Off the Kuff Rotating Header Image

health care

The AG race and the lawsuit to kill Obamacare

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

Justin Nelson

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

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

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

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

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

[…]

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

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

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

The issue is clearly speaking to voters, Nelson said.

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

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

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

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

The hearing for the lawsuit to kill Obamacare

Here we go again.

It’s constitutional – deal with it

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

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

[…]

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

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

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

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

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

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

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

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

Where best to attack Culberson?

Flooding is an obvious issue, but it’s hardly the only one.

Lizzie Fletcher

After Hurricane Harvey flooded much of Houston – including the hotly contested Seventh Congressional District – Republican incumbent John Culberson used his position on the House Appropriations Committee to stamp his name on billions of dollars in disaster recovery funds.

By February, he could claim a leading hand in securing $141 billion in congressional appropriations to help the victims of the 2017 hurricanes in Texas, Florida and Puerto Rico.

But as the nine-term congressman faces an unusually tough reelection against Democratic challenger Lizzie Pannill Fletcher, the city’s troubled history of flooding and the federal government’s long backlog of flood control projects has come under sharp political attack.

Fletcher, a Houston attorney making her first run for office, argues that Houstonians are paying the price for Culberson’s small government philosophy and a Republican-led Congress that she says has been slow to fund critical improvements to the Addicks and Barker dams, both aging structures that were deemed to be at “high risk” of failure as early as 2004.

She also has homed in on key votes cast by Culberson, who she labels a climate change skeptic, saying that they undermined flood prevention efforts in Texas and across the country.

“We can’t just look at the last nine months,” she said in an interview. “We need to look at the last nine terms.”

It’s a long story and I encourage you to read the whole thing. Culberson has done some things and was the only Texas Republican to avoid making himself a sniveling hypocrite when he supported federal relief funds for New York and New Jersey following Superstorm Sandy, but the fact that the rest of his caucus opposed such funds, and the fact that his party has so greatly prioritized cutting taxes and slashing spending over investing in infrastructure and solving problems just highlights why he doesn’t deserve a pass for a handful of decent votes. He’s part of the problem regardless, and the only way forward is a change of leadership in Congress. He can push the occasional bill and make the odd budget appropriation, but as long as he’s a vote for a Republican Speaker and a body in the count for a Republican House majority, nothing’s going to get done.

All this said, health care was the issue everyone was talking about earlier on, when the House – including John Culberson – was trying to kill the Affordable Care Act. That battle has shifted from Congress to the courthouse again, and that should bring this issue, on which Democrats enjoy an electoral advantage, to the fore. It’s never going to be a bad idea to remind people that Culberson has worked tirelessly to take their health care away. And since we’re only ever allowed to talk about mental illness when there’s another mass shooting, it’s also always a good time to remind people that the single biggest thing Texas can do to boost mental health care is to accept Medicaid expansion, which again John Culberson opposes with every fiber of his being. Flooding is a great and vital issue, with lots to talk about, but it’s not the only one.

Health care needs to be a twofer

Lt. Governor candidate Mike Collier is on the right track here, but he needs to keep going.

Mike Collier

Lieutenant governor hopeful Mike Collier announced his health care reform plan Tuesday, which aims to reduce costs and increase access to health care in Texas.

“Achieving these goals will not be easy,” Collier said in a statement. “But it’s time to get cracking. Doing nothing — the only skill our current governor and lieutenant governor seem to possess — is no longer acceptable.”

Colliers faces incumbent GOP Lt. Gov. Dan Patrick in November’s general election. Patrick has been a fierce opponent of the Affordable Care Act and any move to expand Medicaid, the health care program for the poor and disabled, to include the working poor.

Collier said Texas’ decision not to pay for health care costs for Texans who cannot afford health insurance is “unbelievably stupid,” and said that using federal dollars to close the coverage gap will bring Texas an estimated $9 billion per year in federal dollars and create as many as 250,000 jobs.

Collier said his plan also includes deploying state money to encourage Texans to buy insurance, which he said will drive down the cost of health care.

Additionally, Collier emphasized price transparency and a “Patient Financial Bill of Rights,” which would require insurance companies to provide health care prices in advance, show the availability of less expensive drugs and procedures, and itemize bills “in plain language,” among other requirements.

This is all good, but it’s missing an opportunity. You’ve heard me say this before, but it bears repeating – over and over and over again – that if we’re really going to talk about improving mental health care, which is all we ever talk about after another mass shooting, then we have to talk about expanding Medicaid, because it’s by far the biggest and best way to pay for mental health care for the people who need it. If we’re not talking about expanding Medicaid, then we’re just flapping our lips when we bring up the “mental illness” shibboleth. We need to keep saying this until it starts to sink in. You took a good first step, Mike Collier. Now please take the next steps.

Justice Department drops out of latest Obamacare lawsuit

Which of course was filed in Texas by our felonious Attorney General.

It’s constitutional – deal with it

The Trump administration said Thursday night that it will not defend the Affordable Care Act against the latest legal challenge to its constitutionality — a dramatic break from the executive branch’s tradition of arguing to uphold existing statutes and a land mine for health insurance changes the ACA brought about.

In a brief filed in a Texas federal court and an accompanying letter to the House and Senate leaders of both parties, the Justice Department agrees in large part with the 20 Republican-led states that brought the suit. They contend that the ACA provision requiring most Americans to carry health insurance soon will no longer be constitutional and that, as a result, consumer insurance protections under the law will not be valid, either.

The three-page letter from Attorney General Jeff Sessions begins by saying that Justice adopted its position “with the approval of the President of the United States.” The letter acknowledges that the decision not to defend an existing law deviates from history but contends that it is not unprecedented.

The bold swipe at the ACA, a Republican whipping post since its 2010 passage, does not immediately affect any of its provisions. But it puts the law on far more wobbly legal footing in the case, which is being heard by a GOP-appointed judge who has in other recent cases ruled against more minor aspects.

The administration does not go as far as the Texas attorney general and his counterparts. In their suit, lodged in February in the U.S. District Court for the Northern District of Texas, they argue that the entire law is now invalid.

By contrast, the Justice brief and letter say many other aspects of the law can survive because they can be considered legally distinct from the insurance mandate and such consumer protections as a ban on charging more or refusing coverage to people with preexisting medical conditions.

[…]

In an unusual filing just before 6 p.m. Thursday, when the brief was due, the three career Justice attorneys involved in the case — Joel McElvain, Eric Beckenhauer and Rebecca Kopplin — withdrew.

The department’s argument, if adopted by U.S. District Judge Reed O’Connor, “would be breathtaking in its effect,’ said Timothy Jost, a retired Washington and Lee law professor who follows such litigation closely. “Of all of the actions the Trump administration has taken to undermine individual insurance markets, this may be the most destabilizing. . . . [If] I’m an insurer, I don’t know what I am supposed to do or not.”

Jost, an ACA supporter, noted that the administration’s decision not to defend the law comes during the season when participating insurers must file their rates for next year with state regulators. It raises new questions about whether insurers still will be required to charge the same prices to all customers, healthy or sick.

And Topher Spiro, vice president of health policy at the liberal Center for American Progress, said the administration’s legal argument contradicts promises by Trump that he would not tamper with the ACA’s protections for people with preexisting medical conditions.

University of Michigan law professor Nicholas Bagley, another ACA defender, went even further in a blog post. “If the Justice Department can just throw in the towel whenever a law is challenged in court, it can effectively pick and choose which laws should remain on the books,” he wrote. “That’s not a rule of law I recognize. That’s a rule by whim. And it scares me.”

See here for the background. The fact that three Justice Department attorneys withdrew from the case rather than be party to this decision is what really stands out to me. Those are the people who believe the most strongly in the Justice Department’s mission. That’s about as loud a statement as they could make.

There’s a coalition of states that was granted standing to the litigation, and they filed a brief in response, so it’s not like the ACA is on its own in the courtroom. But if you’re someone with a pre-existing condition, which is one of the things that is at stake here, or you know someone who has one – and there are some 130 million people who fall into that bucket – then this is what this action means to you. If you need health insurance, the Trump administration and its enablers like Ken Paxton are working to take it away from you. I don’t know about you, but I want to hear a lot more about this between now and Election Day. Washington Monthly, Daily Kos, ThinkProgress, Mother Jones, the Observer, and the Trib 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.

Another national publication looks at CD07

Mother Jones, come on down.

Rep. John Culberson

In addition to [Laura] Moser, the top competitors for the March primary are first-time candidates with stories that fit the political moment in different ways. Lizzie Fletcher, a well-connected lawyer at a large downtown firm, got her start in politics as a teenager during the 1992 Republican National Convention, when she volunteered to stand outside abortion clinics blocking Operation Rescue types from chaining themselves to the entrance. Alex Triantaphyllis, who at 33 is the youngest of the bunch, co-founded a mentoring nonprofit for refugees in Houston after spending time at Goldman Sachs and Harvard Law School. Jason Westin, an oncologist and researcher at Houston’s MD Anderson Cancer Center, told me he first thought about running a week after the election, after watching his daughter’s soccer game. She had taken a hard fall and Westin told her to “get back up and get back in the game”—but sitting on the couch later that day, scrolling through Facebook, he decided he was a hypocrite. He decided to enter the race with encouragement from 314 Action, a new political outfit that encourages candidates with scientific backgrounds to run for office. The primary is not until March, but in a sign of the enthusiasm in the district, Culberson’s would-be Democratic challengers have already held two candidate forums.

The 7th District starts just west of downtown Houston, in the upscale enclave of West University Place near Rice University, and stretches west and north through parts of the city and into the suburbs, in the shape of a wrench that has snapped at the handle. It had not given any indication of turning blue before last year. But a large number of voters cast ballots for both Hillary Clinton and Culberson. Moser and Fletcher see that as a sign that Republican women, in particular, are ready to jump ship for the right candidate. In the Texas Legislature, West University Place is represented by Republican Sarah Davis, whose district Clinton carried by 15 points, making it the bluest red seat in the state. Davis is an outlier in another way: She’s the lone pro-choice Republican in the state Legislature and was endorsed by Planned Parenthood Texas Votes in 2016. “To the outside world it looks like a huge swing,” Fletcher says of the November results, “but I think that a more moderate kind of centrist hue is in keeping with the district, so I’m not surprised that people voted for Hillary.”

But whether they’re Sarah Davis Democrats or Hillary Clinton Republicans at heart, those crossover voters still make up just a small percentage of the overall population. Houston is the most diverse metro area in the United States, and a majority of the district is non-white—a fact that’s not reflected in the Democratic candidate field. To win, Democrats will need to lock in their 2016 gains while also broadening their electorate substantially from what it usually is in a midterm election. That means making real inroads with black, Hispanic, and Asian American voters in the district, many of whom may be new to the area since the last round of redistricting. “[The] big thing in the district is getting Hispanic voters out, and nobody knows how to do that,” Moser acknowledges, summing up the problems of Texas Democrats. “If we knew how, we wouldn’t have Ted Cruz.”

[…]

At a recent candidate forum sponsored by a local Indivisible chapter, Westin, the oncologist, warned voters against repeating the mistakes of Georgia. “One of the take-home messages was that a giant pot of money is not alone enough to win,” he said. Westin’s message for Democrats was to go big or go home. While he believes the seven candidates are broadly on the same page in their economic vision and in their opposition to Trump, he urged the party to rally around something bold that it could offer the public if it took back power—in his case, single-payer health care. “We’re behind Luxembourg, we’re behind Malta, we’re behind Cypress and Brunei and Slovenia in terms of our quality of health care,” Westin says. “That is astounding.” Who better to make the case for Medicare-for-all, he believes, than someone in the trenches at one of the world’s most prestigious clinics?

Moser, who likewise backs single-payer, may be even more outspoken about the need to change course. She argues that the Obama years should be a teachable moment for progressives. They let centrists and moderates like former Sens. Joe Lieberman and Max Baucus call the shots for a once-in-a-generation congressional majority, she says, and all they got was a lousy tea party landslide. “I don’t know if we would still have been swept in 2010—probably, because that’s the way it goes—but at least we could have accomplished some stuff in the meantime that we could claim now more forcefully and more proudly,” she says. A missed opportunity from those years she’d like to revisit is a second stimulus bill to rebuild infrastructure in places like Houston, where floods get worse and worse because of a climate Culberson denies is changing.

In Moser’s view, Democrats lose swing districts not because they’re too liberal but because they’re afraid to show it. When DCCC Chairman Ben Ray Luján, a congressman from New Mexico, told The Hill in August that the party would support pro-life Democratic candidates next November on a case-by-case basis (continuing a long-standing policy backed by Nancy Pelosi), Moser penned another article for Vogue condemning the position. “As a first-time Congressional candidate, I’ve been warned not to criticize Ben Ray Luján,” she wrote, but she couldn’t help it. Red states like Texas were not a justification for moderation; they were evidence of its failure. “I have one idea of how to get more Democratic women to polling stations: Stand up for them.”

Fletcher and Triantaphyllis have been more cautious in constructing their platforms. They’d like to keep Obamacare and fix what ails it, but they have, for now, stopped short of the single-player proposal endorsed by most of the House Democratic caucus. “I don’t think anyone has a silver bullet at this point,” Triantaphyllis says. Both emphasize “market-based” or “market-centered” economic policies and the need to win Republican voters with proposals on issues that cut across partisan lines, such as transportation. Houston commutes are notorious, and Culberson, Fletcher notes, has repeatedly blocked funding for new transit options.

Still, the field reflects a general leftward shift in the party over the last decade. All the major candidates oppose the Muslim ban, proposals to defund Planned Parenthood, and Trump’s immigration crackdown. Even in America’s fossil-fuel mecca, every candidate has argued in favor of a renewed commitment to fighting climate change. It is notable that Democratic candidates believe victory lies in loudly opposing the Republican president while defending Barack Obama in a historically Republican part of Texas. But Moser still worries her rivals will fall for the same old trap.

“I just think in this district people say, ‘Oh, but it’s kind of a conservative district,’ [and try] to really be safe and moderate, and I find that the opposite is true,” Moser says. “We just don’t have people showing up to vote. We don’t even know how many Democrats we have in this district because they don’t vote.”

Pretty good article overall. I often get frustrated by stories like this written by reporters with no clue about local or Texas politics, but this one was well done. This one only mentions the four top fundraisers – it came out before Debra Kerner suspended her campaign, so it states there are seven total contenders – with Moser getting the bulk of the attention. It’s one of the first articles I’ve read to give some insight into what these four are saying on the trail. They’re similar enough on the issues that I suspect a lot of the decisions the primary voters make will come down to personality and other intangibles. Don’t ask me who I think is most likely to make it to the runoff, I have no idea.

As for the claims about what will get people out to vote next November, this is an off-year and it’s all about turnout. CD07 is a high turnout district relative to Harris County and the state as a whole, but it fluctuates just like everywhere else. Here’s what the turnout levels look like over the past cycles:


Year    CD07   Harris   Texas
=============================
2002  37.37%   35.01%  36.24%
2004  66.87%   58.03%  56.57%
2006  40.65%   31.59%  33.64%
2008  70.61%   62.81%  59.50%
2010  49.42%   41.67%  37.53%
2012  67.72%   61.99%  58.58%
2014  39.05%   33.65%  33.70%
2016  67.04%   61.33%  59.39%

These figures are from the County Clerk website and not the redistricting one, so the pre-2012 figures are for the old version of CD07. High in relative terms for the off years, but still plenty of room to attract Presidential-year voters. Note by the way that there are about 40,000 more registered voters in CD07 in 2016 compared to 2012; there were 20,000 more votes cast in 2016, but the larger number of voters meant that turnout as a percentage of RVs was down a touch. Job #1 here and everywhere else is to find the Presidential year Democrats and convince them to come out in 2018; job #2 is to keep registering new voters. The candidate who can best do those things is the one I hope makes it on the ballot.

The “death by a thousand cuts” strategy

How To Kill A Health Insurance Market, Non-Legislative Division:

It’s constitutional – deal with it

The move by the White House to quietly end the contracts of two companies key to assisting people enrolling for insurance under the Affordable Care Act caught Houston health advocates off guard – but not by surprise.

Given the temperature in Washington these days and efforts by Congress and President Donald Trump’s administration to let the law fail, they said it was just the latest in a string of actions to sabotage the law known as Obamacare.

“It’s clearly by design,” said Elena Marks, president and CEO of Episcopal Health Foundation and proponent of the ACA and its impact on the uninsured and health access for Texans.

Last week, contracts for Cognosante LLC and CSRA Inc., which helped in signup efforts for the past four enrollment periods in 18 cities, including Houston, were not renewed for a final option year, the Associated Press reported.

[…]

Tiffany Hogue, policy director for Texas Organizing Project, an advocacy group for low- and moderate-income Texans, said she had not heard about the contract cancellations but felt, “in the scheme of things it’s not really a surprise.”

“The intent is to let the law die,” she said.

She said the administration from its first day has seemed determined to undercut the law. Hours after inauguration, the new president signed an executive order directing federal agencies to loosen any regulations surrounding the law that were considered “burdensome.”

Days later, as the 2017 enrollment period was coming to a close, the new U.S. Department of Health and Human Services withdrew funding for the final advertising push traditionally aimed to lure a surge of last-minute enrollees.

Additionally, the 2018 enrollment period is being shortened, cut in half to run from Nov. 1 to Dec. 15 instead of until Jan. 31.

The idea is to push enrollment down so that when it does go down you can point at it and say “look, see, it’s in a death spiral” and then take more obvious action to finish the job. Which may not be necessary now, but it’s Plan B as needed. And all those people who will be sicker and poorer as a result? Just a bit of collateral damage. I’m sure they’ll understand.

Trumpcare would be a hospital killer

This is hardly a new problem, but it’s yet another aspect of Trumpcare that gets too little attention.

Texas hospitals stand to lose billions under the Republican-backed health plan, as federal Medicaid dollars shrink, leading to a rise in uncompensated care, according to a new analysis by the Commonwealth Fund, a national health policy foundation.

The study looked only at the U.S. House plan passed last month. It has not yet examined the impact of the U.S. Senate’s version unveiled late last week, which experts have predicted will bring even deeper cuts to Medicaid.

In Texas, uncompensated costs in the state’s 304 acute care hospitals could increase by 7 percent, rising to $38.4 billion over the next decade, the study found.

That compares with an estimated $35.8 billion over the next decade under the current Affordable Care Act.

At issue is a spike in the number of the nation’s uninsured whose care is often absorbed by hospitals. As many as 23 million Americans could become uninsured over the next decade under the House bill because of cuts to Medicaid, and the recalculation of insurance plans and how people afford them, the Congressional Budget Office estimated late last month.

[…]

Texas already leads the nation in the number of uninsured and hospital executives have cautioned that their institutions would be hard pressed to take a bigger hit should the uninsured rate go higher.

“If people think Harris Health can absorb this, that is a miscalculation,” said George Masi, president and CEO of Harris Health System, in a January interview with the Chronicle.

This is basically what the world was like before the Affordable Care Act. People who had no insurance would use hospital emergency rooms for care when they really needed it, which is inefficient and dangerous and super expensive and many other negative things, all of which get picked up by local taxpayers. There are so many things that are wrong with and bad about the GOP’s “health care” plan that it’s hard to focus on any one thing and even harder to prioritize, but this one is really big. And it will hurt rural areas at least as much as urban areas. Not that the Republicans who represent rural areas care, and it’s not clear that the voters who would be affected have figured it out, or if they have if they’re capable of getting past their faith in the Charlatan in Chief. But the facts are stubborn things. The Rivard Report has more.

A tale of two Congressmen

Rep. Ted Poe has a status update.

Rep. Ted Poe

U.S. Rep. Ted Poe, a Republican from Humble, announced Sunday afternoon he is resigning from the hardline Republican group that helped sink GOP attempts to repeal former President Obama’s 2010 health care law.

“I have resigned from the House Freedom Caucus. In order to deliver on the conservative agenda we have promised the American people for eight years, we must come together to find solutions to move this country forward,” Poe said in a statement. “Saying no is easy, leading is hard, but that is what we were elected to do. Leaving this caucus will allow me to be a more effective member of Congress and advocate for the people of Texas.”

“It is time to lead,” he added.

[…]

The Freedom Caucus does not publicize members, but several Texans and their offices have confirmed their membership to the Tribune: U.S. Reps. Joe Barton of Ennis, Louie Gohmert of Tyler and Randy Weber of Friendswood.

One and a half cheers for this, I guess. I mean, any time you can disassociate yourself from the likes of Barton, Gohmert, and Weber, you should, but then one may wonder what you were doing hanging out with them in the first place. Also, too, while we agree that the Freedom Caucus is a stain on the country, if the problem you have with them is their resistance to voting for a bill that would have stripped health care for 24 million Americans in order to fund a massive and everlasting tax cut for the rich, well, I don’t think “kudos” is the right word for that. Rep. Poe has his good points, but anything good one can say here is damning with very faint praise.

And then there’s Rep. John Culberson.

Rep. John Cumberson

A day after House Republicans’ efforts to repeal Obamacare collapsed, U.S. Rep. John Culberson, R-Houston, did not back away from the GOP’s years-long push to scrap the law.

“The only way to fix it is to replace it,” Culberson said before a rowdy town hall audience of several hundred people, some of them chanting “Fix it!”

In an interview before the town hall, Culberson confirmed that he would have voted yes on the American Health Care Act, which House Speaker Paul Ryan pulled from the floor Friday when it became clear there was not enough support for it. Culberson said the legislation would have “repealed about 70 percent of Obamacare, and that’s good enough for me.”

“There’s always going to be another opportunity,” Culberson said. “We’re early in the congressional session, and there’s plenty of time. And we’re going to have an opportunity to do tax reform, and then I’m going to do everything in my power to get us back on track to get Obamacare repealed.”

[…]

After the town hall, attendees said they largely disagreed with Culberson on the issues, but some gave him plaudits for holding the event in the first place. Culberson ended up taking 20-some questions over an hour and a half, allowing audience members to read their questions to him and often wading into the audience to meet them.

“Begrudgingly I give him a B for sticking around and actually engaging with people,” said Frank Ortiz, a 43-year-old graphic designer from Houston. “As far as content, I’d probably give him a D+/C-. I felt he held to a lot of the conservative Republican line on a lot of issues.”

And a golf clap to Culberson for facing his none-too-happy constituents, unlike Ted Poe, among others. I lost count of the number of places I saw advertising this town hall and exhorting people to show up for it. The dynamic of these sessions was a fix of the Republicans’ own making, and they deserve no sympathy for it, but it still can’t have been a pleasant experience. Culberson got some cheers when he stated opposition to Trumpian things and boos when he didn’t – he was a Yes on ACA repeal – but I wouldn’t count on any of that to affect his behavior going forward. He is who and what he is, and he’ll be that for as long as he’s in office. The Chron and the HuffPo 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.

Transgender health directive halted

One last kick in the rear from the annus horribilis that was 2016.

A Texas judge issued an injunction Saturday against a federal mandate aimed to protect transgender people, finding that the federal health rule violates existing law.

The preliminary injunction, granted by U.S. District Judge Reed O’Connor, is in response to a lawsuit filed by Texas, on behalf of religious hospital network Franciscan Alliance, and four other states in August.

In the suit, Texas and the other plaintiffs argued that a federal regulation prohibiting discrimination against transgender individuals in certain health programs would force doctors “to perform and provide insurance coverage for gender transitions and abortions, regardless of their contrary religious beliefs or medical judgment,” according to the order. The plaintiffs also claim they could be required to perform gender transition procedures on children. Texas asked the court to block the federal government from enforcing the regulation.

Transgender rights activists have refuted claims that the health rule prevents doctors from using sound medical judgment, arguing instead that it clarifies that health care providers can’t deny services or insurance to someone because that person is transgender.

In Saturday’s ruling against the federal government, the judge indicated that a preliminary injunction was appropriate because the federal health mandate violates the Administrative Procedure Act, which governs how federal agencies develop and issue regulations, and likely violates federal religious freedom protections for the plaintiffs that are private entities.

“While this lawsuit involves many issues of great importance—state sovereignty, expanded healthcare coverage, anti-discrimination protections, and medical judgment—ultimately, the question before the Court is whether Defendants exceeded their authority under the ACA in the challenged regulations’ interpretation of sex discrimination and whether the regulation violates the Religious Freedom Restoration Act as applied to Private Plaintiffs,” the order reads.

See here and here for the background. The Chron adds on.

Ezra Young, director of Impact Litigation at Transgender Legal Defense and Education Fund, challenged both rulings as misinterpretations of federal law. He called Saturday’s “flatly contrary to law,” “morally repugnant,” and predicted it would be overturned on appeal.

“The U.S. Supreme Court has long recognized that sex discrimination takes many forms, and our nation’s expansive and unyielding nondiscrimination laws necessarily reach sex discrimination whenever and wherever it strikes,” Young said in a statement Saturday.

[…]

Young said the impact could be damaging to transgender people seeking care, who for years have faced denial of insurance benefits or access to doctors they chose because of their gender identity. Young said while some states have similar rules protecting transgender rights, Obama’s move was “groundbreaking.”

“The benefit of the federal law is it sort codifies things and it gave one unifying rule all across the country,” he said.

I’m sure this will be appealed. At least with the intervention of the ACLU, the defense of the lawsuit can’t be tanked by a corrupted Justice Department. I don’t know enough to speculate about the legalities going forward, but I do know this: Some day, and I hope to live long enough to see it, people will look back at the actions of Ken Paxton and the other obstructers of progress, and wonder what the hell they were doing. Paxton and those like him will be seen as the George Wallace and Bull Connor of the early 21st century. I don’t know when that day will come, I just know that it will.

Yet another Obamacare lawsuit

Some things never get old.

It's constitutional - deal with it

It’s constitutional – deal with it

n Texas’ latest salvo against Obamacare, Attorney General Ken Paxton has filed suit over a fee states must help cover to pay for the sweeping federal health reform law.

Texas joins Louisiana and Kansas in suing the Obama administration over the Health Insurance Providers Fee, which Paxton says cost Texas $86 million in 2013 and about $120 million per year since. Texas feels the effect of the fee, levied on health insurers, because it reimburses the companies that operate with public funds in the state’s privatized Medicaid program.

“This threat to cut Medicaid funding to Texans unless the state continues to pay hundreds of millions in taxes to Washington amounts to the very ‘gun to the head’ the Supreme Court warned about in earlier rulings on Obamacare,” Paxton said in a statement Thursday.

[…]

State lawmakers debated the validity of the fee this year as they were crafting a new budget. A handful of Republican legislators briefly entertained the possibility of not reimbursing the private insurers who operate in Medicaid, the joint state-federal insurance program for the poor and disabled, for the health insurance providers fee. They ultimately voted to pay back the Medicaid managed care organizations — after taking the opportunity to lambast the Affordable Care Act, also known as Obamacare.

Now, Paxton says Texas should get its money back, arguing that the state should not have had to pay the “unconstitutional tax to Washington” in the first place.

The attorney general’s office alleges the wide-ranging federal health law is “silent” about whether states should have to pay the health insurance providers fee — under threat of losing federal funding to pay for Medicaid. That, Paxton says, violates a provision of the U.S. Constitution requiring state officials to “clearly understand” the conditions of accepting federal funds and amounts to “coercion.”

The lawsuit was filed in federal court in Wichita Falls. The states are asking for the fee to be ruled unconstitutional and to be reimbursed for the funding already paid to the federal government in previous years.

You can see a copy of the complaint here. A lot of other anti-Obamacare litigation has been telegraphed in advance, but I couldn’t find anything enlightening on the Health Insurance Providers Fee. You’d think all the obvious targets would have been aimed at already, but I suppose there could be a judge out there willing to buy into whatever Paxton et al are selling. Nice to know his self-recusal isn’t keeping him from his most solemn of duties. Gotta give his wife something to sing about, I guess. As for the merits of the claim that Texas is being unfairly deprived of this Medicaid money, I might have a big more sympathy for it if the state, with Paxton’s assistance and blessing, weren’t voluntarily depriving itself of a whole lot more Medicaid money. But hey, all’s fair in politics, right? Trail Blazers and KUHF have more.

2015 Texas Lyceum poll

Issues first, election stuff to come. From the press release:

The 2015 Texas Lyceum Poll Finds: 

  • Immigration remains the most important issue facing the state and Texans support lawmakers’ increased spending on border security.
  • Texans’ views on  gay marriage are changing. Forty nine percent of Texans support gay marriage – up from 29 percent in 2009.
  • Experience with  race-based discriminationshifts greatly depending on the racial or ethnic background of the person polled.
  • Footballrules in Texas. Despite national poll numbers revealing 40 percent of Americans would discourage their children from playing youth football72 percent of Texans would encourage children to play football.
  • A growing number of Texans, 46 percent, support legalizing the use of marijuana (up by 13 percent since 2011) and among those who oppose legalization, 57 percent support decriminalization.
  • Texans are not overly concerned about climate change, but a majority (67 percent) would support new regulations on private companies.

 

2015 Texas Lyceum Poll Infographic

AUSTIN — An independent statewide poll conducted earlier this month (Sept. 8-21) by the Texas Lyceum, the state’s premier non-partisan, nonprofit statewide leadership group, suggests that Texans believe immigration is the state’s number one issue, continue to love their football, have moderated their opinion on the legalization of marijuana and gay marriage over the years, and support some regulation to reduce global warming.

“As the Texas Lyceum celebrates its 35th anniversary, we are proud to conduct this public service offering the media, policymakers, scholars and the general public an annual snapshot of Texans’ views on key issues,” said 2015 Texas Lyceum President Jane Cummins. “This year the Texas Lyceum held meetings focused on the Texas economy and the war on drugs, among other topics, and next year we will address the big business of football in Texas, showing our programs are on point with what Texans are talking about.”

Border Security / Immigration

Border security and/or immigration has remained one of the top three issues for Texans since the inception of the Lyceum Poll. This year the Lyceum Poll gauged Texans’ thoughts on two related policies – one state and the other federal. At the state level, a majority of Texans (62 percent) favor state lawmakers’ approval to spend $800 million on border security operations over the next two years.

Turning to federal policy, 65 percent of Texans approve of the federal government’s decision to halt deportations of undocumented immigrant youth who attend college or serve in the military while providing them with a work permit. Only 20 percent queried believe this policy did “a lot” to encourage illegal immigration.

Gay Marriage

Following the U.S. Supreme Court decision over the summer that legalized marriage for gay and lesbian couples in all 50 states, more Texans favor allowing same sex marriage than say they oppose it. Our survey shows 49 percent of Texans favor gay marriage, up from 33 percent when asked a similar question in 2011. However, 40 percent are opposed to allowing gay and lesbian couples the right to marry legally.

Racial Discrimination

In light of recent national and Texas race-related controversies, the Lyceum Poll asked respondents two related questions: First, was there ever “a specific instance in which you felt discriminated against by the police because of your racial or ethnic background?” Second, was there ever, “a specific instance in which you felt discriminated against by an employer or a potential employer because of your racial or ethnic background?” Reviewing the total sample with regard to police discrimination, only 17 percent of Texans believed they were discriminated against by police because of their racial or ethnic background. However, on closer inspection, these numbers shift significantly according to the race or ethnicity of the respondent. Four percent of whites, 24 percent of Hispanics and 45 percent of black respondents said they had felt discriminated against by the police. This pattern held with regard to Texans’ attitudes about employer discrimination as well. Only 11 percent of whites indicated they had been discriminated against by an employer, while 27 percent of Hispanics and 42 percent of black Texans felt they had experienced a form of workplace discrimination.

Football Reigns

Despite growing national concern that children who suffer repeated head injuries from tackle football can sustain long-term brain damage, Texans would not discourage their children from playing the contact sport. In fact, 72 percent of those polled said they would encourage children to play football while only 21 percent would discourage it. These numbers contrast with a national NBC/Wall Street Journal poll taken last year showing that 40 percent of Americans would steer their children away from playing football due to concerns over concussions.

Legalizing / Decriminalizing Marijuana

As more states either decriminalize or legalize marijuana – with Texas lawmakers passing limited medical marijuana use this past legislative session – a majority of Texans don’t support legalization outright. The survey shows 50 percent of Texans are opposed to legalization, while 46 percent of Texas adults said that they would support legalizing the use of marijuana. However, the numbers are breaking in favor of legalization as support has gone up by 13 points when compared with a question asked in the 2011 Lyceum Poll. Meanwhile, among those who oppose legalization, 57 percent said they would support decriminalization. Specifically, this group agrees on “reducing the maximum punishment for possessing small amounts of marijuana to a citation and a fine.”

Climate Change

Global warming is not a top concern for Texans. When asked if they personally worry about climate change, 50 percent say “only a little” or “not at all.” But when asked “would you support or oppose Congress passing new legislation that would regulate energy output from private companies in an attempt to reduce global warming,” 67 percent of Texans said they would support such regulation.

Daron Shaw, Ph.D., Professor at The University of Texas at Austin and a Texas Lyceum alumnus, oversaw the poll, which was conducted September 8-21, 2015, and queried 1,000 adult Texans. The poll has a margin of error of +/- 3.1 percentage points. Dr. Shaw and Texas Lyceum Research Director Joshua Blank, used the latest statistically-advisable polling techniques: live interviewers contacted respondents both by landline as well as cell phones (40 percent) and administered the survey in the respondent’s language of choice (English or Spanish).

The executive summary is here. A couple of points of interest:

On immigration: “The second policy that we queried asked respondents to evaluate the policy by which the Department of Justice stops the deportation of any undocumented immigrant youth who attends college or serves in the military and provides them with a legal work permit that is renewable. Despite the perception that Texans have particularly harsh attitudes on illegal immigration, 65% of Texas adults said that they supported this policy with only 28% expressing opposition. Majorities of Democrats (81%), Republicans (54%), and independents (62%) expressed support, as did majorities of Anglos (58%), blacks (63%), and Hispanics (75%).

On same sex marriage: “Majorities of Democrats (69%), Hispanics (53%), and Texans 18 to 29 years old (65%) and 30 to 44 years old (52%) said that they favored allowing gay marriage; pluralities of independents (46%) and Anglos (47%) also said that they favored allowing gay marriage. A majority of Republicans (58%) and a plurality of black respondents (45%) said that they oppose allowing gay marriage.” I would add that only the 65-and-over crowd was truly opposed (34% in favor to 53% against). The 45-64 group was barely in opposition, 43% yes and 44% no.

On marijuana: “A majority of Democrats support legalization (54% support; 42% oppose) while a majority of Republicans oppose legalization (37% support; 61% oppose). Fifty percent of whites support legalization while 51% of blacks and 56% of Hispanics stand in opposition. Eighteen to 29 year olds are the only age group in which a majority supports legalization (66%). Interestingly, when it comes to Democrats and Republicans in opposition to legalization, both groups favor decriminalization (60% of Democrats and 59% of Republicans). Majorities of whites (59%), blacks (52%), and Hispanics (56%) initially opposed to legalization are supportive of decriminalization, as are all age groups.”

On climate change: “Not surprisingly, given the partisan dimensions of this issue, 84% of Democrats said that they would support [new legislation that would regulate energy output from private companies in an attempt to reduce global warming] (60% said that they would strongly support them), while 45% of Republicans said that they would support such regulations, with 48% saying that they would be opposed. These results still display a rather surprising willingness among Texas Republicans to consider regulation to combat global climate change.”

On the Affordable Care Act: “Like in past polling, Democrats held a much more positive attitude toward the ACA than did Republicans. While 63% of the former hold a positive view of the ACA (up from 58% in 2014), 76% of the latter hold a negative opinion (down slightly from 80%). Whites continue to hold negative opinions towards the healthcare law with only 26% expressing a favorable opinion, while a majority of blacks hold a positive view (65%). Hispanics were evenly divided in their opinions of the ACA, with 42% holding a favorable opinion and 39% holding an unfavorable opinion.”

Basically, outside of that last issue, the survey respondents were a lot less in agreement with the Republicans that dominate state government than they were with Democrats. Needless to say, that discrepancy is a function of who actually votes, and increasingly when they vote; Republican primary voters are far more extreme than Republican non-primary voters. The question is when election results will more closely reflect this. Perhaps the higher turnout of a contested Presidential primary will draw some more moderate Republicans to the polls in March; that won’t have any statewide effect but it might make the Lege a pinch saner. Beyond that, all I know is that it won’t happen in its own.

The Lyceum will be releasing election poll data today. I’ll link to it later, and will have a separate post tomorrow.

Texas Pulse Poll

Hey look! Someone polled Texas.

A statewide poll of Texas likely voters finds that immigration and the economy are the top issues of concern for residents of the Lone Star State. The poll also found that Donald Trump and Hillary Clinton lead the Republican and Democratic primaries. Barack Obama is viewed unfavorably by a majority of Texans. Gov. Greg Abbott is seen favorably, and Sen. Ted Cruz has a more mixed favorability rating.

The Texas Pulse, a periodic survey of Texans’ opinions on a variety of cultural, economic and political issues, was conducted by Crosswind Media & Public Relations from Sep. 11-14, using a survey of 1,000 Texans. The margin of error is +/- 3 percentage points. A 2014 Texas Pulse survey was recognized by the Houston Chronicle as the most accurate poll in the governor’s race.

In a survey of 452 likely Democratic voters, Clinton leads Democrat Bernie Sanders 53 percent to 21 percent, with Sen. Joe Biden, who has not announced for president, in third with 14 percent in a hypothetical matchup.

“Despite some challenges, the Clinton name is still gold among Texas Democrats,” said Thomas Graham, Crosswind president and CEO. “Hillary’s support remains solid, particularly among minorities and women. While Sanders fares well among white and younger voters relative to his overall numbers, Hillary Clinton still beats him 2-1 in even these categories.”

Clinton even beats Sanders 52 percent to 31 percent among voters identifying themselves as liberal. The former secretary of state does best among African-Americans, with almost two thirds (65%) supporting her. Sanders’ only lead in any category is among voters identifying their ethnicity as “other.” This is a relatively small sample, however.

On the Republican side, as Crosswind announced last week, Donald Trump leads the field with 26 percent, followed by Ben Carson at 19 percent. Texas’ own Senator Ted Cruz is third with 15 percent, and Jeb Bush is fourth with 9 percent.

You can go here to add yourself to their mailing list enter your information to see the full poll information. Honestly, it doesn’t have that much – you will be shocked to know that Republicans like Greg Abbott and Ted Cruz but hate President Obama and Obamacare, while Democrats love the President and Obamacare but can’t stand Abbott or Cruz. There’s a bit more nuance than that, so go get yourself the full poll if you want to know the full details plus some other things. On the GOP primary side, that link above in this paragraph has a pie chart of the full field. Pre-dropout Rick Perry got 3% and Scott Walker got 2%, while pre-CNN debate Carly Fiorina was at 3%. Such are the perils of waiting to release poll data. I would have loved to have seen some potential November matchups, but no dice. There’s also some issues polling – Republicans continue to be obsessed with immigration and “border security” (a full 50% had it as their top issue), while Dems are interested in a broader range of things. The press release linked at the top has some of those numbers, though oddly they disagree with what’s on the full poll page – the release says “Among Republicans, the economy is second (18%) and taxes and spending third (15%)”, but the chart on the poll page shows “economy and jobs” at 15% and “taxes and spending” at 11%. Go figure.

Anyway, much of this is for entertainment value only at this stage. You can be sure it will be different in February, even if neither field is much smaller. The Texas Lyceum will be releasing the results of its 2015 Issues and Elections poll next Wednesday the 30th, so we’ll see how these two compare.

A different push for health care expansion

This ought to spark some interesting conversations.

It's constitutional - deal with it

It’s constitutional – deal with it

Two Democratic lawmakers called Wednesday for Texas leaders to explore a new type of Medicaid waiver that they say could provide health coverage to many of the state’s millions of uninsured.

The waiver, characterized by the legislators as the kind of block grant that Republicans favor, is not predicated on a Medicaid expansion and would allow Texas to avoid many provisions of the Affordable Care Act unpopular with the leadership in the Legislature – including the individual and employer mandates. The waiver, known as 1332, takes effect in 2017.

“Based on where we are now in this state, (the waiver) probably is the best chance or possibility of an agreement… toward coverage expansion,” Rep. Garnet Coleman, D-Houston, said at a news briefing with Sen. Jose Rodriguez, D-El Paso.

In a letter sent to colleagues earlier this week, Coleman added that the waiver must not reduce access to care, increase costs to the federal government, or make insurance more expensive than under the current law. The waiver effectively tells states that “if they know a better, more efficient way to provide health care, then have at it,” Coleman wrote.

[…]

Arlene Wohlgemuth, executive director of the Texas Public Policy Foundation, a conservative Austin think tank, said she had spoken to Coleman Wednesday morning about developing a 1332 waiver aligned with the principles laid out by the foundation.

“Of course, we are interested in reform of the program that truly gives flexibility to the states to provide for better health outcomes in a way that is affordable for the taxpayer,” Wohlgemuth said. “Thus far, the federal government has been unwilling to give exception to the requirements in the Social Security Act (the law that embodies Medicare) that have hamstrung true reform. We are interested to see what Representative Coleman has in mind through a 1332 waiver.”

Vivian Ho, a health care economist at Rice University’s Baker Institute for Public Policy, said there are so many unknowns about the waiver that it’s hard to know what to conclude.

“I can’t believe any waiver is the answer unless the state agrees to some sort of Medicaid expansion, and I don’t see how 1332 is going to help that,” said Ho. “It’s unclear how much money it would actually supply and whether it would provide access to tax credits for people below 100 percent of the federal poverty level.”

Ho added that block grants are a questionable idea unless the amount of money increases with population growth, given Texas’ continual migration and growing uninsured pool.

But Ken Janda, CEO of Community Health Choice, a nonprofit health care organization, called the suggestion “a very good idea” and said it “definitely seems worth talking about.” He said it answers a lot of concerns raised about Medicaid expansion and presents a possible solution to the health-care crisis that’s caused the closure of some private hospitals and threatens the existence of safety-net hospitals.

Rep. Coleman and Sen. Rodriguez filed bills this session to pursue this waiver and the reforms that it would allow. Here’s the letter they sent to fellow legislators outlining what this waiver would mean. Here’s the key bit:

However, there is a catch – the waiver must not reduce access to care, increase costs to the federal government, or make insurance more expensive than it is under the current law. The 1332 Waiver effectively tells states that if they know a better, more efficient way to provide healthcare, then have at it. Texas should take the federal government’s offer and consider ways to reform both Medicaid and private marketplace coverage in this state.

Basically, this is a put-up-or-shut-up challenge to Greg Abbott and the Republicans that have dug their heels in so fiercely against Medicaid expansion, the insurance exchanges, and every other aspect of the Affordable Care Act. You think you can do better? Prove it. My guess is that this will be roundly ignored, since Abbott and Rick Perry before him have shown zero interest in doing anything about the millions of uninsured Texans. Abbott appears to be perfectly willing to set fire to billions more dollars in his continued quest to not do anything about health care. But who knows, maybe someone will rise to the challenge. I agree that it’s at least worth exploring to see what might be possible.

State of the county 2015: Please cooperate more

Harris County Judge Ed Emmett makes his eighth State if the County address.

Judge Ed Emmett

Judge Ed Emmett

In his eighth State of the County address, Emmett had choice words for both Austin – which is weighing a reduction in property taxes that form the backbone of county revenue – and for Houston – which has adopted a strategy of limited annexations of suburban areas but Emmett said will not adequately provide for its poor.

“County government must have the tools and resources necessary to improve those areas because I do not see a scenario in which the city steps up and improves the situation,” Emmett said at NRG Stadium to several hundred business leaders brought together by the Greater Houston Partnership.

A city spokeswoman said the limited annexations were two-sided agreements with utility districts, not city land-grabs.

Emmett nevertheless called for a “new model of urban governance” that would work for a booming unincorporated Harris County that is becoming increasingly urbanized. The county judge expressed concern that the unincorporated part of the county could struggle to provide health care for its indigent and build roads and railways for its economy.

Harris County, which soon will have more people living in these unincorporated areas than in Houston, has been mischaracterized by outside groups and policy makers as merely an urban core, Emmett said.

The city’s governance plan has included limited-purpose annexation of unincorporated areas. Those agreements strip suburban areas of possible revenue, and Emmett said he was prepared to spend some political capital to fight the city as it tries to bring neighboring areas into its jurisdiction.

“Suburbs and close-in areas that have been skipped over are struggling,” Emmett said. “For lack of a better term, suburban blight is staring us in the face.”

Equally menacing, Emmett said, is a state government that looks to implement “arbitrary limits” on the revenue or spending of the county, which is an arm of the state. While he supports lower taxes, Emmett derided proposed property tax caps Friday as merely “good sound bites.”

The state also should take some responsibility for health care for the indigent and the mentally ill, Emmett said, rather than relying solely on county resources.

“Should indigent health care really be a responsibility solely of the county?” Emmett asked. “Or is it time for the state to establish regional health care systems that support public and private clinics, hospitals and programs?”

Here’s the full text of Judge Emmett’s address. Just as a reminder, expanding Medicaid (which Judge Emmett supports) would go a long way towards addressing those needs. I don’t know enough about the annexation issue to have a strong opinion about it, but I wonder if going back to doing more full annexations might be a better way forward. As for the threat to the county’s revenue stream coming from Austin, the main problem there is too many Republicans in Austin that don’t really care about governing but are there to implement an ideological agenda. The Judge’s suggestion is for more November voters to get involved in the primaries. That may help, but I’d point out they could also make some different choices in November, too. Anyway, the end of the speech was about the Astrodome and the ULI plan for it. Whatever else happens, here’s hoping that gets some traction.

Where Texans got their Obamacare information

The Baker Institute tells us.

While most Texans used healthcare.gov earlier this year to get information or to enroll in a health insurance plan under the Affordable Care Act (ACA), larger percentages of Texans found talking to the call center or a navigator was the most helpful. Those are just some of the lessons learned in a report released today by the Episcopal Health Foundation and Rice University’s Baker Institute for Public Policy.

The report found 62 percent of Texans used the healthcare.gov website to learn about ACA Marketplace health plans during the first open-enrollment period, which concluded earlier this year. However, perhaps because of the early problems with the government website, many Texans turned to the toll-free call center or used navigators to sign up for a plan. More than 90 percent of Texans who used navigators said the personalized assistance was helpful, compared to 70 percent who said the website was helpful.

“It’s important to understand what Texans found most effective and where improvements are needed,” said Elena Marks, CEO of the Episcopal Health Foundation and a nonresident fellow in health policy at the Baker Institute. “With the second enrollment period just weeks away, it’s important for each enrollment method to be at peak performance to help the hundreds of thousands of Texans who are eligible for subsidized health insurance plans, but remain uninsured.”

Marks said the Texas survey results that found personalized service most helpful are supported by national results showing people assisted by enrollment professionals were more likely to enroll in coverage.

No matter which enrollment method they tried, many Texans found it difficult to determine whether they were eligible for a subsidy under the ACA, the report showed. Without that information, consumers can’t make informed decisions on whether to purchase a plan. The difference in the price of a subsidized plan versus a nonsubsidized plan can be hundreds of dollars each month.

“This is an important step because the cost of a plan depends on the amount of subsidy available,” said Vivian Ho, the chair in health economics at Rice’s Baker Institute, a professor of economics at Rice and a professor of medicine at Baylor College of Medicine. “We know from previous research that many who were eligible for a subsidy didn’t purchase a plan. If clearer eligibility and financial assistance information had been available, more people might have enrolled in coverage.”

The majority of Texans who used the website said the top way to improve the process would be to have better information available to determine eligibility for financial assistance. For those who used the call center, their top suggestion was shorter wait times. Texans who visited with navigators believed having more navigators available to help would most improve the enrollment process.

The report is the ninth in a series on the implementation of the ACA in Texas co-authored by Marks and Ho.

Here’s the Chron story for this. The study can be found here, and links to previous reports are at the link above. I don’t have anything to add to this, I just like that someone is asking and trying to answer these questions.

Abbott’s health care small ball

Is that all there is?

Increased funding for preventive care and luring medical professionals to Texas are at the center of gubernatorial candidate Greg Abbott’s health care plan, unveiled at St. Joseph’s Women’s Medical Center here on Wednesday.

The Republican attorney general, running to replace Gov. Rick Perry, unveiled a proposal that includes a $50 million budget increase for women’s health programs, additional funding for medical school residency slots in Texas, loan forgiveness for aspiring doctors who practice in underserved areas and compensation for doctors who provide care via telephone.

Abbott said the cost of the entire plan would be $175 million every two years, but said it could actually save more than it costs. “It may actually reduce the cost of health care,” he said.

The left-leaning policy group Progress Texas criticized Abbott’s proposal because it does not include Medicaid expansion to cover impoverished adults, a tenet of federal health reform that Texas’ Republican leadership has staunchly opposed. Texas has the highest uninsured rate in the nation, with about one in every four people lacking health insurance in 2012, according to U.S. Census data. About one million Texans could qualify for Medicaid coverage if the state were to expand the program under current federal guidelines, according to the Kaiser Family Foundation.

“Texans don’t need more small ideas from Abbott — we need and deserve a comprehensive plan for insuring those 1 million Texans, and we need it yesterday,” said Ed Espinoza, the group’s executive director, in response to the candidate’s proposal.

Abbott’s Democratic rival, state Sen. Wendy Davis of Ft. Worth, has endorsed Medicaid expansion.

There’s nothing here that I find objectionable, but let’s be honest – it ain’t much, especially compared to Medicaid expansion and the million or so people it would help. The 2011 cuts to women’s health and family planning services has done such extensive and lasting damage to patients and providers in the state that anything short of a pledge to re-establish a clinic for every one that had to close is inadequate. Even that doesn’t make up for the inconvenience and hassle of finding new doctors and establishing new routines, but it at least makes the attempt. This is little more than a band-aid. Not a surprise, given Abbott’s known priorities, just nothing to write home about.

Just don’t call it “Medicaid expansion”

It’s the public policy that dare not have its name spoken, at least by Republican legislators.

It's constitutional - deal with it

It’s constitutional – deal with it

State lawmakers renewed efforts Thursday to find a “Texas solution” to expand health-insurance coverage for low-income residents without accepting the Medicaid expansion in President Barack Obama’s signature health care law.

Social-services advocates and local officials are among those pushing for a compromise measure that gives the state more flexibility than in the law to spend the money available from the federal government to cover more residents.

On Thursday, the state Senate Health and Human Services Committee met to “start a conversation that will give us an accurate picture of who the uninsured are, what services are available to them and what we can do to help them,” said chairman Charles Schwertner, R-Georgetown.

Katrina Daniel of the Texas Department of Insurance said about 6.5 million state residents do not have health insurance, although some of those can afford insurance and have chosen not to purchase it. An estimated 1.3 million uninsured Texans earn less than the federal poverty level, leaving them in the so-called “coverage gap.” The president’s law assumed all states would expand Medicaid, so it left those eligible for Medicaid out of its subsidies to help poor residents buy insurance.

Caring for those and other uninsured residents is costing counties billions of dollars a year, according to a letter sent to Schwertner on Wednesday by the judges in Harris, Bexar, Dallas, Tarrant, Travis and El Paso counties.

“We write not to complain about this fiscal burden or duty, but to urge your committee to use this interim to find a Texas way forward to fund and increase access to healthcare coverage for low-wage working Texans,” the judges wrote.

Two of those county judges are Republicans, of course, and frankly I think they have every right to complain. The cost of health care for those uninsured people comes out of their budgets, not the state’s. A lot of that cost includes treatment for folks with mental illness, who generally get that treatment in county jails. Medicaid expansion solves a whole world of problems, we just have to be smart enough to take it. If that means calling it something else, or coming up with something that’s almost but not quite exactly Medicaid expansion so we can claim it’s a “Texas solution”, then so be it. Either is better than what we’re doing now.

The people who signed up for insurance via Obamacare got themselves a pretty good deal

It worked the way it was supposed to work, in other words.

It's constitutional - deal with it

It’s constitutional – deal with it

Texans who received financial assistance to purchase health coverage through the federal insurance exchange are paying less in monthly premiums than individuals in most other states using that online marketplace, according to a new report by the U.S. Department of Health and Human Services.

Texas, like dozens of other states with Republican leadership, declined to create its own state-based insurance exchange under the Affordable Care Act, relying on a federally managed marketplace instead.

Texans who receive tax credits to help them purchase health coverage through the federal marketplace pay $72 on average in monthly premiums for their plans — the seventh-lowest monthly premium among the 36 states using the federal marketplace.

The national average for subsidized enrollees in the federal marketplace is $82 a month, with individuals in states like New Mexico, Wyoming and New Jersey paying more than $100 a month on average.

[…]

On average, subsidized enrollees — who make up 84 percent of Texans who purchased coverage through the federal marketplace — have received $233 in monthly tax credits in Texas.

You can see the report here – the breakdown of subsidy amounts by state is on page 23. There are still things that need to be fixed with Obamacare, as with any large new program, but they’re all doable given a non-insane Congress and some time. The best news so far is that premium increases will be modest for next year, and more insurers want in. As Kevin Drum says, it’s time to acknowledge that it’s working pretty well overall.

Not that this will make any of the usual suspects shut up already, of course.

Opponents of the health reform law have attributed low overall enrollment rates to the fact that low premiums often mean high deductibles. Despite the subsidies offered by the federal government, Texas’ total enrollment numbers have not made a big dent in the state’s sky-high rate of uninsured.

John Davidson, a health policy analyst at the conservative Texas Public Policy Foundation, has said that Texans’ reluctance to purchase insurance through the marketplace in bigger numbers stems from the cost of the health plans, even subsidized ones.

He added that individuals are also apprehensive about accepting the subsidies because they might be faced with paying them back if their annual income increases.

I look forward to the day when a story about Obamacare can be written without reporters feeling compelled to include some “on the other hand” quotes by shills like John Davidson. He has no useful insights or criticisms to offer, he’s just here for the FUD. If you must quote a hack like Davidson, then the least you should do is make it clear that his objections have nothing to do with numbers and everything to do with plain old politics. Matt Yglesias lays out what the argument really is.

One of America’s political parties doesn’t like that idea in any non-health context and they don’t like it for health care either. They think the money it costs to provide those subsidies should be taken away, and it should be given to high-income households in the form of tax cuts.

This is an excellent and important policy debate to have. One of the great ideological issues not just of our time and place, but of democratic politics across eras and countries. Should economic resources be distributed more equally or less equally?

But thus far to an amazing extent we haven’t been having that debate. Instead we’ve been having a debate over whether Obamacare works, over death panels, over enrollment numbers, over income verification procedures, and over the minutia of premiums and payments. It’s time to put that debate behind us. It’s clear — as it always should have been — that if you offer people large subsidies to go buy health insurance, lots of people will happily take the money and go buy some health insurance.

It’s time to start debating the real issue: should we do that, or is it more important to keep taxes on high-earners low than to give low-earners comprehensive health insurance?

So to be clear, John Davidson and his overlords absolutely support cutting their taxes so they don’t have to help pay for anyone to get health insurance. That’s what you should read when you see someone like him quoted in one of these stories.

If Louisiana can do it…

By “it” I mean expand Medicaid. What’s Texas’ excuse if that happens?

It's constitutional - deal with it

It’s constitutional – deal with it

Republican U.S. Sen. David Vitter on Monday left open the possibility of expanding Louisiana’s Medicaid program to cover more of the working poor.

Vitter, a candidate for governor and ardent critic of the health overhaul championed by President Barack Obama, said he’s not opposed to accepting the billions of federal dollars if Louisiana can improve the performance of its Medicaid program rather than expand “a pretty broken system.”

“We need to improve and reform Medicaid, and I want to look at everything that could be brought to bear to do that. Now, could more federal resources help to do that? They could, if it’s done right and if it’s done in a constructive way,” he told the Press Club of Baton Rouge.

He said the expansion must not draw state resources away from other spending priorities like higher education, nor build “disincentives for able-bodied folks to work.”

“We welcome the senator to the conversation about covering more than 240,000 uninsured Louisianians. It’s a shame that he waited until after (the legislative) session to make his opinions known,” state Sen. Karen Carter Peterson, chairwoman of the Louisiana Democratic Party, said in a written statement.

Vitter’s willingness to consider Medicaid expansion stands in contrast to Gov. Bobby Jindal’s staunch opposition to the idea. The state’s current Republican governor has refused to consider any such proposals, and lawmakers recently killed several expansion bills.

To be clear, I have no reason to believe in David Vitter, who has done very little of merit in his legislative career. Lord only knows what conditions he might impose on accepting those filthy federal funds, and Lord only knows what kind of dealmaking might be needed to get this through Louisiana’s legislature. Even if one believes that Vitter is sincere, we’re a long, long way from anything happening. But just the fact that he’s willing to talk about it means something, and this will be very much worth watching. If this does eventually happen, three of the four states that border Texas will have taken the plunge. One can only hope that it will eventually be contagious. dKos 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 million Texans used healthcare.gov

Yeah, we had lots of demand for health insurance. That’s what happens when you have so many uninsured people in a state.

It's constitutional - deal with it

It’s constitutional – deal with it

Almost all adult Texans knew of the Affordable Care Act’s health insurance marketplace before its open enrollment ended March 31, new research shows.

In a report released Wednesday, Rice University’s Baker Institute for Public Policy and the Episcopal Health Foundation discovered about 2 million Texans who looked for marketplace information found the healthcare.gov website helpful. Almost half of those who went to the site wanted to buy insurance or check premium subsidy eligibility.

Wednesday’s report was based on responses from 1,595 Texans in September and 1,538 in March. The poll is part of the Urban Institute’s Health Reform Monitoring Survey, a national project on the 2010 health law’s implementation and changes in health insurance coverage and related health outcomes. The Baker Institute and the Episcopal Health Foundation are focusing on factors about Texans from an expanded survey sample of Texas residents. The report is the fifth on Texas’ health law implementation.

“In our previous report, we estimated that 746,000 Texans purchased insurance through the marketplace,” Vivian Ho, chair in health economics at the Baker Institute and a report author, said in written statement. “Given that 2 million Texans looked for coverage through the Marketplace, a strikingly high percentage of them elected to enroll in a health insurance plan.”

Here’s the report. More reports from the same group, which I’ve blogged about before, can be found here. Just imagine how many more visits and signups there could have been if our Republican state leaders weren’t so zealously committed to keeping people unhealthy.

Retail medical clinics

I for one think they’re a good idea.

Here’s a prescription for pediatricians fighting to keep easy-to-treat, well-paying patients: Expand after-hours and weekend services to serve desperate parents in search of quick remedies for their kids’ late-night sore throats and upset tummies. Otherwise, parents will continue choosing the closest CVS, Walgreens or H-E-B clinic.

With the store-based medical clinic business projected to double between 2012 and 2015, analysts and doctors say pediatricians must change their business model to fit parents’ needs. Otherwise, they risk losing their relatively lucrative patients and relying more on chronically ill ones who take longer to diagnose and treat and thus reduce the number of people that doctors can see in a day.

“Well-baby cases help compensate for a Medicaid enrollee who takes half an hour,” said Devon Herrick, senior fellow at the Dallas-based National Center for Policy Analysis. He added that the speed and convenience of retail clinics attract many of the better-paying cases, and doctors are working to keep from losing them.

Despite clear demand in the market, doctors have for years targeted retail clinics for criticism. They argue that doctors best understand their patients’ needs and provide the best care. Most recently, the American Academy of Pediatrics urged parents to avoid store-based health clinics, saying they don’t provide the high-quality care children need.

However, the nation’s leading professional organizations for doctors repeatedly have said there aren’t enough doctors to treat everyone now and won’t be in years to come. The American Academy of Family Physicians projects a shortage of 40,000 doctors nationwide by 2020. Texas already has a ratio of about 165 doctors for every 100,000 residents, which falls below the national average of 220 physicians for every 100,000 people.

“It’s about competition,” said Dr. Kaveh Safavi, global managing director of Accenture health business, adding that retailers came up with the idea for “embedded clinics” because people needed them.

He described pediatricians’ concerns with retail clinics as a “short-term skirmish” that doctors have been waging for years.

[…]

Texas Children’s Hospital’s chief medical officer, Dr. Stan Spinner, recently posted in a hospital website blog that retail clinics employ providers who lack proper training and experience treating children.

“As a pediatrician for more than 25 years, I’ve seen firsthand the inadequate care these clinics can provide,” Spinner wrote. “Numerous patients have come into our Texas Children’s pediatrics practices after visiting a retail-based clinic the night before questioning the medication or dosage they had received.”

When asked to elaborate later, Spinner said he didn’t know how many such incidents had occurred. He said parents waste time and resources at retail clinics and then follow up with pediatricians to ensure children received the correct treatment.

“(Pediatricians) should have seen them the very first time,” Spinner said, adding that some pediatricians are expanding their office hours and working weekends to accommodate patients.

All due respect, Doc, but there are bad physicians out there, too. I’d take your complaint more seriously if we had a more effective means of policing them, but between tort “reform” and the impotence of the Texas Medical Board, there ain’t much that can be done. Be that as it may, my own anecdotal evidence favors the retail clinics. A few years back, what I had figured was an insect bite on my left foot had turned into something painful and alarmingly swelled on a Saturday morning. With my alternatives being a visit to the emergency room and a fervent wish that it wouldn’t get any worse by Monday, I visited a clinic at the HEB on Bunker Hill. They prescribed some meds that did the trick, and by the time I did see my doctor on Monday, my foot looked mostly normal again, and he agreed with their diagnosis. Faced with the same situation again, I’d have no hesitation to pay them another visit.

One more thing:

Retail clinics revolve around a high-volume, low-complexity business model. Services usually range from $59 to $99. They include convenient and basic care – physicals, disease monitoring, vaccinations, and illness and infection diagnosis and treatment. The clinics usually employ nurse practitioners and physician assistants, who are less expensive than doctors.

[…]

Retail clinics will hold nearly 11 million visits annually, saving about $800 million in unnecessary emergency care costs, Accenture said.

One of the dirty secrets of health care and the amount that we spend on it is that controlling our health care costs necessarily means paying less money to doctors. It’s more complex than that, of course – prescription drug costs and a lack of transparency in pricing are other big factors – but in the end, less money being spent by consumers means less money being paid to providers. Given that there’s a shortage of general practice physicians anyway, more retail clinics and a greater use of advanced practice nurses are both modest steps in the right direction. Doctors are going to have to learn to live with that.

What’s the health insurance enrollment status in Texas?

The short answer is that we don’t know. The longer answer, as this Express-News story indicates, is that we’ll never really know.

It's constitutional - deal with it

It’s constitutional – deal with it

Self-sufficiency. Distrust. Desire for flexibility.

Those are some reasons many consumers bypassed health insurance plans sold on government-run exchanges and instead chose to buy coverage directly from insurance agents or brokers before open enrollment ended March 31.

No one is sure exactly how many people did this. There is no singular source that aggregates nationwide health insurance enrollment numbers outside the exchanges. But these consumers will push the total number of enrollments for 2014 health coverage beyond the 7.1 million Americans who went through the federal- and state-operated exchanges.

In Texas, “it could be a big number,” said Stacey Pogue, senior policy analyst at the Center for Public Policy Priorities in Austin. “It could be more people than enrolled in the marketplace in Texas. But we don’t know. It certainly will be a significant number of people.”

The state Department of Insurance doesn’t collect enrollment figures.

Those who did not go through the exchange weren’t able to apply for tax credits or subsidies to reduce their premiums. That’s because tax credits can only be obtained through government-run markets.

There are a number of reasons why some consumers went a different route, independent agents and brokers say. Some made too much money to qualify for tax credits. Some didn’t believe in accepting subsidies. Others feared giving personal information, such as Social Security numbers, to the U.S. Health and Human Services Department.

“Frankly, I have talked to a number of consumers who are concerned about what they feel is an invasion of privacy,” said Carla Adams, president-elect of the San Antonio Association of Health Underwriters and an independent agent. “All of the information that they have to provide once you go on to the exchange … that makes some consumers nervous.”

[…]

Some consumers bypassed the exchange because they wanted the flexibility to choose doctors or hospitals they preferred instead of being limited to a smaller network, several agents said.

For instance, some shoppers who selected certain types of plans on the exchange after verifying their doctor was part of the network learned two weeks later that the doctor was no longer accepting patients with that form of coverage. Loretta Camp, co-owner of Davidson Camp Insurance Services in San Antonio and an independent agent, said her agency intervened in such cases so patients could stay with their doctors.

Local agents also helped consumers going through the federal exchange who wanted professional help to select the most cost-effective plans.

There is no extra cost for consumers who use agents’ or brokers’ services, several experts in the insurance field said. Insurance carriers pay agents’ commissions.

“The reality is, what I’m experiencing with consumers, they’re confused when they try to get on the exchange themselves,” Adams said. “They have no idea what the true differences are between these plans or how to compare, and they’re overwhelmed. Someone like an agent who understands the inner workings of these plans can help them navigate through the differences.”

The state of Texas, of course, tried to make it as hard as possible for non-profits and charitable organizations to provide navigator services, but that’s neither here nor there at this point. We don’t know how many Texans got coverage through the federal healthcare.gov exchange yet. The most recent numbers were 295,025 enrollments as of March 1 – see here for the breakdown – but I haven’t seen anything more up to date than that. The main thing to keep in mind is that whatever the final figure for Texans enrolling via healthcare.gov is, the real number – the number of people who got coverage is higher, perhaps much higher. It would be nice to know how much higher, but that number isn’t available. We’ll have to rely on polling data for that. Here’s hoping we get that soon for Texas.

We really should have expanded Medicaid

We know it would have done a lot of good, at a very reasonable cost. Turns out that cost was even less than what we had been told.

It's constitutional - deal with it

It’s constitutional – deal with it

News reports and state officials have commonly stated that expanding the Medicaid program in this fashion would cost the state about $15 billion over 10 years. Except, that figure, provided by the state Health and Human Services Commission, is actually an estimated total cost for all aspects of the Affordable Care Act, many of which the state is going to have to pay for even though state leaders have remained steadfastly opposed to almost all aspects of the law.

“What?!?,” you say?

In a presentation given to lawmakers in March 2013, state Health and Human Services Executive Commissioner Kyle Janek estimated that because of the publicity and outreach involved with the Affordable Care Act, more people who are eligible for Medicaid but not currently part of the program would likely enroll. The estimated price tag? About $6 billion over 10 years, or approximately 40 percent of the total Affordable Care Act implementation cost.

According to that presentation, the estimated cost for expanding Medicaid eligibility to all adults who make less than the 138 percent of the poverty level was about $8.8 billion over 10 years. However, the Legislative Budget Board, the Legislature’s budget arm, came up with a far lower cost estimate of about $4 billion over 10 years. The differences can be attributed to two factors, HHSC spokeswoman Stephanie Goodman said. First, HHSC projects that more people will join the Medicaid program than the LBB does; and second, HHSC projected it would cost more to provide the coverage than the LBB does.

Secondly, assume that $1.5 billion figure is correct and that adding it to the state budget would cause taxes to skyrocket and the state’s economy to crumble. However, it begs the question why that hasn’t already happened. Taxpayers in the five major urban counties in Texas — Harris (Houston), Dallas, Tarrant (Fort Worth), Bexar (San Antonio) and Travis (Austin) — already shell out more than $1.5 billion a year in hospital district taxes to provide care and facilities for their largely indigent populations. A study commissioned by Methodist Healthcare Ministries and Texas Impact estimated total local government spending on providing health care at roughly $2.5 billion a year.

Thirdly, expanding Medicaid would produce additional revenue for hospital districts, potentially allowing county governments to cut their tax rate. In Bexar County, hospital district officials estimate that expanding Medicaid would save them $52 million a year, roughly 20 percent of the amount of revenue they get from the hospital district tax, and County Judge Nelson Wolff said he would cut property taxes to pass on the savings if it were approved. In Harris County, hospital district officials say the expansion of Medicaid would mean they would receive an additional $77.5 million in reimbursements, or roughly 15 percent of their tax revenue, based on 2013 financials.

Sure would have been nice to get that extra revenue to help pay for what we’re already paying for, wouldn’t it? We can still take advantage of it if we want to. All it takes is a different set of leaders in our state government.

On a side note, remember that the 7.1 million figure you’ve been hearing for Obamacare signups is just for people going through the healthcare.gov webpage. It doesn’t count state exchanges, Medicaid enrollments, or people who got ACA-compliant policies outside of the exchange. Those first two numbers would surely have been a lot higher nationally had it not been for the cruel and mulish refusal by governors like Rick Perry to create state exchanges and expand Medicaid. There was an increase in Medicaid enrollments across the country, as people who had been eligible all along but didn’t know it or hadn’t gone through it did so thanks to the publicity push from Obamacare. Of course, the total enrollment count was much higher in states that expanded Medicaid, but Texas saw new enrollments as well. That 7.1 million number will likely be higher as well when all is said and done, thanks to some lag in the system. I’ll say it again – just imagine how many more people this law could have helped if only everyone agreed that providing coverage to as many people as possible was a worthy goal and not something to fight against. EoW has more.

Last minute health insurance enrollment help

From the inbox:

It's constitutional - deal with it

It’s constitutional – deal with it

The Houston Department of Health and Human Services (HDHHS) will open four of its multi-service centers on Sunday and extend their business hours next Monday to help people sign up for a health insurance plan by the Affordable Care Act’s March 31 deadline.

HDHHS will open Acres Homes, Denver Harbor, Northeast and Southwest multi-service centers on Sunday, March 30, from 12 p.m. to 6 p.m. It will also extend the four multi-service centers’ business hours on Monday, March 31, until 10 p.m., setting the last ACA enrollment appointment for 8 p.m.

Approximately 99,000 Houston-area residents have enrolled in one of the more than 40 low-cost ACA health plans available in the region. Those without health insurance have only one week left to sign up.

Residents can set up an appointment for one-on-one help from certified application counselors at HDHHS by calling 832-393-5423. The counselors are able to help residents compare health plans and find one that fits their budget and health care needs.

The phone number connects residents to an ACA call center that HDHHS set up as part of the Gulf Coast Health Insurance Marketplace Collaborative, a group of 13 agencies helping people obtain insurance coverage through the ACA.

Certified application counselors and outreach staff with HDHHS and the other agencies in the collaborative have met face to face with more than 151,500 area residents since the enrollment period began in October. They have also reached out or distributed ACA brochures and information to approximately 538,000 people.

Documents needed to enroll during an appointment include:

  • Proof of U.S. citizenship: social security number or copy of U.S. passport for all family members
  • State residency: driver’s license, housing lease or utility bill
  • Income:  W-2 forms or pay stubs; unemployment or disability; social security, pension and retirement income; or copy of 2012 tax return
  • Current health insurance: policy numbers for any current health insurance and information about job-related health insurance
  • Immigration status or legal residency: Immigration document status numbers.

The press release is here, and Stace was also on this. There are going to be a number of rallies and other events aimed at getting people signed up while they still can. Another event, via State Rep. Jessica Farrar, will be Saturday, March 29th from 9:00 a.m. – 1:00 p.m. at the Harris County Department of Education Conference Center, 6300 Irvington Blvd. Anyone who has questions about the exchange or is currently without health insurance is encouraged to attend. Here’s a Trib story about the pre-deadline push.

The Affordable Care Act requires most individuals to purchase health insurance by 2014, specifically by March 31, which will mark the final day of canvassing and enrollment outreach by nonprofits, local governments and community organizations.

At the start of March, 295,000 Texans had selected a coverage plan in the federal marketplace, but the number of total enrollees represents a small fraction of the uninsured in Texas.

National advocates for health reform have homed in on Texas’ enrollment in recent weeks, including U.S. Secretary of Health and Human Services Kathleen Sebelius, who was in Texas last week to promote enrollment efforts, including a final push to mobilize young adults to sign up for insurance through the marketplace.

Enroll America, a nonprofit group promoting the federal health reform law, launched a six-city bus tour through Texas last week to help people enroll in the exchange. Anne Filipic, president of the group, said it has focused on Texas because of the amount of people “who stand to benefit” from the federal health reform.

The organization has also set up a series of enrollment events throughout the state, including the one Donnell attended, as part of the final week of enrollment and is following up with individuals who started their process at one of the events to help them complete their enrollments.

Locally, state Democratic legislators have hosted their own enrollment efforts or have worked with entities like the Texas Organizing Project, a group that advocates for low-income Texans, to host regular enrollment events in Dallas, Bexar and Harris counties.

Federally qualified health centers in Texas also received more than $15 million federal grants to help individuals enroll in the marketplace. Lone Star Circle of Care clinics was among the top recipients in the state, receiving a combined $600,000 in grants to provide enrollment assistance.

Lone Star spokeswoman Rebekah Haynes said its 35 certified application counselors have seen an uptick in demand for enrollment assistance in the last few weeks, and they are working with hundreds of individuals to verify whether they qualify to purchase health insurance through the marketplace.

Texas could have delivered half of the enrollees the Obama administration is banking on. The Kaiser Family Foundation estimates that 3,143,000 Texans are potential marketplace enrollees, but only 9.4 percent of that population has enrolled. (Potential enrollees include uninsured Texans who are U.S. citizens and have incomes above the amount needed to qualify for Medicaid.)

You have to wonder what might have been if anyone in the Republican leadership cared even a little bit about the vast number of uninsured people in Texas. Be that as it may, if you know someone who needs coverage but still hasn’t signed up yet, do whatever you can to encourage them to get it done now. Time is very much running out.

Once again, the cost of not expanding Medicaid

Short answer: It’s a lot.

It's constitutional - deal with it

It’s constitutional – deal with it

A team of Harvard researchers recently released a deeply sobering study quantifying how many Americans stand to die needlessly in the unflinching states hellbent on denying Medicaid expansion, as provided by the Affordable Care Act. The study singles out Texas:

“In Texas, the largest state opting out of Medicaid expansion, 2,013,025 people who would otherwise have been insured will remain uninsured due to the opt-out decision. We estimate that Medicaid expansion in that state would have resulted in 184,192 fewer depression diagnoses, 62,610 fewer individuals suffering catastrophic medical expenditures, and between 1,840 and 3,035 fewer deaths.”

Crunching the numbers, the study suggests that Texas could bear almost 18 percent of a potential 17,104 unnecessary deaths nationwide. The figures are stark, damning, and presented with dispassionate and clinical precision—and yes, the study was quickly subjected to right-wing critics arguing the math.

You can read about the study here. The Observer story goes on to carp about the lack of media coverage of this issue, and while I agree that there ought to be a lot more written about it, at this point it pretty much has to be a campaign issue to be news. I hate to be one of those people telling the Wendy Davis campaign what to do – in part because I think most of the “advice” given to her has been in response to trivial matters, and in part because I doubt any of us armchair quarterbacks have any idea how to win statewide races – but I’d really like to see her jump all over this. I see no real downside for her in going big on economic populism, which includes Medicaid expansion and raising the minimum wage. The latter is broadly popular, including in Texas, and the former will put her on the side of most doctors and hospitals, as well as county officials. It fits with her overall message of breaking from the Rick Perry past that Greg Abbott represents and it will help drive turnout from the Democratic base, which is job one for her. We need to be talking about this, and that means we need Wendy Davis talking about it.

More Obamacare enrollments, still lots more needed

That’s pretty much the story.

It's constitutional - deal with it

It’s constitutional – deal with it

Texas enrollment in the online insurance marketplace created by the Affordable Care Act rose steadily in February but did not meet expectations set forth by the Obama administration, according to figures that the U.S. Department of Health and Human Services released Tuesday.

“As more Americans learn just how affordable marketplace insurance can be, more are signing up to get covered,” Health and Human Services Secretary Kathleen Sebelius said in a call announcing the enrollment data. “We expect that even more will sign up as we approach the March 31 deadline.”

The data is the last to be released by HHS before open enrollment closes on March 31, offering a glimpse at the daunting task facing advocacy groups as they make their final push to sign people up for health coverage.

Texas ranked third behind California and Florida in total enrollments since the launch of healthcare.gov on Oct. 1. As of March 1, 295,000 Texans had selected a coverage plan in the federal marketplace, up from 207,500 the month before.

The number represents a small fraction of the uninsured in Texas, the state with the highest percentage of people without health coverage nationwide. In 2012, more than 6 million Texans, about 24 percent of the population, lacked health insurance, according to U.S. census data.

“That is very low,” said Arlene Wohlgemuth, director of the Center for Health Care Policy at the conservative Texas Public Policy Foundation. “If the goal is to get uninsured people onto the exchange, they are such a long way from doing that.”

Wohlgemuth, of course, was the author of the bill in the 2003 Lege that initiated that disastrous privatization of HHSC, and her fingerprints were all over the bill that cut however many hundreds of thousands of kids off CHIP that same year. In other words, she’s a charter member of the Go Ahead And Die caucus, and as such has Cheney-levels of credibility on anything related to health care.

Be that as it may, the numbers are what they are. We’d like them to be higher, but there’s still time, and millions of people are getting covered regardless of what else happens. The good news is that there will be another open enrollment period in October for next year, and there shouldn’t be any technical problems like there were this time. It may take longer than it should have, but we’ll get there. A statement from the Texas Organizing Project is beneath the fold.

(more…)

Inmates and Medicaid

Other states are doing what Texas has declined to do.

go_to_jail

Being arrested in Chicago for, say, drug possession or assault gets you sent to the Cook County Jail to be fingerprinted, photographed and X-rayed. You’ll also get help applying for health insurance.

At least six states and counties from Maryland to Oregon’s Multnomah are getting inmates coverage under Obamacare and its expansion of Medicaid, the federal and state health-care program for the poor. The fledgling movement would shift to the federal government some of the more than $6.5 billion in annual state costs for treating prisoners. Proponents say it also will make recidivism rarer, because inmates released with coverage are more likely to get treatment for mental illness, substance abuse and other conditions that can lead them to crime.

“When someone gets discharged from the jail and they don’t have insurance and they don’t have a plan, we can pretty much set our watch to when we’re going see them again,” said Ben Breit, a spokesman for the Cook County Sheriff’s Office.

The still-small programs could reach a vast population: At the end of 2012, almost 7 million people in the U.S. were on parole, probation, in prison or locked up in jail, according to the federal Bureau of Justice Statistics. About 13 million people are booked into county jails each year, according to the Washington-based National Association of Counties.

[…]

Medicaid expansion also enables more prisoners to have coverage when they are released. States that don’t expand it can help inmates get subsidized coverage in the insurance exchanges created under the law when they’re released.

Counties in about half the states are responsible for some level of indigent care at hospitals, so getting inmates enrolled can reduce costs, said Paul Beddoe, deputy legislative director for the National Association of Counties.

Cook County has been operating a pilot project to enroll prisoners in Medicaid since April under a federal waiver, while states including Connecticut, Illinois and Maryland and counties such as Multnomah, which includes Portland, have helped hundreds of prisoners apply for coverage under the Affordable Care Act since it took effect Jan. 1. California, Ohio, San Francisco and other jurisdictions are starting programs or considering them.

About 90 percent of inmates are uninsured, and many have never had treatment for their illness, Osher said. They have disproportionate rates of communicable and chronic diseases and behavioral disorders, he said. About 488,000 people in U.S. prisons and jails suffer from a mental illness, according to the National Alliance on Mental Illness in Arlington, Virginia.

[…]

The Ohio Department of Rehabilitation and Correction, which plans to start enrolling inmates during the next two months, expects that it will save $18 million a year on hospitalization alone, said Stu Hudson, managing director of health care and fiscal operations.

Ex-prisoners who have insurance will be more likely to get treatment that would help them avoid committing crimes that got them locked up in the first place, Hudson said.

“They’re provided good continuum of care from incarceration through their release into the community and onward,” Hudson said by phone.

We’ve discussed this before. Putting aside the considerable cost savings to the state, the potential impact on the many people that regularly intersect with the criminal justice system who have treatable mental illnesses could be huge. We could save a bunch more money just from the reduced rate of recidivism. There’s really no downside to this. Unfortunately, without a change in state leadership, there’s also no chance of it happening. I don’t really care about the day to day vicissitudes of the Governor’s race. This sort of thing is the prize I keep my eyes on.

More on Texas Left Me Out

The Observer reports on the launch of Texas Left Me Out.

Members of the coalition pointed to two different studies that estimate that thousands of uninsured Texans with chronic conditions are likely to die as a result of not expanding Medicaid.

A Harvard University/CUNY study released last week predicts between 1,840 to 3,035 deaths. Another study, by a University of Texas Medical Branch researcher, projected approximately 9,000 preventable deaths per year. Dr. Robert Luedecke of Doctors for America, a national coalition for healthcare reform, said the death toll associated with the uninsured is something many lawmakers won’t talk about.

“What would people do if they didn’t have health insurance?” Luedecke said of critically ill patients who put off seeing a doctor because they can’t afford it. “They would just die—that’s what they’d do.”

Linda Berman, 63, is one of those who says she’s been left out by Texas. She’s languishing in the coverage gap while dealing with diabetes and high-blood pressure. As a small business owner teaching Science, Technology, Engineering and Mathematics (STEM) skills to kids through a traveling workshop, Berman said she’s left with little to no taxable income at the end of the year. The cheapest individual private plan she’s found comes with a $450 monthly premium—out of her price range. She makes too little to qualify for subsidies on the marketplace and she’s never been eligible for Medicaid under Texas’ strict eligibility standards. Two years ago, Berman racked up $70,000 in medical debt after she was hospitalized.

“I knew I had no money to pay for [the visit] but had I not [paid out of pocket], they wouldn’t have saved my life,” Berman said.

Not long after her hospitalization, a debt counselor told her that she would never be able to pay off her medical debts. Berman soon filed for bankruptcy. The hospital was left holding the bill.

“People without insurance don’t get preventative care,” Berman said. “You don’t die of diabetes, you die of complications.”

See here and here for the background. The Trib also tells Ms. Berman’s story, and adds this extra bit of context to the situation.

State Rep. John Zerwas, R-Richmond, who led efforts to craft “a Texas solution,” said he hoped that the period between legislative sessions would give lawmakers a chance to work on a road for reform. However, he said he wasn’t sure that this particular coalition would have a significant impact, and he said a coalition of businesses concerned with health care issues would have a stronger impact. He said a business-focused coalition would “resonate especially with the conservative Legislature.”

Texas has declined billions of dollars from the federal government to assist with Medicaid expansion and will lose $100 billion in federal funds over a 10-year span, according to a report by Billy Hamilton, a tax consultant and former deputy comptroller, for Texas Impact and Methodist Healthcare Ministries of South Texas Inc. The federal government would cover 100 percent of the Medicaid expansion enrollees’ health care costs from 2014 to 2016, then gradually lower its share of the costs to 90 percent over ten years, resulting in 10 percent of financial responsibility for the state by 2020.

The Texas Association of Business, local government officials, and the state’s largest medical associations, including the Texas Hospital Association, and Texas Medical Association, pushed lawmakers to expand Medicaid during the 2013 session, but the issue still failed to gain traction among Texas’ conservative leadership.

Rep. Zerwas has been an honorable actor in this saga, but I don’t know what he’s talking about here. Look at that last paragraph and the supporters of Medicaid expansion in it. If that’s not a sufficiently business-focused coalition to resonate with the Lege, who else is there? We need a change of leadership at the top. That’s the only way this is moving forward.

The coverage gap

As you may know, the intent of the Affordable Care Act was to get people below a certain income level onto Medicaid, with people at or above that income level receiving subsidized health insurance via the exchanges. Unfortunately, when the Supreme Court ruled that the Medicaid expansion mandate was unconstitutional, it meant that in states that refused to expand Medicaid people who fell below that income level but above the income level for Medicaid eligibility as things were would be left out of coverage – too poor to receive insurance subsidies, not poor enough for Medicaid. More than one million Texas adults fall into that coverage gap. Here’s a story about one of them.

It's constitutional - deal with it

It’s constitutional – deal with it

Damaged discs in Irma Aguilar’s neck make it hard to raise her arms, something she must do repeatedly when stacking boxes at the pizza restaurant where she earns $9 an hour as an assistant manager.

Sometimes, her untreated high blood pressure makes her so dizzy she has to grab onto something to prevent a fall.

And she struggles with anxiety, a heart-pounding fear that can strike at any time, but especially at night, when she lies in bed and wonders how she’s going to make ends meet.

Without insurance, she worries about how she will find the money to treat her health problems, which threaten her livelihood and the well-being of her family.

[…]

Aguilar’s four children are covered by Medicaid, which provides free or reduced-cost health care. But Aguilar makes too much money – $19,200 a year – to qualify. Texas’ Medicaid eligibility requirements are among the tightest in the nation, and Aguilar has to be nearly destitute to meet them – making no more than $4,200 a year as head of a family of five.

Emphasis mine. What that means is that if you make more than two dollars an hour working fulltime, you make too much money as the head of a family of five to qualify for Medicaid in Texas. Think about that for a minute.

Still left out of Medicaid, Aguilar hoped to get insurance under the ACA, but to qualify for a tax credit to help her pay for it, she would need to earn more than she does – at least $27,570 a year. Only those earning between 100 percent and 400 percent of the poverty level are eligible for the subsidies. Aguilar is at 70 percent.

This puts her in the gap, with neither Medicaid nor affordable health insurance.

If she could get a subsidy, Aguilar would have shelled out about $46 a month for a midlevel health plan. Without one, the cost would have zoomed to more than $200 a month, a price that puts health insurance out of her reach.

“I have to scrape by as it is,” Aguilar said. “By the time I pay rent, lights and water, there’s not much left over. Sometimes, I don’t eat so my kids can eat.”

[…]

As Texas rejected the extra Medicaid money, state lawmakers committed more resources to health care in the past session, said Stephanie Goodman, a spokeswoman with the Texas Health and Human Services Commission.

The Legislature set aside $100 million in added money for primary care services for women and an additional $332 million for mental health services, she wrote in an email.

“We’ve also developed a strong network of health centers across the state that provides low-income citizens with access to both preventive care and treatment for medical issues,” she said.

Such clinics depend on a mix of revenue – Medicaid, private insurance and patient fees – to enable them to provide care to those who lack insurance.

But those front-line providers don’t have enough money and resources to care for all the uninsured, including those in the coverage gap, said José Camacho, head of the Texas Association of Community Health Centers.

Nor can health centers provide a broad range of services, making them a too-porous safety net, others say.

“They’re no substitute for not having coverage,” said Anne Dunkelberg, a policy analyst at the Center for Public Policy Priorities, which advocates for low-income Texans. “They can’t provide specialty treatment or trauma care. If you’ve been hurt in a car wreck or have a broken bone or cancer, if you need a CT scan, you’re going to be out of luck. Health centers are wonderful for primary care, but they’re not a substitute for comprehensive care.”

Ms. Aguilar has chronic conditions, as noted above, so these health centers likely wouldn’t be of much good to her anyway, assuming she could afford their fees. Even if she could, she wouldn’t be able to afford any medications they might prescribe. So she’s pretty much SOL. I personally think that Rick Perry, David Dewhurst, Greg Abbott, Dan Patrick, Ted Cruz, and everyone else responsible for Texas’ horrible lack of health insurance for so many of its residents should be made to personally explain to Ms. Aguilar and her kids why they don’t want her to be able to get health care. Not that I think it would have any effect on them, but maybe if they had to explain it to all one million plus Texans that they have excluded from coverage it might eventually wear them down.

I do know one way that Ms. Aguilar and the million others like her could get helped, and that’s by electing Wendy Davis and Leticia Van de Putte this November. No guarantee that they’d be able to overcome legislative resistance, of course, but there was some sentiment for expansion in 2011, and at least they wouldn’t be adding to that resistance. And if the Lege still can’t stand the idea of expanding Medicaid, there’s another way they could help Ms. Aguilar and many others like her: Raise the minimum wage. If Ms. Aguilar earned a bit more than $13 an hour, then her fulltime salary would make it to that magic $27,500 level – which is to say, exactly at the federally defined poverty line – and she’d qualify for insurance subsidies on the exchange. Either way would be fine by me.

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 healthcare.gov 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.