Voters in four states have approved Medicaid expansion by ballot. Will Texas do the same?

Olga Kauffman is tired of the politics surrounding Medicaid.

Kauffman, a San Antonio resident who works as a health specialist with Urban Strategies, a group that builds public housing and provides services to residents, says she sees families struggle every day because of lack of access to health care and insurance.

She recalled helping a 31-year-old mother with ovarian cancer get on Medicaid, the joint federal-state health insurance program for people who are poor or disabled. The mother of three, who evacuated the U.S. Virgin Islands after Hurricane Irma, had Medicaid there but didn’t realize she needed to apply for it again in Texas. Kauffman said it took months for her client to hear an answer, and in that time she missed several chemotherapy appointments and couldn’t afford her prescription drugs. Two weeks after she died, her Medicaid application was approved. It’s those moments that Kauffman thinks about when telling people how Medicaid can leave people behind.

”I’ve had stories of families I’ve seen being torn apart because they lost a loved one because they didn’t have access to health care," Kauffman said.

Stories like that of Kauffman’s client are why some Texas legislators are hoping to gain traction on bills that would put a constitutional amendment on the ballot for voters to decide whether the state should expand Medicaid coverage.

Texas is one of 14 states that have not expanded Medicaid under the Affordable Care Act. An estimated 1.1 million low-income Texans would be eligible for coverage under a Medicaid expansion, according to the Kaiser Family Foundation. Low-income families often make too much money to qualify for Medicaid coverage and too little to buy private insurance.

Idaho, Nebraska and Utah voters approved Medicaid expansion through ballot initiatives during the 2018 elections. Maine voters did the same in 2017.

“If it’s on the ballot, of course I would vote for it, and I would tell everybody I know to vote for it,” Kauffman said.

Seeing other states take Medicaid expansion to voters is what Rep. Celia Israel, D-Austin, says gave her the idea to file House Joint Resolution 40. She said she’s frustrated that Texas “has not shown the political fortitude” to expand the program and that giving the decision to voters may take political pressure off of Republicans.

Expanding Medicaid through the Affordable Care Act — also known as Obamacare — has been a nonstarter in the GOP-dominated Texas Legislature. Republicans including Gov. Greg Abbott, Lt. Gov. Dan Patrick and former Gov. Rick Perry have argued that expanding Medicaid would increase health care costs for the state — especially if the federal government ever breaks its promise to help pay for the surge of newly eligible people.

Israel’s strategy so far has included courting Republicans in districts that have lost rural hospitals. Nineteen rural hospitals have closed permanently or temporarily since 2013, according to the Texas Organization of Rural & Community Hospitals.

“I’m getting mixed responses,” Israel said of her progress. “I’m making the case that we have lost so many rural hospitals in Texas, and one of the reasons we wouldn’t have lost those rural hospitals is if we had said yes to expanding Medicaid.”

Anne Dunkelberg, associate director of the Center for Public Policy Priorities, a left-leaning policy organization, said the 2018 election cycle and polls showed that health care is a top issue for voters.

“The bottom line is even though individual members have seen desirability moving in this direction, it’s not something they’re going to fall on their sword and buck their leadership over,” Dunkelberg said.

Texans making decisions about health care in their state “is a fundamentally good idea,” and Medicaid expansion should be on the ballot for voters, said Dr. Deane Waldman, director of the conservative Texas Public Policy Foundation’s Center for Health Care. But he said Medicaid expansion would not necessarily mean more people would have access to care. He added that the billions of federal dollars Texas receives for expansion would not last long because of the program's expensive mandates.

“You expand Medicaid, and what’ll end up happening is even more people will expect to get care and will be unable to find it,” Waldman said. “That really is the essence of why I think that the evidence shows that expanding Medicaid is bad both for the health of Texas and their access to care and the state of Texas because we’re going to end up with a shortfall.”

State Rep. John Zerwas, chairman of the House Appropriations Committee, attempted an alternative to Medicaid expansion during the 2013 session. The Richmond Republican’s House Bill 3791 would have allowed Texas to receive federal money in the form of block grants to enroll individuals in a private health plan using a sliding-scale subsidy, rather than expanding Medicaid to cover them. The bill also had a “pull the plug” provision if the federal government failed to continue funding. It had some bipartisan support but never reached the House floor for a vote.

He said Medicaid expansion in general still “comes with political radioactivity” that Republicans are hesitant to deal with. Just pursuing a waiver is still “a pretty steep hill to climb.” Zerwas said he doesn’t plan on bringing his bill back and also doesn’t believe Medicaid expansion needs to be taken to voters. He acknowledged that Texas has the highest number of uninsured people in the country but says there’s not a cost-effective way to provide care for the Medicaid population.

“It’s just politics, you know, and I’ve lived through this by virtue of carrying the bill in 2013 and was portrayed as someone who just loved Obamacare and was looking to grow it in the state of Texas,” Zerwas said. “Politically and in my party especially at that time and still so ... it continues to be one of those things that Republicans rail against because they see it as a very heavy cost to the state.”

But Sen. Nathan Johnson, D-Dallas, who filed Senate Joint Resolution 34, which also would create a constitutional amendment to expand Medicaid, said that “it should not take a leap of courage to put this on the ballot.” Amid Texas’ problems with the opioid epidemic, maternal mortality and access to mental health services, he said, it would be difficult for lawmakers to go back to their constituents and tell them why they refused to put Medicaid expansion on the ballot.

“It starts to become a bit of an embarrassment,” Johnson said. “I think we have the potential to be a leader in health care. ... We have vast resources and tremendous amount of power and will when we decide to employ it.”

For Kauffman, she said she understands the politics around Medicaid, but when it starts affecting the lives of families, then it “needs to become apolitical.”

“It needs to become a quality-of-life and health care issue,” Kauffman said. “It needs to be taken into consideration that we need the best health care for families in Texas, and if the only way is to expand Medicaid in Texas, then we should do it.”

Disclosure: The Texas Public Policy Foundation and the Center for Public Policy Priorities have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.