I’m an internal medicine doctor at a safety-net hospital in Houston, providing care to those who can’t afford health insurance. We’re never wanting for patients. Our state has the highest uninsured rate in the country. According to the latest census data, nearly 18 percent of Texans lack health insurance. In the oil refinery town of Pasadena, southeast of Houston, 56 percent of adults are uninsured.

These dismal numbers are due in part to our politics—namely, our state government’s refusal to expand Medicaid.

The fundamental idea behind Medicaid, first signed into law in 1965 by President Lyndon Johnson, was for state governments to partner with the feds to ensure coverage for everyone, including the poor and disabled. But over the years, as health-care costs skyrocketed, Medicaid was perennially underfunded. As a result, eligibility requirements, based on income, were made stricter. A rising percentage of Americans were cut out.

When the Affordable Care Act was passed, in 2010, states were offered a deal under the new law: expand Medicaid by enrolling residents who earn as much as 138 percent of the federal poverty level (as opposed to just the poverty level, a threshold that today is $26,200 a year for a family of four), and the federal government will shoulder a minimum of 90 percent of the costs. Participation would extend coverage to more than a million Texans.

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Texas’s response: no thanks.

It has its reasons. Many conservatives claim Medicaid expansion is a Trojan horse that will grossly inflate the state budget. But studies show that any new costs are offset, as insured patients are less likely to require expensive care in psychiatric hospitals and jails, for instance (or in the emergency rooms of the kinds of safety net hospitals where I work). In other words, Texas’s refusal to expand Medicaid has more to do with political gamesmanship than fiscal concerns. 

Even before the pandemic, a 2019 survey taken by the Episcopal Health Foundation showed that nearly two thirds of Texans favored Medicaid expansion. Now calls for expansion have grown louder. In early May, the Texas Organizing Project, which advocates for the poor in the state’s largest cities, held a Medicaid for Texas virtual rally. Twelve members of the Texas Senate Democratic Caucus recently petitioned Governor Abbott to take up the issue.

In the past, I’ve often resisted such rallying cries. I’ve had my doubts about Medicaid expansion, but not for the reasons offered by conservative lawmakers. My apprehensions are rooted in my training. If there’s a central tenet to responsible medicine, it’s that every therapy, no matter how trivial, poses a tradeoff between potential risks and benefits. Ignoring the risks is how you get in trouble as a doctor. The same goes with politics. As the Man in Black noted in The Princess Bride, anyone who says otherwise is selling something.

Medicaid is a flawed program. A former director of the state’s program once told me that Medicaid isn’t about covering patients; it had been engineered over the years to not cover patients. I learned this the hard way. One of my patients got kicked off Medicaid when his earnings rose just above the $733 monthly income limit. He could no longer afford to seek care, and he ended up dying as a result.

Expanding Medicaid would do nothing to address our system’s intrinsic flaw. Health care would still be transactional, an industry in which profit is the primary incentive, not caring for the sick in a holistic, long-term manner that would result in both better health outcomes and lower costs.

I’ve argued we should be pursuing universal coverage instead. But that was before the novel coronavirus.

We are staring down the barrel of historic unemployment. More than a million Texans are expected to lose health insurance during the pandemic. Texas Medicaid, as it exists right now, will be able to enroll only one third of those laid off. (States that have expanded Medicaid will be able to take on more than 50 percent.) The path ahead for the newly uninsured is financially perilous. A study published last year revealed that 58 percent of all personal bankruptcies in America are caused by crushing medical bills. If we expect to return to business and reboot the economy in the midst of a deadly pandemic, we should assure workers that illness won’t lead to their financial ruin. Solving Texas’s health-care problem is no longer about ideology.

I still believe universal coverage is the only long-term solution. But we should expand Medicaid now. Our state’s prosperity depends on it.

This article originally appeared in the July 2020 issue of Texas Monthly with the headline “Will We Finally Expand Health-Care Access?” Subscribe today.