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In Texas, more than 4.5 million people remain without health insurance. The Affordable Care Act expansion of Medicaid was supposed to take a big bite out of that number and cover more than a million of the state's working poor. But Texas is refusing to participate. Republican lawmakers argue they shouldn't have to work with what they say is a broken system. That decision leaves billions of federal dollars on the table to expand Medicaid over the next decade. NPR's Wade Goodwyn told us about that this morning. Now he reports on the politics behind the Medicaid debate in Texas.
WADE GOODWYN, BYLINE: Imagine you're buying a new set of living room furniture and paying in installments. Every month, you hand over your money. But when you finally go to take delivery, you're told, sorry, you're going to have to pay for it all over again. That's essentially what's happening in Texas because the state's politicians refuse to participate in Medicaid expansion. And it's Texas's taxpayers, and especially Texas's businesses, that end up bearing the brunt of the cost. Bill Hammond is the CEO of the Texas Association of Business.
BILL HAMMOND: We have to make people understand that billions, literally billions and billions of dollars, that we are saying, no, we don't want that money brought to Texas at a time when we're paying twice for the services that are being delivered to the poor.
GOODWYN: When Hammond says Texans are paying twice, he's referring to Texans' federal income taxes. Medicaid and Medicaid expansion is essentially the federal government giving a lot of those taxes back to the states. So when Texas turns down Medicaid expansion, it's leaving between 80 to $100 billion on the table. It's Texas's money to pay for Texans' health care insurance, but Texas won't take it. Why? Because it's part of Obamacare.
JOHN HAWKINS: We've got a very conservative legislature which would like to prioritize tax relief over meeting some of the infrastructure needs of the state.
GOODWYN: John Hawkins is the vice president with the Texas Hospital Association. Hawkins says the state's hospitals lost more than $5 billion last year, providing uncompensated care for the more than 6 million Texans who don't have health insurance. The hospitals can't eat this kind of loss, so they shift some of that cost to their insured patients. Hawkins says Texans pay the second-highest insurance premiums in the nation.
HAWKINS: Probably $1,800 of family premium each year can be attributable to the cost of the uninsured in the state.
GOODWYN: It's fair to say that Texas Republicans are not big on entitlements. Nevertheless, $100 billion is a lot of money to turn your back on, especially when it could buy health insurance for a million to a million and a half working poor people.
JOHN ZERWAS: These are typically childless adults and most commonly adult males, you know, that fall into this category. They're working people, but you would probably describe them as the working poor.
GOODWYN: Republican Representative John Zerwas is himself a physician who represents a conservative suburb southwest of Houston. Like all his Republican colleagues in the Texas House and Senate, Zerwas opposes the Affordable Care Act. Nevertheless, he's trying to find a way for Texas to take the Medicaid expansion money by reclassifying it as something else, like a federal block grant or some other mechanism - something that's not called Obamacare.
ZERWAS: Getting those dollars back to the state to help support a state federal health care program for the uninsured, indigent population - that is not a place my colleagues like to go. I try to argue that when we look at where those monies are invested and how that translates into job growth and economic growth, the health care sector's a very good place for that investment to be made.
GOODWYN: Zerwas is referencing studies by Texas economists that predict if Texas would go ahead and participate in Medicaid expansion, the $100 billion infusion into the state's economy would generate billions of dollars in new economic activity. The reports predict the investment would produce hundreds of thousands of new jobs each year, up to 3 million total over the next decade. But that's just the math, and some politically powerful people in Texas don't believe it.
JOHN DAVIDSON: Expanding government programs doesn't create jobs. The government can't create jobs. So it's fundamentally flawed from an economic point of view.
GOODWYN: John Davidson is the director for the Center for Health Care Policy at the conservative think tank the Texas Public Policy Foundation in Austin. The political language and public policy stands that are generated here often end up coming out of the mouths of the state's Republican leadership, and John Davidson and the Texas Public Policy Foundation not only say no to Obama's Medicaid expansion, they want the administration to give Texas more control over regular Medicaid so the state can toughen the standards.
DAVIDSON: Personal responsibility, work requirements, narrower benefits, penalizing inappropriate use of the ER - these kinds of things that we and other conservative groups wanted to bring into the Medicaid program to try to incentivize certain behaviors on the part of the patient.
GOODWYN: And this is precisely the position the new Texas governor, lieutenant governor and the Texas Senate have taken. So though economists say Medicaid expansion would be good for the economy, for Texas hospitals, for the state's taxpayers and buyers of health insurance, it's not up for discussion. Why? Because Republicans in the Texas House and Senate - who might be open to Medicaid expansion - fear if they do support it, it will earn them the wrath of Texas Tea Party Republicans. Representative Zerwas says he hears this a lot.
ZERWAS: Generally, the issue comes as, politically, how is this going to affect me at my next election? And anything that is seen to be taking advantage of a provision in the health care law is going to be seen as something that's propping-up Obamacare.
GOODWYN: Political districts in Texas are now so thoroughly gerrymandered and turnout so low that Tea Party voters can have outsized influence. Last election for example, more than a half-dozen Republican incumbents in the Texas House were beaten because they were deemed not conservative enough. So Medicaid expansion in Texas is dead, much to the frustration of the Texas Association of Business. But if Texas won't consider taking its money, other states will. A growing number of Republican legislators - Arkansas, Arizona, North Dakota and Montana have held their noses and voted to accept Medicaid expansion money. Utah, Florida and Alaska are discussing it. Wade Goodwyn, NPR News, Dallas.
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