Of all the big issues to be resolved by the 83rd Legislature, none is bigger than Medicaid expansion. This has mainly been a House show up to this point, with Joe Straus acting as the leading proponent of moving forward and allowing himself to become the target of criticism on the right. This is an awkward situation for the speaker, as the GOP caucus is already on record as opposing expansion, while Straus is on record as wanting to move forward. When the Republican caucus voted overwhelmingly to oppose expansion, Straus wisely let the moment pass. He allowed the opposition to run wild and make their statement.
Still, last week he made clear where he stands. "It's time to get our heads out of the sand," he told the San Antonio Express-News. "We need to move beyond the word 'no' to something the administration might entertain." But in that same interview, he insisted that he opposes expansion as it currently stands.
Therein lies the rub, as they say. State leaders have always been willing to take federal money, but only on their own terms—that is, block grants (the trouble with which is, when the money runs out, the health care runs out); and "skin in the game" (meaning co-pays and deductibles, neither of which the feds allow states to require under the current Medicaid system).
Impact Texas has entered the discussion with a report by former Deputy State Comptroller Billy Hamilton, which says that local hospitals spend six times as much on low-income health care as it would take to extend Medicaid coverage to adults with incomes below the federal poverty level. According to Hamilton, the state could save $900 million in GR if it expanded the system.
Straus is trying to maneuver his way through an ideological minefield in which Texas lawmakers, conditioned by years of Rick Perry's anti-Washington rhetoric, loathe the idea of taking money from the federal government, although that didn't stop Perry from doing it when the Obama administration offered federal stimulus funds—which was key to balancing the budget during the 2009 session.
The speaker has been careful not to get too far out in front of the movement to get the Medicaid expansion funds. He has not criticized Perry for his opposition to expansion up to this point, and it would have been premature to do so. He has sympathizers in the Senate, including Finance Chair Tommy Williams, and Robert Deuell, who, as readers are well aware, is a physician. The session is barely past the sixty-day mark. Whatever decision is going to be made on Medicaid expansion will be made later rather than sooner. It is a far wiser strategy for proponents of expansion to let the pressure friom local hospitals and providers grow and wait to see what happens. Let Perry spend some time in the pressure cooker.
Every time a situation like this arises, I think it is appropriate to ask of the opponents and the naysayers—I am referring mainly to Michael Quinn Sullivan and Empower Texans, but also of the anti-government faction generally—"What is your solution?" (Sullivan's group has been hypercritical of Straus but has remained mute about senators who support expansion.) Is it better to turn down federal funds and to dump the cost of health care for the uninsured on hospital emergency rooms and ultimately on local-property taxpayers? Make no mistake about it: The health care costs of the uninsured in Texas are a hidden tax on property. Property taxpayers have to make up the difference in the health care costs of the uninsured, or see local taxes go up. I grant you that there is a cost to accepting federal funds. The cost is in the loss of control over health care policy in this state. But, let's face it, health care policy in this state stinks. We have great hospitals, great research, and lousy government. I'd rather put the money in the hands of the people who deliver the services than in the hands of the politicians. I suspect this is what Straus thinks too. Forget the ideology. Show me the money.
I fear that Texas is going to let a great opportunity slip through its fingers. State officials, including Straus, appear to insist on a "Texas-centric solution" before they will touch filthy lucre. Unless Straus's powers of persuasion are superhuman, it isn't going to work. Medicaid is an entitlement program. If state officials insist upon co-pays, deductibles, and other devices that are incompatible with the concept of an entitlement program, the state is going to pick up its marbles and say no, as it has done in the past. Unless things change, the best we can hope for is to squeeze out some dollars that can be used to obtain insurance for the uninsured. Very few things would be more helpful for business—and taxpayers—in this state.
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