By BETSY TAYLOR
In Texas, the state with the highest rate of uninsured people in the nation, Catholic hospitals that treat the poor and uninsured are advocating for Medicaid expansion, a key part of health care reform under the Affordable Care Act, but one facing strong opposition from Republican Gov. Rick Perry and some Texas legislators.
About 6.1 million people, or 24 percent of Texans, don't have health insurance, according to an analysis by the nonpartisan Kaiser Family Foundation. Hospital systems advocating for Medicaid expansion — a group that includes CHRISTUS Health, Ascension Health, and Covenant Health System — point out that it could significantly reduce the $5.5 billion in uncompensated care provided each year by Texas hospitals. The Texas Health and Human Services Commission estimates that 1 million people could be added to the insurance rolls if Texas would expand Medicaid, as provided in the Affordable Care Act, to people whose income is at or below 138 percent of the poverty level, or about $31,000 for a family of four.
A U.S. Supreme Court ruling last year said the federal government couldn't compel states to expand Medicaid under the Affordable Care Act; but, if states opt not to expand the health program for the poor and disabled, they won't receive billions in related federal funding.
Top-down, bottom-up campaign
Medicaid expansion advocates in Texas are working in conjunction with Texas hospital associations to craft unified messages. And they're not just talking to state legislators; they're working to build community-level support, approaching Chambers of Commerce, county officials, even school boards.
There is a postcard campaign aimed at lawmakers, and a Twitter hashtag #GetTexasCovered, which provides a way to track the topic in online tweets.
In a YouTube video, Ernie Sadau, CHRISTUS Health's president and chief executive, makes the business case for Texas and Louisiana, where CHRISTUS also has hospitals, to opt in to Medicaid expansion. His message to the public is that their federal taxes will fund expansion of Medicaid nationally, and their money will go to other states if Texas and Louisiana don't opt in. He said that CHRISTUS and other "safety net providers" already struggle to serve their Medicaid patients, and that increasing the number of insured people would help fund efforts to provide more primary and preventive care — important components of health care reform that improve health and may reduce health care spending over the long term.
Gabriela Saenz, CHRISTUS' director for advocacy and public policy, noted that Irving, Texas-based CHRISTUS provides more uncompensated care than any other nonprofit hospital system in Texas, spending more than $140,000 a day on care for the uninsured. "We have a lot at stake," Saenz said.
As part of its campaign, CHRISTUS sent emails to 20,000 individuals with ties to its system, asking them to communicate with their legislators in support of Medicaid expansion. Some hospitals are staffing advocacy tables in high-traffic corridors outside their cafeterias to invite care providers, patients and visitors to support the postcard campaign and inform people about the Medicaid expansion issue.
Advocates know they've got a lot of work ahead of them. In an April 1 speech, Perry called Medicaid expansion "a misguided and ultimately doomed attempt to mask the shortcomings of Obamacare. Texas was among the first states to say 'no,'" the governor said.
Getting to 'yes'
As part of its pro-Medicaid expansion efforts, the Texas Hospital Association emphasizes the extent of cost-shifting that occurs to cover the providers' expense in caring for the uninsured. A family's annual health care insurance premium is about $1,800 higher due to cost shifting, the association said, citing a statistic from the Center for American Progress Action Fund.
The Medicaid coverage expansion under the Affordable Care Act is 100 percent federally funded in the first three years. According to the Texas Hospital Association, if Texas were to expand Medicaid in January in 2014, $23.9 billion in federal funds would flow to the state through the end of 2016. Texas would contribute state funds to pay for the expansion beginning in 2017, but the state share would never increase to more than 10 percent.
Many lawmakers who oppose the Medicaid expansion say they don't want to take the federal funds now, because they're worried about the state's long-term financial exposure. Perry said Medicaid already draws a quarter of Texas' budget, and he is concerned Washington might break its promise on future funding.
The Affordable Care Act also calls on states to set up insurance exchanges with federal start-up funds to create a marketplace where consumers can chose among health plans, and receive income-based premium subsidies. Since Texas is not setting up an exchange, its eligible citizens will be able to buy insurance through a federally facilitated state exchange, due to launch in 2014.
Different buckets
Gwen Stafford, vice president for advocacy and public policy for Covenant Health System in Lubbock, Texas, said, "I don't think taking federal money has ever been a problem for highways; it's never been a problem in agriculture, disasters, that type of thing. I want to be very respectful of the governor and those that differ. Unfortunately, when it comes to health care, it's put in a little bit different bucket" than other federal funds to Texas.
She offered a big picture view of health care, and one that she's drawing from in her advocacy work in support of Medicaid expansion. "We see health care as very important because if kiddos are well, they go to school and get an education. If people are well, they get back to work sooner and they're more productive employees, so we really don't separate that out. We look at it in the total."
Kent Keahey, recently retired chief executive of Providence Healthcare Network in Waco, Texas — part of Ascension Health-Texas — said in the discussions leading up to the passage of the Affordable Care Act, the health care industry, including hospitals, voluntarily agreed to $500 billion in reduced federal reimbursement nationally over 10 years. "They did that because there was concern if they didn't take a proactive stand and agree to some reduction in reimbursement in return for expanded coverage, the entire cost of health care insurance could have fallen to the hospitals."
Hospitals agreed to accept $155 billion in reductions in reimbursements from government payers over a decade. "That was based on the belief that the health care reform bill would expand coverage through the insurance exchanges and through Medicaid expansion," which in turn would reduce uncompensated care, Keahey said. "None of us, no one, I believe, envisioned at the time that the Supreme Court would rule that Medicaid expansion would be optional at the state level.
"The point we're trying to make is that in states that don't embrace Medicaid expansion, those hospitals are not going to get those reimbursements reinstated. Those reimbursements are going to be gone," Keahey said.
Advocates of Medicaid expansion said they don't yet see a solution on the horizon in Texas, but they're watching what other states are doing. Some states, like Arkansas, want to use Medicaid expansion money to buy private insurance coverage, and the Department of Health and Human Services has said it will talk with states that want to use premium assistance as a way of accessing some private coverage for individuals who would otherwise be Medicaid eligible. Texas has not yet signaled a move in this direction, and advocates worry this approach will leave out the poorest of the poor since the Affordable Care Act prevents people whose income is at or below 100 percent of poverty from participating in the exchange.
Saenz said, "We're hopeful we'll come to an agreement on Medicaid expansion, even if it is a Texas-style solution."
CHA resource
For state based, grass roots resources supporting Medicaid expansion, visit the Advocacy section.
Source: The Kaiser Family Foundation map is based on an analysis by The Kaiser Commission on Medicaid and the Uninsured looking at gubernatorial "State of the State" addresses, budgets proposed by governors, and recent public statements made by governors. The "weighing options" classification includes states where the governor has made no official statement supporting or opposing the Medicaid expansion, where the governor's budget did not include a decision on the Medicaid expansion, where the governor has indicated he or she is leaving the decision to the legislature, or the governor has indicated he or she is awaiting additional guidance or analysis.
Copyright © 2013 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.