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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.

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.

Just a reminder, CHIP is still running out

In case you were wondering.

Nearly 400,000 Texas children could lose healthcare coverage in late January unless Congress renews funding for the Children’s Health Insurance Program, a decades-old federal program that provides health care to millions of children across the country.

Texas officials have asked the federal government for $90 million to keep CHIP alive through February, but without that funding, letters could go out later this month from state officials alerting parents that their children’s benefits could be at risk.

Congress allowed the program to expire on Sept. 30, leaving Texas and other states with dwindling coffers. CHIP typically receives bipartisan support, but lawmakers have failed to agree in recent months on how to fund it.

“We’re closely monitoring congressional efforts to reauthorize the program and are hopeful that it will be extended prior to the exhaustion of our current allotment,” said Carrie Williams, a spokeswoman with the Texas of State Health Services. “Based on our conversations with [Centers for Medicare and Medicaid Services] … we are confident that a redistribution of funds will happen.”


If the state doesn’t get additional funding soon, it will have to begin shutting down the program, officials said. State law requires termination notices go out to parents a month before they lose coverage; those letters would likely go out days before Christmas.

Catherine Troisi, an infectious disease epidemiologist at the University of Texas School of Public Health in Houston, said many children on CHIP have chronic diseases and rely on regular, monthly appointments.

“That’ll put a lot of stress on families who don’t know if they are going to be able to continue to get that kind of care,” she said.

Unlike other states, Texas doesn’t currently have any plans to fund the program. If the state runs out of money, it will send all CHIP recipients to the federal government’s health care marketplace.

See here and here for the background. This is 100% the fault of Congressional Republicans, who let this lapse during their months-long obsession with Obamacare repeal. They’re not paying attention to it now because of the need to cut taxes for millionaires. Better grow up to be rich, kids. It’s your only hope.

By the way, CHIP is still running out

Just in case you were wondering.

Advocates say Texas will run out of funding for the Children’s Health Insurance Program sooner than they thought. The program, which Congress failed to reauthorize last month, covers nearly 400,000 children from working-class families in the state.

“It’s expected that Texas will run out of CHIP funding in January,” said Adriana Koehler, a policy associate with the advocacy group Texans Care for Children. “With the holidays coming up in the next few months, we really need Congress to get the job done now.”

Just a few months ago, advocates said it was unclear when the state would run out of CHIP funds. Some advocates expected the state had until next September; others said funds would run out in February.

Carrie Williams, a spokesperson with the Texas Health and Human Services Commission, said the funding could run out as early as January.

Williams said the agency pushed up the timeline because of reduced income from co-pays. After Hurricane Harvey hit, the federal government waived co-pays and enrollment fees for CHIP recipients. That meant less money was coming into the program than expected.

“So funds may be exhausted a bit sooner than February,” she said.

See here for the background. One might think that such a fanatically and performatively “pro-life” state like Texas would be full of leaders who would care deeply about 400,000 children losing access to health care, but one would have to be deeply naive to believe it. At this time, it looks like the best bet for action will be CHIP reauthorization as a part of a successful government shutdown hostage negotiation. There’s a sentence I hope I never have to type again. Remember when we had a government that was interested in actually, you know, governing? Those were the days, I tell you.

Sure would be nice if we could not kill CHIP

Just a thought.

Insurance coverage for more than 390,000 Texas children and pregnant women is in jeopardy after Congress failed to renew authorization for a federal program.

Congressional authorization for the Children’s Health Insurance Program, which provides low-cost health insurance for children from low- and middle-income families, expires Sept. 30.

Without federal funding, Texas has enough money for CHIP to last until February 2018, according to estimates by the Texas Health and Human Services Commission. However, federal lawmakers say they’re working on a plan to continue the program before funding runs out for Texas.

“States don’t want to have to disenroll their kids,” said Maureen Hensley-Quinn, senior program director at National Academy for State Health Policy, a non-partisan group that advises states on health policy. But “there may come a time when [they] have to send families letters” letting them go.

Some other states are in worse shape than we are, not that that’s much consolation. You’d think it would be – what’s that word? – pro-life to not want a program that keeps 400,000 children healthy to not go down the budgetary toilet. I’d feel more reassurance if there were some public statements about this from state leaders, but you know how that goes. As a wise man once said, hold on to your butts. TPM and the Chron have more.

Of course Obamacare repeal would have a big negative effect on Texas

I mean, duh.

Right there with them

As many as a half-million Texans could become uninsured under the Republican plan to replace the Affordable Care Act, wiping out at least half the gains the state has made in reducing the number of uninsured residents in recent years, according to health care analysts.

Texas still has the nation’s highest percentage of people without health insurance, but that uninsured rate has dropped significantly, falling to about 19 percent from 26 percent over the past four years. About 1 million more Texans gained coverage under the health care overhaul known as Obamacare, which became law in 2010.

Under the Republican plan to repeal and replace the health care law, 500,000 could lose coverage by 2020, either through changes in federal assistance to purchase coverage and Medicaid, the government health care program for the poor, or the end of individual mandates that require people to have insurance, said Ken Janda, president and CEO of Community Health Choice whose company offers insurance plans on the federal exchanges.

Analysts such as Vivian Ho, health economist at Rice University’s Baker Institute for Public Policy, advocates like Elena Marks, CEO of Houston’s Episcopal Health Foundation, and insurers, such as Molina Healthcare, confirmed Janda’s estimates.

“Certainly, Texas is going to have more uninsured people again,” Janda said. “I don’t see much positive coming out of Congress.”


Dr. Mario Molina, CEO of the California-based Molina Healthcare, a Fortune 500 company, said in an interview he cannot yet commit that his company will be in the Texas market next year on the exchange because of the uncertainty that currently exists surrounding the promise to repeal and replace the ACA. Currently his company is one of only three insurers who offer ACA coverage in Houston.

“I am very nervous,” he said. “There is little that Congress has done so far that indicates the insurance market will be stable.”

Blue Cross and Blue Shield of Texas, which offers plans on the exchange in every Texas county, including Harris, also expressed concerns about the uncertainty of federal health care policy.

“It’s imperative that we have market stability and regulatory certainty,” the company said in an emailed statement. “We will make decisions about our product offerings for 2018 once we have more information about any legislative or regulatory changes that will be made impacting the individual health insurance markets.

Health care providers, meanwhile, worry what will happen if hundreds of thousands of Texas residents lose insurance. Katy Caldwell, executive director of Houston’s Legacy Community Health, which serves many low-income patients, said fewer insured patients will mean longer wait times as clinic staff become overwhelmed. But a jump in the uninsured rate would create more than inconvenience, she said.

“The thing that really concerns me is people foregoing their medication. I hear it all the time now: ‘I have to choose between food and my medicine’ or ‘I cut my pill in half because I can make a 30-day supply last 60 days,'” Caldwell said. “This has every potential to get worse.”

Honestly, I think that half million estimate is very much on the low end, possibly the optimal scenario under the Ryan bill, which to be sure has no obvious path forward at this time. The provision that would not only freeze Medicaid enrollments but prevent anyone who fails to re-enroll for any reason from ever re-enrolling would surely force many more people off, just as the six-month re-enrollment period for CHIP that was passed by the 2003 Legislature contributed to so many more children going without health insurance. And all that is before we consider the possible chaos in the broader healthcare market. So yeah, if a few years from now we come out of this with only a half million people having lost coverage, I’d consider that to be better than I expected.

Let’s please get the children covered

Surely that’s not too much to ask.

It's constitutional - deal with it

It’s constitutional – deal with it

Five nonprofit organizations and community groups in Texas, including three in the Houston area, have been awarded a combined $4.78 million by the Centers for Medicare and Medicaid Services to boost efforts to enroll the state’s nearly three-quarters of a million uninsured children, the federal agency announced on Monday.

Texas leads the nation not only in the number of overall uninsured but also in the number of children under age 18 who lack health insurance coverage. More than one in 10 Texas children 18 and younger remain uninsured, according to an U.S. Census analysis and other studies.

The awards to Texas organizations are designed to get more eligible children enrolled in Medicaid and the Children’s Health Insurance Program, commonly known as CHIP.

The Texas groups receiving funds are Gateway to Care, a Houston-based collaborative assisting in access to health care; Lone Star Legal Aid, also of Houston; Children’s Defense Fund-Texas in Bellaire; the Bexar County Hospital District’s University Health System in San Antonio; and the Community Council of Greater Dallas.

Surely we can all agree that having healthy children is in everyone’s best interest. That means ensuring that all children have access to health care, including dental care, which in turn means getting all eligible children enrolled in CHIP. The return on the investment is pretty good, but beyond that, it’s just the right thing to do. This is a concrete and relatively inexpensive thing we can do for the children that we claim as a society to value. You would think that for the political party that is obsessed with “unborn” children and imaginary predators in public bathrooms, that enrolling as many eligible children as possible in CHIP would be a no-brainer. Sadly, that self-proclaimed concern form children never seems to extend that far. It’s a good thing we have the federal government and a passel of caring non-profits to step in and fill the gap.

More kids in Texas have health insurance now

Thanks, Obama!

It's constitutional - deal with it

It’s constitutional – deal with it

The number of uninsured children in Texas fell by almost 100,000 during the first year of full implementation of the Affordable Care Act, signalling a potential trend across all age groups, a new study by the Robert Wood Johnson Foundation finds.

The findings were welcomed in a place with stubbornly high uninsured rates, particularly among the poor and racial and ethnic minority groups.

“This is good news. Texas is a state with a comparably young population, so the more of them that are insured the bigger the impact for the entire population,” said Elena Marks, president and CEO of Houston’s Episcopal Health Foundation.

The thought is that as parents find coverage options for their children they are more likely to learn about coverage options for themselves, which will lead to higher overall coverage rates.

In 2013, as the health-care law took hold, 977,000 Texas children were without coverage, the new research shows. That equates to 13.2 percent of the state’s under-18 population. By 2014, that uninsured rate had fallen to 11.8 percent.


Typically children are insured in greater numbers than adults since states, including Texas, offer safety net coverage through the Children’s Health Insurance Program, also known as CHIP, which provides low-cost insurance for children whose parents earn too much to qualify for Medicaid or do not have other coverage.

“Despite the politicking around health policy lately, I think we can all agree that coverage for kids is essential for their healthy development and to get a healthy start in life,” Katherine Hempstead, who directs health insurance issues for the Robert Wood Johnson Foundation, said in an interview Monday.

Despite the gains, 880,000 Texas children – the highest number nationally – still have no coverage.

That includes 533,000 Hispanic children, Guerra-Cardus said. She added that 94 percent of those are U.S. citizens.

The Robert Wood Johnson study shows nearly half of the nation’s 5 million uninsured children live in Texas and five other states: California, Florida, Georgia, Arizona and New York.

The research provides a baseline to track future children’s coverage trends, Hempstead said, adding that the report will be duplicated next year.

I couldn’t find a copy of the study when I looked, but there was a lot of news coverage of it out there when I googled around. It goes without saying that having healthy children is one of the best investments that a society can make, but then our state government threw 250,000 kids off of CHIP in 2003 in the name of “fiscal conservatism”, so I guess it doesn’t go without saying. There’s a reason why the reforms of the Affordable Care Act have had such a profound impact in Texas – there was so, so much that needed to be done. And as long as the current crew is in charge, there’s still so much more left to do.

Expand Medicaid or else

Turns out the federal government has more leverage over Texas than you might think.

It's constitutional - deal with it

It’s constitutional – deal with it

If Texas wants to keep receiving billions of federal dollars to help hospitals care for uninsured patients, state lawmakers may have to look again at expanding Medicaid coverage for impoverished adults, some political observers say.

That’s because in 2016, Texas will have to ask the federal Centers for Medicare and Medicaid Services to renew a five-year waiver to pump $29 billion into state health care coffers.

Since landing its first such waiver in 2011, Texas leaders have defiantly refused to expand Medicaid as envisioned under the Affordable Care Act, leaving more than 1 million impoverished Texans with no health insurance.

With the waiver renewal nigh, observers said, there’s some expectation that the federal agency will hold the waiver approval hostage in exchange for Medicaid expansion.

“CMS is going to hold that over Texas’ head to say, ‘You want this money? You do the expansion,’” said Matt Salo, executive director of the National Association of Medicaid Directors. “It’s one of the points of leverage that CMS now has.”

Texas received the 2011 Medicaid waiver in part to reimburse hospitals for care provided to patients who couldn’t pay. Two years later, state leaders under Gov. Rick Perry declined to expand Medicaid, criticizing the program as inefficient.

That left a “coverage gap” of more than 1 million Texans too poor to receive federal subsidies for private health insurance but too rich to qualify for coverage under Texas’ current, restrictive Medicaid requirements.

Now, policy analysts on the left and right say, the feds are likely to be less sympathetic to Texas’ request for another waiver to help pay for uncompensated care.

A similar tug-of-war is playing out in Florida, said Joan Alker, executive director at the Center for Children and Families at Georgetown University. In May, the federal government renewed Florida’s waiver to reimburse hospitals for just one year, rather than the standard three, “which was very unusual,” Alker said.


State Rep. John Zerwas, R-Richmond, one of the lawmakers who advocated for the “Texas solution,” said the Legislature would revisit coverage expansion during the session.

“It still behooves us as a Legislature to figure out, what’s the policy going to be around these people?” he said. “I’ll be the first to say that finding a solution for these million and a half people is important.”

And the transformational waiver from 2011 is already a source of some conflict with the federal government. CMS is currently withholding $75 million in waiver money that Texas used to reimburse private hospitals while federal officials review whether any rules were broken.

Tiffany Hogue, policy director for the Texas Organizing Project, which has worked to get Texans to sign up for health coverage on the exchange, said Medicaid expansion would be a top priority for her group during the legislative session.

“It’s absolutely going to be a battle cry for us,” she said. “The sheer number of uninsured — that’s daunting.”

Still, Alker said she was skeptical that Texas would expand Medicaid anytime soon.

“I remind myself when the Children’s Health Insurance Program was passed in 1997, Texas was the last state in the country to pick up the program,” she said. “That may be instructive moving forward.”

It’s always a safe bet to assume that the Legislature will fail to do the right thing when given the chance. I for one will be rooting for the feds to apply the screws as hard as they can in pursuit of a Medicaid expansion deal that would do untold amounts of good for more than a million people, not to mention be a nice bit of stimulus for the Texas economy. Making Ted Cruz’s head explode would be the cherry on top. Against that, when the Republicans from Greg Abbott on down (with the honorable exceptions of Zerwas et al) dig their heels in, perhaps this will finally be the impetus to get the Texas Medical Association to quit trying to placate the bullies and start working to actually further their own and their patients’ best interests.

Expanding Medicaid the hard way

A lot smaller than it should have been, but it’s still something.

It's constitutional - deal with it

It’s constitutional – deal with it

More than 80,000 additional Texans have enrolled in Medicaid or the Children’s Health Insurance Program since the rollout of the Affordable Care Act last fall despite Republican state leaders’ decision not to expand eligibility to poor adults, according to federal figures.

The 80,435 new enrollees as of May — mostly Texans who already qualified for coverage but did not previously seek it — represent a 1.8 percent increase over pre-Obamacare figures. That places Texas, which has the nation’s highest uninsured rate, in the middle of the pack among states that chose not to expand access to those programs to everyone under 138 percent of the federal poverty line under the president’s signature health law. The expansion, a key tenet of Obamacare, was deemed optional by the U.S. Supreme Court.

This “woodwork effect” or “welcome mat effect” — in which people hear about Medicaid expansions around the country and learn they qualify in Texas — has not been huge. Roughly 874,000 Texans eligible for Medicaid or CHIP have still not enrolled, according to Kaiser Family Foundation estimates. That includes more than 700,000 children, said Christine Sinatra, state communications director for Enroll America, a group seeking to get the uninsured covered under the federal health law.

Stephanie Goodman, spokeswoman for the Texas Health and Human Services Commission, said her agency started seeing enrollment rates rise a couple of years ago, when the conversation on Obamacare was heating up. After the act took effect, and parents took to the federal marketplace to purchase private insurance plans, many discovered that their children were eligible for Medicaid, Goodman added.


Get Covered America and Enroll America, which are leading the charge to bring more people into the coverage fold across the country, also cited the Affordable Care Act’s simplification of the sign-up process as a driver of Texas’ recent enrollment growth, which took off in the spring.

And though Texas leaders did not expand Medicaid, the criteria for eligibility here and elsewhere did broaden slightly: The act raised from 21 to 26 the age at which people formerly in the foster care system have to give up their Medicaid coverage.

Absent the Medicaid expansion that Texas chose not to join, Medicaid and CHIP eligibility in the state is generally limited to members of several vulnerable groups, including children under 200 percent of the federal poverty line and some low-income seniors, pregnant women and parents, Sinatra said.

Texas has historically put up a lot of obstacles to enrollment in Medicaid and CHIP. In addition to the exceedingly stingy income requirements, there has been a six-month enrollment period at times, meaning you have to sign up twice a year. The state, and in particular the Republican leadership, does all this in a deliberate effort to keep enrollment down, since that allows for less spending. By the state, anyway – sucks to be you, counties and hospital districts. I for one would consider it justice if every currently eligible person managed to get themselves enrolled, however much it wound up costing the state. We’d be far better off overall regardless of the price. Texas Leftist has more.

Texas insurance enrollment update

Enrollments are up and the number of uninsured are down, though both could have been a lot better.

It's constitutional - deal with it

It’s constitutional – deal with it

The sky-high rate of Texans without health insurance has dropped only slightly since the launch of the federal Affordable Care Act’s online health insurance marketplace, according to a new report from Rice University’s Baker Institute for Public Policy and the Episcopal Health Foundation.

During the open enrollment period from September through March, the rate of uninsured adults in Texas fell to 23.5 percent from 24.8. And most of that change was attributable to an increase in employer-sponsored health coverage, the report found, rather than new signups in the federal marketplace.

Texas’ decline in the rate of its uninsured was commensurate with those in other Republican-led states that elected not to expand Medicaid to cover poor adults. But while the number of Texans applying for coverage in the online marketplace — about 746,000, according to the report — pales in comparison to the more than 5 million who lack insurance, ACA proponents may see reason for optimism, the authors wrote. The 746,000 figure represents a significant increase in Texas enrollments from the 295,000 reported by the federal government as of March 1.

“You look at the absolute numbers and say, ‘Wow! This is a good start,’” said Vivian Ho, a co-author.

The report, which draws its conclusions from survey data rather than figures that are gradually being released by the U.S. Department of Health and Human Services, offers new insight into what kinds of people are signing up for insurance under the ACA.

For example, only about 30.2 percent of those seeking coverage in the online marketplace were previously uninsured, researchers found. Employer-provided health insurance seemed to be responsible for the biggest drop in the uninsured.

“If I had to guess, a large portion of that is just the upswing in the economy,” Ho said. “There are more people getting jobs.” But she added that some businesses are also preparing to comply with the upcoming coverage mandate for their employees, offering low-cost insurance options for low-wage workers, a trend that may be reflected in the data.

We also now have some specific information about Houston enrollments.

Meanwhile, in an unrelated report, the Associated Press found more than 177,000 Houston residents signed up for health coverage, exceeding expectations and indicating a last-minute enrollment push just before the March 31 deadline might have helped Texas meet projected targets despite months of lagging.

The news service, citing an email by Marjorie McColl Petty, the Department of Health and Human Services’ Dallas regional director, and obtained by the Associated Press, reported that as of April 5, some 177,825 Houston residents signed up for coverage. A previous email by Petty said that as of March 29, 149,273 Houston residents had signed up for insurance, the AP said.

The expectation had been that 138,000 Houston residents would sign up.

You can see the Baker Institute report here. This answers some of the questions raised in my earlier post, though the Kaiser numbers have not yet been updated. As noted, there’s no official tally of who does or does not have health insurance in Texas. We’ll have the enrollment totals, and I presume HHSC has Medicaid and CHIP numbers, but beyond that it’s all estimates and speculation.

We all know how this has gone down in Texas, where the party line from the Republican leadership has been one of unrelenting hostility and obstacles. Not surprisingly, in states like Texas the ranks of the uninsured decreased at a lower rate than in states that are not run by heartless assholes. With the grace period for people who began but were unable to complete the enrollment process now over, the official tally for enrollees is eight million. That doesn’t count state exchanges, Medicaid expansions, the under-26 set that can be on their parents’ insurance, or people who will now have insurance through their employers; the grand total is at least 14 million, and counting. And it could have been so much more.

Opponents of the ACA said the report spelled bad news for President Obama’s signature health law. John Davidson, a policy analyst for the conservative Texas Public Policy Foundation, called the number of previously uninsured people who signed up for coverage on the exchange a “drop in the bucket” compared to Texas’ total uninsured population.

“I believe that cost is driving these numbers,” Davidson said. “Coverage on the exchange is very expensive, and it’s expensive even if you get a subsidy, in many cases.” He compared the report’s projection that 746,000 Texans had enrolled in the marketplace to a recent HHS brief that estimated that 2.2 million Texans could qualify for subsidies.

“Something’s going on there,” Davidson said. “Why so few?”

I’m going to be charitable and not assume that the oft-quoted token Davidson is sufficiently stupid as to be genuinely baffled. The organization for which he is employed is a malignant force in Texas, but they are quite clear-eyed about their goals. He knows what the truth is, and he knows what his role in relation to it is. The real question is why the Tribune, or any self-respecting news organization, thinks there is value in including his disinformation. Why do you think it’s a good idea to let someone lie to your readers, Evan Smith? I can’t think of a good reason for that. The LA Times has more.

What the ACA does, Texas has long done

By now you’ve surely heard about the CBO report on the Affordable Care Act and the workforce, which despite some terribly botched reporting does have a lot of political considerations. There’s something I’d like to point out about this before we get too bogged down in attack ads. Let’s start with Kevin Drum putting a name to the reason behind the effect on the workforce.

It's constitutional - deal with it

It’s constitutional – deal with it

Obamacare will reduce employment primarily because it’s a means-tested welfare program, and means-tested programs always reduce employment among the poor.


If, for example, earning $100 in additional income means a $25 reduction in Obamacare subsidies, you’re only getting $75 for your extra work. At the margins, some people will decide that’s not worth it, so they’ll forego working extra hours. That’s the substitution effect. In addition, low-income workers covered by Obamacare will have lower medical bills. This makes them less desperate for additional money, and might also cause them to forego working extra hours. That’s the income effect.

This is not something specific to Obamacare. It’s a shortcoming in all means-tested welfare programs. It’s basically Welfare 101, and in over half a century, no one has really figured out how to get around it. It’s something you just have to accept if you support safety net programs for the poor.

Kevin expands on his thesis here. The point is simple enough – for people at a certain income level, a raise in income can mean a significant reduction in a benefit like the ACA exchange subsidies, or even the loss of eligibility for that benefit at all. That was touted as an advantage to the Arkansas option for expanding Medicaid, as it would help avoid the situation where people near the line for eligibility see their status swing back and forth. In addition, the decoupling of health insurance from employment was a feature of John McCain’s health care plan from 2008, back before Obamacare made increasing access to health insurance an evil that threatened Ted Cruz’s manhood.

Which brings me to Texas. What does this have to do with Texas? Very simply, Texas has done means testing for its Children’s Health Insurance Program (CHIP) since 2003. Allow me to quote myself from 2006, when restoring cuts to CHIP was a campaign issue in that year’s gubernatorial race.

The point of CHIP is to provide a benefit for lower-income working families. It’s not Medicaid. It’s a program to give health insurance to the children of people who couldn’t otherwise afford it. Before HB2292 in 2003, it didn’t have an asset test, which means that those families could try to put some money aside to save for their kids’ future college educations without it costing them their CHIP eligibility. Not any more: As of 2003, CHIP families with incomes at 150% of the federal poverty level can have no more than $5000 in total assets before losing CHIP. That includes savings, and most frustratingly, automobiles. There’s a $15,000 exemption for a first car, and a $4650 exemption for a second, meaning that a family in which both parents work, one of them had better be driving a junker (or not driving at all) or it’ll go against their ability to get health insurance for their kids. And you better hope your kids qualify for scholarships some day, because you can’t save for their tuition costs.

In that post, I’m summarizing a document provided by Rep. Garnet Coleman, which you can see here, that explained the changes made to CHIP eligibility in 2003 that were passed by the Republican legislature and signed by Rick Perry. It should be noted that these changes were made with the express purpose of booting kids off of CHIP, which is a horrible thing to do and awful, self-harming public policy. But at the margins, it likely had the same effect that the CBO is describing for the ACA. If you had been receiving CHIP and were near the eligibility boundary when the new restrictions were put in place, you might well consider doing things to reduce your household’s level of employment in order to maintain that very needed benefit for your kids. Options would include cutting back on your hours, giving up a second job, having one spouse or the other quit their job, and so on. The means testing requirements have shifted around since then, but they’re still there. I don’t see anyone freaking out over it, if they’re even aware of it.

Anyway. It’s true that some people will quit working now that they can continue to be eligible for health insurance. As many people have pointed out, they’re doing so because they’re better off now. We generally consider that to be a Good Thing. CBO projections aside, the overall effect on the labor market remains unclear, and will no doubt be studied to death in the next decade. But the claim that the CBO report means that Obamacare is “killing jobs” is a flat out lie, one that even some opponents of the law understand.

ACA enrollments in Texas

As was the case with the rest of the country, there was a big surge in December.

It's constitutional - deal with it

It’s constitutional – deal with it

Texas enrollments in the online insurance marketplace created under the Affordable Care Act rose nearly eightfold in December, according to 2013 figures that the U.S. Department of Health and Human Services released Monday.

Texas ranks third in the number of 2013 enrollments following the troubled launch of on Oct. 1. As of Dec. 28, nearly 120,000 Texans had purchased coverage in the federal marketplace, up from 14,000 one month before.

The number represents a tiny fraction of the uninsured in Texas, which has a higher percentage of people without health coverage than any other state. In 2012, more than 6 million Texans, about 24 percent of the population, lacked health insurance, according to U.S. census data.

Florida led the nation in the number of 2013 enrollments, with 158,000. In a media call from Tampa, U.S. Health and Human Services Secretary Kathleen Sebelius praised Florida’s high enrollment numbers. Like Texas, Florida has a largely unfavorable political climate toward the Affordable Care Act, and a high rate of the uninsured, at 21 percent. HHS officials offered no explanation for why more people enrolled in some states compared with others.

“The numbers show that there is a very strong national demand for affordable health care made possible by the Affordable Care Act,” Sebelius said in the call announcing the enrollment data, adding that nationwide enrollment had reached nearly 2.2 million.

The Better Texas Blog breaks the numbers down further.

  • 457,382 individual Texans applied for coverage with completed applications, revealing a high level of interest in Marketplace coverage;
  • 390,658 Texans were determined eligible to enroll in a Marketplace plan, and 180,349 Texans were found eligible for financial assistance in the Marketplace. Many of the 210,000 Texans who are eligible to buy in the Marketplace, but ineligible for subsidies likely fall into the “coverage gap” created when Texas leaders refused federal funds to expand health care coverage through Medicaid to Texas adults below the poverty line;
  • 47,177 Texans were assessed eligible Medicaid/CHIP by the Marketplace (a number that would be much higher with Medicaid expansion);
  • 55 percent of Texans who chose a health plan are women; and
  • 26 percent are between the ages of 18 and 34. Young adults are enrolling in the Marketplace, and previous experience from Massachusetts indicates that enrollment by this age group will increase as we near the March 31 enrollment deadline.

These numbers prove that the law and its website are working–more Texans are able to apply for and select health plans that fit their budgets. (Read about our intern’s experience enrolling in a Marketplace plan). People can enroll in the Marketplace through March 31, 2014.

There’s still a lot more growth to come, in other words. Progress Texas adds on.

Ed Espinoza, Executive Director of Progress Texas, released the following statement:

Twelve weeks of ACA has done more to help Texans without health care than Rick Perry has done in twelve years as Governor.

…Texas Still Has a Significant Coverage Gap

In addition to the top-line numbers, a little digging shows how Rick Perry and Greg Abbott’s refusal to expand Medicaid has created a significant coverage gap in Texas:

  • 210,309 Texans who applied for coverage could have received financial assistance for the Marketplace plans.

Many, if not most, of those 210,000+ Texans who couldn’t get financial assistance would have been covered if Texas had expanded Medicaid. We know that one million low-income Texans are left out of health coverage because elected leaders in Texas chose politics over what was right for our people.

Just imagine how many more people could be getting coverage if Rick Perry wasn’t doing everything in his power to stand in the way. Several Texas Congressional Democrats have now sent a letter to AG Eric Holder asking him to step in and do something about Texas’ ridiculous navigator rules, but I don’t really expect anything to come of that. For more on the national numbers, see Jonathan Cohn, TPM, Sarah Kliff, and Ezra Klein.

Supplement this!

Time for the Lege to pay a few past-due bills from 2011.

That’s where a supplemental budget comes in. It is literally a second budget added to the original one lawmakers approved in 2011. It’s not an unusual course for lawmakers to take to address lingering IOUs, but this year’s efforts are becoming more complicated and politically fraught than in the past.

For starters, lawmakers are planning at least three bills to address the state’s supplemental needs instead of the usual one. The first measure needs to be signed by Gov. Rick Perry in March so the state can pay billions in upcoming health care bills on time. A second supplemental bill will address the state’s costs from fighting wildfires and providing prisoner health care, but it won’t need to pass so quickly. A third measure, also not a rush item, will reverse $1.75 billion in delayed funds to school districts.

State Rep. Jim Pitts, R-Waxahachie, chairman of the House Appropriations Committee, said separate bills were needed to ensure that the emergency item makes it to Perry’s desk quickly.

Texas has $6.8 billion of unmet costs in the current budget, nearly all of it related to Medicaid and public education, according to the Legislative Budget Board. Lawmakers plan to use most of the extra $8.8 billion the Texas comptroller reported collecting from this biennium to pay those costs.

One way of thinking about this is that if Comptroller Combs had given us an accurate revenue estimate in the first place, we we could have dealt with all this in 2011 instead of pretending it didn’t exist for the purposes of “balancing” the budget. This is also a reminder, once again, that the concept of “balancing” the budget as we do in Texas is a fiction imposed by an artificial deadline.

The House Appropriations Committee passed its first supplemental bill on Monday, and Pitts plans to bring it to the House floor for a vote early next week. The bill, House Bill 10, has “emergency” status, a parliamentary designation that allows legislators to vote on the measure during the first 60 days of the session if Pitts can get the support of 120 of the 150 House members.

“It’s the first time I’ve ever had an emergency supplemental,” Pitts said.

The emergency stems from the last Legislature’s decision to fund Medicaid and the Children’s Health Insurance Program for only 18 out of 24 months in the budget cycle, a move that allowed lawmakers to delay $4.5 billion in spending from state coffers. HB 10 will fund those programs for the full two years with $4.5 billion in state money, which will automatically trigger an extra $6.6 billion in federal funding.

The bill needs to get to Perry’s desk by early March so that health care workers aren’t left in the lurch, Pitts said.

“If we do not pass House Bill 10 for Medicaid, the doctors, the hospitals, the nursing homes will not be paid after the middle of March. … That is the emergency,” Pitts told his colleagues on the House floor Monday. The bill also includes $630 million owed to schools districts.

The emergency is one part the result of Combs’ inaccurate revenue projection, and one part the Republicans’ fanatical refusal to find new revenue. Most likely, these bills (about which you can learn more here) will pass, but you never know what the bomb-throwers in the GOP caucus might try to do. You may be wondering about the issue of school finance, for which Democrats have tried to get the cuts from 2011 restored. That’s not going to happen, but some kind of partial restoration may be possible.

House Appropriations Chairman Jim Pitts, R-Waxahachie, said that lawmakers have just under $1 billion available to spend without hitting the constitutional spending limit on the current two-year budget. He and a group of lawmakers, which includes House Speaker Joe Straus, R-San Antonio, are in talks to add some of that money to a supplemental spending bill expected to reach the full House next month.

“We’re still working on it,” Pitts said Thursday.

State Rep. Donna Howard, D-Austin, said the discussions are looking at adding public education money both to the current budget and the next two-year budget cycle.


During debate over the rule, Pitts told lawmakers the second supplemental bill may include funding for public education. That bill is also expected to address unexpected costs related to recent wildfires and prisoner healthcare.

State Rep. Mark Strama, D-Austin, urged Pitts to make clear publicly as soon as he could how much more money school districts could expect so they could properly plan to use it before the end of the fiscal year. He said many districts might use some of the funding to hire tutors for students who need to retake the STAAR end-of-course exams.

“There is time for us to make a meaningful difference in the resources available to them,” Strama said.

The rule in question was one that forbade any amendment to HB10 that added to the total cost without any offsetting cut elsewhere. We’ll see what comes of this. EoW has more.

Then YOU fix it!

Stuff like this really pisses me off.

It’s constitutional – deal with it

On Wednesday, the [Senate Finance] committee heard testimony from state officials on the proposed health budget, which grew 2 percent from the current biennium budget to $70 billion. The chairman of the committee, Sen. Tommy Williams, R-The Woodlands, expressed the need for fiscal conservancy but said the decisions lawmakers make this session will not be “whether we’re going to serve that population or not — it’s going to be about how they are served.”

Bee Moorhead, the executive director of Texas Impact, an interfaith group that commissioned a recent report on the benefits of expanding Medicaid, said taxpayers deserve to have money they paid returned to their communities through the Medicaid expansion. “I think taxpayers deserve a serious answer from lawmakers on why the state doesn’t want to give them this kind of relief when its so easily available to them,” she said.

Sen. Juan “Chuy” Hinojosa, D-McAllen, agreed with testimony that even if Texas does not expand Medicaid, there will be continued costs for caring for the uninsured. “The costs would be born usually by local governments,” he said.

But Republican lawmakers challenged the testimony provided by advocates of the Medicaid expansion.

“You’re going to create a new class of uninsured people at higher income levels,” said Sen. Bob Deuell, R-Greenville, adding that employers will choose to drop employee health coverage if the state expands Medicaid, causing the pool of private insurance to shrink and premiums to rise. “I want everybody to have health care, but I think there are better ways to do it.”

What are those “better ideas”, Senator Deuell, and why haven’t you implemented them yet? Republicans have been in full control of Texas’ government for ten years now, and in that time they have not done a damn thing to improve access to health care. We lead the nation in uninsured residents, and at no time has any Republican, from Rick Perry on down, made a serious proposal to try and do something about that. What they have done is cut CHIP, cut family planning funds, overseen a spectacular fiasco of outsourcing HHSC functions that never saved a dime, made a complete hash of the Women’s Health Program – for which Sen. Deuell can claim partial credit, since he was the one who asked AG Abbott if the state could bar Planned Parenthood from the WHP – and resisted efforts to make Medicaid enrollment an annual process instead of an every-six-months process. One might reasonably conclude that they just don’t care about caring for the sick and disabled. And then when someone else finally solves this longstanding, intractable problem for them, what do they do? Whine, stomp their feet, file lawsuits, and obstruct, obstruct, obstruct. Thanks for nothing, Sen. Deuell. You know what you can do with those “better ideas” you claim to have.

For more of the same, see this example of excuse-making and responsibility-ducking.

Waco-area legislators said Friday they remain wary of expanding the state’s Medicaid program, in comments highlighting their division with local government leaders on the issue.

Top officials with the city of Waco and McLennan County support the Medicaid expansion envisioned as part of national health care reform, saying it would cut the area’s uninsured rate by more than half and bring $58 million a year in new federal funding to the area.

But those benefits are far from certain because there is no guarantee the federal government — facing rising debt and budget deficits — would sustain its funding, area lawmakers told a crowd of more than 100 people at the Greater Waco Chamber of Commerce’s “Waco Day” breakfast.

“It’s smoke and mirrors, folks,” said state Rep. Charles “Doc” Anderson, R-Waco, referring to the $58 million estimate. “It would be nice if we’d get that money and be able to solve some legitimate problems that hospitals and other folks are dealing with, but that’s not dedicated funds. There’s no guarantee that money will be there.”

State Sen. Brian Birdwell, R-Granbury, voiced similar concerns. Medicaid continues to grow as a percentage of the state’s budget, and expanding the program could squeeze money from other priorities such as public education, transportation and water, he said.

No answers, no solutions, just complaints about the one option we do have. But of course they’re not interested in a solution, because if they were they would have offered one by now. After all this time with them in charge, there’s no reason to believe otherwise.

Counties may try to expand Medicaid on their own

The Washington Post reports on the efforts of county and hospital district officials in some of Texas’ largest counties to bypass Rick Perry’s refusal to expand Medicaid for Texas and seek approval to do it themselves for their own jurisdictions.

It's constitutional - deal with it

George Hernandez Jr., CEO of University Health System in San Antonio, came up with the idea of the alternative, county-run Medicaid expansion, and said he has been discussing it with other officials in his county, Bexar. “They are all willing,” he said. He added that he has also been talking up the proposal with officials in other big counties, such as those including Houston and Dallas, and is optimistic they’ll support the idea.

Robert Earley, CEO of JPS Health Network, the public hospital system serving Tarrant County, which includes the Fort Worth area, said he could see the idea catching on.


Under the federal health law, the Medicaid expansion would begin in 2014, and would cover people with incomes of up to 133 percent of the poverty level. The federal government would pay the entire bill for the first three years and 90 percent thereafter. If there were a county-backed expansion in Texas, the local hospital districts would tax residents to come up with the 10 percent state share. Texans living in counties that participated in the expansion would be eligible for Medicaid under the less restrictive rules, while those living in the rest of the state would not.

An official from the U.S. Department of Health and Human Services declined to comment on the idea, but said, “We look forward to continuing our dialogue with states . . . as we work to meet the law’s goals.”

Alan Weil, executive director of the National Academy for State Health Policy, said that the idea, despite its challenges, “is certainly not far-fetched.”

Weil noted that there is precedent for a federal waiver of this type: After California declined to take advantage of a provision in the health-care law that allows states to accelerate their Medicaid expansion, the leaders of several counties got permission from the Obama administration to do so on their own.

The Texas proposal, of course, represents more than a temporary bridge to statewide expansion; it could be a permanent arrangement.

“And federal authorities might feel differently about that,” Weil said. “But as a general proposition, could you have different counties with different eligibility standards? I think the answer would be yes.”

We first heard about this a few weeks ago, after the Perry announcement and the sheepish admission by outgoing HHSC Chair Tom Suehs that Medicaid expansion would not cost nearly as much as his agency had first claimed. It’s an interesting approach, one that I could see being allowed to happen, and I admire creativity and perseverance of the officials who are pursuing it, but let’s be clear that it’s at best a kludge designed to work around a bad decision. For one thing, it cannot possibly be more efficient to have up to 254 potentially different standards for eligibility in Texas than just one statewide standard. For another, while I expect that many counties would do this if they are permitted to do so, some others will choose instead to be free-riding parasites on their neighbors; this is another reason why a statewide solution is better. Given the choice between no Medicaid expansion and a patchwork of Medicaid expansion done by the counties, I’ll gladly take the latter – it’s way better than the status quo, and could easily wind up covering a significant portion of the large uninsured population in Texas, many of which are now served by these overburdened hospital districts. But again, it’s a patch that’s being applied to a strictly self-inflicted wound.

And this approach now has a champion in Congress.

Congressman Henry Cuellar is asking the U.S. Department of Health and Human Services if Texas counties can bypass their state government in order to expand Medicaid coverage.

The Laredo Democrat says he supports giving counties the choice. He said he set up a teleconference call with HHS after reading an article in the Washington Post that said some of Texas’ largest counties want to make an end run around Gov. Rick Perry’s opposition to the expanded Medicaid program included in President Obama’s health-care law.

“I will be talking to HHS next week. I want to know if it is up to the Texas Legislature to decide if counties can do their own thing or whether it is something we can make happen at the federal level. I want to do all I can to give counties the choice,” Cuellar said, in an interview with the Guardian in Rio Grande City on Tuesday.


Cuellar recalled his time in the state legislature when he wanted to give Texas counties the opportunity to expand the Children’s Health Insurance Program. “We do not do as good a job with the CHIP program as other states do and I wanted to negotiate with HHS to give our counties the chance to expand it. I was opposed by the other states. They understood that if Texas sent CHIP money back, they could get some of it,” Cuellar said.

The Washington Post story focused on the larger Texas counties that have large public hospitals and hospital districts. Many border counties do not. Asked if border counties could bypass the state government in order to secure expanded Medicaid coverage under the ACA, Cuellar said he is going to ask HSS if such a maneuver is possible. “I want to see if the border counties can group together. I want to see if we can give them an option,” Cuellar said.

Again, given the constraints of Rick Perry’s obstinacy and antipathy towards non-rich people, that’s a great idea. Any opportunity to bypass the Lege should be grasped with both hands. Make that option available to any group of counties that don’t have a hospital district but want to do right by their taxpayers, too. If there’s any justice, Texas would achieve near-complete coverage by this method. It will probably take something like that to change the status quo. It’s still a stupid way to do business, but you gotta do what you gotta do.

There’s one remaining question that I have about all this, and that’s what Harris County intends to do. Bexar County has been the driving force behind this movement. Harris has the same need and a much bigger population, so its participation would be a big deal. I placed a call and was informed that Harris County Hospital District CEO David Lopez is “not granting interviews” on this topic at this time. Disappointing, but I suppose the politics of this are rather tricky for them, and they want to get as many ducks in a row as possible before deciding on a course of action. If you’re an officeholder in Harris County and you like the idea of providing coverage to the million or so uninsured residents of this county, I suggest you bring this up to Mr. Lopez at your next opportunity. You never know who else might be talking to him if you aren’t.

The working poor are pretty much screwed in Texas

These are the people that Rick Perry doesn’t care about.

It's constitutional - deal with it

Jose Gallegos’ company eliminated employee health insurance to save money, so when his gut started hurting and his skin took on a yellow tinge, he resisted seeing a doctor. When he finally went to the emergency room, physicians diagnosed stomach cancer.

Gallegos made too much money to qualify for Medicaid but not enough to buy his own insurance, so he scraped together what he could, and his wife, Andrea, took on three jobs. Just over a year later, at 41, he died, leaving behind four children.

Two years later, it was Andrea’s turn. A crack and sharp pain in her back drove her to the emergency room, where she learned she had breast cancer. It had snapped one of her vertebra. Now 45, she said the cancer remains in several other vertebrae, but at the moment it’s not spreading.

Families like the Gallegos stand at the center of a debate over President Barack Obama’s health care overhaul, which could have expanded Medicaid coverage to 1.3 million uninsured Texans. But Republican Gov. Rick Perry has said he will not widen the program because it would cost too much.

“It gets me mad,” Gallegos said. Perry “made a decision without us.”

Nowhere did Obama’s health care law hold more promise than in Texas, which leads the nation in the portion of its population that is uninsured. A quarter of Texans have no coverage, many of them families like the Gallegos who are considered the working poor.


Without a Medicaid expansion, the state’s working poor will continue relying on emergency rooms — the most costly treatment option — instead of primary care doctors. The Texas Hospital Association estimates that care for uninsured patients cost hospitals in the state $4.5 billion in 2010.

So at the 2010 rate, the cost of uninsured people using the emergency room, a cost paid by all of us in county taxes and higher insurance premiums, would be about $45 billion over ten years, as opposed to the $16 billion over ten years that Medicaid expansion would cost. Forget the $100 billion plus that the state would pull down from the feds to subsidize Medicaid expansion, how does this math make any sense?

Republicans have had complete control of state government since 2003, and in that time they have done nothing to deal with the issue of the uninsured in Texas. Indeed, they have made the problem worse by throwing a bunch of kids off CHIP in 2003; we’re still not back to the level of coverage we had before that. Now that the federal government has finally done something about this, they’re digging in their heels and saying NO. They say they want the federal money with no strings attached so their can design their own plan. Even if you believed they had a plan, given their long track record and their public comments about how expensive this all is – made without acknowledging the expenses imposed by their own inaction, of course – there’s no reason to believe their plan would do anywhere near as much as expanding Medicaid as is would do. Yes, it will cost the state some money to do that, money they’re currently making us pay by other means. The Legislature, God help them, may have to figure out a way to pay for it, just as they’re likely going to have to figure out a way to pay for public education again. The state has gotten by for a long time without having to pay for these needs. They’re running out of ways to get out of that obligation. There’s an awful lot of people in this state who have been ignored and made to suffer for a long time who will be a lot better off when that finally happens. Lisa Falkenberg and BOR have more.

One million uninsured kids

One point two million uninsured kids in Texas, actually. But who’s counting?

More than 1 million Texas children remain without health insurance, and those kids are not getting the care they need.

The startling condition of the state’s children came into vivid focus last week with the release of the annual Kids Count survey. The analysis of official state and federal data by the non-partisan Center for Public Policy Priorities found that 1.2 million Texas children have neither private nor public health insurance.

Almost 40 percent of Texas mothers received little or no prenatal care and one in seven babies were born premature, statistics show. The difference between being insured and uninsured is stark: 90 percent of insured kids are healthy, while only 58 percent of kids without insurance are considered healthy.

It comes as no surprise that the percentage of children covered by health care is directly related to the employment rate and the parent’s economic status.

With 25 percent of Texas children living in poverty, a rate that consistently runs 5 percent above the national average, Texas ranks 41st in the nation in number of uninsured kids, even though the unemployment rate is lower than the national average.

When uninsured kids get sick, their parents have no place to take them other than a public hospital’s emergency room, which by law cannot turn them away. And if those parents cannot pay the extremely expensive bill? The taxpayer picks up the tab.

“A large percentage of those kids will end up in the emergency room as their primary source of care, which is hugely inefficient and ridiculously expensive,” said Dr. Skip Brown, a medical professor and director of a pediatrics center at the University of Texas Medical Branch

“When you go to the emergency department, those guys are not there to be primary care providers.”

You can see the Kids Count data here. The story notes that many uninsured kids would be eligible for CHIP or Medicaid if they applied for it, but one reason why Texas has so many uninsured kids is precisely because the state does a lot to make it hard for them to apply, including things like requiring in person interviews and a six-month enrollment period instead of a 12-month period like those of us with employer-based insurance have. It’s a deliberate strategy, because insuring those kids would add to the state’s budget, whereas emergency room visits are paid for by counties. If the state’s Republican leadership applied even one tenth of the ferocity they have in fighting Obamacare to doing something about this massive problem at home, there would have eradicated it by now. But after ten years of Republican rule, they have done nothing to improve matters. Insuring kids and providing them with preventative health care is cheap. Paying for the problems of adults who didn’t get health care as kids, that’s expensive. Too bad Rick Perry and his cronies don’t see it that way.

Pediatric dental care

It’s more important than you might think.

While overall oral health care for adults and children has improved, tooth decay continues to be the most common chronic disease among children. It can have serious social and health consequences when untreated and, in rare cases, can be fatal.

“The children with the highest need are the poor,” said [Dr. Martee] Engel, a pediatric dentist for 20 years. “Their tooth decay occurs more rapidly and is more pervasive.”

A surgeon general report in 2000 called the problem a “silent epidemic.” It estimated that children lose more than 51 million school hours because of toothaches. Children whose families are below the federal poverty line suffer 12 times more restricted activity and loss of school hours than other children, the report said.

Texas has done a better job than most states in improving access to dental care during the past decade, according to a study by the Pew Center.

Texas was one of nine states to receive a B for meeting national benchmarks.

In 2007, the state added $258 million to Medicaid to increase dental reimbursement rates on average by 50 percent, which has increased dentist participation.

The action was part of a settlement of a class-action lawsuit.

But even with more access through Medicaid and the Children’s Health Insurance Program, use of benefits remains low. Only 60 percent of the 3.3 million Texas children enrolled use their dental benefits, according to state officials. Figures in most other states are lower.

Health policy analyst Julia Paradise said more dentists, especially pediatric dentists, must participate in public insurance programs to fill the gaps. The need is greatest in rural areas and inner-city communities, she said.

“Coverage is not the same as access,” said Paradise, an analyst with the nonprofit Henry J. Kaiser Family Foundation. “It gets you to the door, but the door has to open.”

The story cites the case of Deamonte Driver, a 12-year-old Maryland boy who died from a brain infection that started out as simple tooth decay, which is caused by bacteria. I’m as surprised as you are to learn that Texas does well on that national benchmark, but given the way the Lege underfunded Medicaid in the 2011 session to help “balance” the budget, I will not be surprised to see that take a hit next year. Keep this story in mind when the subject comes up.

Rick Perry must love uninsured people, because he’s helped create so many of them

Buried in this story about the grim statistics on poverty that were recently released by the Census is this little nugget that hits close to home:

Health insurance coverage also dropped for most age groups, although census officials said the change was not statistically significant. In all, 49.9 million people lacked health insurance, or 16.3 percent of the population.

Texas had the highest rate of uninsured residents, at 24.6 percent.

While the number of uninsured people nationally has crept up, the rate has held steady, thanks in part to an increase in insured 18 to 26-year olds, that being a result of the Affordable Care Act. Texas’ rate of uninsured people has led the nation for some time now. Here’s a story from 2009 that says Texas’ rate of uninsured people from 2006 to 2008 was 24.9%. Here’s a story from 2010 that said the rate in 2009 was 26.1%, or 6.4 million people. It also adds the following:

Despite growth in the total uninsured population in Texas, the population of uninsured children actually declined. Children, like adults, continued to lose coverage through employer-sponsored insurance, but increased coverage through public programs like CHIP and Medicaid more than made up for that loss.

To put it mildly, that trend is unlikely to continue given the budget cuts that were imposed this year. The point I want to make is simply this: Rick Perry has been Governor for ten years now. He’s had ample opportunities to present policy ideas that would reduce the rate of uninsured people, and he’s had ample opportunities to support the policy ideas of others to do the same. He has never done so. In fact, he has supported cutting hundreds of thousands of children from CHIP, he has supported eligibility requirements for Medicaid that make it less available, he has supported biannual enrollments for Medicaid that ensure fewer eligible people stay on the rolls, and of course he pushed for a disastrous privatization scheme for the Health and Human Services Commission that made a huge mess of the system and cost Texas millions of dollars. If you want to ensure that the rest of the country catches up with Texas in this department, Rick Perry is your man for President.

If it weren’t for Obama, we wouldn’t be having this conversation

Rep. John Zerwas writes an op-ed extolling the virtues of the health insurance exchange bill he’s filed.

While it is no secret that I oppose the federal health care reform bill, if we don’t act now to create the Texas Health Insurance Connector, our state could be forced to cede regulatory control of a significant chunk of its health insurance market to the federal government. The desire to avoid such oversight has generated broad support for the connector, which I am proposing in House Bill 636. In addition to members of both political parties, a variety of groups that don’t usually agree on issues have come forward to support keeping Texas in charge of its health insurance market through the passage of HB 636. Those groups include the Texas Association of Business, Texas Hospital Association, Texas Medical Association, Texas Restaurant Association and two Texas health insurance industry groups.

Why must we do this? Among the provisions of the federal health care reforms is a requirement that an organized health insurance market known as an American Health Benefit Exchange be established in every state to provide coverage for U.S. citizens or legal immigrants who do not have access to affordable employer-based coverage. Each state must demonstrate by 2013 that it will have the structure in place to operate its exchange or the federal government will establish and manage it for that state. The Texas Health Insurance Connector, a simplified health insurance market, would serve as our state’s exchange.

Although I support the efforts by Texas Attorney General Greg Abbott and others to have the health care bill ruled unconstitutional, the connector proposal is more about what’s best for Texas and less about what the federal government has passed. It’s about ensuring that Texas maintains regulatory oversight over what could end up being a large segment of its health insurance market.

The exchange concept did not originate with Obamacare. The idea was first proposed in the 1970s, and the model is being used in such politically opposite states as Utah and Massachusetts. Because of the federal government’s 2013 deadline, our current legislative session may provide us the only opportunity to take action to keep the federal government out of our health-insurance market.

I’ve already said something nice about Zerwas and HB636, so I’ll just take a moment to note his almost defensive touting of his Republican bona fides in these paragraphs. It’s almost as if he’s a bit bashful about proposing legislation that would make it easier for someone to get health insurance, which is certainly understandable given the direction of the modern day Republican Party and its hostility to the concept of universal coverage. Be that as it may, if it weren’t for “Obamacare”, none of this would be a topic for discussion. In four regular legislative sessions under unified Republican control, the state hasn’t done a damn thing to improve access to health care; indeed, the two most notable achievements in that time were slashing CHIP in 2003 and settling the Frew lawsuit over Texas’ insufficient Medicaid payments in 2007. None of the bills Zerwas filed in 2009 had anything to do with insurance exchanges, which as he notes existed as a concept well before they became mandatory. It would be the same thing this year if the Affordable Care Act passed by President Obama and the Democratic Congress hadn’t forced Texas Republicans to do something. See this Trib interview with Rep. Zerwas for more.

This is your government on dogma

We won’t get Jim Pitts’ bare bones budget outline till late tonight, so as not to be a buzzkill on the Perry coronation inauguration. We did, however, get an opening bid from the ideological purists, and while it’s not worth looking at in details, because life is too short and a mind is a terrible thing to waste, there are a couple of things worth mentioning.

Education will have to bear the brunt of budget cuts, conservative legislators said Tuesday, because the federal government has left them no other options.

“Indeed, Texans can thank President Obama and the Congress led by former House Speaker Nancy Pelosi for the passage of (federal health care reform), which is directly responsible for the massive reductions that are required in other areas of the budget, and particularly public and higher education,” according to the Texas Conservative Coalition Research Institute, which released its plan for reducing state spending in the face of a significant budget shortfall.

Federal health care reform prevents states from reducing eligibility and benefits for people who use Medicaid and the Children’s Health Insurance Program.

“We are forced to tinker at the edges of those programs and focus disproportionately on public and higher education,” said state Sen. Tommy Williams, R-The Woodlands, who led the budget task force with state Rep. Warren Chisum, R-Pampa.

The state’s budget shortfall ranges from $15 billion to $27 billion depending upon who is doing the counting. The conservative legislators lay the cause of that shortfall mainly at the feet of the Obama administration and the economy, dismissing the legislators’ own role in digging the hole.

You know, like giant unaffordable property tax cuts. I took the liberty of running these guys’ excuses through a reality filter, and this is what it gave me:

I ran out of gas. I, I had a flat tire. I didn’t have enough money for cab fare. My tux didn’t come back from the cleaners. An old friend came in from out of town. Someone stole my car. There was an earthquake. A terrible flood. Locusts. IT WASN’T MY FAULT, I SWEAR TO GOD.

Much better. Moving on:

The group found $18 billion in potential savings without touching transportation, public safety or criminal justice. Among their suggestions are the following:

— Lift the elementary classroom size from 22 students to 25: $558 million

— Eliminate the pre-kindergarten grant program: $209 million

— Institute a 10 percent pay cut for state employees and two-day furlough per month : $1.7 billion

— Reduce the state’s contribution to health care for dependents of employees: $108 million

Let there be no doubt that there are two types of people in this state: Those who will be required to sacrifice extensively for the benefit of others, and those for whom any sacrifice is too great. State employees, who as a commenter notes are effectively getting a 20% pay cut under this plan, are an example of the former; Dan Patrick and his untouchable property tax cuts are an example of the latter. There is no class war in Texas – it’s long been over, and Dan Patrick’s team won.

As for the education-related cuts, you will note that there is no discussion of any possible effects on student performance, or possible long-term costs to the state as a result of any potential drop in student performance. It’s a lot easier to make proposals like these if you pretend there are no consequences. The only question I have is why stop at simply raising the class size limit? Why not go whole hog and impose class size minimums? Just imagine how many schools we could close, how many teachers and other school employees we could fire, and how much money we could save if we mandated that every class must contain at least 30 students? Or 40, or 50, or hell, 100? The answer, obviously, is that even guys like Tommy Williams and Warren Chisum recognize that there might be some bad things resulting from such a decree, and that the accompanying savings would not be considered worth it by everyone else. Their hope is that the ill effects of their proposal will be small enough to be “acceptable”, or – better yet – won’t be apparent for a few years, long enough for the facts to be fudged in the retelling. Hey, it beats having to make justifications now.

UPDATE: House Democrats will give their response to the Pitts budget tomorrow morning at 9 AM.

UPDATE: The Trib has an early peek.

New flash: Dropping Medicaid would be bad

Don’t take my word for it, take the Texas Department of Health and Human Services’ word for it.

Opting out of federal Medicaid, something Republican leaders have been considering as a method to wipe out Texas’ estimated $25 billion budget shortfall, would create major difficulties, the report states — not just for the millions of poor and vulnerable Texans covered by Medicaid, but for the county governments and public hospitals where much of the financial burden would be shifted.

Up to 2.6 million Texans — many of them children — could become uninsured. And hospitals would still be required by federal law to treat medical emergencies, potentially adding billions of dollars in annual uncompensated care costs funded at the local level. Meanwhile, Texans would continue to pay federal taxes to support other states’ Medicaid spending, the report notes.

Texas would “lose billions each year in federal funds; billions of dollars in indigent health care costs would shift from the state and federal levels to local governments, public hospital districts, medical providers, and the privately insured; and 2.6 million Texas residents could lose health insurance,” the report states.

Still, the escalating Medicaid costs facing the state — up 170 percent in the last 11 years, and accounting for a quarter of the state budget — have far exceeded the growth in state tax revenue, inflation and population, and are unsustainable, the report notes. The HHSC report says the best solution is for the federal government to give states greater responsibility over program costs, allowing them to design their own eligibility systems and benefit packages, and making it easier for them to get waivers. They also recommend reforming the new federal health care law, as well as revising how the federal government calculates the state vs. federal contribution to Medicaid.

“Virtually every state in the nation is facing a severe budget shortfall made worse by rising costs in Medicaid,” the report states. “…Without significant reform at the federal level, states are left facing a no-win dilemma.”

Actually, the best solution, which a number of people have proposed and were pushing during the debate over the Affordable Care Act last year, is a complete federalization of Medicaid. This would be a huge relief for state budgets now and in the future and would ensure a single standard of coverage, so that you don’t have states like Texas which deliberately make it hard to qualify as a way of saving itself a few bucks. Needless to say, this ain’t gonna happen, and if President Obama proposed it you’d see Republicans in Texas and everywhere else tell him to keep his dirty hands off of this beloved program of theirs that they intend to kill if they can get away with it.

The Trib has more here, and Dave Mann notes that what this really constitutes is not an attempt to kill Medicaid, but a move to basically privatize it:

The report concludes that the federal government should allow the state to “incorporate market oriented principles and greater accountability into the Texas Medicaid program.

“Under one waiver proposal, the state would establish consumer-directed medical accounts with sufficient funding to allow a client to purchase an individual or family high-deductible private insurance policy and fund a related health savings account.

“The proposal would empower Medicaid recipients to use health saving accounts for out of pocket health care expenses, job training, child care, or other qualifying purchases.”

This would represent a fundamental shift in how Medicaid functions. In the current model, the government reimburses doctors and other providers for the health care services they offer Medicaid patients.

Under the Perry plan, the government would fork over Medicaid money directly to individuals who would then shop for and purchase a private insurance plan. Instead of one money transfer (government to health care providers), we would have three (government to patient to insurance company to providers). Perry and the report authors pitch the latter system as more efficient, despite the added bureaucracy that would no doubt come along with these added transactions.

I don’t know if it would be more efficient. But it certainly would be a boon for the insurance industry and whatever financial institution would maintain these health savings accounts.

You can read the full report here. Those of you who have been paying attention may notice that this is very similar to the Paul Ryan plan for Medicare, basically by replacing the government as the insurer with vouchers for purchasing private insurance. You then can control costs easily by simply refusing to increase the voucher amounts over time, with predictable results for their purchasing power. One way or another, it all leads to the same end. One more thing from the original story:

HHSC raised eyebrows earlier this year with its big-figure estimates for how much federal health reform was going to cost Texas. The latest agency estimate indicates health reform will cost the state quite a bit less — about $5 billion between 2014 and 2019. This estimate excludes non-mandatory rate increases that were included in the original calculation. And it includes roughly $760 million in state revenue from premium taxes expected to be paid by health plans that cover new Medicaid clients.

I guess now that it’s actually been passed, there’s less point in exaggerating about it. Funny how these things work, isn’t it? A statement from Rep. Garnet Coleman is beneath the fold.


Because that’s who he is

Before Thanksgiving, Ezra Klein asked “Why does Gov. Rick Perry want more uninsured Texans?”

Consider the case of Texas, which with 25 percent uninsured, leads the nation in not providing for its residents. If the state pulls out of Medicaid, as Gov. Rick Perry (R) is suggesting, that would put it at 40 percent uninsured, as Medicaid covers 15 percent of the state. Texas might try some other form of coverage, but it will have lost hundreds of millions of dollars of federal funding. You can occasionally do less with more, but when you have a lot less, you generally just do less. Whatever the state tried next would cover fewer people with less-comprehensive insurance, and it’s a safe bet that the rate of uninsured would ultimately settle above 30 percent. Some legacy.

Conversely, if Perry does nothing, the federal government is going to come in and pick up most of the cost of a massive coverage expansion. Texas, in fact, will be one of the biggest winners from health-care reform, as its huge pool of uninsured residents means the state will get an uncommonly large amount of subsidies to bring that down to manageable levels. Texas “can expect to see Medicaid enrollment rise by 46 percent while state spending on Medicaid rises by about 3 percent.” Pretty good deal.


There is nothing that states can do that would cover residents at a lower cost to their budgets than simply letting the new health-care law take effect. Any governor that is even vaguely interested in covering the uninsured should be celebrating the federal government’s willingness to pick up 96 percent of the tab. Of course, as these trial balloons over Medicaid show, plenty of governors don’t care about that at all. You’d think Perry, who runs a state where one out of four residents don’t have health insurance, would be obsessed with figuring out ways to cover more Texans. Instead, he’s leading the way in concocting schemes to cover fewer of them.

There are several factors that need to be considered here. One is Texas’ huge budget shortfall, for which the only allowable solution will be budget cuts. Simple accounting for those with that mindset notes that Texas spends about $17 billion per biennium on Medicaid, which amounts to somewhere between two thirds and four fifths of the deficit, so if we just simply stopped funding Medicaid, we’d have an almost-balanced budget. Yes, I know, it’s way more complicated than that, but that’s where this is coming from. Second is Perry’s newfound jihad against the federal government, which conveniently coincides with a Democrat being in the White House. Whatever else you make of this, you can’t separate these two things from the whole.

But even without these factors, we should not forget that at no time during his ten years in office has Rick Perry ever done anything to substantially expand health care coverage in Texas. Quite the opposite, in fact. In 2003, Texas threw 300,000 kids off CHIP, and only some of those who lost coverage were able to regain it in subsequent legislative sessions. Texas’ Republican leadership, including Perry, has repeatedly opposed simple things like changing from a six-month re-enrollment period for CHIP and Medicaid to a 12-month period, thus ensuring that a significant portion of eligible recipients lose coverage due to failure to re-enroll in a timely fashion. Even more basic than that, I can’t think of a single program that Perry has introduced or touted that would have attempted to deal with the huge number of uninsured residents we have. Other Republican Governors, like Mitch Daniels and Mitt Romney, have gotten legislation passed in their states, and whether you agree with what they’ve done or not they at least made an attempt to tackle their states’ problems in a way that’s consistent with their stated principles. Perry has done nothing. I can’t help but think that a big part of the reason why he and his cronies are so ferociously opposed to the Affordable Care Act is precisely because it so clearly shows the extent of their failure to do anything about this. After ten years of Rick Perry and eight years of a Republican legislature and mostly the same state leadership, I can only conclude that they genuinely don’t care about making health care accessible for the uninsured. It’s just not on their radar, and so it’s just another line item in the budget that they’d like to target for cuts so they can keep giving Dan Patrick property tax cuts. It’s who they are, it’s what they do, and we should not be surprised by it.

UPDATE: I refer you to Peggy Fikac:

Some Republicans who talk about Texas potentially opting out of Medicaid are quick to say the changes wouldn’t throw people out on the street — but not House Appropriations Committee Chairman Jim Pitts.

Pitts didn’t advocate the change in health care for the poor at a meeting of the Ellis County Tea Party, just noted that it will be discussed by lawmakers.

But unlike others who have painted a rosy picture of a potential health-care restructuring without filling in the details, Pitts gave a stark answer when an audience member asked about an ill friend who is on Medicaid.

The questioner reacted with concern when Pitts said the state is looking at getting out of the program. What will my friend do then? Will you throw him out in the street?

“If we did exactly what we’re doing today, we wouldn’t be throwing him out in the street. But if we have any savings in getting out of Medicaid, we will have to throw some people out in the street,” said Pitts, R-Waxahachie. He noted, “I’m not telling you that your friend would be.”

But he probably would be. Aren’t you glad you voted for that?

Medicaid: Ideologues versus experts

The fascinating thing in this story about the Republican plan to kill Medicaid is just how half-baked the idea is.

GOP Gov. Rick Perry, fresh off a big re-election win and touting his new book on states’ rights, is among those who say it’s a good idea. The election results — which included a huge haul of state House seats for Republicans — have left some Capitol watchers wondering whether they should take seriously an idea that might have been immediately discarded in the past.

Never mind that no state has ever ditched Medicaid. Or that the federal government typically kicks in about 6 of every 10 dollars spent on the health care program in Texas.

Medicaid pays for more than half of all births and chips in for the care of nearly two-thirds of all nursing home residents in the state. And top medical industry officials say opting out of Medicaid would cripple the state’s health care system and hurt the economy.

The opt-out idea surfaced nearly a year ago in a memo by the Heritage Foundation, a conservative think tank in Washington.


Perry hasn’t laid out details of how he envisions that opting out would work. A spokeswoman for the governor, Lucy Nashed , said that “these discussions are just beginning and will continue as we move into the legislative session.”


Arlene Wohlgemuth , executive director of the Texas Public Policy Foundation — the think tank to which Perry is donating the proceeds from his new book — is working on a proposal that would be an alternative to Medicaid.

Wohlgemuth, a former state lawmaker, is not proposing forgoing the federal funds because they’re Texas taxpayers’ dollars, too. She wants to use them in a different way.

“Medicaid is an unsustainable program,” Wohlgemuth said. “We have got to find a better way to deliver care to the people that need care.”

She declined to be specific, though she did say that options could exist through a totally new system, or through waivers or block grants that could give the state freedom to run the program as it sees fit.

But Anne Dunkelberg , associate director of the Center for Public Policy Priorities , which advocates for low-income Texans, said that “those aren’t options under law.” She said that there are no block grant options for Medicaid and that “there’s certainly not any new waiver ability that gets us out of the fact that health care is expensive.”

Perry frequently talks about a Medicaid waiver he proposed in 2007 that he says is languishing in Washington. His program would have redirected some federal Medicaid dollars into a pool to pay for health insurance subsidies for uninsured, low-income adults.

But the George W. Bush administration had concerns about the proposed limits on benefits and asked for a revision, which Texas has not submitted.

Though Perry’s proposal is technically still pending, Goodman said it would need to be revised “if the Medicaid expansion is implemented” as required by the federal health reform law.

Does anybody see a serious proposal on the horizon here, one that addresses the needs that Medicaid and CHIP currently handle while actually saving the state money? Or like me do you see an ideological wish list item that provides “savings” by simply ignoring a need and pretending that doing so doesn’t have its own costs, which may dwarf the alleged “savings” that are being touted? I have the same question for the medical establishment, which has largely been in bed with the Republican Party that is now threatening to do it serious damage with this proposal, that I have for the business interests that claim to be concerned about anti-immigrant legislation: Are you going to actively fight this, up to and including putting resources into defeating the legislators that will be working against your interests here, or are you just going to pay this all lip service because you care more about your other pet causes than you do about this? It’s put up or shut up time.

Yes, let’s enroll more kids in CHIP

What a great idea.

The Obama administration today ballyhooed a new Urban Institute report that suggests a path to enrolling 5 million kids in government-sponsored health insurance who are eligible but not signed up. The report says increasing the number of Texas kids on Medicaid and CHIP is “critical” to reaching this national goal.

A few stats mentioned in the report about Texas:

— Texas, California and Florida account for 38.6 percent of all eligible uninsured children in the country.
— The 74.7 percent of eligible Texas kids participating in the programs is “well below” the national average.

Yes, I know, budget shortfall blah blah blah. This is one of those situations where spending a little money here will save you a ton of money there. Kids who grow up healthier turn out better. This is not rocket science. “Saving” money by making kids sicker, which is what the Republican leadership forced on us in 2003, is nothing but a false economy. Getting every eligible kid onto CHIP would be one of the smartest things Texas ever did.

How much do kids count?

In Texas, the answer is not much at all.

Between 2000 and 2008, the number of Texas kids living in poverty grew by 240,000, accounting for 23 percent of the total child population. The national child poverty rate is 18 percent. [Frances Deviney, president of the Texas KIDS Count branch housed at the Center for Public Policy Priorities] also said Texas ranks last in child food insecurity, meaning 1.6 million Texas children don’t know where their next meal will come from. According to the 2006-08 survey conducted by the KIDS Count data center, hungry children are more likely to miss school, be less attentive in class, and fail or drop out of school.

Other key indicators for Texas kids:

—Low birthweight babies have increased in Texas by 17 percent since 2000.

—Infant mortality has spiked by 11 percent since 2000.

—The number of children with special health or medical needs has jumped by 42 percent since 2001.

—Economically disadvantaged children are more likely to fail the TAKS test.

—About 72 percent of Texas fourth graders are not proficient in reading, putting Texas in the bottom quarter of reading proficiency.

During this time, we’ve created a multibillion dollar structural deficit by irresponsibly cutting property taxes, thrown hundreds of thousands of kids off of CHIP, and frozen allocations for school districts at 2006 levels. That’s even before we deal with the current budget shortfall and the fanatical desire among Republican base voters to ensure people remain uninsured. Yeah, we pretty much don’t give a crap about kids in this state. BOR has more.

Why we can’t just cut our way out of the budget deficit

For one thing, there’s very little fat, and not much discretionary spending in the biggest budget items like health and human services.

Of the $23 billion in state dollars appropriated in the current budget for health and human services programs, $20 billion is “restricted” because of state law, constitutional provisions or federal laws and regulations.

That restricted money is not necessarily off-limits. But trimming from the biggest pieces — the $17 billion in state dollars that goes to Medicaid and the Children’s Health Insurance Program — could exacerbate the effects of the budget cuts because some of the $30 billion in federal dollars would be lost as a result.

Legislators also will not be allowed to reduce the rolls of those programs by making eligibility criteria or application rules more stringent, as they did in 2003 when the state faced a similar budget conundrum. This year’s federal health care overhaul prohibited such moves, said Anne Dunkelberg , associate director of the Center for Public Policy Priorities, which advocates for low-income Texans.


Another vulnerable area of the budget could be the state programs that seek to protect children and elderly people from abuse and neglect, said state Sen. Bob Deuell .

“I’m not telling you I want to; I’m just giving examples” of areas that aren’t restricted, said Deuell, a Greenville Republican . “It’s going to be painful. I pray every day the state tax revenue goes up.”

And he worries that beds at state mental health hospitals could be eliminated. For the first round of trims, state officials considered cutting hospital capacity at four locations but decided against it.

“They don’t have enough beds as it is,” said Deuell, a member of the Senate budget-writing team who is also vice chairman of the Senate Committee on Health and Human Services.

With all due respect to Sen. Deuell and his concerns, which I have no doubt are genuine and heartfelt, he does have the power to do something about revenue. Just pushing back against the head-in-the-sand mindset of some of his Senate colleagues about eliminating tax expenditures and sales tax exemptions would be a start. I mean, if you think it’s preferable to allow tattoo parlors and bottled water to be tax-free than it is to provide basic levels of service to sick and needy children and elderly folks, well, that’s your right, but don’t expect me to light a candle for your soul. What bugs the crap out of me in all of this is the impression that many legislators want to create that their hands are tied, they have no options, etc etc etc. Bullshit. They chose to carve a huge hole in the budget four years ago with that ginormous irresponsible property tax cut (by the way, revenues from the business margins tax are falling short of projections again), they can choose to do something to fix it.

I don’t mean to pick on Sen. Deuell, who I believe does care about this, unlike some of his Republican colleagues. But having your heart in the right place only carries you so far. There’s been an awful lot of concern expressed by just about everyone in office or running for office about how big a tax burden people have during these tough economic times, and how much of a hardship it would be to get anyone to pay anything more. Well, budget cuts impose burdens on a lot of people, too. The burden on them is often far greater than a $200 hike to Dan Patrick’s property taxes would be, too. Yet they’re expected to shoulder that burden entirely, to the point where even mentioning the possibility of an alternative is an abomination. That’s just wrong.

Who can get health care in Williamson County

This is a bad idea.

Williamson County commissioners have decided to stop paying health care costs for indigent adults and children who don’t have valid Social Security cards.

County Judge Dan A. Gattis said last week that he wanted to ensure that there was enough money for the residents of Williamson County who qualified for indigent care to remain covered. In the first five months of the current fiscal year, 265 people who didn’t have Social Security cards received county-paid health care out of a total of 1,153 indigent patients , said Bride Roberts , the coordinator for Williamson County’s indigent health care system.


Roberts said there were several reasons for the increased expense, including a large number of “very sick” people and new hospitals in the area identifying more people who may qualify for the program.

Williamson County residents without legal Social Security cards can still get care at four clinics in Georgetown, 10 clinics in Round Rock and one in Granger, all operated by Lone Star Circle of Care, a nonprofit community health organization, said Rebekah Haynes, the group’s communications director.

Roberts said patients without valid Social Security cards accounted for 12 percent of the $3.7 million spent under the program in the first five months of the fiscal year. During fiscal year 2009, 1,505 people were covered, and 331 of those didn’t have valid Social Security cards , she said.

The county estimated that it can save $1 million a year by denying coverage to people without legal Social Security cards, Roberts said.

Medicaid doesn’t cover health care costs for adults and children without legal Social Security cards. Texas law doesn’t address whether counties can exclude people without legal Social Security cards, said Anne Dunkelberg, the associate director of the Center for Public Policy Priorities in Austin.

“Virtually all counties do include undocumented residents in their county indigent health care programs,” said Dunkelberg, who called the county’s decision “a bad idea.”

“Making sure you are providing good access to prenatal care is extremely important because all babies are U.S. citizens,” she said.

My first reaction when I read this was “Do they really make people produce their Social Security card when they show up needing a doctor?” I mean, I sure don’t carry my SocSec card around with me. Having it on my person makes me more vulnerable to identity theft, and while I’m occasionally asked for my SSN, outside of a periodic I9 check at work, I can’t remember anyone ever asking me to produce my card. Is this really the procedure, or was this another way of saying “people with valid SSNs”?

My second reaction, as is usually the case when some public official expresses in words or actions indifference to the health and well-being of some subset of the population for which he or she is responsible, is to wonder if they’ve ever read The Masque of the Red Death. At least there’s still someplace in Williamson County for the less equal than others to go, which makes WilCo a notch above Collin County, but it’s still the case that making it harder for people who need health care to get it ensures that more people will be needlessly sick, and some of them will die. Some of these people, as the story notes, will be children. Maybe I’m just not cut out to be a County Commissioner, but I sure wouldn’t want that on my conscience.

I realize that WilCo is facing budget issues, and that they don’t have infinite resources. Rising health care costs is a big problem, one that the Affordable Care Act will eventually make some headway on, but which they need to cope with now. I just think they made a poor policy decision, one that offers a false savings in the same way that cutting back on CHIP did in 2003. I hope they figure it out before it hurts too many people. EoW has more.

Accounting tricks

Everyone knows that the current budget shortfall means the Lege will be searching for cutbacks and new revenue sources. But there is a third option, too, one that doesn’t usually get much attention but which has certainly been done before: Accounting tricks. Delaying payments, sometimes as little as a day, to push them into the next fiscal year, is the main trick in the bag.

The state’s accounting tricks really came into their own in 1991, during yet another budget crunch — one so bad that lawmakers approved a new tax bill, some “efficiencies” in existing programs, the state lottery and hundreds of millions of dollars in “smoke and mirrors” budgeting that moved costs out of the troubled period and into a future budget. They delayed state payments to local school districts by a day, “saving” an astonishing amount of money. They held money that was destined for state highways, along with other payments that would ordinarily come due in the last days of a biennial budget.

A few years later, lawmakers “repaid” the money they’d borrowed from themselves, adding an extra payment to, for instance, the Foundation School Program, to make up for the payment they “borrowed” from the previously cash-strapped budget.


Delaying the school payment by a day would chop $1.4 billion from the total, without the political pains of a new tax or spending cuts. Delaying payments to the employee and teacher retirement systems, Medicaid payments and transfers of gasoline taxes into the state highway fund — all will be on the table.

As the story notes, some of the old tricks won’t work any more, but quite a few of them are still available. The main downside to all this, of course, is that by putting off payments from one budget cycle to the next, you’re artificially increasing expenditures for the next biennium, just as you reduce them for this one. If we’re still facing a shortfall in 2013 – and given the structural deficit caused by the irresponsible property tax cuts of 2006, we almost surely will be – it’ll be that much more difficult to deal with it.

By the way, if you don’t like this kind of accounting sleight of hand, please be aware that the reason for it is the artificial requirement that the books need to be in balance as of a certain date. If the state were allowed to carry a balance forward into the next fiscal year – that is to say, if it were allowed to run a deficit – none of this would happen. The effect would still be the same – lawmakers would either gamble that the finances in the coming years would be good enough to wipe out the remaining amount due, or they’d be forced to take concrete steps to make it happen – there would just be less chicanery about it. For better or worse, this is the way we prefer to deal with it.

And I must say, I’ll take a dozen accounting tricks any day over hair-brained privatization schemes and the hundreds of millions they claim to save but never actually do.

The most touted budget-shrinking initiatives have rarely lived up to the political hype of providing better state services for less. And the promised savings have often proved elusive.

Consider, for example, the 2005 legislation that mandated the consolidation of 27 agency data centers that house mainframes and servers. The data center consolidation was sold as a money-saver – $178 million over seven years – that would also improve operations and security.

The project, which is being run by IBM Corp. under an $863 million contract, has been mired by delays, equipment failures and service complaints. The contract is being amended, and IBM is said to have asked for as much as another $500 million to complete the task.

Then there is the sweeping 2003 legislation that aimed to save $1.1 billion in health and human services spending in 2004-05.

About half of the actual $927 million in savings from that legislation came from policy changes that trimmed the rolls of health care programs, including the Children’s Health Insurance Program.

“The last time when we cut the budget, we did not do it by operating a more efficient government. We did it by not offering services,” said Eva DeLuna Castro , a budget analyst with the Center for Public Policy Priorities , which advocates for low-income Texans.

This is one of those places where having experience in the business world ought to be an asset as a legislator, but as that usually means possessing deal-making skills and having connections, it rarely works out that way. Frankly, a Lege full of Dilberts would have done a much better job assessing the baloney that IBM and Accenture managed to sell us. The good news, I suppose, is that there don’t seem to be any such plans being floated at this time. The bad news is that it’s still early days, and the allure of Great Big Savings at the invisible hand of the privatization fairy is just too tempting for a lot of folks in Austin to resist. EoW has more.

Don’t be like Arizona

I don’t have a whole lot of hope for the 2011 legislative session and the budget that it will produce. But at least we won’t do anything quite this stupid.

Arizona on Thursday became the first state to eliminate its Children’s Health Insurance Program when Gov. Jan Brewer signed an austere budget that will leave nearly 47,000 low-income children without coverage.

The Arizona budget is a vivid reflection of how the fiscal crisis afflicting state governments is cutting deeply into health care. The state also will roll back Medicaid coverage for childless adults in a move that is expected to eventually drop 310,000 people from the rolls.

State leaders said they were left with few choices because of a $2.6 billion projected shortfall next year. But hospital officials and advocates for low-income people said they were worried that emergency rooms would be overrun by patients who had few other options for care, and that children might suffer enduring developmental problems because of inadequate medical attention.

The cuts also mean the state will forgo hundreds of millions of dollars in federal matching aid, and could lose far more if Congress passes a health bill that requires states to maintain eligibility levels for the two programs.

It’s hard to imagine a policy that’s more penny-wise and pound-foolish than that. In addition to all of the lost matching funds, you’re ensuring that thousands of families will use the least efficient and most expensive form of health care there is – emergency rooms, which by the way pushes a whole bunch of cost onto local governments – and thousands of children will be less healthy. That will lead to poorer educational outcomes and to such longer term consequences as reduced earning potential and higher rates of crime. You really couldn’t do worse if you tried.

The good news is that the just-passed health care bill includes a provision that prohibits states from dropping CHIP. I didn’t think that would have been an option here anyway – it’s a bridge too far, even for us – but now any temptation to go for it is gone. Doesn’t mean we won’t have some CHIP cuts, but at least there will be a limit. Link via Yglesias.

The effect of health care reform on Texas

Here’s an email from the Legislative Study Group, via State Rep. Garnet Coleman, who has been a constant source of health care reform updates:

LSG Policy Update: CBO Estimates of Impact of Healthcare Reform to Texas

With the United States House of Representatives poised to take a vote on health care reform [today], we wanted to provide you with some data on the expected financial impact on Texas state government.

Congressman Henry Cuellar provided us with a letter from Congressman Henry Waxman, Chairman of the Committee on Energy and Commerce. The Chairman responds to an inquiry from Congressman Cuellar on the fiscal impact of the Medicaid provisions in health reform on the State of Texas.

The House will take two main votes [today]: one on final passage of health insurance reform, and one on a sidecar reconciliation bill that improves upon the main legislation. Taken together, these measures will have an historic impact on our country and especially in Texas where almost 28 percent of the population is uninsured.

One important provision is the Medicaid expansion that will bring a million Texans living at or near the poverty level into coverage. Currently, Texas covers parents with incomes up to 26 percent of federal poverty level (FPL). The legislation will increase that to 133 percent of FPL while covering 100 percent of the costs of new enrollees until 2018, then stairstepping down the reimbursement level to 90 percent by 2020.

There have been various estimates of the proposed impact on the Texas state budget – Congressman Cuellar’s letter sheds some light on the projected state impact as viewed by the nonpartisan Congressional Budget Office (CBO). To begin with, the legislation under consideration would be in effect for ten years – through the end of 2019 – at which point Congress would have to reauthorize it. Going on the timeline of the bill (2010 – 2019), Texas should expect to spend around $1.4 billion over ten years, the bulk of which would not come until after the changes go into effect, after 2014.

This stands in contrast to estimates by HHSC you may have seen cited in the press that peg the cost at approximately $24 billion. That estimate is on a different timeline: going from 2014 – 2023, or four years past the legislation’s life. It also includes approximately $6 billion in possible cuts to Medicaid Disproportionate Share Hospital (DSH) funding that is generally used to compensate hospitals that perform uncompensated care. The HHSC estimate also does not include many of the provisions in the proposed reconciliation improvement bill – for instance, Medicaid DSH reductions are smaller in the Medicaid bill. The CBO projects a $1.2 billion reduction in DSH funds over the course of the legislation (2010-2019).

All told, Texans and Texas state government stand the chance to benefit greatly from federal healthcare reform legislation. Most of the 5.9 million uninsured Texans will gain health insurance, all insured Texans will gain protection from the worst practices of the insurance industry, and Texas will likely receive over $120 billion in federal dollars.

Economist Ray Perryman noted that spending on CHIP and Medicaid has a 3.25 multiplier effect – meaning every dollar spent generates 3.25 times that amount in economic activity. The legislation has the potential to create jobs and boost economic activity in our state while also ensuring the health and well being of all its citizens.

Thank you again to Congressman Cuellar for passing along Chairman Waxman’s analysis. You can view a pdf of the letter here.

So there you have it. Now pass the damn bill already, and let’s get on with it.

Those evil, dirty, federal dollars

Rick Perry loves ’em.

Which of the following revenue sources has grown the most since Rick Perry became governor?

A. Sales tax, driven by a strong economy.
B. Natural gas production tax revenue, driven by a strong economy and the Barnett Shale discovery.
C. Federal income.

The answer is C, though you’d never know it from listening to the rhetoric from the governor. Rick Perry is trying hard to capture the anti-Washington mood of voters, and he likes to argue that he is turning away federal dollars because, by golly, we Texans are independent and can solve our own problems. Problem is, the numbers just don’t support that assertion.

Compare the 2009 revenue for the state of Texas with the 2000 revenue, and you’ll see something you might not expect from a state that is led by someone who is sypathetic to secessionists. Federal income has grown 108.53 percent since 2000, more than double the revenue growth of taxes (50 percent). That means the Texas miracle is producing half as much revenue growth as reliance on federal dollars. As a portion of the state’s total revenue, taxes actually decreased by 6 percentage points while federal dollars increased by 7 percentage points.

There are a lot of causes for this, some of which are beyond a Governor’s control, but not all of it; the figures aren’t broken down, but I’d bet a lot of that growth in federal revenue comes from things like food stamps, Medicaid, and CHIP, for which there might be less need if there were less poverty in Texas. The point here is simply that what Rick Perry says – and what some people believe about him – often has little to do with reality. I know, big surprise, but one can never have too many reminders of it.

If we must cut the budget, let’s be smart about it

The Trib remembers the last time the state of Texas had a huge budget hole, and how it made things worse in its attempt to deal with it.

For some, it’s not too early to fret that lawmakers will balance the budget in 2011 by doing what they did seven years ago, the last time it was this bad. “Well, they cut Medicaid and CHIP (the Children’s Health Insurance Program), and otherwise they pretty much balanced it on the backs of other people,” said Eva DeLuna Castro, a former analyst at the Comptroller’s office and now a budget analyst with the Center for Public Policy Priorities. “The Medicaid and CHIP cuts — I mean, that is hundreds of thousands of children losing healthcare.”

A CPPP analysis of the 2004-2005 budget found that decisions in 2003 rendered approximately 350,000 children and adults ineligible for Medicaid services that they would have qualified for in 2005 had policies remained unchanged. The study also concluded that nearly $4 billion in federal Medicaid dollars destined for Texas was “left on the table” after the state failed to allocate the necessary amount in general revenue funding to qualify for the federal aid.

Adding insult to injury, the cuts may not have had the impact on the budget that some believe. “Let me say this, and it’s not an overstatement: Many of the savings that were promised [in 2003] were not realized,” says former State Rep. Dianne White Delisi, R-Temple, who chaired the House Select Committee on Health Care expenditures before she retired in 2007. “So if I had one warning for this [upcoming] Legislature, it would be: Go for substance, not window dressing.”

Along those lines, another veteran of that session, former State Rep. Ray Allen makes the case that the place to consider deeper cuts is the place that largely escaped such cuts in 2003: prisons.

In 2003, the state prison budget saw few budget cuts. Probation, parole and treatment programs were decimated. That decision triggered an immediate influx of new direct sentencing to prison by concerned judges whose concerns also led to a flood of technical probation revocations based upon their assessment that reduced supervision budgets would degrade local probation departments’ ability to adequately protect the public.

That 2003 budget cutting of probation, parole and treatment programs backfired.

Yes, the cuts helped balance the budget in 2003-4, but they led to significantly expanded spending in subsequent years in the most costly category of criminal justice spending–prison beds. 2003’s cuts saved nickels in that budget cycle, but forced future spending of millions.

An old, familiar saying expresses a phrase worth remembering: “Penny wise; pound foolish(referring to the British Pound Sterling).” The immediate urgency of a crisis should not be addressed without considering the long-term consequences which may follow.

In his piece, Allen refers to this Statesman op-ed by Ana Yanez Correa of the Texas Criminal Justice Coalition, which notes that it’s prisons that’s the fattest part of the corrections budget anyway:

In 2007, lawmakers decided that continuing the status quo by building additional, costly facilities was no longer an option. Instead, they worked ardently in a bipartisan and historic effort to mandate “smart on crime” strategies that would tackle the root causes of prison overcrowding head-on — including stronger probation and parole structures and increased numbers of treatment beds to improve programming delivery.

These strategies have begun to deliver taxpayers a greater return on their investment while promoting a safer Texas. Indeed, despite the fact that 88 percent of Texas’ $2 billion corrections budget goes towards incarceration — while only 12 percent is dedicated to diversions — these alternatives to incarceration have saved more than $443 million through the rerouting of thousands of offenders from prison and into effective programming. The bottom line: fewer victims in the long term and more taxpayer savings.

This in a nutshell is the problem with across-the-board budget cuts, such as the five percent cut that Governor Perry, Lt. Gov. Dewhurst, and Speaker Straus have mandated. It’s reflex over thought, and it fails to take into account the fact that some dollars are much better spent than others. What we need, and what we’ll get with new leadership for Texas, is an approach that prioritizes where cuts need to be and where they should be avoided. Otherwise, well, we shouldn’t be surprised by what we get, because we got it before just a few years ago. Thanks to Grits for the Ray Allen link.

UPDATE: And more from Grits.