The Supreme Court ruled in 2012 that the federal government couldn’t force states to expand Medicaid as part of the Affordable Care Act. Ever since, Democrats and hospital lobbyists have looked for ways to push state legislators to let able-bodied adults earning up to 138% of the federal poverty level into Medicaid. In the last Covid relief bill, Democrats tried to give states more temporary money to expand Medicaid. Now they are considering legislation to allow Democratic cities in Republican states to expand Medicaid on their own. But Texas Republicans have modeled a better way to get Americans affordable healthcare.
Unfortunately, the Lone Star State is in the minority. Thirty-eight states and the District of Columbia have expanded or approved expansion of their programs. Democrats complain the other 12 states are turning down billions of “free” federal dollars while leaving millions uninsured. As a candidate,
proposed creating a government-run plan for low-income people in states that don’t expand Medicaid.
Republicans resisting expansion argue that taxpayers end up paying for “free” federal dollars. State governments receive federal funding for a portion of each dollar they spend on Medicaid, but must provide matching funds from their own coffers. Expansion costs states billions in match requirements.
Conservative Texans who oppose Medicaid expansion point to the explosion in spending in states that have expanded their programs. More than half of Texas doctors said in 2016 they wouldn’t accept all new Medicaid patients due to low reimbursement and increased paperwork.
Medicaid isn’t well run and increasing dependence on government should be avoided. Oregon expanded Medicaid in 2008 using a lottery system, allowing for randomized selection, and a Harvard T.H. Chan School of Public Health study showed no significant improvements in physical health outcomes.
Unfortunately, some GOP states that initially held their ground against Medicaid expansion have surrendered in recent years. As recently as mid-April, Texas seemed poised to relent. Nine Republican state representatives joined Democrats to co-sponsor H.B. 3871, giving Medicaid expansion enough votes to pass the 150-member House, but conservatives acted quickly to present a bipartisan package of bills called Healthy Families, Healthy Texas. In June,
Gov. Greg Abbott
signed into law this better, more targeted and market-friendly way to help Texans access the care they need.
The Healthy Families, Healthy Texas legislative package includes a law to expand access to telehealth services, on which regulations had been temporarily loosened during the pandemic. Telehealth especially benefits rural and medically underserved areas. The law also increases access to preventive and behavioral healthcare, reduces unnecessary emergency room use, and reduces “no-show” appointment rates.
A second new law makes it easier for doctors to work with patients across state lines and entered Texas into the Interstate Medical Licensure Compact, streamlining the process for physicians to practice in multiple states. Physicians in other compact states can receive expedited licenses to practice in Texas. Increasing the supply of providers will help underserved areas.
A third law extends Medicaid coverage for pregnant women from 60 days after delivery to six months. A biennial state report indicated black women and Medicaid enrollees were more likely to die from pregnancy-related complications and that a majority of such deaths are preventable. A fourth law makes children continuously eligible for Medicaid by reducing the number of midyear reviews from four to one. Many eligible children have been losing coverage and access to primary care because of these reviews, leading to expensive—and preventable—emergency treatments.
A fifth law creates a prescription-drug program allowing a private pharmacy benefit manager to offer rebates to uninsured Texans. A sixth law builds on President Trump’s executive order requiring hospitals to provide price transparency. This is intended to encourage comparison shopping by patients and competition among providers.
A seventh law allows the Texas Mutual Insurance Co. to offer alternative healthcare-coverage products that are technically not insurance. The Texas Mutual was created by the Legislature in 1991 to provide affordable workmen’s compensation insurance, and the law will expand benefits to rural residents, small-business employees, and others. An eighth law allows the nonprofit Texas Farm Bureau, an advocacy group for the state’s agriculture interests, to offer health benefits to its members. Both the Texas Mutual and Farm Bureau plans would be exempt from many state insurance regulations. These plans won’t be the right choice for every Texan, but they will increase competition and offer lower cost options to many.
While liberals moaned about the “free” federal money Texas was missing out on, conservatives found ways to reduce the cost of prescription drugs and health plans, increase access to providers, and improve outcomes for women and children. These new laws may not all work as intended, and Democrats will keep pressing for Medicaid expansion, but the legislative fight in Texas shows Republicans can’t simply avoid the healthcare debate. They can win by offering their own ideas.
Mr. Jindal was governor of Louisiana, 2008-16, and a candidate for the 2016 Republican presidential nomination.
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