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...

Bills restricting abortion, including one that bans procedure as early as six weeks, gets Texas Senate OK

The slate of bills must still go to the House for approval.

By Shannon Najmabadi, The Texas Tribune.

The Texas Senate on Tuesday approved five bills restricting access to abortion, including a priority measure that could ban abortions before many women know they are pregnant.

The measures, which abortion rights advocates call some of the most "extreme" nationwide, are among the earliest bills to be debated by the full Senate — whose presiding officer, Lt. Gov. Dan Patrick, has given two abortion proposals top billing this session. The bills were passed 19-12. They must still be approved by the House before becoming law.

Senate Bill 8 would ban abortions after a fetal heartbeat has been detected, which can be as early as six weeks, according to a legislative analysis. The bill has an exception for medical emergencies but not for rape or incest.

The bill would also let anyone in Texas sue an abortion provider if they believe they violated state laws, regardless of whether they had a connection to someone who had an abortion or to the provider. A person who knowingly “aids or abets” others getting abortions prohibited under state law could also be hit with lawsuits, according to a bill draft.

“We're setting loose an army of people to go sue somebody under a bill that will likely be held unconstitutional,” state Sen. Nathan Johnson, D-Dallas, said during a debate about the bill. “They could be sued over and over and over again having to pay $10,000,” which is the minimum proposed damages in the bill.

Similar “heartbeat bills” have been passed in other states but have been blocked by the courts.

State Sen. Bryan Hughes, R-Mineola, the lead author of SB 8, said unique legal language in the bill makes him believe it will be upheld. It’s intended to “protect our most vulnerable Texans when the heartbeat is present,” he said.

Senate Bill 9, another Patrick priority, would bar nearly all abortions if the U.S. Supreme Court overturned the Roe v. Wade decision or otherwise altered abortion laws. It would create a possible fine of $100,000 for doctors who perform abortions after the law goes into effect. Sen. Carol Alvarado, D-Houston, said the fine for sexual assault in Texas has a $10,000 maximum.

“Why would we punish a doctor who performs an abortion on a victim of rape or incest more than the actual rapist?” she asked.

“I would say that the problem here is not the amount of the fine on the doctor but on a rapist,” state Sen. Angela Paxton, SB 9’s author, responded.

Other legislation approved by the Senate Tuesday would bar later-term abortions in the case of severe fetal abnormalities — closing what the bill’s authors have likened to a “loophole” and forcing people to carry ill-fated or unviable pregnancies to term, according to experts and advocates. Women in that situation would be provided with information about perinatal palliative care, or support services, which they may not have been aware of, the bill’s author said.

Another bill, Senate Bill 394, would bar pill-induced abortions after seven weeks. Guidelines from the Food and Drug Administration approve the use of abortion pills up to 10 weeks. Nearly 40% of abortions performed on Texas residents in 2019 were medication-induced, according to state statistics.

Most abortions in Texas are banned after 20 weeks. Women seeking an abortion must get a sonogram at least 24 hours before the procedure, and their doctor must describe the sonogram and make audible any heartbeat.

Dozens of abortion-related measures have been filed this legislative session, including one that would open up abortion providers to criminal charges that carry the death penalty. Anti-abortion activists have urged lawmakers to challenge the Roe v. Wade decision, citing the new conservative makeup of the U.S. Supreme Court. Nearly every Republican in the Senate has signed on as an author of SB 8, one of Patrick’s priorities, as has Brownsville Democrat Sen. Eddie Lucio Jr., who said during a debate Monday that he believes life begins at conception.

A sixth abortion-related bill advanced Tuesday would require a contractor to offer counseling and other resources to a person seeking an abortion. That person would receive a pin to verify she received the offer, and the pin would then be destroyed, said Paxton, the bill’s author. Earlier bill drafts said the woman would get an identifying number that would be stored in a state database.

Sen. Sarah Eckhardt, D-Austin, asked what services the women would be referred to — pointing to how poor most parents must be to qualify for Medicaid in Texas. A parent with one child would need to make less than $200 a month to qualify, the strictest criteria of any state, according to the Kaiser Family Foundation.

“So we're going to spend $7 million annually for somebody who is less qualified than their doctor to give them advice on something that they probably aren't eligible for?” she asked Paxton.

Paxton said the bill could connect women to support services like housing, resume development, child care and adoption services, and said it could help women who would prefer to carry their pregnancy to term if the circumstances were different.

“If she wants to call” and ask for her code, she can get it and just hang up, Paxton said. Her bill was passed by the Senate 20-11.

Despite inactivity in the Legislature, Senator says Texas is moving closer to Medicaid expansion

By Eli Kirshbaum, State of Reform

This year’s legislation to expand Medicaid in Texas — neither the Senate or the House version of which have been scheduled for an initial committee hearing — has garnered notable support from some Republican lawmakers. Sen. Nathan Johnson, the sponsor of the bill’s Senate version, said he is hopeful about advancing his proposed “Live Well Texas” program this year, but acknowledged that it will be an uphill battle.

“Neither one of them has a hearing set, and that’s going to take some doing … It’s not only opposed by powerful people — it scares a lot of people.”

He affirmed he is still actively pushing to get a hearing date set, and is optimistic about the bill’s increasing Republican support.

A legislative insider familiar with the issue shared a similar perspective with State of Reform. They believe a committee hearing has a reasonable chance of happening before the end of the session. Regarding any further legislative advancement, however, they said chances are very slim.

Johnson and Republican lawmakers have been communicating on what the bill should look like for over a year. He and other advocates have been speaking to people throughout the state, attempting to correct misunderstandings about what expansion would do. He said these conversations were necessary given state leaders’ history of strict opposition to it.

Johnson said the bill’s use of a Medicaid 1115 Waiver to control its expansion of Medicaid is the reason behind some of the novel Republican support. The waiver would give Texas permission to conduct the program with considerable independence from the federal government, which Johnson said is more likely to appeal to his conservative colleagues.

“It simulates a private sector experience with health insurance rather than the traditional model …  Many believe traditional models of state-run health care systems create a culture of dependency, and whether or not that’s true, I wanted to go with a system that has been tried in other states that more closely simulates the experience of the private sector, and therefore doesn’t foster dependency, but rather, fosters independence.”

The waiver will also provide recipients of Medicaid with a state-funded health savings account, which will help support them as they transition out of Medicaid into a private plan. Recipients, their employers and community organizations can also add to the account under certain conditions for the recipient to receive enhanced benefits like dental coverage.

While he believes a couple of Republicans would see the fiscal benefit of expanding Medicaid and sign on to “straight Medicaid expansion,” he said these key differences are likely the only reason some Republicans are starting to consider the measure.

“Politically, it matches some beliefs and values that they hold very important, and it allows them to communicate to their own voters why this program is consistent with their values.”

Johnson highlighted that notable progress has still been made, albeit not in the Legislature. Two years ago, Republican legislators would barely even agree to discuss Medicaid expansion. The fact that both sides of the aisle and numerous media outlets are talking about it today points to how far the idea of expansion has come in just a couple years, he said.

Public support for Medicaid expansion among Texans is substantial, with nearly 70% of the population in support. According to Johnson, state lawmakers nonetheless oppose it primarily for political reasons. He said electoral politics play a significant part in how these lawmakers approach the subject, and Republicans with constituencies that would likely disapprove of support for a government-sponsored program refuse to risk losing constituent support — even if they themselves acknowledge the benefits of the program.

“I’m sympathetic to people who are nervous about election consequences. But I think this issue is so clearly right that you’ve got a duty to take the risk. Bring your voters with you.”

“We’ve had years of misunderstanding this issue, and it takes a long time to disabuse people of a deep conviction about something, and people have deep convictions about the Affordable Care Act. Anything associated with it was deemed to be terrible.”

He said the first Medicaid expansion conversations among Texas leaders weren’t based in fact and cemented a false perception of the measure that remains in place today.

“Back when the story was first told, the story kind of stuck, and it didn’t change, even while the rest of the country was experiencing the changes that Medicaid expansion could bring.”

With less than 70 days left in the session, committee leaders have limited time to place the bill on the calendar and initiate a hearing.