at the state capitol in Austin.

A study by the Rand Corporation recently published in Health Affairs analyzed the impact of the 14 states that have announced they will opt out of participating in Medicaid expansion.  The authors of this study concluded that “the cost to states of expanding Medicaid would generally be lower than the cost of uncompensated care borne by states and localities after the implementation of the Affordable Care Act.”  The authors of this study recognize the political barriers of expanding Medicaid to those individuals at 138% of the federal poverty level.  Instead, they recommend expanding Medicaid to those individuals who are below 100% of the federal poverty level (which is $11,490 for one person and $23,550 for a family of four).

My suspicion is that even this kind of reasonable compromise would fall on deaf ears in Austin.  And although Rick Scott changed his previously hardened stance against the Affordable Care Act, the Florida legislature in Tallahassee adjourned in May without any plans to fund Medicaid expansion in the Sunshine State.  Barring a call for a special session, Florida may join Texas in not embracing any kind of Medicaid expansion.  This is a true travesty for reasons of both social justice and economic policy.  To quote Dickens, “it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity.”

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