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Texas still hasn’t expanded Medicaid. Leaving a gap in coverage for hundreds of thousands.

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In 2012, Tanya Walker took the $200 her father loaned her to see a doctor. She was in the aftermath of a divorce and needed a prescription for antidepressants, she said. But her doctor in Texarkana found signs of hypertension and prediabetes — problems Walker knew she could not afford to have.

Although her five kids were covered under Medicaid, Walker was ineligible for the state program and had no health insurance.

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Walker fell into the uncertain terrain of the health care coverage gap — she earned too much from her part-time job at a local Walmart to qualify for Medicaid, but too little to qualify for tax credits for private insurance under the Affordable Care Act, better known as Obamacare.

Under Obamacare, Medicaid — the joint state-federal program that provides health care to low-income individuals — was intended to fill that gap by expanding to cover individuals who earn up to about 138 percent of the federal poverty level, or about $34,638 a year for a family of four. A recent ruling from a federal judge in Texas invalidated Obamacare, throwing the whole program into question; for now, the sweeping law remains in effect.

Texas Governor Rick Perry hosts a working session on Medicaid expansion for U.S. Senators John Cornyn, Ted Cruz and other conservative stakeholders at the Texas Capitol on April 1, 2013.
Texas Governor Rick Perry hosts a working session on Medicaid expansion for U.S. Senators John Cornyn, Ted Cruz and other conservative stakeholders at the Texas Capitol on April 1, 2013.  Bob Daemmrich

First, individual states had to agree to expand their Medicaid program, and the federal government offered to pay for 100 percent of states’ Medicaid expansion from 2014 to 2016 — aid that decreased to 90 percent by 2020.

But a number of states, including Texas, fought the Obama administration’s mandate to expand Medicaid, and in 2012 the Supreme Court ruled states were not required to comply with the mandate. That left about 638,000 non-elderly Texans in the Medicaid gap as of 2016 — the most among the states that didn’t expand Medicaid, according to the Kaiser Family Foundation.

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“When the Supreme Court decision came down, people who were in that kind of middle-income band, they still had access to the subsidies through the marketplace,” said Rachel Garfield, associate director of the foundation’s Program on Medicaid and the Uninsured. “It was people at the lower end of the spectrum who were left without that coverage option.”

People like Walker.

Even after she got a job as a substitute teacher that paid around $800 per month — and offered health insurance through the school district — she still didn’t earn enough to pay the almost $1,000 a month for coverage. In Texas, substitute teachers don’t receive the same level of state contribution for health insurance as full-time teachers, said Amy Nix, director of human resources for Texarkana Independent School District.

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Walker, 51, said Texas’ decision not to expand Medicaid under Obamacare left vulnerable Texans with few options for health care.

“It felt like in Charles Dickens’ Christmas Carol when Scrooge says, ‘Let them die and reduce the surplus population,’ ” Walker said. “That’s how I felt other Texans and my legislators felt about the working poor, ‘If you can’t afford insurance then we don’t care about you.’”

Many states, including Virginia and Louisiana, have since changed course and expanded Medicaid, while in other states — like Idaho, Nebraska and Utah — voters have bypassed their elected leaders to approve Medicaid expansion in recent elections. But Texas leaders haven’t budged on the issue and the state remains one of 14 with a coverage gap.

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“Medicaid expansion is wrong for Texas,” Gov. Greg Abbott said during a 2015 press conference in which he called Obamacare a “massive expansion of an already broken and bloated Medicaid program.”

Kids on Medicaid, parents not

To examine the role state and local policy play in issues related to income inequality such as health care, the Tribune collaborated with news outlets in Georgia, New York and Washington state.

New York and Washington state both expanded Medicaid, and their rates of uninsured citizens — 6 percent and 7 percent, respectively — have fallen below the 2016 national average of 9 percent, according to Kaiser Family Foundation. Texasand Georgia, both non-expansion states, had uninsured rates exceeding the national average, by 6 and 3 percent respectively, in 2016.

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Advocates and experts say if the state were to expand Medicaid, the coverage gap would disappear and more than a million uninsured Texans would obtain health coverage. Like Walker, many of them are the parents of children who qualify for Medicaid or the Children’s Health Insurance Program based on their parents’ income, said Anne Dunkelberg, program director for the health and wellness team at the left-leaning Center for Public Policy Priorities.

“Many [legislators] have incorrectly believed that the parents of our kids on Medicaid get Medicaid too. They don’t,” Dunkelberg said. “We have about 3.2 million children on Medicaid on any given day, and only about 150,000 parents.”

Although about 64 percent of Texans favor expanding Medicaid, the main support comes from Democrats — 82 percent approve — while 59 percent of Texas Republicans prefer keeping the state’s current Medicaid program, according to a recent survey from the Episcopal Health Foundation and the Kaiser Family Foundation.

Walker said her opinion on health care has been influenced by her personal experiences “trying to make ends meet and trying to stay healthy.”

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“Generally I’m very conservative in my politics,” Walker said. “But I’d really like to see Medicaid expanded and health care changed completely in all states, everywhere.”

The gap’s origins in Texas

Texas has “one of the most restrictive Medicaid systems in the country,” said Tiffany Hogue, policy director for the Texas Organizing Project, a state nonprofit that advocates for low-income and working families.

In Texas, adults who have children can receive Medicaid, but can’t make more than about 18 percent of the federal poverty level. According to Texas Health and Human Services Commission, a family of four can only make up to about $285 per month for parents to qualify for Medicaid. Adults without children can’t qualify for Medicaid unless they are disabled or pregnant and meet specific income thresholds.


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