The Great State of Texas

Did any of you see the coverage of Governor Rick Perry of the great state of Texas announcing that Texas would not create a Healthcare Exchange and wouldn’t participate in the Medicaid Expansion Initiative created under the Affordable Care Act? I don’t have the exact quote, but I think he said that Texas wasn’t going to be forced by the federal government to spend money on the poor. I guess I’m not surprised by anything coming out of Texas. That’s the state that seems to encourage people to carry concealed weapons and leads the nation in administering the death penalty. The Governor’s statementprompted me to look at some statistics on the uninsured in Texas. I went to the Texas Medical Association, not exactly a left wing organization, to get some data about the uninsured in Texas. Surprise, Texas is number one in the nation in the percentage of the population that is uninsured, a whopping 25 percent. By the way, that’s about 6.2 million people without health insurance out of almost 50 million, or 16 percent of the U.S. population. Seventeen percent of children and 33 percent of adults ages 19-64 are uninsured in Texas. Texas leads the nation in the percent of children without health insurance. You’d think that at least the people of Texas would want to give children a chance at living a healthy life.

The Texas Medical Association says “The uninsured are up to four times less likely to have a regular source of health care and are more likely to die from health related problems.” In addition, we all know that someone is paying for the episodic care the uninsured do receive, often provided in emergency rooms. That someone are those of us who have insurance. The uninsured generally avoid seeking care until the problems are serious. As a result, we end up spending more for their care. Most importantly, the lack of insurance is a source of anxiety and suffering for millions of people.

I think that reducing the number of uninsured

would result in savings of at least the 10 percent

of costs the states are required to pick up.

If we could reduce suffering and probably save money by extending coverage to the 50 million uninsured, why is there such resistance? Let’s put aside the issue of presidential politics, which may play a role. There is the issue of states’ rights. Texas and Florida don’t want the federal government telling them how to solve their problems. I’m not into the states’ rights thing, but I can appreciate the sentiment. If that is the issue, what does Governor Perry want to do in Texas to address the problem? Governor Perry wants Medicaid to be a block grant to states. I get that. Healthcare is local. So what is the Governor’s plan? It doesn’t appear that he has one. Vermont also wants to shape its own destiny by creating a single payer system. The federal government can be flexible: witness Massachusetts. Another argument is that states cannot bear the additional 5 to 10 percent of the cost of the Medicaid expansion once the federal government’s commitment to 100 percent of the cost of the Medicaid expansion expires. This is also a credible argument. Having watched the RI Legislature struggle with balancing a budget for the last 12 years, the state share of Medicaid is usually the biggest issue. I think that reducing the number of uninsured would result in savings of at least the 10 percent of costs the states are required to pick up. However, if being responsible for 10 percent of the cost is the issue, why don’t the states ask Congress to pick up 100 percent of the costs? The final argument against expansion of Medicaid is that it reinforces a fee-for-service system that rewards volume rather than outcomes. As far as I can tell, this is a red herring. The states have the right to change the reimbursement system to reward providers for better outcomes and reduced overall medical costs. The Right Care Program in RI seems to illustrate the ability of the states to experiment with different incentives.

So why am I fixated on Texas? After all, RI is committed to the Healthcare Exchange and the Medicaid Expansion Program. The answer is that the Affordable Care Act is under attack and could easily be undermined by the upcoming election. I would like those people who are on the fence to understand what’s at risk. I’d like them to think through the issues and decide what kind of society they want. Do we want a society in which a substantial number of children, due to no fault of their own, cannot access appropriate care? Do we want a society in which many adults put off routine preventive care and, because they become sick and disabled, become dependent on the state? I might be missing something, but it doesn’t make sense from a humane or economic perspective to delay extending coverage to all Americans. I look forward to your comments. --Lou Giancola