Transgender students in Texas would be barred from school sports teams matching their gender identity under a bill advanced by state Senate

The Texas Tribune | By Shawn Mulcahy

The proposal would prohibit students from participating in a sport “that is designated for the biological sex opposite to the student’s biological sex as determined at the student’s birth.”

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Transgender students would be banned from competing on school sports teams based on their gender identity under a bill that passed the Texas Senate on Thursday.

Despite immense opposition from civil rights groups and Democrats, the upper chamber voted on an 18-12 vote to advance Senate Bill 29. The measure now heads to the Texas House.

The proposal would prohibit students from participating in a sport “that is designated for the biological sex opposite to the student’s biological sex as determined at the student’s birth.” Students would be required to prove their “biological sex” by showing their original, unamended birth certificates.

State Sen. Charles Perry, R-Lubbock, argued on Wednesday that the prohibition is necessary to keep girls safe from injury and to retain fairness in interscholastic athletics. But Perry acknowledged that he doesn’t know of any transgender students currently competing in Texas school sports.

And medical professionals have largely debunked the argument that transgender athletes have an advantage, with one study showing people taking hormones did not have a significant performance edge in distance running.

Opponents said the Republican leadership-backed bill was a “fear tactic” in search of a problem that doesn’t exist.

“Trans kids, they just know they are not what their birth certificate says,” said state Sen. José Menéndez, D-San Antonio. “And that’s where we’re creating a problem that we don’t need to.”

The measure would codify existing school athletic policy. The University Interscholastic League of Texas, which governs high school athletics and extracurricular activities, currently relies on students’ birth certificates to determine whether they participate in men’s or women’s athletics. Notably, the UIL recognizes changes made to birth certificates to alter a student’s gender marker, though that would no longer be allowed under the proposal.

Both the NCAA, the governing body for college athletics, and the International Olympic Committee allow athletes to compete based on their gender identity.

State Sen. Nathan Johnson, D-Dallas, suggested that if lawmakers were truly concerned with player safety, they’d focus on legislating injury-prone contact sports such as football. He also worried that the proposal could be harmful to cisgender or nonbinary students whose gender expressions don’t align with traditional social constructs. And he questioned whether his colleagues were trying to legislate a situation that isn't widespread.

“I think we spend a lot of time anticipating things that aren’t going to happen,” Johnson said. “If this becomes a real problem, there might be a more subtle way we can handle it.”

Wednesday afternoon, Equality Texas held a news conference outside the Capitol building in Austin to bring awareness to over 30 bills filed in the legislature that would discriminate against LGBTQ youth. Ricardo Martinez, the organization’s CEO, noted that the first of these anti-trans bills was filed 156 days ago, on the first day of bill filing for this session.

“That day kicked off the Texas portion of a nationally-coordinated attack on our community,” Martinez said. “This attack, which intentionally targets transgender and intersex youth, who are some of the most vulnerable members of our community, is especially cruel given that we’re still in a deadly pandemic.”

Landon Richie, an 18-year-old transgender Texan, skipped his classes at the University of Houston to speak outside the Capitol Wednesday.

“Trans kids belong in Texas and deserve the same rights, access to health care, access to sports, access to public facilities, as any other Texan,” Richie said.

Mack Beggs, a transgender athlete from Texas, garnered national headlines after he won back-to-back wrestling titles in 2017 and 2018. Beggs competed in the women's division because the UIL ruled he had to compete against the gender that appeared on his birth certificate. Attorney Jim Baudhuin sued the UIL in 2017, arguing that Beggs posed an injury risk to other athletes and possessed an unfair advantage. A Travis County judge tossed out the case.

“Mentally, it took a toll on me,” Beggs told Yahoo News last month. “I think we need to have resources in place for other [trans] kids who are in those positions.”

He spoke out against proposals like SB 29, calling them "revolting and honestly appalling."

The move by the Texas Senate is part of a national push by conservatives to restrict rights for transgender students. Similar bills have been filed in at least 20 states. Three states — Arkansas, Mississippi and Tennessee — earlier this year signed the prohibition into law.

Idaho was the first state to pass a law seeking to block transgender youth from sports last March. The law has been challenged in federal court and has been blocked by a federal judge as the legal challenge proceeds through the courts.

On Monday, the National Collegiate Athletic Association Board of Governors warned that it will only hold college championships in states where transgender student-athletes can participate without discrimination.

“Inclusion and fairness can coexist for all student-athletes, including transgender athletes, at all levels of sport,” the NCAA statement said. “Our clear expectation as the Association’s top governing body is that all student-athletes will be treated with dignity and respect. We are committed to ensuring that NCAA championships are open for all who earn the right to compete in them.”

Multiple games in the 2022 NCAA men’s March Madness tournament are already scheduled to be played in Fort Worth and San Antonio and the 2024 college football national championship is slated for NRG Stadium in Houston.

Disclosure: Equality Texas and University of Houston have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

State Sen. Nathan Johnson, D-Dallas, suggested that if lawmakers were truly concerned with player safety, they’d focus on legislating injury-prone contact sports such as football...“I think we spend a lot of time anticipating things that aren’t going to happen,” Johnson said. “If this becomes a real problem, there might be a more subtle way we can handle it.”

Medicaid expansion picks up bipartisan support in the Texas House, but hurdles remain

The Texas Tribune | By Karen Brooks Harper

Expanding the Medicaid rolls to include more than a million Texans could get a floor vote during House budget hearings on Thursday.

When a neighbor’s dog nipped her hand near the fingernail last winter, Trish W. put off going to the doctor because it didn’t seem worth the dent it would put in her already tight budget.

It wasn’t until her hand swelled to the point where her finger nearly burst that she finally gave in.

The doctor told Trish, a 33-year-old from Canyon Lake who has a genetic blood disorder that hinders her ability to fight bacteria, that she’d narrowly escaped deadly sepsis and that she could have lost her hand. The hospital kept her overnight to be sure. She later received a $2,000 bill that she couldn’t afford.

“Of course as a single mother, you're thinking, ‘Oh, my God, I might not leave this hospital,’” said Trish, who asked that her last name not be used in order to protect her family’s privacy. “‘This could be the last time I see my kid.’ And that’s terrifying.”

It’s a scenario she might have avoided with a Medicaid card, but her pay as a certified nursing assistant, which she said can reach $1,700 "on a good month," means she makes too much to qualify under Texas eligibility rules — but not enough to buy her own insurance.

“I fall right in that gap,” said Trish, who lives in an RV with her 12-year-old son.

Texas lawmakers have been presented with billions of dollars in federal incentives this year to join 38 other states in expanding the state-run Medicaid program to adults like Trish who earn up to 138% of the federal poverty level.

That’s about $1,500 per month for an individual, or $3,000 a month for a family of four. Currently the threshold in Texas is about $200 per month for a family of two, or about $300 per month for a family of four.

Among several bills filed in the conservative Texas Legislature is a Medicaid expansion plan with bipartisan support that is similar to those adopted in some Republican-led states.

Nine House Republicans and all 67 House Democrats have publicly signed on to House Bill 3871, which would give it enough votes to pass the 150-member chamber. Although none of the proposals have gotten a hearing this session, Medicaid expansion is expected to be introduced in some form as a floor amendment Thursday when the House debates the state budget.

First introduced as part of President Barack Obama’s Affordable Care Act in 2010, the requirement to expand eligibility for Medicaid was fiercely resisted by Republican-led states, including Texas, on the argument that it was fiscally unsustainable and, equally importantly, expanded an entitlement program when the goal should be to make people less dependent on the government.

Since then, however, all but 12 states have expanded their Medicaid programs.

Texas, meanwhile, has relied on a federal funding agreement, known as the 1115 waiver, that was first approved in 2011 as a means to help hospitals care for uninsured people until the states expanded their Medicaid programs under the ACA. Then the U.S. Supreme Court ruled that states couldn’t be required to expand Medicaid.

In the years after, Texas leaders fought to keep the waiver while resisting expanding Medicaid. The uncompensated care funding for providers and the innovative health project funding in the waiver do not provide comprehensive health care coverage or drug coverage.

The new federal incentives, combined with news last week that Texas may lose its 1115 funding after October 2022, bring a new pitch to the decadelong debate over adding more than a million people to the Medicaid rolls in Texas.

“The time to do this is now,” said state Rep. Julie Johnson, D-Carrollton, the author of House Bill 3871. “The deal on the table that the [federal] government offered to us is, in my opinion, irresponsible not to accept.”

Conservative lawmakers are weighing their historic opposition to Medicaid expansion against the potential of billions in federal incentives coming to Texas during a tight budget cycle.

“There is a bipartisan desire to see the cost of health care decrease. The unsustainable increase in prices, whether at the hospital, the doctor, or in health insurance premiums hits all Texans,” GOP state Rep. James Frank, chair of the House Human Services Committee, said in emailed comments to the Tribune. “But there is also concern that when Medicaid expands, that adds pressure to the private insurance market to make up the difference in reimbursements. Hence, expansion is a hidden tax on those who have private insurance, driving up the cost of care for everyone.”

Medicaid expansion in Texas

Some 4.2 million people are on Medicaid in Texas — including more than 3 million children. The rest of the recipients are people with disabilities, pregnant women and parents living below 14% of the federal poverty level. Adults with no disabilities or dependent children don’t qualify for Medicaid, and the vast majority of children on Medicaid have parents who do not qualify.

Texas has the highest rate of uninsured residents in the nation.

If Texas expanded Medicaid, the federal government would bump its reimbursement to the state from 62% of Medicaid expenditures to 67% — and it would pay 90% of the costs for the estimated 1.4 million adults who would become newly eligible for the program.

A recent report by Texas A&M University and sponsored by the Episcopal Health Foundation showed that an estimated 954,000 newly eligible adults would likely enroll, bringing $5.41 billion in federal matching dollars to pay for them each year. The Kaiser Family Foundation, a health care research organization, estimates that about 75% of the newly eligible would be people of color.

Economists predict that expansion in Texas would be an economic driver, increasing health-related spending, decreasing uncompensated care spending by local governments and raising productivity with a healthier workforce.

“It’s really critical at this point that Texas be looking at solutions for our worst-in-the-country insurance rates,” said Anne Dunkelberg, who oversees health care policy for Every Texan, a public policy group.

But state leaders and many Texas conservative groups have so far chosen to decline the expansion.

Lt. Gov. Dan Patrick’s and Gov. Greg Abbott’s offices did not respond to requests for comment, but both have opposed expanding Medicaid in the past. In January, House Speaker Dade Phelan expressed doubt that Medicaid expansion would happen this session.

Among other arguments, opponents say it would crowd out current Medicaid patients who are already getting a low quality of care due to the limited number of physicians who accept Medicaid patients because of low reimbursements.

“I think it’s unfortunate to put a price on the heads of those that are most vulnerable,” said David Balat, director of the Right on Healthcare initiative at the conservative Texas Public Policy Foundation. “We’re talking about people that are not getting the greatest of care, stand to get worse care and we’re saying we should probably just take the money anyway. That's unconscionable.”

“We exist, and we matter”

The Medicaid legislation getting the most attention in the Legislature this session are companion bills filed by Johnson in the House and state Sen. Nathan Johnson, D-Dallas, modeled after programs in conservative states like Ohio and Indiana.

The identical bills offer incentives for recipients to achieve self-sufficiency and independence through health savings accounts, employment assistance and healthy behavior rewards, rather than cultivating an attitude of state dependency, said Nathan Johnson, whose Senate Bill 117 is awaiting a committee hearing. The legislation would also increase provider reimbursements to encourage physicians to accept more Medicaid patients.

Medicaid expansion would also potentially generate hundreds of thousands of jobs and bring in billions in additional tax revenue to the state and to local governments, according to a recent analysis by The Perryman Group, an economic research firm in Waco.

“I’ve got to ask my colleagues, ‘How much are you willing to reject, in order to not provide health care to people for free? In order to not have people healthy enough to go to work?” Nathan Johnson said. “There’s a narrative that says, ‘We created the Medicaid program to help the truly vulnerable, the elderly, the disabled, the children. We’ve taken care of everything. Everybody else, you’re on your own.’ And that just refuses to look at reality.

Better reimbursements for doctors and the personal responsibility incentives are the two biggest reasons why House Republican Rep. Steve Allison, a San Antonio freshman and co-author of House Bill 3871, said he signed on to the legislation after years of skepticism.

“In the past, we just talked about expanding coverage and didn't talk about care. I've always been stuck on care,” he said. “The incentives, too, are so important. … I think that's what's starting to move some of the Republicans, because that's been a legitimate concern in the past. That we’re just further promoting welfare.”

But first it needs to reach the House floor. Frank, a Wichita Falls Republican, said he has not decided whether to allow a hearing on the House bill.

“I remain convinced that there are better ways for Texas to improve access and affordability of health care for all Texans than Medicaid expansion,” Frank said, adding that he worries Medicaid expansion could drain the state budget over time and lead to fewer private employers offering health benefits to workers.

Earlier this month, Phelan, Frank and other House members from both parties championed a set of bills called “Healthy Families, Healthy Texas” that Frank said would improve quality of care and health care access “for all 29 million people in the state.”

They include measures to reduce the cost of some prescription drugs for uninsured people, make it easier for children on Medicaid to continue coverage during income verification processes, require transparency in medical billing, expand availability of telehealth and broadband services, and increase insurance plan options through small businesses, agricultural nonprofits and associations, among others.

They also supported a bill expanding Medicaid coverage for new mothers to 12 months after the birth of a child, up from the current two months.

In Canyon Lake, what the politicians do at the Capitol could have a big impact on Trish, whose son inherited the same blood disorder and does have Medicaid coverage. If they expand Medicaid, she could stop having to make the difficult choice between paying for her own health care or putting food on the table and keeping the lights on.

“It’s not like we’re going to go see a doctor every chance we get,” she said. “It’s just to have that card in your back pocket to go get a physical or see a doctor if there’s an emergency. It means a lot to people like us. We exist, and we matter, and we don’t deserve to be treated like trash on the bottom of someone’s feet.”

Disclosure: Texas A&M University, Episcopal Health Foundation, Every Texan and the Texas Public Policy Foundation have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

Correction, April 21, 2021: A previous version of this story gave the incorrect number for Sen. Nathan Johnson’s Medicaid expansion bill. It’s Senate Bill 117, not Senate Bill 118.

Clarification, April 23, 2021: An earlier version of this story said the 1115 waiver that was rejected by the federal government does not cover Medicaid services. The uncompensated care funds in the waiver help Texas hospitals cover costs of caring for the uninsured but does not pay for health care coverage or drug coverage for patients.

“I’ve got to ask my colleagues, ‘How much are you willing to reject, in order to not provide health care to people for free? In order to not have people healthy enough to go to work?” Nathan Johnson said. “There’s a narrative that says, ‘We created the Medicaid program to help the truly vulnerable, the elderly, the disabled, the children. We’ve taken care of everything. Everybody else, you’re on your own.’ And that just refuses to look at reality.”

Advocates Say White House Decision To Rescind Medicaid Deal Could Lead To Talks On Texas' Uninsured Rate

KUT 90.5 | By Ashley Lopez

Health care advocates in Texas say they see an opportunity to address the state’s rising uninsured rate after the Biden administration announced last week that it is rescinding a health care deal the Trump administration cut with Texas.

The 10-year extension of the state’s Medicaid waiver would have provided federal funds to help pay for the cost of hospital care for uninsured Texans through 2032. In a letter to the state’s Medicaid director, federal health officials said Texas hadn’t followed public notice rules when applying for the waiver.

“Upon further review, we have determined that [Centers for Medicare and Medicaid Services] materially erred in granting Texas’s request for an exemption from the normal public notice process,” the officials wrote. They said the state didn't show an emergency existed to allow it to deviate from the normal process.

Gov. Greg Abbott accused the administration of “obstructing healthcare access for vulnerable Texans and taking away crucial resources for rural hospitals” in the state.

“The State of Texas spent months negotiating this agreement with the federal government to ensure vital funds for hospitals, nursing homes, and mental health resources for Texans who are uninsured,” Abbott said in a statement Friday. “With this action, the Biden administration is deliberately betraying Texans who depend on the resources made possible through this waiver.”

But health care advocates said the deal made during the waning days of the Trump administration was out of the ordinary and raised concerns.

For one thing, state officials initially applied for a five-year waiver to cover the costs of uninsured people, commonly referred to as uncompensated care costs. These waivers allow states to receive Medicaid funding for health care outside of how the program traditionally operates. In this case, the Trump administration agreed to give Texas an extra five years – 10 years total — to use Medicaid funds to shore up hospital costs for this care.

Anne Dunkelberg, an associate director with the policy think tank Every Texan, said it’s unheard of for waivers to be granted for such a long time. She said when Biden took office, officials told Texas they were going to take a closer look at this fast-tracked deal.

“This process did skip the public notice and comment period that are not just some light guidance — they are in law and in federal regulation,” she said.

"This is the chance for all the stakeholders — the hospitals, people like us, people who are uninsured, clinics — everybody to weigh in and offer their opinion about what a best Medicaid program would be moving forward.”

Patrick Bresette, executive director of the Texas office of the Children’s Defense Fund

Basically, the Biden administration found state leaders skipped an important step for advocates and stakeholders to weigh in on this issue. Patrick Bresette, executive director of the Texas office of the Children’s Defense Fund, said that's not a minor thing.

“I mean this is the chance for all the stakeholders — the hospitals, people like us, people who are uninsured, clinics — everybody to weigh in and offer their opinion about what a best Medicaid program would be moving forward,” he said.

Dunkelberg said nothing has technically been taken away from Texas. The state was approved for a waiver several years ago that pays for uncompensated costs until September 2022, so hospitals aren't going to lose funding any time soon. And, she said, Texas can just go back and renegotiate.

“I think it is a little on the overly dramatic side to suggest that there is definitely going to be any kind of interruption, much less anything in the near term,” she said.

Advocates say this could open the door for a broader conversation about Texas’ climbing uninsured rate. The state has the highest number of people without health insurance in the country, as well as the highest rate of uninsured. However, instead of seeking ways to expand health care coverage to more people, Republican leaders have focused on bringing in federal funds to cover the costs incurred by hospitals when they treat these patients.

Bresette said the fact that Republican leaders have been largely ignoring the state’s health care coverage issues has been a mistake.

“It’s not good for the economy to have so many people who are uninsured who may lose time from work because they didn’t get the care they needed,” he said. “It’s expensive when people have to go to the emergency room and they are not insured. Those costs get passed down.”

And, Bresette said, expanding coverage would prevent many people from ending up in the hospital due to preventable medical issues that could have been dealt with by a primary care physician.

“Insurance is the key to getting health care and … getting those kinds of preventive and maintenance care covered,” he said. “And that makes a difference and not just for individuals, but for basically how the whole community functions.”

And advocates say Texas does have an option for dealing with this problem: expanding Medicaid.

Texas is one of only 12 states that has refused to expand Medicaid coverage to more low-income adults. Even though the state will always have uncompensated care costs, getting more people insured could make a big dent in bringing down those costs for hospitals.

"Once people get over the initial anger — the misplaced anger — at thinking that the federal government has taken money away from us, then we settle down and realize, ‘OK, let’s just reapply and this time do it right.’”

State Sen. Nathan Johnson, D-Dallas

State Sen. Nathan Johnson, a Democrat from Dallas, has been pushing for bipartisan approaches to expand coverage to Texans using Medicaid dollars, whether it’s a straight up expansion through the Affordable Care Act or thought one of these waiver programs.

“There’s definitely an acceptable — actually a very good — avenue available to the Legislature,” he said.

Johnson said the Biden administration’s decision could be a flashpoint in the ongoing fight over expanding Medicaid in the Texas Legislature.

“I do see some momentum,” he said. “I do see the conversation increasing. Once people get over the initial anger — the misplaced anger — at thinking that the federal government has taken money away from us, then we settle down and realize, ‘OK, let’s just reapply and this time do it right.’”

Johnson said that means Texas health officials could include expanding coverage when it reapplies for the waiver, which would make it all the more likely the Biden administration would cut it a good deal.

He said the federal government has long helped states with uncompensated care costs, but states should do what they can to bring down those costs.

Democratic Congressman Lloyd Doggett said the Biden administration is already doing a lot to make expanding Medicaid here an even better deal.

“The Biden administration advised Texas that it could gain another $3.9 billion over the next two years by expanding Medicaid coverage,” he said. “That would provide assistance to over 2 million of our uninsured neighbors in Texas.”

And like most advocates and Democrats in the state, Doggett said he hopes this situation eventually leads to some serious discussions, even though the politics are tough on this issue.

“I think it will encourage a conversation,” he said. “Overcoming the ideological blinders is a very difficult thing in this Legislature with a governor who is so concerned about political opponents from the far right.”

Doggett said if Texas misses this opportunity yet again to expand coverage, it could become harder to negotiate these deals to cover uninsured costs. He also said he’s going to consider proposing legislation in Congress to work around the state – which would make it easier for major cities like Houston, Dallas, San Antonio and Austin to work directly with the federal government to get people covered.

State Sen. Nathan Johnson, a Democrat from Dallas, has been pushing for bipartisan approaches to expand coverage to Texans using Medicaid dollars, whether it’s a straight up expansion through the Affordable Care Act or thought one of these waiver programs.

“There’s definitely an acceptable — actually a very good — avenue available to the Legislature,” he said...