Senior Politics Writer
AUSTIN — A few years ago, with the nation in the throes of a pandemic, Sen. Nathan Johnson’s effort to add 1 million low-income Texans to Medicaid drew support from a handful of Republicans in the GOP-dominated Texas Legislature.
Most of those lawmakers are gone from the Capitol, an exodus that strips away at the Dallas Democrat’s slim hope of seeing Texas join 40 other states and Washington, D.C. in expanding Medicaid under the 2010 Affordable Care Act.
Even so, Johnson filed his bill for the upcoming session — his third try — just in case the leaders of an increasingly conservative Texas Legislature change their minds.
“I just want a million people to get health insurance, I want health insurance premiums to come down, and I want to do it without levying any new tax on the people,” Johnson said.
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“The strategy is to present something that would allow Republican leadership to say, ‘This is a win for all of us.’ I think if there were a signal from leadership, then we would see Republicans fall in line behind this,” he said.
Senate Bill 232 would create the Live Well Texas program, which would expand Medicaid while adding elements passed in other conservative states – including incentives to encourage self-sufficiency through health savings accounts, employment assistance and rewards for healthy behaviors.
Additionally, the legislation seeks to increase reimbursements to health care providers who see Medicaid patients, potentially expanding access to care for Medicaid patients by bringing more hospitals, doctors and others to the program.
In 2021, Johnson’s Medicaid-expansion bill had no Republican support in the Senate, but nine GOP House members joined 67 Democrats as co-authors of an identical House bill. The legislation was bottled up in a committee.
Johnson tried again in 2023, but the effort gathered less bipartisan momentum during a particularly contentious session.
“I was very serious about passing it when I first filed it, and we had a really good run at it, but I don’t see how the situation has improved,” Johnson said. “But I want something out there to say that if this state wants a conservative way to bring home its own tax dollars and improve the health of its population and bring down health premiums and stabilize family finances and help set people on a path to independence, there is a way to do it that has conservative bona fides.”
Opponents of expanding Medicaid say the program is mismanaged, financially unstable, too expensive and fosters government reliance. They also argue that expansion does not improve health outcomes and prioritizes able-bodied adults over children and adults with disabilities who rely heavily on the program.
Caroline Welton, who heads health care policy research at the Texas Public Policy Foundation, a conservative think tank, said talk of expansion should be replaced by talk of reform.
“Even to the extent there may be a need or a desire for some state coverage, Medicaid is a failing system which does not provide for the needs of the Texans currently enrolled in it,” said Welton, campaign director of the group’s Center for Health and Families. “So we should fix it and provide better options before expanding this failing system to more people.”
Supporters point to billions of dollars in federal incentives available if Texas expands Medicaid, saying the state is rejecting money that would add to the state’s general revenue and lower costs for hospitals, which would lower costs for patients.
“There’s no scenario in which this is not a good idea,” Johnson said. “This is the single-largest change we could make, and we’re not doing it. And it’s free.”
An estimated 20 percent of adult Texans lack health insurance — the highest rate in the nation. The state also has one of the country’s most restrictive Medicaid programs.
Roughly 4.1 million residents are on Medicaid, including 3 million children. The program is also open to pregnant Texans, people with disabilities, and parents who earn up to 15% of the federal poverty level, which comes to about $390 per month for a family of four.
Adults with no disabilities and no dependent children don’t qualify for Medicaid, no matter how little income they have. Many children who qualify for Medicaid have parents who don’t.
The Affordable Care Act allows states to expand the Medicaid threshold up to 138% of the poverty level, or a monthly income of $3,588 for a family of four, and would allow people in the gap to be covered, including working single adults making $1,731 or less a month.
In Texas, an estimated 1 million working adults with no access to job-related insurance make too much money to qualify for Medicaid, yet not enough for the government-subsidized health plans in the ACA marketplace.
Prospects for including them in Medicaid will be particularly difficult in the 2025 session because lawmakers will be debating school choice, a divisive issue that could take time and attention away from something as complicated as Medicaid reform, said Tanner Aliff, visiting research fellow with Paragon Health Institute who was formerly with the Texas Public Policy Foundation.
“It’s a competition for attention, and I think it detracts legislators from having the adequate amount of time to have the necessary robust and bipartisan conversation to reform Medicaid,” Aliff said. “If there’s anything to be bipartisan on, time-wise, school choice is the priority, and subsequently it will take up much of the political horse-trading dialogue.”
Medicaid is significantly limited by a doctor shortage, with up to 30% of doctors not accepting new Medicaid patients and many rural areas being health care deserts where hospitals have closed, Welton said.
“If there isn’t a primary care doctor in your county due to the physician shortage, having a Medicaid card won’t help you,” Welton said in an email.
Welton also said recent studies show a significant number of uninsured people are eligible for Medicaid — nationally, that number is about 25%. While some say that’s a problem with the enrollment and access system, Welton says it’s also an indicator of the program’s inherent problems.
“If more Medicaid were the solution, you’d expect people to be more excited about actually using Medicaid as it stands,” Welton said.
Many GOP lawmakers aren’t motivated to debate Medicaid because President-elect Donald Trump is likely to have a very different relationship with Texas than President Joe Biden, who refused to entertain Texas’ suggestions to change the program and criticized how the state was spending its federal contribution for Medicaid, Aliff said.
At the same time, enrollment in ACA marketplaces in Texas and other states is at an all-time high after some Biden policies expanded access to low-cost subsidized policies, which “kind of watered down the demonstrated need for Medicaid expansion,” Aliff said. The expanded access, part of Biden’s American Rescue Plan, is set to expire in 2025.
Both sides of the debate acknowledge Trump’s plans for Medicaid are unclear, which makes it difficult to devote time to debating policy, Aliff said.
“Conservatives in Texas are excited about the new freedoms they might have to reform Medicaid with Trump in office and a more friendly-run Centers for Medicare and Medicaid Services,” he said.
Without support from Texas leaders or from Trump, Johnson doesn’t see how expansion can move forward in Texas next year.
In its absence, Johnson said, he will look for other ways to improve health outcomes, such as getting more people into the subsidized ACA marketplace.
“It’s not easy – there is no low-hanging fruit out there,” Johnson said. “I will support other things. I want people to have health care. … [But] anything that’s not Medicaid expansion, almost anything we can do to give some identifiable group of people health insurance, is more expensive and covers less people.”
Karen Brooks Harper has covered Texas politics in and out of Austin for nearly 30 years. She's also covered the cartel wars along the TX-MX border, Congress in Mexico City, and 6 hurricanes, among other stories. Raised on blues and great food in the MS Delta, she lives in ATX with her family, her guitar, and her boxing gloves. In that order.
