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It’s the year 2022 and we’re still litigating the Affordable Care Act

Isn’t this horse dead yet?

A federal judge in Fort Worth agreed Wednesday with a group of Christian conservatives that Affordable Care Act requirements to cover HIV prevention drugs violate their religious freedom.

U.S. District Judge Reed O’Connor also agreed that aspects of the federal government’s system for deciding what preventive care is covered by the ACA violates the Constitution.

O’Connor’s ruling could threaten access to sexual and reproductive health care for more than 150 million working Americans who are on employer-sponsored health care plans. It is likely to be appealed by the federal government.

This lawsuit is the latest in a decade of legal challenges to the Affordable Care Act, many of which have run through O’Connor’s courtroom. In 2018, O’Connor ruled that the entirety of the ACA was unconstitutional, a decision that was struck down by the U.S. Supreme Court.

At issue in the class-action lawsuit is a 2020 mandate requiring health care plans to cover HIV prevention medication, known as PrEP, free of charge as preventive care.

In the suit, a group of self-described Christian business owners and employees in Texas argue that the preventive care mandates violate their constitutional right to religious freedom by requiring companies and policyholders to pay for coverage that conflicts with their faith and personal values.

The lawsuit was filed in 2020 by Austin attorney Jonathan Mitchell, the legal mind behind Texas’ civilly enforced six-week abortion ban. In the suit, Mitchell also challenges the entire framework through which the federal government decides what preventive services get covered.

O’Connor threw out several of Mitchell’s arguments but agreed that the U.S. Preventive Services Task Force’s system for deciding what health care services are required to be fully covered under the ACA violates the Appointments Clause of the U.S. Constitution.

“At a high level, this lawsuit is part of a larger pushback against the government’s ability to regulate,” said Allison Hoffman, a law professor at Penn Carey Law at the University of Pennsylvania. “And then also asking what happens when regulations and religion clash.”

[…]

The lawsuit specifically addresses PrEP, but O’Connor’s ruling, which addresses how the federal government can decide what preventive care is covered in employer health care plans, may end up having much more wide-reaching consequences, Hoffman said.

“We’re talking about vaccines, we’re talking about mammograms, we’re talking about basic preventative health care that was being fully covered,” she said. “This is opening the doors to things that the ACA tried to eliminate, in terms of health plans that got to pick and choose what of these services they fully covered.”

The American Medical Association, along with 60 leading medical organizations, issued a statement condemning the lawsuit.

“With an adverse ruling, patients would lose access to vital preventive health care services, such as screening for breast cancer, colorectal cancer, cervical cancer, heart disease, diabetes, preeclampsia, and hearing, as well as access to immunizations critical to maintaining a healthy population,” the organizations wrote.

While implementation has not been as universal as hoped, fully funded preventive care through the ACA has been shown to be largely effective at improving health outcomes, reducing health care spending and increasing uptake of these services.

It’s a familiar set of villains, including the hand-picked judge, making the same kind of tired arguments about how “Christians” deserve to be exempt from laws they don’t like, even at the expense of literally everyone else’s health. And while SCOTUS has regularly batted aside these malicious lawsuits, I don’t have any faith they’ll do the same this time. TPM, Reform Austin, and The 19th have more.

At least you’re (probably) not giving birth in West Texas

This is a long story about the lack of prenatal and obstetric care in West Texas. It’s mostly set in Alpine, Presidio, and Big Bend, which are the “big cities” in the area that actually have doctors and medical facilities in them. The one hospital in the area is in Big Bend, and its labor and delivery unit is now closed much of the time, for a variety of reasons. This is a small taste of what it’s like to be pregnant in this part of the state.

Big Bend is the only hospital in a 12,000-square-mile area that delivers babies. If Billings’s patient goes into labor when the maternity ward is closed, she’ll have to make a difficult choice. She can drive to the next nearest hospital, in Fort Stockton, yet another hour away. Or, if her labor is too far along and she’s unlikely to make it, she can deliver in Big Bend’s emergency room. But the ER doesn’t have a fetal heart monitor or nurses who know how to use one. It also doesn’t keep patients overnight. When a woman gives birth there, she’s either transferred to Fort Stockton—enduring the long drive after having just had a baby—or discharged and sent home.

This situation is stressful and dangerous for pregnant women. Uterine hemorrhages, postpartum preeclampsia (a potentially deadly spike in blood pressure), and other life-threatening complications are most likely to occur in the first few days after childbirth. This is why hospitals usually keep new mothers under observation for 24 hours to 48 hours. “This is not the ‘standard of care’ that women should receive,” Billings says. “You’re not supposed to discharge patients and leave it up to chance.”

Big Bend doesn’t really have a choice. In the past two years, almost all its labor and delivery nurses quit. The hospital has tried to replace them, but the national nursing shortage caused by the pandemic has made that impossible. When Big Bend is too short-staffed to deliver a baby safely, its labor and delivery unit has to close.

[…]

Medicaid pays for 42 percent of all hospital births, but it doesn’t reimburse hospitals for the full cost of care. (In most states it pays between 50 cents and 70 cents on the dollar, which means a hospital loses money when it cares for someone on the program.) To offset its losses, a hospital often charges its privately insured patients significantly higher fees. But if it’s in a poor neighborhood and doesn’t have enough privately insured patients, it can’t recoup the money. So most pre-pandemic maternity ward closures were in low-income areas and disproportionately affected pregnant women of color. Pandemic-related nursing shortages have only made the situation worse. Nowhere is this problem more evident than in Texas.

The state is the national leader in maternity ward closures. In the past decade, more than twenty rural hospitals have stopped delivering babies. More than half the state’s rural counties don’t even have a gynecologist. Texas has some of the lowest income eligibility limits for Medicaid and has declined to expand them, as allowed by the Affordable Care Act. (Childless adults don’t qualify for the program unless they’re disabled.) As a result, more than 18 percent of Texans don’t have health insurance, the highest percentage of uninsured residents in the U.S. Income eligibility limits jump for pregnant women—$36,200 for single mothers, $45,600 for married ones—but the application process takes at least a month. According to the March of Dimes, a fifth of all pregnant women in Texas don’t get prenatal care until they’re five months along. In other words, when a poor woman gets pregnant in Texas, it’s hard for her to find a doctor or even a hospital.

“What we’re seeing in terms of health outcomes, it’s not good,” says John Henderson, chief executive officer and president of the Texas Organization of Rural & Community Hospitals. “We have lower birth weights, more preterm births. When it comes to caring for pregnant women and their babies, Texas does not compare favorably to other states.”

Like I said, this is a long story and it’s worth your time to read. I’m old enough to remember when tort “reform”, in particular putting a cap on damage awards that can be given in medical malpractice lawsuits, was supposed to usher in a new era of doctor abundance in Texas. I don’t think that has worked out in the way we were promised. Towards the end, one of the doctors the author spoke to for the story notes that since abortion was already impossible to get in their region, the new state ban on abortion likely won’t result in more babies being born there. These docs will still deal with miscarriages and ectopic pregnancies and other life-threatening situations – they tell some amazing stories – despite the threat to their own safety. Click over and read on for more.

There’s a lot of anti-LGBTQ litigation out there

Sorry to be the bearer of bad news, but this is where we are.

In the wake of the toppling of Roe v. Wade and with Justice Clarence Thomas urging the U.S. Supreme Court to revisit rulings on gay sex and marriage, Texas is the stage for several lawsuits dealing with LGBT rights.

Right now, a half dozen cases on everything from insurance coverage for HIV prevention to employment discrimination and same-sex marriage are wending their way through state and federal courts here. Their outcomes could radically alter rights for lesbian, gay, bisexual and transgender people in Texas and across the country.

The lawsuits all have one thing in common: former Texas solicitor general Jonathan Mitchell.

Best known as the man behind the state law that allows Texans to file civil lawsuits against people who help pregnant people get abortions, Mitchell opened up a law firm in Austin four years ago with the goal of systematically dismantling decades of court rulings he believes depart from the U.S. Constitution.

The Dallas Morning News is tracking six of his cases that originated in Texas and deal with LGBT rights. Here’s a summary of each case.

Gay Marriage

Dianne Hensley vs. State Commission on Judicial Conduct (Third Court of Appeals)
Brian Keith Umphress vs. David Hall, et al. (Northern District of Texas)

Summary: Both of these cases were brought by Texas officials with the authority to perform weddings but who do not want to offer marriages to same-sex couples because they say it violates their religious beliefs.

Insurance Mandates

John Kelley, et al., vs. Xavier Becerra (Northern District of Texas)

Summary: Plaintiffs in this federal lawsuit argue that insurers or self-insured employers should not have to cover certain kinds of preventive medical care because that would force them “to underwrite coverage that violates their religious beliefs.” The suit also targets the Affordable Care Act’s mechanisms for deciding which care private insurers must cover, arguing it gives the federal agencies and other unelected bodies undue control over decisions that should remain with Congress.

Employment Discrimination

Braidwood Management v. EEOC (Fifth Circuit Court of Appeals)

Summary: The case in federal court, filed on behalf of Hotze’s Braidwood Management and the Keller-based Bear Creek Bible Church, argues that religious employers should be able to hire and fire workers based on their sexuality and gender identity.

LGBT Library Books

Leila Green Little, et al. vs. Llano County (Western District of Texas)

Summary: The federal lawsuit, filed by citizens of Llano County, argues their First and Fourteenth Amendment rights were violated when local leaders pulled certain titles from the library’s child and teen sections that they deemed “pornographic.”

‘Save Chick-fil-A’

Patrick Von Dohlen, et al. vs. city of San Antonio (438th District Court in Bexar County)

Summary: This state lawsuit, filed by a handful of would-be Chick-fil-A customers, argues San Antonio violated a state’s so-called Save Chick-fil-A law by booting the fast food chain Chick-fil-A from the local airport based on its charitable donations to Christian groups that oppose LGBT rights. The law, which Gov. Greg Abbott signed in 2019, prohibits governmental entities from taking “adverse actions” against a business or person for their contributions to or memberships in religious organizations, and allows citizens to sue over apparent violations.

Some of these I’ve written about before, but you get the idea on them all. The plan of course is to get one or more of these cases to SCOTUS to have a shot at overturning Windsor and/or Obergefell. I assume that the recent bill passed by the House to offer federal protections to same sex marriage would have some effect, but it’s hard to say how much and I’d rather not find out. The underlying philosophy is that some people, namely Jonathan Mitchell and his fellow travelers, have more rights and legal protections than anyone else. I’m sure you can see why they’re aiming to take this path to achieve those ends. Anyway, I don’t know how this ends but I do know we can’t be sitting idly waiting for it. It would be lovely if we had a Senate that was up to doing something not only about the overall erosion of civil rights but also the radical nature of the federal judiciary these days. Maybe next year, if we’re lucky and can make it till then.

The empty “mental health” promise

What’s going on in Uvalde these days.

Days after the May 24 shooting, Texas Gov. Greg Abbott promised an “abundance of mental health services” to help “anyone in the community who needs it … the totality of anyone who lives in this community.” He said the services would be free. “We just want you to ask for them,” he said, before giving out the 24/7 hotline number — 888-690-0799.

That’s a tall order for a community in an area with a shortage of mental health resources, in a state that ranks last for overall access to mental health care, according to a 2022 State of Mental Health in America report.

Mental health organizations are assembling a collection of services to assist those who seek help in Uvalde. But there have been hiccups and hitches along the way.

There is worry that what’s being offered is not coming together as fast or efficiently as it could be, and that it’s being assembled without keeping in mind the community it serves: Many residents are lower income, and some may have difficulties with transportation, or are mainly Hispanic. Many are not accustomed to seeking out therapy, or are distrustful of who is providing it.

Quintanilla-Taylor didn’t believe many would use the mental health services and had doubts about their long term availability.

“It’s not going be prevalent. … I don’t trust the resources, and that’s coming from an educated person,” said Quintanilla-Taylor, who’s pursuing a doctorate in philosophy and specializing in organizational leadership at the University of Texas at San Antonio.

[…]

Uvalde County Commissioners, the countywide government body, voted Thursday to purchase a building to create the Uvalde Together Resiliency Center to serve as a hub for long-term services, such as crisis counseling and behavioral health care for survivors.

Abbott set aside $5 million in funding for the center, which has been operating at the county fairgrounds.

Texas Sen. Roland Gutierrez, whose vast district includes Uvalde, said the community needs continuity of care and rather than create a new building the state could invest in the existing local community health clinic, in operation for 40 years and already serving 11,000 uninsured Uvalde residents.

“These are people who have behavioral health on the ground. They actually have the one psychiatrist in Uvalde right here,” Gutierrez said Friday referring to the clinic. “We needed to have the budget so that we can bring in therapists, which we would have been able to do with that money. Instead, they’re starting from whole cloth this promised center you’re going to have the district attorney run?”

Gutierrez, who has shifted a district office from Eagle Pass to Uvalde, said he met with 11 families whose children survived the shootings and were either wounded or sent to the hospital.

“What the families have been telling me is they don’t want to see one therapist one week, a different one the following and another one yet maybe the next week,” he said. “So, they are having trouble with appointments, with continuity and that’s very, very important, especially when we are talking about young children.”

Gutierrez said he sent a letter to Abbott asking for $2 million for the existing free community clinic to provide crisis care but has not heard back.

I’ve discussed this before, and this is another illustration of the problem. We can count on hearing two things whenever there’s a mass shooting in Texas. One is the usual blather about guns and why restricting access to guns isn’t the answer. The other is a rush to talk about mental health, both as a means of explaining the shooter’s actions and now more regularly as an alternate mitigation for gun violence that doesn’t restrict access to guns. It was a big component of the Cornyn bill, and may have been a key to its passage since there’s no question that more mental health services and funding for those services are badly needed. I’m happy to see that happen, it’s just that we all know this is only one piece of a much larger puzzle.

From the state perspective, any and all talk of mental health and services for mental health that comes from our state leaders is guaranteed to be little more than hot air. We have the longstanding issue of healthcare in general being out of reach for too many people because of lack of insurance, and the continued resistance to expanding Medicaid, which would be the single biggest step forward in that regard. We have the also longstanding issue of healthcare in rural areas, from hospitals closing for lack of funds to scarcity of doctors in rural areas, a problem that was supposed to have been solved by the passage of the tort “reform” constitutional amendment nearly 20 years ago. More recently there was Abbott’s redirection of over $200 million in funds from the Department of Health and Human Services to his never-ending border boondoggle. At every opportunity, the Republican leadership has made it clear that they don’t care about funding healthcare in general, and mental health services in particular. But they are willing to use the promise of mental health services as a distraction when the next crisis hits. That’s where we are now, and where we will be again if nothing changes.

Maybe this is finally the end of that zombie same sex employee lawsuit

I dream a dream.

The Texas Supreme Court has declined to consider a challenge aimed at preventing the city of Houston from offering benefits to employees’ same-sex spouses.

The ruling is the latest blow to two Houston residents’ prolonged fight against a policy they consider an illegal use of taxpayer dollars.

Plaintiffs Jack Pidgeon and Larry Hicks have waged a legal battle against the policy since 2013, when the city, then led by former Mayor Annise Parker, granted government benefits to municipal employees’ same-sex spouses. Parker was the city’s first openly gay mayor.

On Friday, the state Supreme Court declined to review the pair’s case against the city, which originated nine years ago and has failed to find footing even in the conservative-leaning Texas judiciary.

[…]

Of the pair’s decade-long campaign to overturn her administration’s policy, Parker said Tuesday she hoped the court’s decision would quash future challenges.

“I didn’t do it to make a point,” Parker said of the policy. “I did it to be fair to all married city employees. Marriage should be marriage. Equal should be equal.”

See here and here for the previous updates. These guys and their stooge lawyer Jared Woodfill have more than proven that they really really hate gay people, but surely even this kind of rabid bigotry has its limits. The bell has rung, the lights are out, the doors have closed, and Elvis has left the building. Go find a less destructive hobby, fellas. I’ve heard gardening is nice.

“Silver loading”

I did not know this.

Sen. Nathan Johnson

The latest state to take strong action to improve affordability in its ACA marketplace is … Texas?

[…]

But let me explain some background details first. Below 200 percent of the federal poverty level (that is, $25,760 for an individual or $53,000 for a family of four in 2022), benchmark silver plans on the exchanges are both very cheap—costing nothing up to 150 percent of FPL, and just 0 to 2 percent of income between 150 and 200 percent of FPL—and further enhanced with cost-sharing reduction (CSR) subsidies, which make them roughly equivalent to platinum plans.

At incomes over 200 percent of FPL, however, the marketplace’s offerings will be greatly improved by Texas’s new state-enforced pricing regime.

More than two-thirds of Texas enrollees in ACA plans (69 percent) have incomes below 200 percent of FPL. But thanks to the more generous subsidies created last March through 2022 by the American Rescue Plan—which removed the prior income cap on subsidy eligibility—2022 enrollment in Texas grew fastest at higher incomes. Enrollment at incomes over 200 percent of FPL rose 57 percent, to 566,000. Those enrollees stand to gain most by the change in law. At higher incomes, silver plan deductibles average over $4,500 (though many services are not subject to the deductible). Gold plan deductibles, by contrast, average $1,600.

So if gold plans have lower deductibles, why should they be cheaper than silver plans? As mentioned above, for low-income enrollees, CSR raises the value of silver plans (by reducing out-of-pocket costs) to a roughly platinum level, with average deductibles under $200 for the lowest-income enrollees and $800 at the next level (150 to 200 percent of FPL). In Texas, 89 percent of silver plan enrollees have incomes below 200 percent of FPL, and so the average silver plan sold in the state really does match a platinum-level “actuarial value,” or the percentage of the average enrollee’s costs the plan is designed to cover.

During the Obama administration, the federal government reimbursed insurers directly for providing CSR, and silver plans were priced as if no CSR were attached. When Trump abruptly cut off those direct CSR payments in October 2017, however, almost all state regulators responded by allowing or encouraging insurers to price the value of CSR directly into silver plans—a process that came to be known as “silver loading.”

Here’s where the quirk comes in. Because ACA premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (specifically, the second-cheapest silver plan), higher silver premiums mean higher premium subsidies across all plans—and discounts for subsidized buyers in bronze and gold plans.

But silver loading has stopped halfway. As the author of the “focused rate review” bill, Texas state Sen. Nathan Johnson, points out in the bill analysis, “insurers have not approached silver loading in a uniform manner. The resulting misalignment of premiums has caused Texans to lose out on hundreds of millions of dollars in federal marketplace subsidies, making coverage less affordable.”

Why? Since a majority of marketplace enrollees have incomes below 200 percent of FPL, silver is still the most popular metal level, and so when insurers are in a competitive market, the price of a silver plan gets competed down (though when there is just one insurer, or a dominant insurer, they can and do take advantage of the rules, often to create huge discounts).* In most of the country, gold plans are still priced well above silver, and bronze plan discounts are not as big as analysts (including the Congressional Budget Office) expected them to be when anticipating Trump’s cutoff of direct payments for CSR. A handful of states, however, have effectively ordered insurers to fully price the value of CSR into silver plans.

With Johnson’s bill, Texas joined them. S.B. 1296 directed the Department of Insurance to, as the bill analysis phrases it, “focus its rate review in a manner that uniformly maximizes the benefits of silver loading, making coverage more affordable.”

On March 28, the Texas Department of Insurance issued a proposed rule to flesh out that legal directive. The rule directs insurers to use a “CSR pricing factor” of 1.35—that is, to price silver plans at 1.35 times what they would charge if there were no CSR. That rule effectively prices silver plans close to a platinum level. Gold plans are generally priced at about 1.2 times the cost of silver with no CSR.

The CSR pricing factor is slightly below the level implemented in 2022 in New Mexico, 1.44, which led to the lowest-cost gold plan in each rating area being priced an average of 11 percent below the benchmark silver plan. In New Mexico markets, several gold plans are priced below benchmark. Accordingly, in 2022, 69.5 percent of New Mexico enrollees with incomes above 200 percent of the federal poverty level chose gold plans, compared to 24.4 percent of Texas enrollees above the same threshold.

The rest of the story is about how momentum for this idea came from a couple of conservative actuaries plus a former aide to Greg Abbott now working at the non-partisan think tank Texas 2036, who were able to get Republican buy-in for the idea, and the House sponsor for Sen. Johnson’s bill, Rep. Tom Oliverson. The details are wonky and I definitely don’t understand all of them, but the bottom line is that in Texas another 200,000 people now have access to affordable heal insurance. And the guy that wrote the bill to make it happen is the guy that escorted the vile Don Huffines out of the Senate in 2018. Not too shabby. Charles Gaba, who brings even more wonkiness, has more.

Time once again for Texas hospitals to struggle financially

I feel their pain, but…

More than $3 billion in federal money has flowed to Texas health care providers in recent months to help pay for COVID-19 treatments, tests and vaccines for patients without health insurance, according to national health officials.

Of that, a tiny fraction — some $2.2 million — went to the local independent hospital in rural Titus County for treating patients during wave after overwhelming wave of the devastating virus in an area where 1 in 3 residents are uninsured.

But the 174-bed Titus Regional Medical Center in northeast Texas needed every penny it could get as it struggled to cover the sudden, skyrocketing expenses of the pandemic: paying staff competitive wages to keep them on the job, keeping up with federal safety rules and managing record-breaking numbers of patients pouring into in the intensive care unit from a 150-mile radius, said CEO Terry Scoggin.

Now, after sending some $19 billion to hospitals and other health care providers nationwide, the fund known as the Health Resources and Services Administration COVID-19 Uninsured Program — created to help hospitals like Titus Regional pay for the care of uninsured COVID patients — has dried up.

While the halting of funds comes as Texas has seen infection numbers fall dramatically, the virus is still largely uncontrolled, causing surges and lockdowns in other countries. In the past, those surges abroad have always occurred before new cases rise again here in the United States, including Texas, which has more uninsured residents than any other state.

The failure to renew the program in time to continue reimbursing providers means that hospitals, clinics, private practices and others that don’t get public health funding from the state will have to “eat the cost” if they don’t charge for COVID-related services, Scoggin said.

“It’s a huge issue for us because we have so many adults who are uninsured,” Scoggin said. “And so it was kind of a kick in the gut for us when they shut that program off because I thought it was a good use of funds for the COVID piece.”

Refusing care to those patients who can’t pay is not an option, legally or morally, he said.

“We can’t turn people away, so we’re still going to pay for it,” Scoggin said. “It just shifted the expense of the uninsured from federal funds to individual hospitals.”

We’ve discussed the financial straits of rural hospitals in Texas before. I am once again pointing out that the locale in which this story is sited, Titus County, is yet another place that votes heavily Republican – Trump and Cornyn in 2020 and Abbott and Cruz in 2018 all topped 70% of the vote. I continue to have empathy for the employees of these hospitals, who for all I know may be habitually voting for politicians whose stated policy preferences are to help them. But I’m also saying it would be nice for these stories to include that easy-to-look-up data, because the simple fact is that if the likes of Greg Abbott or John Cornyn wanted to help the Titus Regional Medical Center, by expanding Medicaid or helping to push through more federal funds for the care of uninsured COVID payments, they could absolutely do so. The dots are just sitting there, waiting to be connected. We should do that.

Texas gets its Medicaid 1115 waiver back

Hrmph.

It’s constitutional – deal with it

A federal district judge on Friday temporarily reinstated a 10-year extension of a federal health care program that Texas uses to help pay for health care for uninsured Texans and is worth billions of dollars annually.

The agreement was set to expire next year after federal health officials in April rescinded the Trump-era extension to the 1115 waiver agreement — which Texas has had with the U.S. Centers for Medicare and Medicaid Services since 2011 and is up for review every few years — and ordered Texas to collect public input, as the agreement requires, while it renegotiates a new extension beyond its original October 2022 expiration date.

The decision did not stop the funding for the current waiver, which provides $3.87 billion in annual funding to partly offset free care provided by Texas hospitals to the uninsured, and to pay for innovative health care projects that serve low-income Texans, often for mental health services.

In his order on Friday, the U.S. District Judge J. Campbell Parker granted a preliminary injunction sought by Texas to block the federal government from rescinding the original Trump-era agreement. The decision removes the requirement, at least for now, for Texas to negotiate its deal with CMS if it wants 1115 funding beyond October 2022.

The decision by CMS was “likely unlawful” and resulted in “turmoil in the state’s Medicaid program,” in part because the state had already begun “reassigning staff, making plans, appropriating money, passing regulations, and engaging stakeholders to work towards implementing the necessary changes” allowed by the original deal, which was confirmed in January before it was rescinded by the Biden administration in April, Barker said in the order.

[…]

The 1115 waiver was meant to be temporary while Texas transitioned to an expanded Medicaid program under the Affordable Care Act of 2010, but that never happened because the U.S. Supreme Court ruled in 2012 that states couldn’t be forced to expand Medicaid.

Since then, the state has relied on the waiver for various programs to care for Texas’ uninsured, with Republican state leaders frequently leaning on it in their arguments against Medicaid expansion.

See here, here, and here for some background. I don’t know the technical details well enough to know if this is a reasonable decision on the merits or if Paxton once again found himself a super friendly judge. I’m not even sure if this means that the entire Trump-approved ten-year extension is back in play, or if there will be another opportunity for the Biden administration to force the issue, perhaps next year when the previous agreement was to expire. Perhaps if one of the alternate means of allowing/forcing Medicaid expansion is part of the reconciliation package, the issue can be revisited, or perhaps largely rendered moot. It does seem likely to me that Congress could change the terms of the 1115 waiver, as the issue here was over the executive action, I just don’t know who would be pushing that in the legislative process. All in all, a deeply unsatisfying state of affairs at this time.

An alternate route to Medicaid expansion

I’m okay with this.

Texas Democrats have tried for years to convince Republican state leaders to increase access to Medicaid. Now they think they have found a way to do it with or without their help.

U.S. Rep. Lloyd Doggett and lawmakers from 11 other GOP-led states introduced a measure this week that would give money directly to local governments that want to provide coverage for hundreds of thousands of low-income Texans who currently fall into what is known as the “coverage gap.”

The Cover Outstanding Vulnerable Expansion-eligible Residents (COVER) Now Act would allow counties to apply for the money directly with the federal government, and it would prohibit state leaders from retaliating against them if they do.

Doggett said his aim is to avoid conflict with Republicans.

“You have your ideological objections to Medicaid expansion — I don’t agree, but I accept your position,” he said. “At least let those local leaders who want to take advantage of this and who recognize both the health and economic advantages of doing it, at least let them do that, and walk away and see how it works.”

[…]

Doggett estimated that if Houston, San Antonio and Dallas alone signed on to the proposal, half of the state’s eligible uninsured population would gain access. All three cities are led by Democrats and have pushed for Medicaid expansion.

Statewide, more than 1.2 million Texans would be eligible for Medicaid if state officials were to expand the program, according to a study by the The Bush School of Government and Public Service at Texas A&M University

More than two million people are thought to be in the coverage gap today, meaning they make too much to qualify for traditional Medicaid but not enough to qualify for subsidized insurance under the Affordable Care Act. Most are people of color, and the biggest group is in Texas, a state that has long had the highest uninsured rate in the country.

Anne Dunkelberg, a policy analyst for the left-leaning think tank Every Texan, said the new legislation would also increase funding to state health officials for any added administrative costs.

“Congressman Doggett’s bill really recognizes how entrenched the ultra conservative opposition to expansion is in Texas and the need to really connect the dots about what it’s going to take for us to get possibly a million and a half uninsured adults — the vast majority of them working — coverage,” she said.

I don’t know if the reconciliation process that Rep. Doggett envisions for this would be part of the infrastructure package or as a later budget bill, but either way there will be opportunities. I think the odds of it avoiding conflict with Republicans is basically zero, so the more important consideration is how well-defended it will be from Republican attempts to screw with it or obstruct it. We have seen too many examples in recent times of the state having control over federal money intended for local governments that have resulted in all kinds of bad outcomes, from the delays in appropriating COVID relief to the GLO’s screw job against Houston and Harris County. Cut the state completely out of it, and then hope it’s too difficult for a future Republican Congress or President to mess with it.

Assuming this does go through, I would expect quite a few more counties than those three cited would jump at this. Travis, El Paso, Fort Bend, Cameron, Webb, some other South Texas counties, probably Hays, would certainly take advantage. Nueces, Tarrant, and Williamson would be interesting to watch, and I bet this would add some spice to county races in Collin and Denton and maybe Brazoria. It’s possible that some Republican counties, especially ones with hospitals teetering on the brink of financial disaster, might decide to put aside politics and grab the money, as several Republican states have done. I could definitely see this making a huge dent in the uninsured population, and providing some fodder for the 2022 elections as well. It’s mostly a question of how durable it is, and that’s something that Rep. Doggett can work on. Here’s hoping.

SCOTUS upholds Obamacare again

Another Ken Paxton failure, for which we should be grateful and also really pissed off.

It’s constitutional – deal with it

The U.S. Supreme Court struck down a Texas-led legal challenge to the Affordable Care Act on Thursday, saying the plaintiffs in the 2018 lawsuit are not being harmed by the law’s unenforceable individual mandate provision — a central argument of the challenge.

The 7-2 ruling did not include an official opinion on whether the ACA, a sweeping piece of health care legislation commonly known as Obamacare, was constitutional.

Instead, the court focused its rejection of the lawsuit — brought by 18 states and two individuals — on its opinion that the plaintiffs didn’t have any standing to sue over the individual mandate, which requires Americans to purchase health insurance and had originally included a financial penalty for those who chose to remain uninsured. That penalty was zeroed out in a later Republican tax bill.

“A plaintiff has standing only if he can ‘allege personal injury fairly traceable to the defendant’s allegedly unlawful conduct and likely to be redressed by the requested relief,’” the opinion reads. “Their problem lies in the fact that the statutory provision, while it tells them to obtain that coverage, has no means of enforcement.”

It was the third time the high court defended the ACA against legal challenges, including a 2012 ruling that the initial mandate — and its tax penalty for noncompliance — was constitutional because it was within Congress’ taxing power.

Texas Attorney General Ken Paxton, a Republican, set out in 2018 to achieve through the courts what his party tried and failed for years to achieve in legislation: the end of President Barack Obama’s landmark health law.

And he failed, because Ken Paxton is a failure in life and in law, and we really need to dump his ass. I recommend you read Mark Joseph Stern’s analysis, which explains why this was a strong ruling. The next step is to elect a better class of Attorney General, here and elsewhere. The Chron has more.

Paxton sues over revocation of Medicaid 1115 waiver

Someone please explain to me if this has any merit.

Best mugshot ever

Texas Attorney General Ken Paxton sued the Biden administration Friday to reinstate an eight-year extension to a federal health care funding agreement, worth billions of dollars annually and set to expire next year, that the state uses to help pay for health care for uninsured Texans.

Last month, federal health officials rescinded the Trump-era extension to the 1115 waiver agreement — which Texas has had with the U.S. Centers for Medicare and Medicaid Services since 2011 and is up for review every few years — and ordered Texas to collect public input, as the agreement requires, while it renegotiates a new extension beyond its current October 2022 expiration date.

The decision did not stop the funding in the current waiver, which will continue to provide $3.87 billion in annual funding for 2021 and 2022 to partly offset free care provided by Texas hospitals to the uninsured, and to pay for innovative health care projects that serve low-income Texans, often for mental health services.

The extension, granted in the waning days of Donald Trump’s presidency, would have continued hospital reimbursements until September 2030 but allowed the innovation fund to expire.

In his lawsuit filed Friday, Paxton said the decision was a political move by President Joe Biden that was meant to force Texas to expand its Medicaid program under the Affordable Care Act of 2010.

Forcing Texas back to the drawing board on negotiations over the extension, which Paxton said would have amounted to $30 billion in federal funding through 2030, threatens to “destabilize” the programs the state funds through the waiver, he said.

[…]

The 1115 waiver was originally granted to Texas as a temporary funding bridge while the state developed its plan to expand its Medicaid program, but the U.S. Supreme Court ruled in 2012 that the ACA could not require states to do so — and Texas has since leaned on the 1115 waiver to help pay for care for the uninsured.

Supporters of Medicaid expansion have said that the state should utilize both 1115 waiver funding and expanded Medicaid eligibility, and have expressed confidence that the state would be able to negotiate the extension — with the required public input — before it expires.

“We have an attorney general and other state leaders who have made crystal clear the last few months and last few years that they have little interest in health care for working Texans — although they do have an obsession with filing lawsuits against the White House,” said Patrick Bresette, executive director of Children’s Defense Fund-Texas. “This misguided lawsuit is the cherry on top of a legislative session in which state leaders shot down all attempts to give an affordable health insurance option to janitors, cooks, grocery store clerks, and other Texans.”

“This would be a disaster for our state, and yet President Biden seems intent on thrusting his bloated model of government on everyone — including Texas,” he said in a statement Friday.

See here and here for some background, and here for a reminder that the Republicans have once again passed on the opportunity to fully expand Medicaid and make this issue moot. Let’s put aside the irony of a guy who is the lead attorney on a still-active case that would entirely kill the Affordable Care Act if he wins suing to keep federal funds flowing into Texas and ask the key question: This is a federal program, which requires federal approval. Doesn’t that mean that the federal government has some discretion here? If one accepts the premise that this move by the feds was purely capricious and driven by partisan motives, then sure, a lawsuit would be an appropriate remedy. On the other hand, if the feds reasonably believe that the extension, granted in the waning days of a President that gave little care to details and openly favored Republican states, was done in error, well, don’t they have the authority to correct that? I’m asking because I have no idea what the fine points of the law are here, and I have no reason to believe anything Ken Paxton says. That by itself doesn’t mean that the law couldn’t be on his side, though. I welcome any informed feedback on this. The Chron has more.

Zombie same sex employee lawsuit denied again

Shuffling along like the undead flesh eater that it is.

A Texas appellate court struck a challenge Thursday to Houston’s policy giving same-sex spouses of city employees the same benefits as different-sex spouses, saying that the city was immune from the case and that three major U.S. Supreme Courtrulings barred the claims.

A split Fourteenth Court of Appeals panel affirmed a state trial court’s February 2019 ruling against Jack Pidgeon and Larry Hicks, who challenged the benefits policy in an October 2014 suit.

“Because appellants’ attempt to prevent the city from offering employment benefits to married same-sex couples on the same terms and conditions as married different-sex couples cannot be reconciled with the requirements of the U.S. Constitution, we reject it,” Justice Margaret Poissant said in an opinion for the panel.

Mayor Sylvester Turner is not liable for the plaintiffs’ ultra vires claim, a claim used to target government officials for acting beyond their authority, because the 2013 directive issued by his predecessor was discretionary, the panel found.

The plaintiffs had even conceded that point when they argued the mayor and other officials spurned state marriage law “because it conflicts with their personal beliefs of what the U.S. Constitution or federal law requires,” the panel noted.

Further, Houston didn’t waive the immunity it typically has in ultra vires claims, according to the opinion. For a city to be a party to such a suit, the case must challenge a statute or ordinance, but the plaintiffs instead alleged violations of state law.

The plaintiffs also failed to establish that the directive was made without legal authority, according to the opinion.

Justice Poissant said the plaintiffs were wrongly trying to relitigate the U.S. Supreme Court’s 2015 ruling in Obergefell v. Hodges , which legalized same-sex marriage and made the Texas state laws at issue unconstitutional.

The panel also cited the high court’s 2017 ruling in Pavan v. Smith , which allowed same-sex parents the right to be listed on their children’s birth certificates, and its 2019 decision in Bostock v. Clayton County , which protected transgender individuals from discrimination.

The panel further denied the plaintiffs’ request for an injunction barring the city policy, saying their claim that the city used their tax dollars to “subsidize homosexual relationship,” which they believe is “immoral and sinful,” didn’t demonstrate imminent harm.

Justice Randy Wilson penned a partial dissent, saying the rest of the panel took the issue too far.

The trial court, Wilson said, had “paradoxically” dismissed the claims for lack of jurisdiction while essentially granting summary judgment on the merits. The appellate court should have addressed only the former and simply vacated the latter, he said.

See here for the previous update, and for the case information, including the opinion and concurrence and dissent from Justice Wilson. The original lawsuit was filed in 2013, for those keeping score at home. How much do you have to hate gay people to continue to pursue this eight years later? Jared Woodfill is their lawyer, if that helps you answer that question. Let us hope there is no further news to note on this.

Today is not the day we expand Medicaid

Tomorrow isn’t looking so good either.

It’s constitutional – deal with it

The Texas House on Thursday rejected an attempt to direct the governor and state health officials to use billions in federal dollars to expand health care coverage for uninsured Texans, including working poor who earn too much to qualify for Medicaid but too little to afford their own health insurance.

On a vote of 80-68, lawmakers voted down the proposal, which was floated as a two-page amendment to the state budget on Thursday.

The debate, which was highly anticipated by advocates of expanding coverage for uninsured Texans, was expected to be heated and drawn out. It lasted less than 20 minutes.

[…]

State Rep. Garnet Coleman, a Houston Democrat who sponsored the amendment, said it wouldn’t force the state to expand traditional Medicaid but would direct Abbott and the Texas Health and Human Services Commission to negotiate a federal funding agreement, known as a 1115 demonstration waiver, to create a plan that would cover more uninsured Texans, including those who would qualify for coverage under a traditional Medicaid expansion plan.

The resulting plan could have been a traditional expansion of Medicaid to cover adults who earn up to a certain amount, or a “look-alike” that combines state and federal funds to create a state program that accomplishes a similar goal, Coleman said.

Such state-crafted plans have been passed in several states, mainly conservative states like Indiana and Ohio.

“I would like for us to expand traditional Medicaid in the optional way that the ACA says you can do it,” Coleman said on the House floor. “But we can’t do that. And we know that … That is not what this amendment does.”

Rep. Richard Peña Raymond, D-Laredo, said the idea “puts Texas in the driver’s seat, and really Gov. Abbott in the driver’s seat” instead of forcing their hand or pushing through a program unpopular with conservatives.

But Republican state Rep. Giovanni Capriglione, the only House member to speak against the bill during Thursday’s debate, said that creating a new health care program — Medicaid or otherwise — is far too complicated an endeavor to tackle in a two-page amendment and cautioned that it in fact looked like a way to expand Medicaid without a public hearing or extended floor debate.

“This topic is incredibly important, it’s complex, and frankly, it’s not appropriately handled in this amendment,” Capriglione said.

House Democrats, a handful of Republicans, and health care advocates, as well as nearly 200 groups and community leaders across Texas, still have some hope for House Bill 3871 by state Rep. Julie Johnson, D-Carrollton. That bill creates the “Live Well Texas” plan that uses a 1115 waiver to capture the federal dollars and expand Medicaid eligibility, and it includes incentives for people to continue working as well as increases in Medicaid reimbursements to attract more doctors to the program.

The bill has 76 House sponsors, nine of whom are Republicans, giving it enough support to pass the House. But it has been stuck in the GOP-led House Human Services Committee since March, waiting on a hearing that becomes increasingly less likely as the Texas Legislature barrels toward its final days at the end of May.

Only one of the Republican sponsors of HB 3871 voted for the Coleman amendment.

See here and here for the background. In a vacuum, I can accept Rep. Capriglione’s explanation for why this was the wrong vehicle to handle a complex health care topic, but given that the Lege has refused to consider Medicaid expansion for a decade, and as Rep. Coleman notes we’re only trying to do this the hard way because Republicans refuse to do it the easy way, I’m less sympathetic. Even if this amendment had been adopted, there would be no guarantee it would be in the final budget – as Scott Braddock notes, what matters is the conference committee. In theory, that means this could be revived there, but let’s just say one should not bet on that outcome. All respect to Reps. Coleman and Johnson, but we’ve seen this movie before, and I don’t expect it to end any differently this time around.

Medicaid expansion by any means necessary

Whatever it takes. But I’ll believe it when I see it, and I have a very hard time believing that the current cast of characters will do anything to make it happen.

It’s constitutional – deal with it

Texas Republicans have been swift to condemn the Biden administration for rescinding early approval of a multibillion dollar Medicaid program that would help fund emergency care for the state’s booming uninsured population through 2030.

Gov. Greg Abbott said the federal government was “deliberately betraying Texans.”

Attorney General Ken Paxton vowed to “use every legal tool available to regain the assistance Texans need.”

But the decision federal health officials announced Friday could end up being one of the biggest steps yet to extend government health coverage to low-income people in Texas since the Affordable Care Act, according to health advocates and political observers. That’s true even if it doesn’t spur immediate change.

“The Biden administration has all the cards here,” said Brandon Rottinghaus, who teaches political science at the University of Houston. “They aren’t playing nice anymore with health care expansion. They’ve got the money, so they have the leverage.”

Pressure is also coming from inside the state. On Tuesday, a group of more than 150 organizations, including chambers of commerce, trade associations and local officials signed a letter calling on lawmakers to “support increased health coverage for Texans.”

“We specifically support a coverage initiative that is bipartisan, funded through available federal dollars, structured to be neutral for the state’s budget, and designed to meet Texas’ specific needs, values and circumstances,” it said.

The letter notably did not include the Texas Hospital Association, which criticized Friday’s decision. It has supported expanded coverage in the past.

[…]

Health care advocates have been quick to downplay Friday’s announcement, saying there is still plenty of time for the state to apply again for the waiver before next year. Texas was originally approved for the extension as part of a flurry of eleventh-hour orders by Trump health officials. In doing so, it allowed the state to forgo the normal comment period.

“I think of it in terms of, Texas didn’t follow the rules, and now it’s being told to follow the rules,” said Elena Marks, president of Episcopal Health Foundation in Houston. “It’s not being told, ‘you can’t have an uncompensated care pool.’ In fact, we need an uncompensated care pool, we ought to have one. But we have to follow the rules.”

See here for the background. Rescinding the 1115 waiver extension and making Texas follow the process to re-apply for it is a shot across the bow, but a limited one. If Texas does re-apply correctly, that extension will almost certainly be granted, though perhaps for a shorter period of time or with more strings attached. The current position of the Texas Hospital Association, which is on the sharp end of the stick right now, gives Abbott et al some cover. And as the story notes, Abbott has a primary election coming up, and the very last thing he will want to do before he wins that is anything that will make it look like he capitulated to Joe Biden and the Democrats. Maybe something happens after that, but politically speaking the incentives are all wrong.

This Trib story from Wednesday afternoon appears to offer a bit of hope, but don’t be fooled into thinking it’s more than that.

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.

[…]

“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.”

[…]

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.

It’s nice that there are 76 votes for a bill that hasn’t gotten a hearing and would still have to get through the Senate and be signed by Greg Abbott, but it’s still vaporware for now. (Rep. Frank, the House Human Services Committee Chair, is not among the nine Republican co-authors.) The same old tired arguments against Medicaid expansion, by people who don’t like Medicaid but claim to want to “protect” it, continue to have sway. Honestly, about 95% of this story could have been written in 2019, or 2017, or 2015, or 2013. It’s a tale as old as time at this point. The urge among Republicans to stick it to Obamacare at all costs has not abated. I don’t see anything to suggest to me that something has changed in this dynamic. I will be delighted to be wrong, but until I am proven wrong I say it ain’t gonna happen until we elect enough Democrats to make it happen.

Now it really is time for Texas to expand Medicaid

Good for the Biden administration putting the pressure on.

It’s constitutional – deal with it

The Biden administration on Friday rescinded changes to a federal funding agreement, known as a 1115 waiver, that would have extended for 10 years Texas’ health care safety net for uninsured residents — teeing up a new round of negotiations before the existing waiver expires in 2022.

The Centers for Medicare and Medicaid Services said in a statement that it erred in exempting the state from the normal public notice process before granting an extension to the waiver in the waning days of the Trump administration.

The agency “has rescinded the extension approval, which corrects this oversight with as little impact as possible to the people of Texas, since the original demonstration remains intact through September 30, 2022,” it said in a statement.

The Washington Post, citing two federal health officials, said the decision was a bid to push Texas toward expanding Medicaid to cover more low-income adults, a move the state and eleven others have resisted.

The 1115 waiver reimburses hospitals for the “uncompensated care” they provide to patients without health insurance and pays for innovative health care projects that serve low-income Texans, often for mental health services. The extension — worth billions of dollars a year — would have continued hospital reimbursements until September 2030, but allowed the innovation fund to expire this year.

The earlier waiver is still in effect, and federal authorities “stand ready to work with the state” if it wishes to extend it beyond next year, according to a Friday letter from the Centers for Medicare and Medicaid Services.

The state’s rationale to get out of the normal public notice process was that health care providers needed financial stability during the coronavirus pandemic, the letter said. But the state’s request did not “meaningfully explain why the extension request addressed the COVID-19 public health emergency or any other sudden emergency threat to human lives,” it said, in part.

See here for some background, and be sure to click on the NBC News link in that post. The 1115 waivers were used during the Trump years to approve the skinniest and stingiest Medicaid expansions possible, and in typical Trump fashion were done with zero regard for existing law or protocol. The Chron has some more details.

While the state’s current 1115 waiver won’t expire until September of next year, the reversal has immediate political impacts because the state Legislature has only weeks left in its session and won’t meet again until 2023. Without certainty over how much the federal government will contribute going forward, lawmakers risk leaving huge funding gaps for counties and hospitals.

Texas Republicans, who control the state government, have long campaigned against the Affordable Care Act and have declined to expand Medicaid under the act’s provisions as they seek to overturn the law in court. The state has depended on the waiver system as a cheaper alternative that nonetheless leaves millions of Texans uncovered.

Today, Texas has the highest uninsured rate in the country, with nearly 1 in 5 people lacking coverage. That results in staggering amounts of uncompensated emergency room visits each year, some of which is reimbursed by the 1115 waivers.

[…]

Earlier this year, a group of national health associations including the American Cancer Society, the American Heart Association and the American Lung Association called out the Trump administration’s expedited approval, saying there was plenty of time to hold a public comment period before the existing waiver expires next year.

“The waiver application was hundreds of pages, I don’t think it even mentioned COVID,” said Joan Alker, a Medicaid expert at Georgetown University who had signed on to the letter. “So it was a blatant disregard of what the exemption was supposed to be for.”

The Texas Hospital Association said it was disappointed with the decision.

“This action undermines the safety net and hospitals’ ability to protect people,” president Ted Shaw said in a statement. “It puts the state’s health at serious risk and creates unprecedented levels of uncertainty for an industry that is charged with saving lives.”

Others noted that the waiver was never meant to be a permanent solution.

“The waiver was always intended to serve as a temporary bridge until the state implemented an insurance option — with federal Medicaid expansion funds — for low-wage workers whose jobs don’t provide health coverage,” said Patrick Bressette, who directs the Children’s Defense Fund Texas. “Now would be a good time to have a real conversation about Medicaid expansion.”

Texas Sen. Nathan Johnson, a Democrat from Dallas who authored an expansion bill that has some Republican support, said the state should immediately reapply for the waiver while also taking up the expansion question.

“The story being told on the Republican side is Biden’s taking away resources from vulnerable people. False,” he said. “There’s still time left under the old waiver protections to do this the right way.”

I can understand why the Texas Hospital Association is unhappy with the decision, but the root of that is the failure to expand Medicaid, which has cost Texas hospitals tons of money. The waiver lets them get a few of those dollars back, but why settle for pennies when the dollars are available? Do the expansion, like we should have done a decade ago, and everyone is better off. It may be late in this session but there will need to be at least one special session for redistricting anyway, so the legislative calendar isn’t actually a problem. The choice and the benefits are clear, and the only reason not to is sheer partisan obstinance. Quit whining and get it done already.

A brief summary of what the next two years will be like

What will Republicans do without Trump?

“The Republican Party is at a crossroads like it’s never been before, and it’s gonna have to decide who it is,” said Corbin Casteel, a Texas GOP operative who was Trump’s Texas state director during the 2016 primary.

No one seems to be under the illusion that Trump will fade quietly. Since losing the election to Joe Biden in November, Trump has launched baseless attacks on the integrity of the election as most prominent Texans in his party let his claims go unchallenged. Some of Trump’s most loyal allies in Texas expect he’ll be a force here for years.

“The party is really built around Donald Trump — the brand, the image, but most importantly, his policies and what he accomplished,” [Dan] Patrick said during a Fox News interview Thursday. “Whoever runs in 2024, if they walk away from Trump and his policies, I don’t think they can get through a primary.”

To Texas Democrats, Trump has been a highly galvanizing force who created new political opportunities for them, particularly in the suburbs. He carried the state by 9 percentage points in 2016 — the smallest margin for a GOP nominee in Texas in two decades — and then an even smaller margin last year. But his 6-point win here in November came after Democrats spent months getting their hopes up that Trump would lose the state altogether, and they also came up woefully short down-ballot, concluding the Trump era with decisively mixed feelings about his electoral impact at the state level.

More broadly, some Texas Democrats believe Trump is leaving a legacy as a symptom of the state’s current Republican politics, not a cause of it.

“Frankly I don’t think he changed the Republican Party in Texas,” said Gilberto Hinojosa, the state Democratic Party chair, adding that Trump has instead magnified the “extreme politics and tendencies” that Texas Republicans have long harbored. “The things that [Trump] stands for — the white nationalism, the anti-LGBT [sentiment], the just flat-out racism, just the absolute meanness — that’s what the Republican Party has been in Texas for quite some time.”

As for Texas Republicans’ embrace of Trump, Hinojosa added, they “are the people that Trump talks about when he says he could shoot someone in the middle of Fifth Avenue and not lose their support.”

[…]

To be sure, it’s entirely possible Republicans unite in the next year the way political parties do when they’re in the minority — with an oppositional message to the opposing administration. But the GOP’s longer-term challenges could prove harder to resolve. In the final years of Trump, some in the party drifted from any unifying policy vision. At the 2020 Republican National Convention, the party opted not to create a new platform, saying it would instead “continue to enthusiastically support the President’s America-first agenda.”

November’s elections in Texas did little to settle the debate over which direction the party should go. Those who want to move on note that Trump won with the narrowest margin for a GOP presidential candidate this century, and swing-seat Republican congressional contenders largely outperformed him in their districts.

“Most every Republican that was successful, with the exception of a handful, outperformed Donald Trump by a significant margin,” Hurd said. “If you’re not growing, you are dying, and if we’re not expanding to those voters that are disaffected and don’t believe in the message that Democrats are providing, then we’re not going to be able to grow.”

On the other hand, Trump’s 6-point margin was bigger than expected, and he performed surprisingly well in Hispanic communities in South Texas. Former Texas GOP Chair James Dickey said Trump’s message was “particularly effective” in swaths of the state that aren’t typically looked at as political bellwethers.

“His biggest impact has been a return to populist roots and an expansion of the party in minority communities, which, again, is a return to its roots,” Dickey said.

My medium-lukewarm take based on 2018, 2020, and the Georgia runoffs is that Republicans do better with Trump on the ballot than not. Dems made the big gains in 2018 in part because Republican turnout, as high as it was in that off-year, wasn’t as good as it could have been. The GOP got some low-propensity voters to turn out in November – as did Dems – and now they have to try to get them to turn out again. Maybe they will! Maybe with Trump gone some number of former Republicans who voted Dem because they hated Trump will find their way back to the GOP. Or maybe those folks are now full-on Dems. The national atmosphere will be critical to how 2022 goes – the economy, the vaccination effort, the Senate trial of Trump, further fallout from the Capitol insurrection, and just overall whether people think the Dems have done too much, too little, or the right amount. Dems can only control what they do.

And that’s going to mean playing some defense.

Democrats are headed back to the White House, and Texas Republicans are gearing up to go back on offense.

For eight years under President Barack Obama, Texas was a conservative counterweight to a progressive administration, with its Republican leaders campaigning against liberal policies on immigration, the environment and health care and lobbing lawsuit after federal lawsuit challenging scores of Democratic initiatives. When Republicans could not block policies in Congress, they sometimes could in the courts.

Now, as Joe Biden enters the White House promising a slew of executive orders and proposed legislation, the notorious “Texas vs. the feds” lawsuits are expected to return in full force. And state leaders have begun to float policy proposals for this year’s legislative session in response to expected action — or inaction — from a White House run by Democrats.

[…]

Under Trump, Texas has often found itself aligned with the federal government in the courts. Most notably, the Trump administration lined up with a Texas-led coalition of red states seeking to end the Affordable Care Act. That case is pending before the U.S. Supreme Court.

Once Biden enters the White House and his appointees lead everything from the Environmental Protection Agency to the Department of Homeland Security, Texas’ conservative leaders will return to a familiar posture: adversary, not ally, to those making national policy.

Paul Nolette, a professor at Marquette University who studies federalism, said he expects Texas to be “at the top of the heap” among Republican attorneys general challenging the new administration in court.

According to Nolette, the number of multi-state lawsuits against the federal government skyrocketed from 78 under eight years of Obama to 145 during just four years of Trump.

“Republican AGs will take a very aggressive multi-state approach,” Nolette predicted. “It’ll happen quickly.”

It should be noted that a lot of those lawsuits were not successful. I don’t know what the scoreboard looks like, and some of those suits are still active, so write that in pencil and not in Sharpie. It should also be noted that the goal of some of these lawsuits, like ending DACA and killing the Affordable Care Act, are not exactly in line with public opinion, so winning may not have the effect the GOP hopes it would have. And of course AG Ken Paxton is under federal indictment (no pardon, sorry), leading a hollowed-out office, and not in great electoral shape for 2022. There’s definitely a chance Texas is not at the front of this parade in 2022.

My point is simply this: There’s a lot of ways the next two years can go. I think the main factors look obvious right now, but nothing is ever exactly as we think it is. I think Democrats nationally have a good idea of what their goals are and how they will achieve them, but it all comes down to execution. Keep your eye on the ball.

Here’s the official budget forecast

“Could be worse” remains the watchword.

Texas lawmakers will enter the legislative session this week with an estimated $112.5 billion available to allocate for general purpose spending in the next two-year state budget, a number that’s down slightly from the current budget but is significantly higher than what was estimated this summer when the coronavirus began to devastate the economy.

Texas Comptroller Glenn Hegar on Monday announced that number in his biennial revenue estimate, which sets the amount lawmakers can commit to spending when they write a new budget this year. But he acknowledged that Texas’ economic future remains “clouded in uncertainty” and that numbers could change in the coming months.

Hegar also announced a nearly $1 billion deficit for the current state budget that lawmakers must make up, a significantly smaller shortfall than Hegar expected over the summer. That number, however, doesn’t account for 5% cuts to state agencies’ budgets that Gov. Greg Abbott, House Speaker Dennis Bonnen and Lt. Gov. Dan Patrick ordered this summer or any supplemental changes to the budget lawmakers will have to make.

Hegar’s estimates portend a difficult budget-writing session for lawmakers. But Hegar acknowledged that things could have been a lot worse. The $112.5 billion available is down from $112.96 billion for the current budget.

See here for the previous update. I continue to hope that Congress will throw a boatload of state and local aid our way in the coming months, which will also help, but at least we’re not in truly dire territory. And bizarrely enough, there may be a silver lining in all this.

But advocates hope the pandemic, combined with the revenue crunch, could lead to an unlikely bipartisan agreement. Before the pandemic hit, Democrats saw a takeover of the Texas House as key for advancing the prospects of Medicaid expansion in the state. But as COVID-19 has ravaged the state economy and thrown even more Texans into the ranks of the uninsured, Democrats are guardedly optimistic this could persuade enough Republicans to put aside their political hangups and support expansion—even as Republican Attorney General Ken Paxton leads a national lawsuit to eliminate the entire Affordable Care Act.

Texas is one of 12 remaining states that have refused the federally subsidized Medicaid expansion, despite having the highest rate and largest population of uninsured residents in the country. Expanding Medicaid would cover 1 million uninsured Texans and bring in as much as $5.4 billion to the state, according to a September report by researchers at Texas A&M University.

State Representative Lyle Larson, a moderate Republican, voiced his support for expanding Medicaid soon after the election, pointing to six GOP-led states that have done so in the past three years. “It is a business decision,” Larson wrote on Twitter, noting that the move would help with the revenue shortfall and COVID-19 response, address rural hospital closures, and expand access to care. Dallas County Representatives Morgan Meyer and Angie Chen Button, both Republicans, pulled out razor-thin victories to keep their House seats after voicing support for some type of Medicaid expansion in their campaigns.

Even conservative state Senator Paul Bettencourt acknowledged that the fiscal crunch will force consideration of Medicaid expansion. “My back-of-the-napkin analysis shows that’s a $1.6 billion item, like that—boom!” he told the Dallas Morning News in September. “I’m pretty sure we don’t have that falling out of trees,” he said. “You can put Medicaid expansion up at the top of the list. There will be a debate.”

But there’s still plenty of staunch opposition. “For those that promote [expansion], I haven’t heard what they’re willing to cut,” state Senator Kelly Hancock, a Republican who chairs the Business and Commerce Committee, said in November. “It’s easy to talk about it until you have to pay for it, especially going into this budget cycle.”

As with casinos and marijuana, the smart money is always to bet against Medicaid expansion happening. But this is a bigger opening than I’ve seen in a long time, and while that’s still not saying much, it’s not nothing.

We’re number one (million)!

One million COVID cases in Texas. Hooray?

Texas’ grim distinction as the national leader in terms of COVID-19 infections came as little surprise to some local medical experts, who blamed politicians for conflicting messages about the virus and warned the worst is yet to come.

Texas this week breached a milestone of 1 million cumulative cases since the start of the pandemic, recording more infections than any other state in the U.S. For reference, more people have been infected in the Lone Star state than live in Austin, the state’s capitol.

If Texas were its own country, it would rank 10th in terms of total cases, according to data from Johns Hopkins University, placing it higher than European hotspots like Italy.

The big numbers are not a shock in a state that’s home to roughly 29 million people. The number of cases per 100,000 residents is lower here than in about half of the states in the country. But Texas also had more newly reported cases in the last seven days — an average of about 8,200 — than other large, hard-hit states such as New York, California and Florida. Only Illinois has a higher seven-day average.

Dr. David Callender, president of the Memorial Hermann Health System, called the 1 million cases “a sobering statistic.”

“It’s not a surprise in the context of all that’s happened,” Callender said. “But it’s a significant number — 3 percent of the population — and cause for worry about the trend continuing as we go forward.”

Callender attributed the high number to “too much division” in the attempt to contain the virus.

“To me, politics entered in an inappropriate way,” said Callender. “People making a political statement with their behavior — that the pandemic is a hoax, that no one can make them wear a mask — really interfered with efforts. It was the wrong mindset.”

To be fair, California is a couple of days behind us, and may have passed one million by the time I publish this. Of course, California also has ten million more people than Texas, so.

The state’s positive test rate is now 11.24%, compared to 7.64% a month ago.

Hey, remember when a 10% positivity rate was considered to be a “warning flag” by Greg Abbott? You know, as part of his famous “metrics” for reopening the state?

Abbott’s office didn’t immediately respond to messages Tuesday.

Too busy propping up Donald Trump’s ego to deal with this kind of trivia, I suppose.

Meanwhile, in El Paso

The number of coronavirus patients in Texas hospitals has nearly doubled since October, and average infections are at their highest point in almost three months — leaving health officials bracing for a potential crush of hospitalizations going into the holidays.

In El Paso, hospitals are so overwhelmed with COVID-19 patients that in early November the Department of Defense sent medical teams to help, and the county has summoned 10 mobile morgues to hold dead bodies. Local funeral homes are readying extra refrigerated storage space, as the number of hospitalized coronavirus patients in the far West Texas city has shot up nearly tenfold since the start of September.

The new wave of infections stands in contrast to the summer surge, when Gov. Greg Abbott held regular press conferences about the virus and mandated that face coverings be worn, earning him the ire of the far-right. Now, state officials seem reluctant to crack down on the virus’ spread by further curtailing economic activity — and are fighting the El Paso county judge’s attempt to impose a curfew and a stay-at-home order in the face of record-breaking cases.

The state will not do anything to help, and you local leaders are not allowed to do anything to help. You’re on your own. If you’re very lucky, maybe you won’t have your health insurance taken away while you recover. Did I mention that disaster and emergency response ought to be a big theme of the 2022 election? Texas Monthly has more.

UPDATE: Nothing to see here.

We don’t need a vote to expand Medicaid

There’s a fundamental truth that needs to be addressed in this.

It’s constitutional – deal with it

On Tuesday, Missouri became the 38th state to expand Medicaid, opening healthcare to over 230,000 Missourians. It joins a lengthy list of GOP-led states in expanding healthcare, including Nebraska, Utah, and Oklahoma. Meanwhile in Texas we still lead the country in the number of uninsured and, since the COVID-19, pandemic another 650,000 have lost their health insurance.

The ballot initiative to expand Medicaid passed in Missouri by 53 percent, with several suburban counties in St. Louis and Kansas City voting overwhelmingly for the measure. The governor of Missouri, a staunch conservative, actually added the ballot initiative to the August primary ballot instead of November’s presidential ballot, hoping a smaller turnout would defeat the measure.

Clearly, the voters of Missouri felt expanding Medicaid was important for their state. The vote also comes as the Trump administration continues its effort to dismantle the Affordable Care Act, potentially kicking 20 million Americans off their health care and denying preexisting conditions coverage to over 120 million. Both Gov. Greg Abbott and Texas Attorney General Ken Paxton support ending the ACA.

Texas has been in a health crisis for a long time, well after the state decided not to expand Medicaid through the ACA. According to a report from 2018, over 17 percent of Texas residents lacked health coverage. That’s about 5 million Texans without access to health care.

With COVID-19, that health crisis has only exacerbated. While cases and hospitalizations from COVID-19 have gone down in parts of the state, those numbers will likely rise precipitously as schools open. Over 7,000 Texans have died from the coronavirus. Many hospitals, particularly rural ones, are overwhelmed. The health care status quo has never felt so dangerous and untenable.

So will Texas ever get a chance to vote on expanding Medicaid? According to Republican lawmakers in the state, that would be a “no.” Rep. Celia Israel commented on Twitter that she and Rep. John Bucy sponsored a bill in the last legislative session that would allow voters to “weigh in and expand Medicaid,” but that it never got a hearing.

[…]

If Texans do get a chance to vote on expanding Medicaid, it will surely be opposed by Republicans statewide and in the legislature. If history is any guide, however, improving health care will transcend partisan lines.

The people of Missouri voted on the question of expanding Medicaid because the state of Missouri allows for laws to be enacted by referendum. In other words, in the state of Missouri and a number of others, you can collect petition signatures to put a proposed law up for a vote by the people, which is then enacted if it passes. Different states have different rules for this, but that’s the basic idea. The city of Houston allows for charter amendments to be put up for a vote via the petition process, which is always a fun thing to endure. For better or worse, the state of Texas does not allow for this.

The key thing to understand here is that the folks who pushed Medicaid expansion in Missouri via referendum did so for the explicit purpose of bypassing Missouri’s legislature and governor, both of which opposed Medicaid expansion. Most states early on passed Medicaid expansion via their legislatures, including some Republican states, but in recent years most of the action has come via the ballot box, in states like Idaho and Nebraska and Oklahoma. The key ingredients there were a combination of legislators and governors that opposed expanding Medicaid, and a petition process that allowed for the legislative process to be circumvented.

So if you’ve wondered why if those states can vote to expand Medicaid why can’t Texas, the answer is because the law doesn’t allow for it. It can only be done via the Legislature. Indeed, bills to do some form of Medicaid expansion have been proposed but have not gotten anywhere. The reason for that of course is intransigent Republican opposition, but guess what: The Democrats have a shot at taking the majority in the State House this year (as you may have heard), which would overcome one of those obstacles. We’d still need to take the Senate and elect a new Governor to finish the job, but at the very least the House could pass a Medicaid expansion bill, or put something for it in the budget, and dare the Senate and Greg Abbott to oppose it. I for one would be fine with having the 2022 Governor’s race be defined in large part by expanding Medicaid (in addition to, you know, COVID-19 response).

If that’s the case, then what was Rep. Israel tweeting about? Very simply, it was a political move to try to force the issue in a slightly different way. What Reps. Israel and Bucy proposed was a Constitutional amendment, which is something that the voters have to approve, which would have expanded Medicaid. Why propose a Constitutional amendment, which requires a two-thirds vote in both chambers, instead of a regular old bill that needs only a simple majority? Three reasons: One, constitutional amendments do not need the governor’s approval, so it would go to the voters regardless of what Greg Abbott wanted. Two, it offered Republican legislators who opposed Medicaid expansion but might have felt the need to do something a way out, as in “just vote to let the people decide, and we’ll never bother you about it again”. And three, constitutional amendments can only be changed or repealed by subsequent constitutional amendments, with their two-thirds-majority requirements, thus protecting Medicaid expansion via this avenue from the whims of a future Republican legislature.

The point is, though, we don’t need to vote to expand Medicaid. At least, we don’t need to vote on a ballot proposition to do it. We just need to vote for a Legislature and a Governor who are willing to do it. We’re a lot closer to that than we’ve ever been, and we’re closer to it than states like Missouri and Idaho and Nebraska and Oklahoma had any hope of being. The votes we need to expand Medicaid are this November, and November of 2022. Those are the prizes to keep your eyes on.

Matt Glazer: A way to end surprise medical bills

(Note: The following is a guest post that was submitted to me. I occasionally solicit guest posts, and also occasionally accept them from people I trust.)

At a young age, I had to deal with medical issue after medical issue. It started with trips to M.D. Anderson and ended with an emergency appendectomy. Three major illnesses in 2 years was hard, but we were fortunate enough not to be financially destroyed by these unexpected medical expenses.

Fast forward to now and I am constantly nervous to go see a doctor. Yes, I have insurance now (something that was impossible before the Affordable Care Act), but I am also a pawn in a subterranean fight between health care providers and insurance companies. Basic treatments that should be covered sometimes aren’t and with no rhyme or reason. Then I am hit with unexpected bill that sends me back to eating ramen or cutting expenses again.

There is a real, bi-partisan opportunity to do something about this and protect consumers.

As COVID-19 continues to disrupt life in Texas throughout the country, health care access has never been more important. Now more than ever, people need to see a doctor when they’re sick – not just for their own health, but (given the contagiousness of the disease) for the health of those around them.

Yet some in Washington, D.C. are putting that access at risk in a ham-fisted attempt to stop surprise medical bills.

Most of us have dealt with the shock of a surprise medical bill in recent years – those charges you get billed for after getting medical care, when your insurance company refuses to foot the bill for an out-of-network health provider. Congress has been debating this issue for over a year, and two main camps have emerged. One group wants to end these disputes by creating an independent dispute resolution (IDR) system, where providers and insurance companies are pushed toward a negotiating table to figure out their differences, and patients are left out of the process. The other group wants pre-determined reimbursement rates for services based on insurance companies’ in-network rates.

The first option, IDR, is similar to what we passed last year for insurance plans regulated by the state of Texas – one of the country’s most patient-friendly surprise medical bill laws which won bipartisan support. Other states, such as New York, have instituted a similar system with successful results. (Unfortunately, these state fixes only apply to plans regulated by the state, which is why Congress needs to act. For example, in Texas only 16% of health plans are covered by the state surprise billing law.)

The problems with the second option become obvious quickly: If insurance companies are setting rates, they have all the negotiating leverage. Surprise bills go from being a dispute over how much to charge for a medical procedure to a take-it-or-leave it edict to hospitals, doctors, and other care providers. The rate-setting option would artificially drive insurance payouts down and create dire financial situations for doctors and hospitals – particularly in rural areas, where hospitals function as major hubs for local health care services. It would pad the bottom line for health insurance companies, though – not like they need it, since they have been among the few companies making more money during the pandemic.

Worst of all: Rate-setting would allow insurance companies to further enrich themselves on the backs of the doctors, nurses, and other health care providers who have been serving on the front lines of the pandemic, shouldering more risk than any of us in fighting COVID-19.

(Last month, the Trump administration proposed a third option: an outright ban on surprise medical bills with no outline for resolving the underlying dispute. That figures to throw any disputed bill into the court system, with costly lawsuits driving up the costs of both health care and insurance premiums. Everyone except the lawyers would lose in that scenario.)

Thankfully, surprise medical billing is one of the few truly bipartisan issues on Congress’s agenda, outside the drama of November’s elections. And there is bipartisan support for an IDR-based solution, which means that we can have some hope that Sen. John Cornyn, Sen. Ted Cruz, and the rest of our Congressional delegation will step up and do the right thing. And there are legislative options, put forward by members of Congress who are actual doctors: Sen. Bill Cassidy (R-La.) has more than 30 bipartisan co-sponsors for his “STOP Surprise Medical Bills Act,” and more than 110 House members have similarly signed on to the “Protecting People from Surprise Medical Bills Act,” sponsored by Rep. Phil Roe (R-Tenn.) and Rep. Raul Ruiz (D-Ca.). Both of these bills solve surprise medical bills using IDR and keep the patients out of it.

We still have a long way to go in facing COVID-19 pandemic. During this time, and the time to come after, one thing should be crystal clear: We cannot make it harder for people to get health care when they need it. Access to health care will be essential as the economy struggles to recover in fits and starts, we need workers and customers who don’t have to worry about finding care if they get sick.

Forcing doctors out of business and pushing hospitals to the brink of financial collapse is no way to fight a pandemic – or to help patients.

This is a necessary solution for millions. A generation later, I am still terrified to go see a doctor because of the uncertainty surrounding every trip. I am still affected by the bad luck I was afflicted with before I could drive a car, vote, or serve our country. A generation later, I still feel the effects of being a pawn in a game I don’t want to play. There is a real opportunity to do something about this now. All it takes is for our elected officials to do it.

Matt Glazer is the past Executive Director of Progress Texas and co-founder of Blue Sky Partners.

The extraordinary danger of being pregnant and uninsured in Texas

So utterly appalling.

Right there with them

From 2012 through 2015, at least 382 pregnant women and new mothers died in Texas from causes related to pregnancy and childbirth, according to the most recent data available from the Department of State Health Services; since then, hundreds more have likely perished. While their cases reflect the problems that contribute to maternal mortality across the United States — gross medical errors, deeply entrenched racism, structural deficiencies in how care is delivered — another Texas-size factor often plays a significant role: the state’s vast, and growing, problem with health insurance access.

About one in six Texans — just over 5 million people — had no health insurance last year. That’s almost a sixth of all uninsured Americans, more than the entire population of neighboring Louisiana. After trending lower for several years, the Texas rate has been rising again — to 17.7% in 2018, or about twice the national average.

The numbers for women are even worse. Texas has the highest rate of uninsured women of reproductive age in the country; a third were without health coverage in 2018, according to a DSHS survey. In some counties, mainly along the Mexico border, that estimate approaches 40%.

Public health experts have long warned that such gaps can have profound consequences for women’s health across their lifespans and are a critical factor in why the U.S. has the highest rate of maternal deaths in the developed world. Texas’ maternal mortality numbers have been notably troubling, even as errors in key data have complicated efforts to understand what’s going on and led skeptics, including the governorto question whether there’s really a crisis.

Hardly anyone outside the policy world has taken a deep look at how these insurance gaps play out for women in the second-largest state in the U.S. — at how, in the worst-case scenarios, lack of access to medical care endangers the lives of pregnant women, new mothers and babies.

ProPublica and Vox have spent the last eight months doing just that — combing through government data and reports, medical records and research studies, and talking with scores of women, health care providers, policymakers and families of lost mothers around the state. We learned about Rosa Diaz and dozens of others, mostly women of color, by scouring medical examiner’s databases for sudden, “natural” deaths, then inspecting investigator and autopsy reports for clues about what went wrong.

The picture that emerges is of a system of staggering complexity, riddled with obstacles and cracks, that prioritizes babies over mothers, thwarts women at every turn, frustrates doctors and midwives, and incentivizes substandard care. It’s “the extreme example of a fragmented system that cares about women much more in the context of delivering a healthy baby than the mother’s health in and of itself,” said Eugene Declercq, professor of community health sciences at Boston University School of Public Health.

Most of the mothers whose cases we examined were covered by Medicaid for low-income pregnant women, a state-federal health insurance program that pays for 53% of the births in Texas, more than 200,000 a year, and 43% of all births nationwide. In Texas, the program covers OB-GYN visits, medications, testing and nonobstetric care, from endocrinologists to eye exams.

But the application process is so cumbersome that women in the state have the latest entry to prenatal care in the country, ProPublica and Vox found. It can take months to be seen by regular providers and even longer to access specialists. This poses the greatest danger for high-risk mothers-to-be — as many women on Medicaid are, having had no medical care for significant parts of their lives. Then, roughly two months after delivery, pregnancy Medicaid comes to an end, and the safety net gives way to a cliff. For many new mothers, the result is a medical, emotional and financial disaster.

More than half of all maternal deaths in the U.S. now occur following delivery, according to the Centers for Disease Control and Prevention, with as many as 24% happening six or more weeks after a woman gives birth. In Texas, the proportion of late-postpartum deaths is closer to 40%, with black women bearing the greatest risk. “To lose health care coverage really has a tremendous potential to worsen outcomes,” said Dr. Lisa Hollier, chief medical officer for obstetrics and gynecology for Texas Children’s Health Plan and chair of the state’s maternal mortality review committee.

This is a long excerpt, but there’s a lot more to the story, so please read the whole thing. There are numerous policy decisions at fault here – not expanding Medicaid, low Medicaid reimbursements, cutting off Planned Parenthood and substituting in wholly inadequate alternatives, and more – and all of them can be laid at the feet of the state’s Republican leadership. Whoever runs against Greg Abbott and Dan Patrick and Ken Paxton in 2022 should loudly and repeatedly assert that every maternal death in Texas is their fault. I keep saying this, and it keeps being true: Nothing will change until we have different, and better, government in this state. There’s no other way to do it.

On to the next big financial issue for the city

It’s always something.

Mayor Sylvester Turner

Four years ago, the main source of Houston’s deteriorating financial health — billions of dollars in unfunded pension obligations — loomed over the race for mayor, promising a massive test for the winner.

Now, Mayor Sylvester Turner, having overhauled the city’s troubled pension systems, is running for re-election and touting the reforms as his signature policy accomplishment. He faces several challengers, including Bill King, the businessman he defeated four years ago, millionaire lawyer and self-funder Tony Buzbee, City Councilman Dwight Boykins who has clashed with the mayor over firefighter pay and former Councilwoman Sue Lovell, as well as a handful of lesser known candidates.

Whoever wins will be forced to confront another simmering financial problem: Houston’s $2.4 billion unfunded liability for retiree health care costs, the result of years of deferred contributions, an aging city workforce and, experts say, growing medical costs that outpace the city’s revenue.

The total has grown in recent years by an average of $160 million a year, or more than $400,000 a day. That is less than the $8.2 billion unfunded pension liability’s $1 million-per-day growth rate, but enough to require swift and sweeping changes, experts and local officials say.

“We’re in the earlier stages in this. It’s not a crisis by any means, but it would be better to address it now,” Controller Chris Brown said. “We don’t want to let this thing grow to another $8 billion unfunded liability. … Let’s pay a little now instead of paying a lot later.”

The unfunded liability refers to the city’s obligations in the coming decades for retired employees’ medical, life and prescription drug insurance, commonly called other post-employment benefits, or OPEB. Houston has covered its OPEB expenses through a pay-as-you-go system, akin to making a minimum credit card payment while the balance grows.

[…]

“We have also been in discussions with the employee groups working toward consensus, while keeping in mind the sacrifices employees have made to help us achieve the city’s historic pension reform,” Turner said.

The proposals align with recommendations from a separate firm, Philadelphia-based PFM, which said in its 10-year Houston financial plan the city should eliminate OPEB coverage altogether for retirees or dependents who have access to other coverage.

Other cities have taken a similar approach, limiting cuts for retirees and older employees who were promised certain benefits, while requiring bigger sacrifices from younger and future employees with more time to prepare.

The good news here is that the city doesn’t need to go through the Lege to fix this, and the basic plan for a fix is already in the works. Mayor Turner will be proposing his plan later in the year, and most likely that will put the city on a path towards containing this problem. There’s still a big piece of the puzzle missing, though.

Even after reigning in the city’s OPEB liability, Brown said, the city faces numerous looming financial problems, including annual deferred maintenance and, in the recent city budget, recurring spending that outstrips recurring revenue. In addition, Houston has been operating under a voter-imposed cap on property tax revenue since 2004 and has trimmed its tax rate to avoid collecting more money than allowed.

“This is another piece of the larger problem that’s looming for the city of Houston, which is the structurally imbalanced budget,” Brown said. “Essentially, we want to be paying for all of our current expenses in the fiscal year in full. And we don’t want to defer anything out, i.e. kick the can down the road.”

Yes, the revenue cap, which costs the city many millions of dollars for no good purpose. There’s a lot the city can do to control costs, but not everything is within its power. Some things just get more expensive over time, and if the city is not allowed to reap the benefit of economic growth, it cannot deal with those expenses. If we can get past this issue, and Mayor Turner gets re-elected, then maybe, just maybe, we can get a rev cap repeal measure on the 2020 ballot. There will never be a friendlier electorate to deal with t.

The Fifth Circuit Obamacare hearing

Remember, the Fifth Circuit is where hope goes to die. Adjust your expectations accordingly.

It’s constitutional – deal with it

On the left was Judge Carolyn Dineen King, an appointee of Jimmy Carter; on the right sat Judge Kurt Engelhardt, a nominee of Donald Trump, and in the center sat Judge Jennifer Walker Elrod, the George W. Bush appointee expected to represent the critical swing vote on a three-judge panel now charged with deciding the constitutionality of the Affordable Care Act.

It was that perhaps fitting seating arrangement that greeted attorneys for Texas on Tuesday afternoon, as the state and its allies asked this three-judge panel on the U.S. 5th Circuit Court of Appeals to strike down the sweeping health law known as “Obamacare,” a legal means to a political end that has eluded conservatives for the better part of a decade.

Texas won a major victory in its bid to end the law in December, when a federal district judge in North Texas sided with the state, declaring that the law is unconstitutional in its entirety after Congress in 2017 gutted one of its important provisions, a tax penalty for individuals who chose to remain uninsured. The U.S. Department of Justice, in a highly unusual move, has declined to defend the law.

A California-led coalition of blue states that has stepped in to oppose Texas in the lawsuit quibbles with that question of “severability,” arguing that even if one slice of the law must fall as unconstitutional, its other hundreds of provisions — including a host of popular patient protections — should stand. The question of how much of the law may rightly be salvaged was a focal point of court discussions on Tuesday.

Texas’ odds of total vindication remain in question after nearly two hours of questions before the three judges.

Most of the unusually-large courtroom audience of journalists and interested but unaffiliated attorneys focused on Elrod at the center. By far the most vocal judge of the three, Elrod probed both sides on the issue of standing — whether they have the right to participate in the lawsuit at all. And she seemed highly focused on her court’s options for ordering a remedy, seeming to weigh options for sending the case back to a lower court for further consideration.

Engelhardt, who is among the newest appointees to the court, was harsh and occasionally sarcastic, asking more questions of the blue state coalition than he did of the Texas-led team. He seemed skeptical of the standing of both the California-led coalition and the Democratic-majority U.S. House of Representatives, which intervened in the case although the Republican-majority U.S. Senate did not.

The Senate, Engelhardt remarked, “is sort of the 800 lb. gorilla that’s not in the room.”

King, meanwhile, did not speak at all.

See here and here for the background. The legal basis of this lawsuit is so ridiculous that anything short of tossing it and its lawyers out of court is insufficient, but given where we are I could find a way to live with the idea of sending it back to the idiot district court judge for reconsideration. I fear we’ll get some kind of split-the-baby decision that strikes down parts of the law but leaves some crippled skeleton of it intact, which dumbass pundits will then call a “moderate compromise”, in the same way that the midpoint between “I murder you and burn down your house” and “I leave you alone” is a moderate compromise. Not much to do at this point but wait and work your ass off voting these morons out in 2020. NBC News, CNN, Daily Kos, Mother Jones, and Think Progress have more.

The lawsuit to kill Obamacare has its hearing at the Fifth Circuit today

Brace yourselves.

It’s constitutional – deal with it

Last year, after a federal judge in Texas declared the entirety of the Affordable Care Act unconstitutional, throwing into question millions of Americans’ health coverage, the state’s Republican leaders promised they would come up with a plan to replace it.

But on Tuesday, after a legislative session that seemed to have no room for issues other than property tax reform and school finance, Texas will ask a federal appeals court in New Orleans to end the law in its entirety — without offering a replacement plan.

The conservative crusade against portions of the act, known as Obamacare, has spanned a decade. But Texas’ latest lawsuit, filed in February 2018, became an existential threat to the law after U.S. District Judge Reed O’Connor ruled in December that it is unconstitutional in its entirety. At stake: the subsidized health coverage of roughly 1 million Texans, sweeping protections for patients with preexisting conditions, young adults staying on their parents’ insurance plans until age 26 and a host of low-cost benefits available to all people with health insurance, including those covered through their employers.

Texas already has the highest uninsured rate in the nation.

In a highly unusual — if not entirely surprising — move, the U.S. Department of Justice has declined to defend the federal law, leaving a California-led coalition of blue states to protect it. As the case proceeds, Obamacare has remained in place, and likely will until the litigation is finally resolved.

Attorneys for the state of Texas argue the health law cannot stand since the Republican-led Congress in 2017 zeroed out Obamacare’s individual mandate — a penalty imposed on people who chose to remain uninsured. Democrats had favored the penalty as a way to induce more people to purchase health insurance, with the goal of reaching near-universal coverage. Without it, Texas argues, the whole law must fall.

But the state’s Republican leaders have offered few ideas about what should replace Obamacare, a law that touches practically every aspect of health care regulations and includes several popular protections for patients. Gov. Greg Abbott — a vocal critic of the law — pledged in December that if the law remained struck down on appeal, “Texas will be ready with replacement health care insurance that includes coverage for pre-existing conditions.”

Since then, he’s been quiet on the issue, including during this year’s 140-day Texas legislative session. Abbott did not respond to questions for this story.

See here for the background. And of course Greg Abbott doesn’t have a single thing to say about reducing the extremely high uninsured rate in Texas. That’s because Abbott’s plan to reduce the uninsured in Texas, supported by Dan Patrick and Ken Paxton and the rest of the Republicans, is for more of them to die. Just as a reminder, Republicans have been in complete control of Texas government since 2003. Not once during that time have they taken any steps to improve access to health care in the state. Indeed, on multiple occasions, beginning in 2003 with the savage cuts to CHIP and continuing through their assault on women’s health via attacks on Planned Parenthood, they have time and time again make accessing health care harder. That’s what is at stake here. The only fix, regardless of the ruling in this case, is to vote them out. The WaPo, the Chron, and Think Progress have more.

Trump goes all in against health care

Game on.

It’s constitutional – deal with it

The Trump administration wants the federal courts to overturn the Affordable Care Act in its entirety, an escalation of its legal assault against the health care law.

The Justice Department said in a brief filed on Monday that the administration supports a recent district court decision that invalidated all of Obamacare. So it is now the official position of President Trump’s administration that all of the ACA — the private insurance markets that cover 15 million Americans, the Medicaid expansion that covers another 15 million, and the protections for people with preexisting conditions and other regulations — should be nullified.

When combined with Trump’s endorsement of the various Republican legislative plans to repeal and replace Obamacare and other regulatory actions pursued by his subordinates, the Trump administration’s clear, consistent, and unequivocal position is that millions of people should lose their health insurance and that people should not be protected from discrimination based on their medical history.

The Justice Department had previously said that only the ACA’s prohibition on health insurers denying people coverage or charging people higher premiums based on their medical history should fall in the lawsuit being brought by 20 Republican-led states. But their latest brief removed that subtlety, saying that the entire law should go.

Legal experts dismiss the states’ argument as “absurd,” yet they have worried it could find a receptive audience among conservative jurists, given the prior success of anti-Obamacare lawsuits thought to be spurious that still found their way to the Supreme Court.

The argument has already won in the US district court in northern Texas, after all, though that decision is on hold pending appeal.

See here and here for some background. Did we mention this ridiculous lawsuit got its start in Texas? Bad lawsuits seem to be our main export these days. There’s not much we can do about what the Fifth Circuit and SCOTUS will do, but in the meantime, health care is once again a huge issue for the next election. We won once on that, we need to do it again.

Texas is not going to expand Medicaid

Don’t get me wrong, Texas should have expanded Medicaid at its first opportunity. It would do so much to improve health care in the state, including and especially mental health care, which would have significant spillover effects on criminal justice. Other states have passed voter referenda mandating Medicaid expansion, but those states can do that via citizen petition. They don’t have to go through their legislature, which is a requirement here and the place that the effort will go to die.

Rep. Celia Israel

Seeing other states take Medicaid expansion to voters is what Rep. Celia Israel, D-Austin, says gave her the idea to file House Joint Resolution 40. She said she’s frustrated that Texas “has not shown the political fortitude” to expand the program and that giving the decision to voters may take political pressure off of Republicans.

Expanding Medicaid through the Affordable Care Act — also known as Obamacare — has been a nonstarter in the GOP-dominated Texas Legislature. Republicans including Gov. Greg Abbott, Lt. Gov. Dan Patrick and former Gov. Rick Perry have argued that expanding Medicaid would increase health care costs for the state — especially if the federal government ever breaks its promise to help pay for the surge of newly eligible people.

Israel’s strategy so far has included courting Republicans in districts that have lost rural hospitals. Nineteen rural hospitals have closed permanently or temporarily since 2013, according to the Texas Organization of Rural & Community Hospitals.

“I’m getting mixed responses,” Israel said of her progress. “I’m making the case that we have lost so many rural hospitals in Texas, and one of the reasons we wouldn’t have lost those rural hospitals is if we had said yes to expanding Medicaid.”

Anne Dunkelberg, associate director of the Center for Public Policy Priorities, a left-leaning policy organization, said the 2018 election cycle and polls showed that health care is a top issue for voters.

“The bottom line is even though individual members have seen desirability moving in this direction, it’s not something they’re going to fall on their sword and buck their leadership over,” Dunkelberg said.

[…]

State Rep. John Zerwas, chairman of the House Appropriations Committee, attempted an alternative to Medicaid expansion during the 2013 session. The Richmond Republican’s House Bill 3791 would have allowed Texas to receive federal money in the form of block grants to enroll individuals in a private health plan using a sliding-scale subsidy, rather than expanding Medicaid to cover them. The bill also had a “pull the plug” provision if the federal government failed to continue funding. It had some bipartisan support but never reached the House floor for a vote.

He said Medicaid expansion in general still “comes with political radioactivity” that Republicans are hesitant to deal with. Just pursuing a waiver is still “a pretty steep hill to climb.” Zerwas said he doesn’t plan on bringing his bill back and also doesn’t believe Medicaid expansion needs to be taken to voters. He acknowledged that Texas has the highest number of uninsured people in the country but says there’s not a cost-effective way to provide care for the Medicaid population.

“It’s just politics, you know, and I’ve lived through this by virtue of carrying the bill in 2013 and was portrayed as someone who just loved Obamacare and was looking to grow it in the state of Texas,” Zerwas said. “Politically and in my party especially at that time and still so … it continues to be one of those things that Republicans rail against because they see it as a very heavy cost to the state.”

But Sen. Nathan Johnson, D-Dallas, who filed Senate Joint Resolution 34, which also would create a constitutional amendment to expand Medicaid, said that “it should not take a leap of courage to put this on the ballot.” Amid Texas’ problems with the opioid epidemicmaternal mortality and access to mental health services, he said, it would be difficult for lawmakers to go back to their constituents and tell them why they refused to put Medicaid expansion on the ballot.

“It starts to become a bit of an embarrassment,” Johnson said. “I think we have the potential to be a leader in health care. … We have vast resources and tremendous amount of power and will when we decide to employ it.”

I agree with everything Rep. Israel and Sen. Johnson say. As you know, I’ve been beating the drum for Medicaid expansion in Texas since 2011. It’s just that there’s zero Republican support for it – Rep. Zerwas’ watered-down version went nowhere, and no one is coming up behind him with something else. A constitutional amendment, which is what a Joint Resolution is and the only way the Lege can send something to the voters, requires a two-thirds majority in each chamber to pass. It’s highly unlikely there’s a simple majority for this in the House, and zero chance of that in the Senate. What Israel and Johnson and others are doing is valuable and necessary and sure to be a big campaign issue again in 2020. What it’s not is legislation that will pass, not while Republicans are in charge.

Same sex employee benefits lawsuit tossed again

This is great, but as always that’s not the end of it.

The lawsuit dates back to 2013, when pastor Jack Pidgeon and accountant Larry Hicks sued the city to end the policy. In 2015, after the U.S. Supreme Court handed down the landmark Obergefell ruling that opened up marriage rights to same-sex couples in all states, Pidgeon and Hicks continued to pursue the lawsuit, arguing that the decision did not extend to the right to city spousal benefits.

In June 2017, the Texas Supreme Court agreed, ruling unanimously that while same-sex marriage had been made legal, there is still room for state courts to explore the “reach and ramifications” of the landmark Obergefell ruling. The all-Republican high court sent the case back to a Houston trial court for further consideration.

Nearly two years later, Judge Sonya Heath on Monday threw out the case, ruling for Houston in what the city has touted as a major win.

“This is a victory for equality, the law of our nation and human rights,” Houston Mayor Sylvester Turner said in a statement Thursday evening. “I thank our Legal Department for its diligent work defending common sense and fairness, and I’m glad we get to continue the policy established by the city 6 years ago.”

Still, that win won’t go unchallenged. Jared Woodfill, the lawyer who represents Pidgeon and Hicks, said Thursday night that his clients will appeal the ruling — and that he expects the case to land again before the Texas Supreme Court and that it could eventually be decided by the U.S. Supreme Court.

See here, here, and here for some background. There’s a bunch of blathering by Jared Woodfill in the story about how unfair it was that a Democratic judge, who ousted the Republican judge that originally gave him an injunction that was quickly overridden, got to rule on his case, while also gloating that Republican judges up the line and on SCOTUS will surely be in the bag for him. He failed to mention that the only reason this case is still being litigated is because the State Supreme Court bowed to political pressure after initially giving him the brushoff. I don’t know what will happen in this case once the appeals process starts up again, but I do know two things. One is that Woodfill and his crank case plaintiffs represent a shrinking fringe, and two is that we need to win more elections so we can pass some more robust laws protecting the fundamental rights of all Americans. (Honestly, just ensuring that no more bad legislation gets passed would be a big step forward.) Mayor Turner’s press release has more.

Anti-Obamacare ruling appealed

The big non-Mueller story to follow for 2019.

Best mugshot ever

The Democratic coalition of states battling Texas over the fate of the Affordable Care Act has formally begun the process of challenging a Dec. 14 decision ruling the law unconstitutional in its entirety.

California Attorney General Xavier Becerra, who’s leading the charge, filed a notice of appeal Thursday morning before the U.S. 5th Circuit Court of Appeals. The blue states will ask the federal appeals court to overturn last month’s ruling from U.S. District Judge Reed O’Connor, who declared that President Barack Obama’s signature health care law is unconstitutional after Congress in December 2017 gutted one of its major provisions, the individual mandate.

The notice of appeal marks the next stage of what is expected to be a long-running litigation process that could reach the U.S. Supreme Court. A Texas-led coalition of 20 states kicked the process off nearly a year ago by suing the federal government to kill the law; after the Justice Department sided partially with Texas, the California-led coalition of states stepped in to defend Obamacare in court.

“The wheels start turning as of now,” Becerra said on a press call Thursday morning.

See here and here for the background. Every legal scholar with a shred of integrity has denounced this ruling as ridiculous, but we all know that what matters is what five members of SCOTUS think is legal. One story I read about this noted that the coalition of states defending Obamacare picked up an ally after the 2018 election, the new Attorney General of Colorado. One can only wonder what might be happening today if we could have added a new Attorney General of Texas to this. Alas, we’ll have to file that under What Might Have Been.

Ridiculous anti-Obamacare ruling remains on hold

It is what it is.

Best mugshot ever

The federal judge in Texas who ruled the Affordable Care Act unconstitutional said today that the law can stand while his judgment is under appeal.

In his order issuing a stay and final partial judgment in the controversial case, U.S. District Court Judge Reed O’Connor reiterated that he believes the entire ACA cannot stand without its individual mandate penalty, which Congress zeroed out last year. O’Connor argued that appellate judges will agree with his judgment, but said it should not take effect while the case is being appealed. “[M]any everyday Americans would otherwise face great uncertainty,” he wrote.

The judge’s order means that Obamacare will likely remain the law of the land for at least another year. Depending on how the appeals proceed, it also tees up the possibility of a Supreme Court ruling on the case in 2020, during the presidential campaign.

[…]

In his new filing, O’Connor expanded his reasoning for siding with the conservative states seeking to strike down Obamacare, arguing that they have standing to bring the case. This point has been disputed, because the conservative states have struggled to show how the ACA has harmed them.

O’Connor also stressed that “courts must refrain from resolving policy disputes” created by Congress. His conclusions were widely panned, including by conservative legal scholars who maintain that O’Connor continues to misread the law and is engaging in the same judicial activism that he decries.

“I’ve been very critical of Judge O’Connor’s severability analysis, but the standing analysis in these opinions may be even worse — and that’s saying something,” tweeted Jonathan Adler, a Case Western Reserve University law professor who was a legal architect of another major ACA challenge. “I will be gobsmacked if O’Connor’s opinion survives review in the Fifth Circuit.”

O’Connor also noted that four other counts remain unresolved — signaling that even if the appeals court overturns his ruling, conservative states could find further paths to weaken the ACA. The remaining issues include challenges under the Administrative Procedures Act and the Fifth and 10th amendments.

See here for the background. Basically everyone has panned this ruling as legally unsound – I’m being kind here – and most people believe that the ruling will be reversed. I have less faith in the Fifth Circuit than that, but we’ll see. In the meantime, we can’t get a Congress and a President who are committed to providing health care for all soon enough.

Now how much would you pay for that emergency room visit?

Guess higher, and it is a guess because who knows what you’ll wind up getting charged for it.

Fifteen months after Texas enacted a law to bring transparency to the state’s for-profit free-standing emergency rooms, many of the facilities continue to send mixed messages about insurance coverage that could expose unsuspecting patients to surprise medical bills.

A Houston Chronicle review of websites representing the 52 free-standing emergency rooms in the Houston area shows a pattern in which many of the facilities prominently advertise that they “accept” all major private insurance. Some even list the insurers’ names and logos.

But often tucked under pull-down tabs or at the bottom of the page is a notice that the facilities are outside the networks of those insurers, followed by a reassurance that under the Texas insurance code, network status does not matter in emergency treatment, implying patients needn’t worry about coverage.

What the websites fail to disclose is that out-of-network status can result in insurance reimbursements far below the charges, leaving patients on the hook for the remainder of the bill — sometimes thousands of dollars.

“The word ‘accept’ means something very different to them than to the consumer, and they know that when they write their websites,” said Stacey Pogue, senior health policy analyst at the Austin-based Center for Public Policy Priorities. “They do not tell the rest of the story.”

For example, many of the Houston-area facilities advertise that they accept Blue Cross and Blue Shield of Texas, the state’s largest insurer. But the Chronicle’s review found that only five — about 10 percent — are in that insurer’s network.

Those findings are consistent with a statewide report by AARP Texas, to be released Monday at a state Senate committee hearing, that found 77 percent of the state’s 215 free-standing emergency rooms said they “take” or “accept” Blue Cross and Blue Shield insurance, but were out-of-network.

Free-standing emergency rooms defend their websites, describing concerns raised by advocacy groups and Texas lawmakers as manufactured outrage.

“I don’t see a problem with saying they ‘accept,’” said Dr. Carrie de Moor, CEO of Code 3 Emergency Partners, a Frisco-based network of free-standing emergency rooms, urgent care clinics and a telemedicine program. She insisted that patients understand that accepting someone’s insurance is different from being in that company’s network.

It may seem like a hair-splitting distinction, but it can carry high costs, health policy experts said.

Obvious point #1: It’s ridiculous that we live in a society where basic medical needs, including emergency care, are not met. It’s utterly scandalous that prior to the Affordable Care Act, there were thousands upon thousands of bankruptcies caused every year by medical issues. Plenty of other countries have figured this out. Our standard of medical care is no better than theirs. It’s just more expensive.

Obvious point #2: For those who believe in the power of the free market, why is it that medical services, especially those tied to emergency and hospital care, are so utterly opaque when it comes to their pricing? Think of all the other goods and services you buy. In nearly all of them, you know up front how much it’s going to cost. That is universally untrue for the vast majority of medical services, from basics like painkillers and bandages to anaesthesia and specialist fees to higher-end products like EKGs and colonoscopies. There’s no such thing as a free market with unknowable prices. You want to move towards something like a free market in health care, fix that.

The ACA decision

Utterly ridiculous, and likely to be short-lived.

Best mugshot ever

A federal judge in Texas threw a dagger on Friday into the Affordable Care Act, ruling that the entire health-care law is unconstitutional because of a recent change in federal tax law.

The opinion by U.S. District Judge Reed O’Connor overturns all of the sprawling law nationwide.

The ruling came on the eve of the deadline for Americans to sign up for coverage in the federal insurance exchange created under the law.

Since the suit was filed in January, many health-law specialists have viewed its logic as weak but nevertheless have regarded the case as the greatest looming legal threat to the 2010 law, which has been a GOP whipping post ever since and assailed repeatedly in the courts.

The Supreme Court upheld the law as constitutional in 2012 and 2015, though the first of those opinions struck down the ACA’s provision that was to expand Medicaid nationwide, letting each state choose instead. No matter how O’Connor ruled, legal experts have been forecasting that the Texas case would be appealed and could well place the law again before the high court, giving its conservative newest member, Justice Brett Kavenaugh, a first opportunity to take part.

Not mentioned in this story, as it came out very quickly after the ruling was released late Friday afternoon (*), is that the judge also denied the plaintiffs’ request for an injunction. This means that the ruling, which is so absurd that even conservative legal experts who oppose the ACA were appalled by it. What happens next is a bit unclear – there will of course be an appeal, and this will almost certainly go to SCOTUS – but for now this is mostly a big legal turd in the punch bowl. Enjoy that health insurance while you can, sure would be a pity if something happened to it. The Trib, Nicholas Bagley, and Daily Kos, among many others, have more.

The AG race and the lawsuit to kill Obamacare

I feel like this is a better issue for Justin Nelson than it is for Ken Paxton. Of course, on the down side, for it to really be salient millions of people will have lost health insurance. Not that Ken Paxton cares, of course.

Justin Nelson

Can a Texas-led lawsuit to kill Obamacare boost Democrats even in deep-red Texas?

Justin Nelson sure hopes so. The well-credentialed Austin lawyer is challenging the architect of that case, incumbent Republican Texas Attorney General Ken Paxton, in this fall’s general election, betting that the controversial case can help him overcome the partisan disadvantage that’s proved insurmountable for statewide Democratic candidates for the past two decades.

In February, Paxton — who was indicted in 2015 for securities fraud and has not yet gone to trial — launched a 20-state challenge to the landmark health care law, arguing that after Congress gutted the individual mandate, the rest of the law is unconstitutional and must fall. Critics have cast doubt on the case, from its motivations — many argue it’s rooted partisan politics, not genuine constitutional concerns — to its legal arguments.

As the lawsuit comes into play in races across the country, Nelson’s campaign has seized on it as perhaps its best bet at victory. Focusing on protections for pre-existing conditions — one of the most popular provisions of Obama’s landmark health law — Nelson has framed the lawsuit as his opponent’s attempt to wrench health care away from Texas’ most vulnerable residents. The Democrat brings the issue up almost as often as he cites the criminal charges against his opponent.

Republicans have been running against Obamacare practically since before it passed. But now, as they butt up against a midterm election season widely considered friendly to the Democrats, the issue may be becoming an advantage on the other side. Polling from the Kaiser Family Foundation shows that 75 percent of Americans consider protections for pre-existing conditions “very important.”

[…]

Brendan Steinhauser, a Republican strategist, said the Texas-led lawsuit is “creating a microscope” on a statewide race that tends to fly under the radar.

“To some extent, sure, yes, it keeps the name in the news in a positive way among [Paxton’s] base,” Steinhauser said. But it’s also “giving the Democrats something to use,” he added.

Nelson has pledged to withdraw from the lawsuit on his first day in office. Earlier this month, his camp hosted a protest in a park across the street from the Fort Worth courtroom where Paxton’s staff was asking a federal judge to block Obamacare nationwide. Dozens of protesters wielded signs with messages like “Why Oh Why Are You Killing Me?” and one protester dressed as the grim reaper.

The issue is clearly speaking to voters, Nelson said.

“People come up to me at events and hug me for what I’m doing, speaking out on protections for pre-existing conditions,” Nelson said.

His campaign claims the numbers bear that out. In internal polls, just over half of likely voters had either “serious doubts” or “very serious doubts” about Paxton’s efforts to roll back Obamacare’s protections, a spokeswoman said. Once voters are briefed on Paxton’s background, including on the indictment, she added, Nelson pulls ahead by a small margin.

A Paxton campaign spokesman said the incumbent carries a consistent 10-point lead in his campaign’s polling.

See here, here, and here for the background. I can believe that both candidates’ polling is accurate, or at least plausible. Nelson’s depends on people being aware of the Paxton-led lawsuit and its effect. An injunction from the judge would accomplish that, though I think the judge will heed the request to hold off till after the election. Wouldn’t want to get the rabble all roused up, after all. As the story notes, this lawsuit has been an issue in elections in other states. Breaking through here is harder – dozens of media markets, lots of oxygen being consumed by other races, not that much money in this race, etc – but a little media coverage can’t hurt. The more, the better.

The hearing for the lawsuit to kill Obamacare

Here we go again.

It’s constitutional – deal with it

At the hearing Wednesday, Texas aimed to convince U.S. District Judge Reed O’Connor to block the law across the country as it continues to fight a months- or years-long legal case that could land before the U.S. Supreme Court.

Citing rising health care premiums, Texas says such an injunction is necessary to preserve state sovereignty and to relieve the burden on residents forced to purchase expensive insurance coverage. California counters that temporarily blocking or ending the law would cause more harm to the millions of people insured under it, particularly the 133 million people the state says enjoy the law’s protections for pre-existing conditions. The U.S. Department of Justice, which has taken up many of Texas’ positions in the case, nonetheless sided with California, arguing that an immediate injunction would throw the health care system into chaos.

[…]

Inside the courtroom, where protesters’ shouts were inaudible, Darren McCarty, an assistant attorney general for Texas, argued that “the policies, the merits of the ACA are not on trial here” — just the legality. In that legal argument, McCarty leaned heavily on a 2012 U.S. Supreme Court decision on Obamacare, which upheld the law by construing the “individual mandate,” a penalty for not purchasing insurance, as a tax that Congress has the power to levy. Texas argues that after Congress lowered that fee to $0 in a slate of December 2017 tax cuts, the fee is no longer a tax and thus no longer constitutional. With it must go the rest of the law, the state claims.

“There is no more tax to provide constitutional cover to the individual mandate,” McCarty said. “Once the individual mandate falls, the entire ACA falls.”

California countered that a tax can be a tax even if it doesn’t collect revenue at all times. And, attorneys for the state claim, even if the individual mandate is unconstitutional, the court should let lie “hundreds of perfectly lawful sections,” argued Nimrod Elias, deputy attorney general for California.

The case will likely turn on that question of “severability”— whether one slice of a law, if ruled unconstitutional, must necessarily doom the rest. O’Connor, who nodded along carefully throughout the hearing, lobbed most of his questions at the California attorneys, and many of them focused on whether the various pieces of Obamacare can be unentangled.

Elias said that in the vast majority of cases, the Supreme Court acts with “a scalpel, not a sledgehammer,” leaving in place most of a law even if one provision must be struck. The Texas coalition pointed to a more recent case in which the high court struck an entire law based on a narrow challenge.

O’Connor — a George W. Bush-appointee who has ruled against Obamacare several times, albeit on narrower grounds — also honed in on the question of legislative intent. Texas argued that the individual mandate was a critical piece of the law’s original version. But California argued that in 2017, in gutting the individual mandate without touching the rest of the law, lawmakers made it clear they wanted the law to persist without that provision.

“Would the legislature prefer what is left in statute to no statute at all?” Elias questioned. “We know what Congress intended based on what Congress actually did.”

See here and here for some background. Justin Nelson was at the hearing as well, pressing his attack on Paxton for his ideological assault on so many people’s health care. That really deserves more coverage, but the fact that most everyone outside of Paxton’s bubble thinks his legal argument is ridiculous is probably helping to keep the story on a lower priority. (Well, that and the unending Wurlitzer shitshow that is the Trump administration.) I mean, I may not be a fancypants lawyer, but it sure seems to me that eight years of Republicans vowing to repeal Obamacare plus the entire summer of 2017 trying to repeal Obamacare plus the abject failure to repeal Obamacare would suggest that the Republicans did not intend to repeal Obamacare with the bill that they finally did pass. If they could have they would have, but they couldn’t so they didn’t. I don’t know what else there is to say, but we’re going to have to wait till after the November elections – wouldn’t be prudent to do that before people voted, you know – to find out what this hand-picked judge thinks. Ken Janda, the Dallas Observer, and ThinkProgress have more.

Nelson attacks Paxton over Obamacare lawsuit

Good.

Justin Nelson

The Democrat challenging Ken Paxton is denouncing the attorney general for suing to wipe out the Affordable Care Act‘s health care protections for Americans with pre-existing conditions.

Justin Nelson, a Houston attorney, plans to hold a rally outside the federal courthouse in Ft. Worth where Paxton’s team will argue its case next week. He’s also launched a webpage urging Texans to share how axing the ACA, also known as Obamacare, will affect their access to health care.

“Paxton is leading the charge to take away pre-existing condition protections not just from all Texans but from all Americans and that is so wrong,” Nelson said in a video message Monday. “We’ve started the hashtag, #MyPreExisting, and on this website you can click on the button below and record your video. Tell us how you are affected in this life and death issue.”

Nelson’s campaign website also includes a list of common pre-existing conditions, like arthritis, sleep apnea and pregnancy. Texans with these conditions and many others could see higher health care costs if the Obamacare protections are rescinded.

[…]

About 27 percent of non-elderly Texans — or around 4.5 million people — have pre-existing conditions that could result in them facing difficulty obtaining insurance if Obamacare is overturned, according to the Kaiser Family Foundation. More than 52 million Americans fall into this category, 20.7 million of whom live in the 20 states suing to end the pre-existing condition protections.

In addition to Texas, officials from Alabama, Arkansas, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Utah, West Virginia and Wisconsin are parties to the Obamacare lawsuit.

See here and here for the background. You can feel however you want to feel about Obamacare and Ken Paxton and whatever else, but something that would affect this many people in such a direct fashion ought to be part of the discussion in an election year. Good for Justin Nelson for doing that.