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Paxton goes after DACA

I have no words.

Best mugshot ever

Texas Attorney General Ken Paxton and officials from nine other states on Thursday urged the Trump administration to end an Obama-era program that’s allowed hundreds of thousands of undocumented immigrants to live and work in the country without fear of being deported.

In a letter to U.S. Attorney General Jeff Sessions, Paxton urged the White House to rescind the 2012 Deferred Action for Childhood Arrivals, or DACA, program. DACA applies to undocumented immigrants that came to the country before they were 16 years old and were 30 or younger as of June 2012. It awards recipients a renewable, two-year work permit and a reprieve from deportation proceedings.

As of August 2016, more than 220,000 undocumented immigrants in Texas had applied for a permit or a renewal of one under the program, and nearly 200,000 of those have been approved, according to government statistics. It’s the second-highest total behind California’s estimated 387,000 applications and 359,000 approvals during the same time frame.

“We respectfully request that the Secretary of Homeland Security phase out the DACA program,” Paxton wrote. He was joined by the attorneys general of Arkansas, Alabama, Idaho, Kansas, Louisiana, Nebraska, South Carolina, Tennessee and West Virginia, as well as Idaho Gov. C.L. Otter.

“Specifically, we request that the Secretary of Homeland Security rescind the June 15, 2012 DACA memorandum and order that the Executive Branch will not renew or issue any new DACA or Expanded DACA permits in the future,” Paxton wrote.

[…]

The Mexican American Legal Defense and Educational Fund, or MALDEF, blasted the move and warned the signatories they’ll be remembered for being on the wrong side of history.

“Their evident xenophobia is not remotely consistent with the trajectory of our nation’s history and future progress,” MALDEF president and general counsel Thomas Saenz said in a statement. “Their political careers and each of their states will suffer from their mean-spirited stupidity.”

I don’t even know what to say about this. It’s cruel, it’s stupid, and I can’t think of a meaningful definition of “Christian” that would allow for it. The one sure to be effective thing we can do about this is to elect an Attorney General who won’t pull this crap. Nothing will change until we change who we elect. The Press, the Current, and Daily Kos have more.

Medicaid expansion: Still a good idea

I know, right?

It's constitutional - deal with it

It’s constitutional – deal with it

Fewer low-income residents of Kentucky and Arkansas, two poor states that expanded Medicaid in 2014, reported problems paying medical bills after the coverage expansions, especially compared with residents of Texas, which has rejected the health law.

And hospitals in Medicaid expansion states saw a marked decline in the share of patients without insurance, compared with hospitals in states that have not broadened access to Medicaid, a second study found.

“Our findings underscore the significant benefits of Medicaid expansion not only for low-income adults, but also for the hospitals that serve this population,” the authors of that study conclude.

The two studies, both published Tuesday in the journal Health Affairs, come as new states consider Medicaid expansion, a key pillar of the health law that President Obama signed in 2010.

[…]

GOP resistance to Obamacare is already affecting low-income residents of those state, the new studies suggest.

In Texas, for example, the percentage of residents reporting trouble paying medical bills, skipping prescriptions or delaying care because of cost barely moved between 2013 and 2014.

By comparison, Kentucky and Arkansas saw major declines in all three measures of access to medical care after the Medicaid expansion began in 2014.

The share of residents of the two states who reported skipping a medication due to cost fell more than 10 percentage points. And the percentage of Kentucky residents who said they had trouble paying medical bills dropped by more than 14 percentage points, from 42.7% to 28.4%.

Researchers also found major gains in the share of residents who said they had a check-up in the prior year, which increased more than eight percentage points in both Kentucky and Arkansas.

And they found sizable increases in the percentage of patients with chronic medical conditions who got regular care, which increased more than 6 percentage points in the two states.

Texas, by contrast, saw a decline in the percentage of chronically ill residents who got regular care between 2013 and 2014, according to the study, which was based on a telephone survey of 5,665 low-income, working-age adults in the three states.

But hey, we sure are pro-life around here, right? Just not pro-healthy life, or at least not pro-healthy life for non-rich people. I’m sure that’s in the bible somewhere. The Chron and Daily Kos have more.

Two anti-gay bills advance

Look out.

RedEquality

Gay rights advocates began sounding the alarm Wednesday after two anti-LGBT bills cleared House committees and another received a favorable hearing.

Kathy Miller, president of the Texas Freedom Network, said if LGBT groups and their corporate allies don’t work quickly to generate the type of backlash seen over a religious freedom bill in Indiana last month, it could soon be too late.

Miller made the statement on a day when separate House panels advanced bills that would bar county clerks from issuing same-sex marriage licenses and allow state-funded adoption agencies to turn away gay couples based on religious beliefs. The two bills, which breached a dam that had kept a record number of anti-LGBT measures at bay for the first 100 days of the session, now head to the Calendars Committee.

“My fear is that if the Indiana-style outrage doesn’t happen now, before these bills make it to the floor of the House, it will be too late, because the membership of the House will pass these bills, and then the Senate will fly them through, and Gov. [Greg] Abbott will have no choice but to sign them in his mind,” Miller said.

Miller and others said with the U.S. Supreme Court set to hear oral arguments on same-sex marriage Tuesday, moderate Republicans in the Legislature are feeling the heat from social conservatives.

“I feel like the Republican base is desperately afraid of the Supreme Court’s ruling on marriage this summer,” Miller said. “I think there’s a tremendous amount of pressure on the leadership in the House to pass anti-LGBT legislation. I think some of Speaker [Joe] Straus’ lieutenants are more likely to cave in to that pressure than others.”

[…]

The House Committee on State Affairs voted 7-3 along party lines to advance House Bill 4105, which would prohibit state or local funds from being used to license or recognize same-sex marriages.

Among those voting in favor of the bill was Rep. Byron Cook (R-Corsicana), a moderate who chairs the committee and has come out in support of one pro-LGBT bill.

“For me, I believe in the sanctity of marriage between one man and one woman, so that’s why I voted for it,” Cook said.

All due respect, and I do respect Rep. Cook for his support of the birth certificate bill, but he’s not a moderate. As I noted before, he received an F on the 2013 Equality Texas report card. His support of Rep. Anchia’s bill is great and appreciated, but it doesn’t change who he is.

The Texas Association of Business, the state’s powerful chamber of commerce, has come out against two proposed religious freedom amendments that critics say would enshrine a “license to discriminate” against LGBT people in the Texas Constitution. But the TAB has remained silent on the bills that cleared committee Wednesday.

“We have not taken a position and doubtful (with timing of the session) that we will be able to,” TAB President Chris Wallace said in an email. “We will continue to monitor the business-related implications.”

Late Wednesday, the House Committee on Juvenile Justice and Family Affairs voted 6-1 to advance House Bill 3864, by Rep. Scott Sanford (R-McKinney), which would allow state-funded child welfare providers to discriminate based on sincerely held religious beliefs.

Meanwhile, dozens of pastors gave hours of testimony in support of House Bill 3567, also by Sanford, which he said is designed to prevent clergy from being forced to perform same-sex marriages. Critics of HB 3567 say it’s so broadly written that it could allow any religiously affiliated organization—from hospitals to universities and homeless shelters—to discriminate against LGBT people.

None of this is good, so now would be an excellent time to call your State Rep and ask him or her to vote against these bills. It would also be nice if the TAB and its other corporate allies would remember that not only are these bills bad for business, they will inevitably lead to expensive litigation (that the state will lose) because they’re clearly unconstitutional. The cheaper and safer route is to keep them bottled up in the House.

It’s hard to overstate just how out of step with public opinion all of this is. I can only conclude that the GOP is more in thrall to its zealot wing than it is to the business lobby. Maybe this will finally help cause a bit of a schism. As far as those “Christians” that were there to lobby for these bills, they don’t represent all people of faith. Not by a longshot. And finally, if Indiana and Arkansas weren’t object lessons enough for Republicans, just keep an eye on Louisiana, where Bobby Jindal has decided that the best strategy is to double down. Imitating Arkansas is bad enough – do we have to do what Louisiana does, too? The Trib has more.

Let Indiana be our guide

Chron business columnist Chris Tomlinson has a warning for us.

PetitionsInvalid

Watching Indiana Gov. Mike Pence call for a revision to a week-old religious freedom law this morning should be required viewing for every Houston politician and business person.

After refusing to denounce discrimination against lesbian, gay, bisexual and transgender individuals for days out of fear of alienating his political base, Pence did what all politicians who see their careers slipping away do. He flip-flopped, called it a clarification and denied there was a problem.

Why did this conservative Republican suddenly speak out against LGBT discrimination? Because American consumers and businesses made it clear that they would not accept bigotry in any form, even when disguised as religiosity. Corporations announced they would not subject their LGBT employees to the chance they may face legally-sanctioned discrimination. Angie’s List announced it would not expand in Indiana and numerous other groups began canceling conventions in the state.

What happened to Pence could happen to Houston and Texas.

[…]

Can you imagine what would happen if the small number of Houston voters who actually show up to the polls approved a repeal of the law? Houston would be labeled a city of bigots and the firestorm over Indiana would look like a campfire.

I know business people don’t like to think about social issues, most are concentrating on running the best business they can. But the business community needs to pay attention to what’s happening to Houston’s civil rights ordinance in court and what could happen at the ballot box. If the repeal passes, those new hotels and the updated convention center may have a hard time finding customers.

We should know soon whether or not there were enough valid signatures after the recount. In the meantime, as Tomlinson noted, there are bills in the Legislature that would do to Texas what Mike Pence did to Indiana; Arkansas was also going down that path before their Governor had a dose of sanity. Maybe all that WalMart lobbying against it made a difference. In any event, you might think that organized opposition from the business community here might help sway some opposition, but 1) the type of person that supports this kind of law doesn’t believe any of the bad things that everyone tells them will happen will actually happen, even with the evidence of it happening now, and 2) I don’t believe the business community will follow up by actually opposing any of the supporters of those bills in the next election.

To be fair, the business community is talking a good game.

“This thing is equally bad or worse than Indiana, and look what’s happening there,” said Bill Hammond, head of the powerful lobbying group the Texas Association of Business. Organizations as disparate as NASCAR, Walmart and Apple have blasted Indiana and Arkansas for their laws, already prompting the governors of both states to backpeddle on their support.

Sen. Donna Campbell, R-New Braunfels, one of at least three lawmakers proposing so-called religious freedom legislation this session, said she will narrow her bill in the face of a slew of similar concerns.

Campbell’s Senate Joint Resolution 10 seeks to enshrine the 15-year-old Texas law in the state Constitution, but without the key civil rights and local control protections. Her original proposal also removed the word “substantially,” which critics said would have allowed anyone who thinks the government is infringing upon his free expression, however slightly, to sue the state.

On Wednesday, however, Campbell’s staff confirmed she will re-insert the word “substantially.” Rep. Matt Krause, R-Fort Worth, who has proposed an identical bill in the House, said he is not opposed to amending his legislation the same way.

“That’s an improvement,” Hammond said. “But we have a long list of concerns with the legislation and the issue of ‘substantial burden’ is just one of them.”

Hammond cited the civil rights protections and local control issue, saying not exempting cities and municipalities could put local nondiscrimination ordinances like those in San Antonio and Houston on the chopping block. Enshrining the law in the Texas Constitution would make it much harder to amend or repeal if problems arise, he said. He also noted Campbell’s bill does not include a $10,000 cap on damages included in the existing law, potentially opening the state to unlimited litigation costs.

The impact on the Texas’ economy could be substantial, Hammond and other opponents said. Houston and other cities could lose the opportunity to host valuable sporting events and companies planning to expand their Lone Star State footprint could pull out – like Angie’s List did with its now-canceled expansion in Indianapolis.

“The motivation is to permit discrimination on the basis of religious belief,” said Rebecca Robertson, legislative and policy director for the American Civil Liberties Union of Texas. “That’s not the brand we want to be associated with.”

The opposition was heavy enough to lead Jason Villalba, R-Dallas, to drop his religious freedom proposal in early March, after which Krause picked it up. Krause said he would be amenable to tweaking his bill, but he chalked up business opposition to opponents simply not understanding the legislation.

“I think it’s a bunch of overreaction, and not understanding what the law really does or what it means,” Krause said.

Oh, I think we all understand it just fine, but thanks for demonstrating my point. Like I said, people like Bill Hammond talk a good game but they are notoriously short on action. A credible threat of primary opposition might open some eyes. If one is not inclined to do the right thing, one needs to fear the consequences of doing the wrong thing. I don’t think enough legislators do.

It’s still not Medicaid expansion

The Legislature may do something that could sort of be called “Medicaid expansion”, if only for lack of a better term, but we would all do well to remain deeply skeptical of what they might consider.

It's constitutional - deal with it

It’s constitutional – deal with it

The once taboo subject of expanding Medicaid in Texas has been broached in recent weeks by some Republicans and GOP-friendly organizations, as the Legislature prepares to reconvene early next year.

[…]

In 2013, state Rep. John Zerwas, R-Richmond, wanted to use federal dollars and a Medicaid waiver to create a new insurance program for poor Texans, but he was never able to build much support among his Republican colleagues.

“Last time, everybody was pretty reactionary,” said Zerwas, a physician. “We were playing defense.”

But with Perry leaving office in January and a new legislative session set to begin, Zerwas and his allies once again are pushing for a new program.

The difference this time is the dialogue is more thoughtful and the effort is more organized, he said.

Zerwas and other legislators had the chance after the 2013 session to go back to their districts and listen to their constituents. Many expressed interest in insuring people who can’t get coverage under the new law, he said, but many more have indicated that they want to see the already stressed, safety-net hospitals get some relief from being forced to care for so many uninsured people.

Gov.-elect Greg Abbott said on the campaign trail that he opposed Medicaid expansion, but spoke of seeking a block grant from the federal government to reform Medicaid in the state, echoing some other Texas Republicans.

The words “block grant” are your first clue that despite the sincere words of people like Rep. Zerwas, this is the same old song and dance with some fresh wrapping paper on it. Block grants are a shibboleth and a mirage. The Bush administration refused to grant waivers to allow for these things. President Obama will nominate Ted Cruz to be its next Attorney General before his administration will consent to block grants for Texas.

The Texas Association of Business, an influential group with close friends in the Republican Party, has come out again in support of expanding Medicaid, just as it did in 2013.

Bill Hammond, president of the organization, said it will take a “massive effort” in 2015 to increase coverage for Texans, but it’s a fight he is willing to take on.

“It just makes sense for us from the business perspective,” he said.

[…]

Dan Stultz, president and CEO of the Texas Hospital Association, said in a presentation that hospitals need meaningful coverage expansion.

Stultz told the Associated Press earlier this year that hospitals agree with Perry that the Medicaid program is “severely flawed,” but he also said that “without the Medicaid expansion, many will remain uninsured, seeking care in emergency rooms, shifting costs to the privately insured and increasing uncompensated care to health care providers.”

The Texas Medical Association, one of the most powerful lobbies in state government, also supports allowing state leaders to work with the federal Centers for Medicare and Medicaid Services to come up with a solution that fits Texas’ health care needs.

The association’s leaders are pushing the Legislature to create a concept, as it says on the group’s website, that “works for the state and helps Texans in the coverage gap get affordable and timely care.”

The “support” these organizations have for Medicaid expansion doesn’t extend to supporting candidates that support Medicaid expansion, of course. In that way, it’s like their support of immigration reform. Fill in your own definition of insanity, and go search healthcare.gov for insurance policies that would cover that affliction.

Be all that as it may, we now have an interim report with recommendations on the subject.

Texas should pursue a waiver from the federal government for more flexibility to administer Medicaid, heighten the “visibility” of the state’s mental health programs to “ensure adequate leadership and accountability” and consolidate its three major women’s health programs, the Senate Committee on Health and Human Services said Monday.

In a lengthy report, the interim committee released its recommendations for the 2015 legislative session, addressing charges from outgoing Lt. Gov. David Dewhurst to expand access to women’s healthcare, improve the state’s mental health services, stop prescription drug abuse, and provide affordable care options for the state’s uninsured — all under the constraints of a fiscally conservative budget.

[…]

Among the report’s other recommendations:

Texas should not expand Medicaid to cover low-income adults, a key tenet of federal health law. Lawmakers should, however, seek to renew the “transformational” Medicaid waiver that, among other things, helps reimburse hospitals for the emergency care they provide to the uninsured. Notably, the report does not rule out pursuing a transformational waiver like the one the feds approved in Arkansas, which provided for a private health coverage expansion to low-income people using the Medicaid expansion dollars made available under the Affordable Care Act.

See here for some background, and here for a copy of the report. Rather than get distracted by shiny objects, read these two paragraphs from page 23:

The state’s first order of business must be to repair this broken Medicaid system and bring these costs under control. By enacting common-sense reforms such as cost sharing, health savings accounts, variable benefit packages, and high-deductible emergency care plans, Texas can reform its Medicaid program in a way which contains costs, encourages personal responsibility, and lessens the burden of providing uncompensated care.

Unfortunately, most of these innovative solutions are not able to be implemented under the strict Medicaid guidelines imposed by the federal government. By receiving a federal waiver from these restrictions, Texas can finally have the flexibility it needs to design a sustainable and cost-effective Medicaid program that is appropriate for the citizens it serves and accountable to taxpayers.

Like I said, let’s keep our eyes on the ball. The feds have been making noise about that “transformational” waiver not being a guarantee if Medicaid isn’t expanded in some acceptable form. What “acceptable” looks like is the hundred billion dollar question. The feds have been fairly accommodating to recalcitrant states, but there’s only so far they’ll go. Block grants ain’t happening, and those pet rocks masquerading as “common sense reforms” are more smoke than substance. Texas is going to have to give something to get something, and I’ll believe that will happen when I see it. A press release from Sen. Charles Schwertner, the chair of the HHS committee, is here, and Texans Together has more.

The Texarkana experience

The city of Texarcana literally sits on the border between Texas and Arkansas, partly in one state and partly in the other. That means that some of its residents may be eligible for a health insurance subsidy under Arkansas’ Medicaid expansion/privatization hybrid. Or they may be in Texas and be screwed like anyone else.

It's constitutional - deal with it

It’s constitutional – deal with it

Arkansas accepted the Medicaid expansion in the Affordable Care Act. Texas did not.

That makes Texarkana perhaps the starkest example of how President Obama’s health care law is altering the economic geography of the country. The poor living in the Arkansas half of town won access to a government benefit worth thousands of dollars annually, yet nothing changed for those on the Texas side of the state line.

[…]

None of the low-income Texarkana residents interviewed realized that moving to the other side of town might mean a Medicaid card. In fact, health researchers and those who work with the poor expect very few Americans to move between states to take advantage of the law.

“It’s impossible to understand what it is to move when you have nothing,” said Jennifer Laurent, the executive director of Randy Sams’ Outreach Shelter, where Ms. Marks is staying until she puts together enough savings from her two low-wage jobs to find her own place. “To risk everything — losing your bed, your sense of community — for an uncertain benefit? There’s no way you want to risk that.”

Research on other expansions of government benefits has borne that out: A study in the journal Health Affairs looked at the “welfare magnet hypothesis” and found no evidence that it exists.

“I’m sure, anecdotally, that some people will move,” said Benjamin Sommers, an assistant professor of health policy and economics at the Harvard School of Public Health and a co-author of the study. “But is this a major budget issue for states expanding Medicaid? Will there be a major wave of people moving to get insurance? Probably not.”

[…]

Indeed, until the Supreme Court ruling, the Obama administration had intended for the Medicaid expansion in the Affordable Care Act to be universal, covering all adults earning up to 133 percent of the federal poverty line, about $15,500 annually for a single adult or $32,000 for a family of four.

That’s the way it is working out on the Arkansas side of the border, where health clinics and social service agencies are signing up eligible residents, even though this corner of the state is largely Republican and broadly resistant to the health care law.

The expansion is already having an effect on the city’s biggest provider of charity care, the nonprofit Christus St. Michael Health System. “We’re seeing more patients with a payer,” said Chris Karam, its president, referring to those with health insurance coverage.

On the Texas side, though, it’s business as usual. “It makes me mad,” said Mr. Miller, who is not receiving any federal benefits at the moment despite his array of illnesses. “They need to quit playing games with people’s lives. Rich people. Government people.”

Yeah, that would be nice. I believe I’ve mentioned once or twice that there’s an election this fall in which issues like this will be at stake. One hopes the people of Texarkana will recognize the opportunity that gives them. The rest of us, too.

Two wins against voter ID

Good news from Wisconsin.

Still the only voter ID anyone should need

Still the only voter ID anyone should need

Trying to crack down on in-person voter fraud isn’t a strong enough justification for Wisconsin’s voter ID law, a federal judge ruled Tuesday, because voter impersonation virtually never occurs now and is unlikely to become a real problem in the future.

In striking down the 2011 law signed by Gov. Scott Walker (R), U.S. District Judge Lynn Adelman held that although the U.S. Supreme Court had ruled in 2008 that states had an interest in preventing voter fraud, Wisconsin’s voter ID law wasn’t justified because voter fraud in person doesn’t really exist.

“The evidence at trial established that virtually no voter impersonation occurs in Wisconsin,” Adelman ruled in Frank v. Walker. “The defendants could not point to a single instance of known voter impersonation occurring in Wisconsin at any time in the recent past.”

The judge also held that re-enforcing public confidence in the electoral process wasn’t a sufficient justification for the voter ID law. He noted that there was no evidence that law enforcement authorities were simply failing to catch instances of voter impersonation because they were hard to detect.

If voter impersonation is occurring “often enough to threaten the integrity of the electoral process, then we should be able to find more evidence that it is occurring than we do,” Adelman wrote. “If, for example, voter impersonation is a frequent occurrence, then we should find more than two unexplained cases per major election in which a voter arrives at the polls only to discover that someone has already cast a ballot in his or her name.”

[…]

“This is a warning to other states that are trying to make it harder for citizens to vote,” Dale Ho, director of the ACLU Voting Rights Project, said in a statement. “This decision put them on notice that they can’t tamper with citizens’ fundamental right to cast a ballot. The people, and our democracy, deserve and demand better.”

This ruling follows on the heels of a state judge in Arkansas finding that state’s voter ID law unconstitutional. That ruling has been temporarily stayed pending appeal, and the Wisconsin ruling will also be appealed, so it’s still early days.

Rick Hasen analyzes the Wisconsin ruling.

This is about the best possible opinion that opponents of voter identification laws could have hoped for. It is heavy on both facts and on law. It is thoughtful and well written. It finds that a voter id law serves neither an anti-fraud purposes (because “virtually no voter impersonation occurs in Wisconsin and it is exceedingly unlikely that voter impersonation will become a problem in Wisconsin in the foreseeable future”) nor voter confidence purposes. It finds that it burdens lots of voters (up to 300,000) voters. It finds these burdens fall especially on Black and Latino voters and that the reason is does is poverty, which is itself the result of prior legal discrimination.It enjoins enforcement of the law for everyone, and expresses considerable doubt that the Wisconsin legislature could amend the law to make it constitutional. It is about as strong a statement as one might imagine as to the problems the voter id law.

[…]

On the VRA issue, this is the first full ruling on how to adjudicate voter id vote denial cases under section 2. The key test appears on page 52 of the pdf: “Based on the text, then, I conclude that Section 2 protects against a voting practice that creates a barrier to voting that is more likely to appear in the path of a voter if that voter is a member of a minority group than if he or she is not. The presence of a barrier that has this kind of disproportionate impact prevents the political process from being ‘equally open’ to all and results in members of the minority group having ‘less opportunity’ to participate in the political process and to elect representatives of their choice.” The judge also approaches the causation/results question in a straightforward way. It is not clear whether the appellate courts will agree or not agree with this approach, which would seem to put a number of electoral processes which burden poor and minority voters up for possible VRA liability.

In sum, this is a huge victory for voter id opponents. But time will tell if this ruling survives.

So reasons for hope, but it’s way too early to celebrate. What the trial courts have done, the appeals courts and the Supreme Court can still undo. On the bright side, Kevin Drum explains why this case was different than Crawford v. Marion County, the 2008 Supreme Court decision that allowed for voter ID:

In a word, better arguments from one side. In Crawford, the state presented virtually no evidence that in-person voter fraud was a problem in Indiana—but neither did the plaintiffs provide much evidence that a voter ID law presented a serious obstacle to voting. Given this, the state’s interest in preventing voter fraud—even if that interest was more speculative than real—carried the day.

This time, the state once again produced virtually no evidence that in-person voter fraud was even a potential problem. But the judge was presented with loads of evidence that the burden of obtaining a photo ID was, in fact, quite high for low-income voters in particular. Since Crawford mandated the use of a balancing test to assess whether a photo ID law was justified, that made the difference and Wisconsin’s law was struck down.

He goes on to highlight parts of the decision that show the burden on some 300,000 voters in Wisconsin to get an accepted form of voter ID. The parallels to Texas should be obvious to anyone that has followed the issue in our state.

Speaking of Texas, there’s a hearing scheduled for today on motions made by AG Abbott to quash subpoenas to current and former members of the Legislature on their role in crafting the voter ID law – see here for the background, and here for the plaintiffs’ responses. How the judge rules on this motion will determine how much these legislators will have to testify in this case, and how much is protected by legislative privilege.

Arkansas will expand Medicaid

If they can do it

It's constitutional - deal with it

It’s constitutional – deal with it

[Friday], the Center for Medicaid and Medicare Services notified state officials in Arkansas that it has approved the states’ Medicaid expansion plan. And this is not any old expansion plan: Arkansas will be the only state in the country that will use Medicaid dollars to purchase private health insurance for its new public program enrollees.

“CMS is pleased to approve Arkansas’s Medicaid 1115 Waiver application,” Medicare spokeswoman Emma Sandoe said in a statement. “Arkansas and CMS worked together to find flexibilities that gave the state the tools to build a program that worked for them and their residents. We appreciate the collaboration with Arkansas throughout the process and applaud their commitment to providing Arkansans with access to high-quality health coverage.”

There are about 200,000 Arkansans who qualify for the Medicaid expansion. Instead of having them enroll in the public program, like other states will do, Arkansas will send them to their new health insurance marketplace to buy individual plans. When they get to the point of purchase, the Medicaid agency will foot the tab for their health insurance coverage.

The Arkansas expansion will start open enrollment just five days from now, on Oct. 1, alongside the 25 other states planning to expand the program. Benefits will begin Jan. 1.

The idea of using Medicaid expansion funds to pay for private insurance for those that would have qualified for Medicaid under Affordable Care Act expansion guidelines was proposed earlier this year, while the Lege was in its first session. House Speaker Joe Straus seemed open to this kind of idea, but he had precious little company on his side of the aisle. The quasi-Medicaid “expansion” bill that made it out of the House before withering on the vine insisted on asking for a block grant first, as that is Rick Perry’s obsession, but maybe – MAYBE – once that door is slammed shut again there will be some willingness to look at this plan again, however imperfect it is.

I do not expect another Ardmore

The AusChron tries to get out the Democrats’ strategy for Special Session 2.

When the Texas House convened last last month to pass, on third reading and onto the Senate for final passage, Senate Bill 5, the omnibus abortion regulations bill, Austin Rep. Elliott Naishtat heard several colleagues discussing whether House Dems would be ready to walk out – to break quorum – in order to stop the measure from moving forward.

Among the questions before Democrats as they face today’s start of a second-called special session, with passage of abortion regulations first on Gov. Rick Perry’s to do list, is whether a mid-summer, out-of-state sojourn may be in the cards. “There was talk about it” on the floor last month, he said, “and there will undoubtedly be talk about it again.”

[…]

With the 30-day special-called session only getting under way today, there is plenty of time for Republicans to maneuver to pass the divisive measures – as one Capitol staffer said last week, not even Davis can talk for 30 days. But there remain other strategies to explore, said Austin Democratic Sen. Kirk Watson – though he declined to offer specifics. “I’m not going to get into strategies,” he said, “but we’re not going to give up the fight.”

[…]

Requiring testimony in each chamber may be one way to moderate the legislation’s forward progress, but it is unlikely to do much to halt the ever-forward movement. So, might a mid-summer trip to a nearby state be the way to go? That’s certainly an option, says [Rep. Donna] Howard. Though, realistically, says Naishtat, he isn’t sure that it would work to derail the measure completely. “I don’t see how House or Senate Democrats could break quorum for the amount of time necessary to defeat the bill – it could be as much as three weeks,” he said. “On the other hand, other people doubted that Sen. Wendy Davis could pull off a filibuster. So what I’m saying is, you never know.” Indeed, Naishtat agrees that at this point, every option is on the table. And it would be “foolish,” he said, for Republicans to “underestimate our power, our intelligence, our mastery of the rules, and our commitment to doing everything legal to prevent the passage of … anti-pro-choice bills.”

I’m not privy to the Dems’ thinking, and I certainly wouldn’t dismiss any feasible possibility out of hand, but I have a hard time seeing how a quorum break would be successful. As with the Davis filibuster, all it can do is delay. It can’t prevent any of this awful legislation from passing, because Rick Perry can just keep calling more sessions, which you know he will. The reason why Ardmore was doable in 2003 was that the Dems only needed to be gone for five days. As with the previous special session, the re-redistricting bill came up late, and it was close enough to the deadline for passing bills out of the House for the Senate to take up that they could bug out on Monday and return on Saturday having accomplished their task. Busting quorum now would be like what the Senate Dems tried to do later that summer. As was the case back then, there was no magic day after which you could say you were in the clear. Maybe they’ve though this through and they know what their endgame is, but I have my doubts. It’s asking an awful lot of a lot of people, and I don’t know how practical it is. I hate to be a wet blanket, and I could be wrong about this, but that’s how I see it.

Two more factors to consider. One is that in the aftermath of Ardmore and Albuquerque, there were some rule changes made in each chamber to make future quorum busts more difficult and more punitive to the fleeing party. I don’t remember the details, but I do feel confident that the Rs would be extremely vengeful towards a caucus that skipped town. Two, back in 2003 the Governors of Oklahoma and New Mexico were both Democrats, and thus unwilling to cooperate with the efforts to locate and extradite the Killer Ds. Both Governors are Republicans now, so no such assistance would be in the offing. The only neighboring state now with a Democratic Governor is Arkansas, but I would not want to put my fate in that state’s hands. The nearest state where I’d feel safe, politically speaking at least, is Colorado. Point being, any out of state excursion would need to be done by air, not by bus, which increases the cost, the risk factor, and the likelihood of something going wrong because there’s just too much you can’t control.

Anyway. If it were up to me, I’d do everything I could to drag the proceedings out, while giving the crazier members of the GOP caucus as many opportunities to say something as stupid as Rep. Laubenberg did last session, and I’d lay whatever groundwork I could for litigation to block the law. The name of the game is the 2014 election. Go down fighting, keep everyone engaged, and be ready to pick up where you left off as soon as the session ends. Be sure to read the whole AusChron story, there’s a lot more in there besides quorum breaking.

The limits of the Arkansas option

I’ve mentioned the Arkansas option for expanding Medicaid several times, under which the state uses Medicaid money to buy private health insurance for those who would be eligible for Medicaid under the Affordable Care Act. It’s not my preferred solution, but it has some merits and would certainly be better than doing nothing. However, while the federal government has shown a great deal of flexibility in allowing an arrangement like this and like what is on the table in Florida if their legislature doesn’t deep-six it, that flexibility has its limits, as the state of Tennessee found out.

It’s constitutional – deal with it

Tennessee wanted to pursue a plan like that of Arkansas, one where it would use the Medicaid expansion dollars to buy private insurance coverage. And while Arkansas received a preliminary go-ahead from HHS, Gov. Bill Haslam had a quite different experience: He says that Health and Human Services would not support his plan to expand Medicaid and, as a result, he will not move forward.

“As a result of the lack of clarity from HHS,” his office said in a late Wednesday statement, “the governor will not ask the General Assembly for approval to accept the Medicaid expansion federal funds as he continues to work for the flexibility needed to implement his plan.”

Haslam told local reporters that the Obama administration didn’t reject the entire proposal. “Of our request to Medicaid,” he said, “we got one or two yes’s, one or two no’s, and a whole lot of I don’t knows.”

[…]

But some of the other points in the Tennessee proposal might have raised eyebrows in the Hubert Humphrey Building. The governor proposed “co-pays for those who can afford to pay something.” As for what that would mean in practice, Andy Sher at the Chattanoga Times Free Press reports that the governor wanted Medicaid beneficiaries to pay the same cost-sharing as other exchange enrollees.

Medicaid experts I’ve spoken with have made it clear that such an approach wouldn’t fly: Even if they receive private coverage, the Medicaid agency would need to ensure they aren’t spending more out of pocket than they would in the public plan.

Officials in Arkansas agree with this interpretation, too. “Medicaid definitely has strict rules for people below the poverty line and then they issued some new rules this year, for people above the poverty line,” Arkansas Medicaid spokeswoman Amy Webb told me last month. “We still believe those apply, and we intend to follow those.”

I bring this up because while there has been some talk about the “Arkansas solution” among Texas Republicans, what they’re really talking about is more akin to the Tennessee proposal. Specifically, “copays, deductibles and premium payments on a sliding scale for poor patients, using asset testing to ensure services are going to people who truly need them” are among the items Rick Perry and his ideological cohorts are demanding. The shell bill filed by Rep. John Zerwas that would direct HHSC to negotiate with the Obama administration over a “Texas solution” includes this language, though it’s not clear to me if it’s an option or a requirement. If it’s the latter, I think we now know how these negotiations are going to go.

The point I’m trying to make here is that we need to pay attention to the contents of HB 3791 and listen carefully to what people like Rep. Garnet Coleman have to say about it. If the final bill includes demands for things that the feds have already categorically rejected, then we need to be aware of that up front. Because if it does contain such a requirement, then we need to be prepared for when Rick Perry claims that he “tried” to negotiate with the Obama administration but they were too inflexible and unwilling to compromise so we can call it out for the BS that it is. If Texas negotiates in good faith, the feds have shown that they can be very accommodating. If not, we shouldn’t be surprised when the negotiations fail, and we shouldn’t let the state claim that they made a legitimate effort. Perry and his cronies have made it abundantly clear that they really, really don’t want to expand Medicaid. We should take them at their word and not be distracted by side issues.

Straus wants someone to do something on Medicaid

Don’t we all, Joe. Don’t we all.

Rep. Joe Straus

Seeking to light a fire under fellow Republicans to provide health care to more uninsured Texans, House Speaker Joe Straus said Wednesday that it is time to “get our heads out of the sand” and find an alternative to Medicaid expansion that would bring billions of federal dollars to the state.

Straus said he and other Republicans have made it clear that they oppose expansion of Medicaid as the program now stands.

“But I think it’s time that we said more than that,” he said. “It’s time that we put forth a good-faith effort to find a Texas solution. We need to move beyond the word ‘no’ to something that the administration might entertain. There are no winners if nothing is agreed to. We have a very large state, a significant population of uninsured people … and I think it could be an opportune time to put some proposals on the table that could be supported by Texas leadership.”

Straus, R-San Antonio, said elements to focus on include subsidies to allow people to obtain private coverage, promoting personal responsibility and cost-sharing, such as co-pays and deductibles.

Straus said there may be a way to tie a plan to a reduction in local taxes, since a key argument for expansion is that it would relieve local taxpayers of some of the burden they now bear to cover the cost of treating uninsured people in public hospitals.

[…]

It is unclear exactly how the conversation will move forward, but Straus said it is important to gear up talks with the aim of building consensus behind a Texas solution.

“We need to make the right business decision for Texas taxpayers,” Straus said. “Local governments have to carry a very heavy burden and look, poor people are going to get sick. They’re going to be treated. And somebody’s going to pay for it.”

Nice talk, if plenty vague. But let’s keep these things in mind:

– Medicaid is going to be cheaper than private insurance. If there’s a problem with doctors not accepting Medicaid, that’s entirely within the Lege’s discretion to fix, since the Lege sets the amount that doctors get paid from Medicaid. But even with more generous reimbursements, Medicaid is going to be less expensive than insurance provided by a profit-seeking enterprise.

– The single biggest obstacle in all this is Rick Perry, with Greg Abbott right behind him. These guys just don’t care about this issue. I can’t state it any more plainly than that.

– Of course, after ten years of complete Republican control of Texas government, the only reason people like Joe Straus are even talking about this is because they have to, thanks to the efforts of President Obama and Congressional Democrats. Texas leads the nation in uninsured people, a situation that has only gotten worse under the Republicans. What little progress there has been has been in spite of the Republicans. It didn’t have to be that way, but it was and is. I’m glad that Straus wants to do something, but I don’t take it as a change of mind, just as a recognition of the lay of the land. He hasn’t exactly been powerless to effect change before now, after all.

Be that as it may, there was a hearing in the House on Friday to talk about just what Texas might do to expand health care access, whether Medicaid or something else.

There are thousands of scenarios that the state could take to expand and reform Medicaid, Kyle Janek, executive commissioner of the Texas Health and Human Services Commission, told the committee. But “we don’t have something on paper,” he said. Janek said he is awaiting further direction from the Legislature to craft a specific plan.

Rep. Sylvester Turner, D-Houston, referenced a compromise Arkansas’ Republican-led Legislature reached with the federal government, and said if “the people in Arkansas are much more capable of designing a system than the people in the state of Texas, that has taken us to a different level.” He called on his colleagues to stop being critical of the Medicaid expansion presented by the Affordable Care Act and to ask themselves “whether or not Texas has the ability to design something that works for Texas.”

Requiring Medicaid patients to make co-payments for their care — an option that has received support from Perry, Straus and other GOP members — is allowed under the Affordable Care Act, Janek said. He said if Texas took a different route and attempted to subsidize private health plans through an Orbitz-style health insurance exchange like Arkansas, the state would need to set up policies to ensure benefits offered by Medicaid that weren’t covered by private plans didn’t disappear.

“I think the public has a misconception that Medicaid expansion will get us the greatest bang for our buck,” said Rep. Lois Kolkhorst, R-Brenham, who chairs the House Public Health Committee. “For Texas, the bang for our buck is really in the exchange, the subsidy [for] people going into private insurance.”

Kolkhorst said without expanding Medicaid, other tenets of the Affordable Care Act would reduce Texas’ uninsured rate from 24 percent — the highest in the nation — to 16 percent. Including the Medicaid expansion would drop the uninsured rate slightly more, down to 12 percent.

As noted above it’s actually almost 29 percent. But who’s counting?

In total, unreimbursed charity care creates a $4.3 billion annual tax burden on local government entities and public hospitals, Billy Hamilton, the state’s former chief budget estimator, told the committee. Overall, he said, there is enough local and state spending in the current system to cover the state’s share of Medicaid expansion costs.

“I know this is a controversial issue… but I don’t really think you’re going to see a more overwhelming fiscal opportunity during your service here,” said Hamilton. “I served this Legislature for 30 years and I’ve never seen anything like it.”

The committee also heard testimony from judges from Harris and Dallas counties who spoke in favor of expanding Medicaid, and from John Davidson, a policy analyst from the conservative Texas Public Policy Foundation, who spoke against Medicaid expansion.

Rep. John Zerwas, R-Simonton and an anesthesiologist, said Texas needs to ensure that any expansion of reform of Medicaid include ways to incentivize more health care providers to accept those patients. If it doesn’t, those patients will end up in the highest-cost environments, emergency rooms. Zerwas pointed out that only 32 percent of doctors are willing to take Medicaid patients in the existing program, under current reimbursement rates.

Rep. Donna Howard, D-Austin, said the Legislature should be held responsible for this lack of Medicaid providers, because lawmakers set those reimbursement rates. “The provider capacity is a real issue for this system, whether we expand or not,” she said.

So that’s Ed Emmett and Clay Jenkins, two guys who live in the real world and have to deal with the real world consequences of having thousands of uninsured people needing medical services their counties provide, versus some pampered, well-paid shill from a right-wing think tank. In a just world, that would be no contest. I’m glad to see Rep. Turner address the Arkansas plan, as that’s the first comment I’ve seen from a Democratic official about it. Again, it’s not my preference but if it’s that or nothing I’ll grab it with both hands.

In the end, as the updated story from the Trib notes, the Lege punted to the HHSC for now.

Rep. Zerwas filed legislation Friday that would grant the Health and Human Services Commission authority to craft “a Texas solution” to Medicaid reform and negotiate with the Obama administration to draw down billions in federal financing to expand Medicaid services.

As debate in the House Appropriations Committee on Medicaid expansion revealed Friday morning, the House remains divided on how Medicaid should be reformed and whether the program should be expanded. Currently, House Bill 3791 is a shell bill that will be altered as state legislators continue to negotiate how Medicaid should be reformed.

“We felt like it was time to start to get the ball moving on this. We’ve made it pretty clear that we’re not for current Medicaid expansion, but we do need to be for something else,” said Zerwas on Saturday, “because I think its very important for the state that we determine a way to cover this group of people that are currently uninsured.”

HB 3791 directs the HHSC to negotiate with the Obama Administration, so that Texas can draw down Medicaid expansion financing while implementing Medicaid reforms that enhance “personal responsibility” of Medicaid recipients, such as copayments or deductibles. It also includes a severability clause to end the agreement if the federal government reduces it share of Medicaid expansion financing.

As it stands, the HHSC does not “have a legislative directive or mandate to go forward on this, and that’s what this is intended to be,” said Zerwas, explaining the bill gives state lawmakers the opportunity to weigh in on how Texas should tailor a Medicaid expansion agreement with the federal government. The bill prompts the HHSC “to move forward on something that the Legislature, the [state] leadership is comfortable with that is in the best interest of Texans and allows us to pull down those dollars, which ultimately are our dollars,” he said.

In other words, they still don’t know what they want, but some of them at least have decided that doing nothing isn’t the best idea. I’m confident the Obama administration will be flexible in the negotiations given what we’ve seen them allow so far. It remains to be seen how flexible the state of Texas will be.

Finally, Sara Kliff provides some useful information about what the Arkansas plan really means, via an interview with George Washington University’s Sara Rosenbaum, an expert on Medicaid policy.

Sarah Kliff: Right now, you have a number of governors looking at the idea of using Medicaid expansion funding to buy private health insurance for enrollees. How novel of an idea is that?

Sara Rosenbaum: It’s been treated as this brand, new thing, but I don’t actually think it’s completely revolutionary. Keep in mind that states have been using Medicaid to buy managed care plans since the beginning of Medicaid. The whole notion of this as a conceptual breakthrough for Medicaid feels a bit off for me.

It does happen though that this is in Arkansas, which traditionally has not been a buyer of managed care, not a place like Arkansas, and not somewhere like Texas which has been buying managed care.

One of the good things about it, from my perspective, is that it gives you more stability of coverage, or gives you the chance at stability. You’re brought into a plan to stay.

SK: So the idea is, if your Medicaid expansion population is in private insurance, they won’t have to bounce back and forth between private and public plans.

SR: It does address a problem of churn. Four years ago I raised this and put this forward to House and Senate committees as a model. It was met with a lot of opposition from Medicaid advocates, which I didn’t totally understand having worked in Medicaid for almost four years now.

The need for stability of coverage is so great. These are the youngest, healthiest and lowest-income workers. All they have to do is churn from different insurance plans two or three times, and they’re going to say I’m through with this. And these are the exact people we want to enroll.

There’s more about the costs and other aspects of this that are worth your time to read. I still don’t believe the Republicans care enough to actually do something about this – note Kyle Janek’s remark about not having something on paper – but I will be happy to be proven wrong. EoW has more.

House Republicans reject Medicaid expansion

But that’s not quite the end of the story.

It’s constitutional – deal with it

House Republicans on Monday agreed not to expand Medicaid as called for under the federal Affordable Care Act — but left the door open to doing so if the Obama administration grants Texas enough flexibility.

“The current path as proposed is unsustainable from a fiscal standpoint,” said caucus chairman Brandon Creighton, R-Conroe. He said the caucus would continue to “propose solutions on the issue, which we’re formulating and will continue to do so throughout the session.”

Several Republican-led states have in recent weeks reached compromises with the federal government to expand Medicaid coverage to poor adults. Arkansas, for example, has received permission to use Medicaid expansion financing to subsidize private health coverage for individuals who would qualify for Medicaid under the expansion.

“State by state we’re going to study what every state proposes and compare it to what’s best for Texas,” Creighton said. “We are Texas, so we are very different. We’re not making a blanket statement or a hard position on anything.”

[…]

Some of the solutions Creighton said GOP lawmakers are considering include implementing co-pays to hold Medicaid enrollees fiscally responsible for their care or using the expansion funds to help subsidize private health coverage for poor Texans — similar to what Arkansas is considering.

The Arkansas option has its share of flaws – it’s likely to be more expensive up front, and in the longer term, especially once the federal match drops below 100% – but it’s a viable path forward that would cover a lot of people and would have a few advantages over traditional Medicaid. I haven’t seen any reaction to the Arkansas plan yet from Democratic leaders on health care, so there may be some gotcha I’m not aware of and I may be speaking out of school, but if the Lege pursues something like this I will consider it to be real progress. But first the Republicans have to decide what they want, and then they have to sell the Centers for Medicare & Medicaid Services that they’re serious. They don’t have a plan yet, so this is all theoretical anyway. Even if they get to the point of formulating a plan and advancing a bill, there’s still the little matter of Rick Perry.

“I’ve known Rick Perry for a long time and there’s nothing to make me believe that he’ll back down,” said Sen. Bob Deuell, a family doctor and Greenville Republican.

Another GOP physician-legislator, Rep. John Zerwas of Richmond, said it would be folly for lawmakers to support expanding Medicaid without first addressing Perry’s demands that the federal government allow Texas to administer the program the way the state wants.

“For us to try to move something at this end that isn’t going to incorporate any kind of flexibility in the program, he’s made it very clear that he would veto something like that,” said Zerwas, chief writer of the House’s budget for Medicaid and social services.

On Tuesday, supporters of the Medicaid expansion will march and rally at the Texas Capitol. On Monday, the House’s GOP caucus hurriedly met and pushed back, calling for continued resistance. In a closed-door meeting, the 95-member caucus supported Perry’s stand and voted overwhelmingly for a motion to reject the Medicaid expansion “as proposed” in the federal law.

Rep. Lois Kolkhorst of Brenham said House Republicans want to see “if we can work out a Texas-centric solution.” But she said House lawmakers are just starting to confer and are nowhere close to putting an alternative proposal to the Obama administration.

“The vote in the caucus reflects the governor’s current position,” said Kolkhorst, who heads the House Public Health Committee. Asked if House Republicans differ at all from Perry on Medicaid expansion, she replied, “I wouldn’t say there’s any daylight now.”

So don’t get your hopes up just yet. There’s still no evidence that the Republicans really care about this problem; they certainly don’t care enough to push Perry on it. While we sit around waiting for them to begin to care, people will die. “Pro-life”, my rear end.

The Arkansas way

The state of Arkansas will move forward with a plan to expand Medicaid, except that it’s not really Medicaid even though it will cover all of the Medicaid-eligible population. Here’s the explanation.

It’s constitutional – deal with it

Gov. Mike Beebe met with about twenty lawmakers this afternoon to announce the results of his meeting with Sec. Kathleen Sebelius last Friday.

The feds have given Arkansas permission to pursue a plan that would provide private health insurance to anyone between 0-138 percent of the federal poverty level, giving coverage to more than 200,000 of the currently uninsured. The government would pay for the entirety of the premium, though consumers might be subject to some co-pays.

Beebe brought questions and ideas from legislators to his meeting with Sebelius and “basically they’ve agreed to give us about everything we’ve asked for,” he said. “What that really amounts to is take the Medicaid population that would be expanded…and use those federal Medicaid dollars and purchase insurance through the exchange. So they would buy private insurance through the exchange for the entire population, and [the feds have] given us permission to do that.”

This isn’t “partial expansion.” The full pool of folks that would gain coverage under full expansion of Medicaid would still get it. But Arkansas is the first state to publicly get a deal that accomplishes this not via the Medicaid program but via the exchange (Florida will be allowed to send some Medicaid recipients to private insurance through their managed care system).

Just as with Medicaid expansion, the feds would foot the entire bill for the first three years. Thereafter, the state would have to start kicking in a little bit, eventually settling at 10 percent in 2020. (Technically, these are Medicaid dollars, but they would be flowing to private companies and consumers would be interacting with private companies, not with the Medicaid program.)

Such a deal would potentially be a windfall for insurance companies, as well as hospitals, who would likely see higher reimbursements from private insurance on the exchange. For low-income citizens without health insurance, the deal would be similar to expansion, they would just get private insurance instead of Medicaid.

Gov. Beebe also announced that, prompted by strong support from House Speaker Davy Carter, the state will likely use the “sunset provision” idea from Florida, which would require the legislature to re-approve the deal in three years time, after the full federal match rates run out. States are already allowed to opt in or opt out at any time, but Beebe got approval from Sebelius on the sunset idea as well, just in case. Carter told reporters that a sunset was a prerequisite to any deal.

As for costs, buying private insurance for citizens is likely more expensive than providing Medicaid. That almost certainly means that this deal will have a higher price tag for the feds. And it could mean higher costs for Arkansas once the state has to start chipping in. Beebe acknowledged that possibility but said the sunset will allow lawmakers to analyze the question with hard data in three years time.

[…]

Beebe did not offer an opinion on whether this approach was better than simply expanding Medicaid. One way or the other, he believes accepting federal money to cover the uninsured is a good deal and his focus now is on closing the deal.

“My main objective is to make this legislature as comfortable as I can make them,” he said. “With a three fourths vote requirement in both houses, that’s a steep, steep burden….If the majority would prefer to go this way to get this done, I’m happy with that. If they want to go the other way, I live with that as well. The cost to the taxpayer for the first three years in the state of Arkansas is going to be the same.”

Beebe said that for some legislators, subsidizing folks to buy private insurance was preferable to directly covering people through a government program for “philosophical” reasons.

Let’s pause for a second to consider that last paragraph. I’m writing about this story because the main objection to Medicaid expansion here in Texas is the oft-stated belief that “Medicaid is broken”, seen most recently here. I don’t particularly agree with that statement, but I’m not the majority in the Legislature. But whatever you think about this solution, it completely addresses that concern. The federal Medicaid funds would be used to buy private insurance through the insurance exchange instead. Don’t want to expand Medicaid because you think Medicaid doesn’t work? Fine, here’s a way to serve the vast uninsured population that doesn’t use Medicaid? What’s your objection to that?

Now, just because I think this is an interesting option doesn’t mean I think it’s awesome. Ed Kilgore points out the obvious:

So let’s be clear: using the exchanges will be more expensive, and perhaps less generous to beneficiaries, than traditional Medicaid, but because Republicans prefer private insurers for “philosophical reasons”.

[…]

This draws attention to two pretty important national issues: the first is the persistent gap between the faith conservatives place in the “efficiency” of private-sector health insurance and all the available evidence. And the second is the emerging long-term conservative strategy of undermining Obamacare by limiting its “public” elements as much as possible and then chipping away at the regulations that make it available and the subsidies that make it affordable. This is precisely what Douglas Holtz-Eakin and Avik Roy called for in their much-discussed recent op-ed on how conservatives should adjust to the enactment of Obamacare.

Note that providing coverage by this method will ultimately be more expensive to Arkansas as well, once the federal subsidy drops to 90%. The potential for states like Arkansas, Florida, and Texas if they go a similar route to drop the expansion at that time is sure to be a thorny issue down the line. Still, there is some upside to this, as Kevin Drum observes.

I’m a little more willing to wait and see how it works out. In particular, I happen to think this may solve a legitimate problem. Here’s the tail end of [that article in the Arkansas Times]:

Department of Human Services Director John Selig speculated that things would actually run more smoothly. “The most difficult part of the exchange was going to be people going from Medicaid to private insurance, back and forth as they went up and down [the] income line,” he said. “Now, you just keep [the private insurance company] as you go up or down. In a lot of ways this simplifies what happens on the exchange.”

This really is an issue with the Medicaid expansion, and it’s a well known one. If you’re at 130 percent of the poverty level this year, you qualify for Medicaid. If you get a raise and go up to 140 percent next year, you no longer qualify and instead have to navigate the exchanges. If your hours are cut back and you fall to 130 percent again the year after that, it’s back to Medicaid.

How big a deal is this? That’s hard to say. But it’s not a made-up issue, and it’s possible that the Arkansas approach could legitimately be better. What’s more, I’m OK with allowing states to experiment within limits. It’s the only way to find out whether or not the exchanges really are more expensive, and whether or not the Medicaid ping-pong really is a serious problem. The ideology behind this decision might be misguided, but there’s a good chance we’ll get some useful data out of it regardless.

If the Republicans are willing to consider this, I’m willing to see how it goes, too. Providing the coverage to those who don’t have it is Goal #1. If a minor sacrifice has to be made at the altar of ideology in order to achieve that goal, fine. For all of the background chatter about the possibility of a “deal” on Medicaid expansion, predicated on the federal government willing to be flexible, it should be clear by now that the feds will be flexible if the objective of covering the uninsured population is met. Florida, Ohio, and now Arkansas have all found ways to make deals with the feds. As it happens, there is now a Republican “plan” for expanding health care access, but it’s pretty darned skimpy, and even more ideologically driven.

[State Sen. Bob] Deuell said he was considering a plan that would have Texas request a waiver from Medicaid officials in Washington. The request would include asking for $50 billion over 10 years, which is about half the funding the state would otherwise get from Washington over that period to expand Medicaid under the Affordable Care Act.

The state then would use that $50 billion to cover the roughly one million Texans who don’t get Medicaid today but could if the state expanded it up to 138 percent of poverty. (138 percent of poverty equals about $31,000 for a family of four.) The state would give those one million folks the equivalent of what they otherwise would get from Medicaid, which he says is $4,800 per person in Texas.

I admit this is technical, but bear with me for a few more details:

Recipients could use that $4,800 to purchase private insurance, buy into the state health plan that legislators like Deuell use or buy into the state’s Medicaid plan. As part of this waiver, he said, the state would set up health exchanges that would allow the eligible population to shop for health insurance.

Here’s more on the Deuell concept – it’s not really developed enough to be called a “plan”.

[Deuell would] force everyone who benefits to work, even if it’s volunteer work, unless they’re disabled or stay at home parents or caretakers of the disabled. He’d force hospital districts to cut their property tax rates; and health care providers and insurers, their charges and premiums, once more of the 6 million uninsured Texans got private insurance coverage, thereby squeezing down uncompensated care. He’d force all new recipients to be “locked in” to a primary care physician — such as himself. That doc would serve as gatekeeper, and would have to flash the green light before the newly insured people could tap into care from other providers. Children now on government health care would be wrapped into new, family coverage policies. Low-income people with high deductible coverage, and who “act as if they’re uninsured,” would be able to apply the subsidies to their copays and deductibles. And Deuell would encourage healthier lifestyles by charging newly covered Texans more if they smoke or are obese.

His four-page letter, though, is more of a sketch than a blueprint. He speaks of how Texas should negotiate with the feds to use the block grant money to “form group or individual policies in conjunction with insurance companies and/or a health system. The recent joint venture of the Baylor system and Scott & White comes to mind.” But no matter how he and others debunk the federal law’s exchanges, his federal counterparts’ conservative template blithely says there will be “guaranteed access and minimum benefit standards” in the non-Obamacare exchanges. And that requires some serious regulation of health insurers, which critics say has not exactly been a Texas bragging point. (For the blithe reference, see question No. 5 on this Paul Ryan FAQ sheet.)

The “exchange” in question is modeled on the Coburn/Ryan “Patient’s Choice Act”, because of course we can’t have the taint of anything Obama-related in Texas. I see this as pretty much a non-starter, since block grants aren’t going to happen and it’s clear that maximizing coverage is not a priority. I give Deuell partial credit for at least coming up with something, however half-baked and impractical, though I will point out again that Deuell has been in office since 2003, which is to say for as long as the Republicans have had complete control of state government, and this is only being proposed just now, because the Republicans have been embarrassed by a Democratic President they hate. It’s something, in the sense that it’s not nothing, but it’s not any more than that. Call me back when they really mean it. Wonkblog has more.

UPDATE: Hope?

“From the standpoint of looking at how Texas could possibly expand coverage for this group of individuals, it fits very well with what my philosophy is,” said State Rep. John Zerwas, R-Simonton, an anesthesiologist and former hospital executive who called the plan a “private sector remedy.”

“I don’t know if it’s something the governor would particularly smile upon,” he added, “but certainly from my perspective this would be something worth looking at.”

It’s a start.