The Washington Post reports on the efforts of county and hospital district officials in some of Texas’ largest counties to bypass Rick Perry’s refusal to expand Medicaid for Texas and seek approval to do it themselves for their own jurisdictions.
It's constitutional - deal with it
George Hernandez Jr., CEO of University Health System in San Antonio, came up with the idea of the alternative, county-run Medicaid expansion, and said he has been discussing it with other officials in his county, Bexar. “They are all willing,” he said. He added that he has also been talking up the proposal with officials in other big counties, such as those including Houston and Dallas, and is optimistic they’ll support the idea.
Robert Earley, CEO of JPS Health Network, the public hospital system serving Tarrant County, which includes the Fort Worth area, said he could see the idea catching on.
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Under the federal health law, the Medicaid expansion would begin in 2014, and would cover people with incomes of up to 133 percent of the poverty level. The federal government would pay the entire bill for the first three years and 90 percent thereafter. If there were a county-backed expansion in Texas, the local hospital districts would tax residents to come up with the 10 percent state share. Texans living in counties that participated in the expansion would be eligible for Medicaid under the less restrictive rules, while those living in the rest of the state would not.
An official from the U.S. Department of Health and Human Services declined to comment on the idea, but said, “We look forward to continuing our dialogue with states . . . as we work to meet the law’s goals.”
Alan Weil, executive director of the National Academy for State Health Policy, said that the idea, despite its challenges, “is certainly not far-fetched.”
Weil noted that there is precedent for a federal waiver of this type: After California declined to take advantage of a provision in the health-care law that allows states to accelerate their Medicaid expansion, the leaders of several counties got permission from the Obama administration to do so on their own.
The Texas proposal, of course, represents more than a temporary bridge to statewide expansion; it could be a permanent arrangement.
“And federal authorities might feel differently about that,” Weil said. “But as a general proposition, could you have different counties with different eligibility standards? I think the answer would be yes.”
We first heard about this a few weeks ago, after the Perry announcement and the sheepish admission by outgoing HHSC Chair Tom Suehs that Medicaid expansion would not cost nearly as much as his agency had first claimed. It’s an interesting approach, one that I could see being allowed to happen, and I admire creativity and perseverance of the officials who are pursuing it, but let’s be clear that it’s at best a kludge designed to work around a bad decision. For one thing, it cannot possibly be more efficient to have up to 254 potentially different standards for eligibility in Texas than just one statewide standard. For another, while I expect that many counties would do this if they are permitted to do so, some others will choose instead to be free-riding parasites on their neighbors; this is another reason why a statewide solution is better. Given the choice between no Medicaid expansion and a patchwork of Medicaid expansion done by the counties, I’ll gladly take the latter – it’s way better than the status quo, and could easily wind up covering a significant portion of the large uninsured population in Texas, many of which are now served by these overburdened hospital districts. But again, it’s a patch that’s being applied to a strictly self-inflicted wound.
And this approach now has a champion in Congress.
Congressman Henry Cuellar is asking the U.S. Department of Health and Human Services if Texas counties can bypass their state government in order to expand Medicaid coverage.
The Laredo Democrat says he supports giving counties the choice. He said he set up a teleconference call with HHS after reading an article in the Washington Post that said some of Texas’ largest counties want to make an end run around Gov. Rick Perry’s opposition to the expanded Medicaid program included in President Obama’s health-care law.
“I will be talking to HHS next week. I want to know if it is up to the Texas Legislature to decide if counties can do their own thing or whether it is something we can make happen at the federal level. I want to do all I can to give counties the choice,” Cuellar said, in an interview with the Guardian in Rio Grande City on Tuesday.
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Cuellar recalled his time in the state legislature when he wanted to give Texas counties the opportunity to expand the Children’s Health Insurance Program. “We do not do as good a job with the CHIP program as other states do and I wanted to negotiate with HHS to give our counties the chance to expand it. I was opposed by the other states. They understood that if Texas sent CHIP money back, they could get some of it,” Cuellar said.
The Washington Post story focused on the larger Texas counties that have large public hospitals and hospital districts. Many border counties do not. Asked if border counties could bypass the state government in order to secure expanded Medicaid coverage under the ACA, Cuellar said he is going to ask HSS if such a maneuver is possible. “I want to see if the border counties can group together. I want to see if we can give them an option,” Cuellar said.
Again, given the constraints of Rick Perry’s obstinacy and antipathy towards non-rich people, that’s a great idea. Any opportunity to bypass the Lege should be grasped with both hands. Make that option available to any group of counties that don’t have a hospital district but want to do right by their taxpayers, too. If there’s any justice, Texas would achieve near-complete coverage by this method. It will probably take something like that to change the status quo. It’s still a stupid way to do business, but you gotta do what you gotta do.
There’s one remaining question that I have about all this, and that’s what Harris County intends to do. Bexar County has been the driving force behind this movement. Harris has the same need and a much bigger population, so its participation would be a big deal. I placed a call and was informed that Harris County Hospital District CEO David Lopez is “not granting interviews” on this topic at this time. Disappointing, but I suppose the politics of this are rather tricky for them, and they want to get as many ducks in a row as possible before deciding on a course of action. If you’re an officeholder in Harris County and you like the idea of providing coverage to the million or so uninsured residents of this county, I suggest you bring this up to Mr. Lopez at your next opportunity. You never know who else might be talking to him if you aren’t.
So what if the Feds decide to let Planned Parenthood run Medicaid for Texas?