The Texas House on Thursday rejected an attempt to direct the governor and state health officials to use billions in federal dollars to expand health care coverage for uninsured Texans, including working poor who earn too much to qualify for Medicaid but too little to afford their own health insurance.
On a vote of 80-68, lawmakers voted down the proposal, which was floated as a two-page amendment to the state budget on Thursday.
The debate, which was highly anticipated by advocates of expanding coverage for uninsured Texans, was expected to be heated and drawn out. It lasted less than 20 minutes.
Proponents said the proposal would have let Gov. Greg Abbott and the Texas Health and Human Services Commission design a program that falls in line with Texas’ conservative values — while reducing the number of uninsured people in the state.
At least one opponent said it was a back door to expanding Medicaid, which Texas conservatives have strongly resisted.
Passage of the amendment would have indeed opened the door to Medicaid expansion if that’s what Abbott or the HHSC proposed, but it would have also allowed the state to instead use federal funds earmarked for Medicaid expansion to create a program unique to Texas to cover some of Texas’ estimated 5 million uninsured people.
The Texas Legislature has declined to pass any broad expansion of state and federal health care coverage for uninsured Texans since the Affordable Care Act of 2010 required states to expand Medicaid — a provision that was later struck down by the U.S. Supreme Court.
Since then, Texas lawmakers have occasionally debated Medicaid expansion during budget votes, but the state has resisted expanding the program, while 38 other states have done it in some form.
State Rep. Garnet Coleman, a Houston Democrat who sponsored the amendment, said it wouldn’t force the state to expand traditional Medicaid but would direct Abbott and the Texas Health and Human Services Commission to negotiate a federal funding agreement, known as a 1115 demonstration waiver, to create a plan that would cover more uninsured Texans, including those who would qualify for coverage under a traditional Medicaid expansion plan.
The resulting plan could have been a traditional expansion of Medicaid to cover adults who earn up to a certain amount, or a “look-alike” that combines state and federal funds to create a state program that accomplishes a similar goal, Coleman said.
Such state-crafted plans have been passed in several states, mainly conservative states like Indiana and Ohio.
“I would like for us to expand traditional Medicaid in the optional way that the ACA says you can do it,” Coleman said on the House floor. “But we can’t do that. And we know that … That is not what this amendment does.”
Rep. Richard Peña Raymond, D-Laredo, said the idea “puts Texas in the driver’s seat, and really Gov. Abbott in the driver’s seat” instead of forcing their hand or pushing through a program unpopular with conservatives.
But Republican state Rep. Giovanni Capriglione, the only House member to speak against the bill during Thursday’s debate, said that creating a new health care program — Medicaid or otherwise — is far too complicated an endeavor to tackle in a two-page amendment and cautioned that it in fact looked like a way to expand Medicaid without a public hearing or extended floor debate.
“This topic is incredibly important, it’s complex, and frankly, it’s not appropriately handled in this amendment,” Capriglione said.
House Democrats, a handful of Republicans, and health care advocates, as well as nearly 200 groups and community leaders across Texas, still have some hope for House Bill 3871 by state Rep. Julie Johnson, D-Carrollton. That bill creates the “Live Well Texas” plan that uses a 1115 waiver to capture the federal dollars and expand Medicaid eligibility, and it includes incentives for people to continue working as well as increases in Medicaid reimbursements to attract more doctors to the program.
The bill has 76 House sponsors, nine of whom are Republicans, giving it enough support to pass the House. But it has been stuck in the GOP-led House Human Services Committee since March, waiting on a hearing that becomes increasingly less likely as the Texas Legislature barrels toward its final days at the end of May.
Only one of the Republican sponsors of HB 3871 voted for the Coleman amendment.
Thursday's vote comes as the Biden Administration offers billions in federal incentives to Texas to join 38 other states in expanding the state-run Medicaid program to include any adults who earn up to 138% of the federal poverty level — or about $3,000 a month for a family of four.
Currently, people with disabilities and adults with children can only qualify for Medicaid in Texas if they earn $300 per month or less for a family of four, or $150 per month or less for an individual. Adults without disabilities or dependent children do not qualify, no matter how little they earn.
Children can qualify if their parents earn up to 200% of the poverty level depending on the child’s age — well above the threshold for adults. About 4.2 million Texans are currently covered by Medicaid, including more than 3 million children; most of those children have parents who earn too much to be covered themselves.
With 18% of its residents lacking health coverage, Texas has the highest rate of uninsured residents in the nation, and many are concentrated in the Panhandle and the Texas-Mexico border. Three out of four of them are people of color. And many of them don’t qualify for subsidies in the state’s health care marketplace, either, because they don’t earn more than the federal poverty level, which is about $1,100 per month for an individual.
About 1.4 million more Texans would become eligible for Medicaid coverage if the state were to expand its program and about 75% of them would be people of color, according to a recent study by the Kaiser Family Foundation.