Perry's Tea Party Cuddle Up Over Medicaid Dollars Will Cost Millions of Texan's Lives
Rick
Perry’s Refusal to Expand Texas’ Medicaid Program Could Result In Thousands of
Deaths
Jeff Newman/Globe Photos/ZUMAPRESS.com
Members of the Texas Chapter of ADAPT
celebrate the United States Supreme Court’s upholding of the Affordable Care
Act, also known as Obamacare, in front of the Texas Capitol.
You could say that the idea
for Medicaid began in Texas. In the late 1920s, a middle-school
teacher named Lyndon B. Johnson saw the crushing poverty and inequality his
Mexican-American students faced in the small South Texas town of Cotulla.
Nearly 40 years later, then-President Johnson declared a War on Poverty and, in
1965, signed the bill that created Medicaid—a program funded jointly by the
states and the federal government to provide health insurance to low-income
Americans. It was part of his vision for a “Great Society,” which he boldly
defined as “a society where no child will go unfed, and no youngster will go
unschooled.”
Johnson probably couldn’t
have imagined the program’s impact. In the past 47 years, Medicaid has provided
medical care to hundreds of millions of Americans—including low-income
children, the elderly, disabled, and pregnant women—and has saved millions of
lives. More than 50 million are currently enrolled.
In Johnson’s home state, however, the commitment to Medicaid has
always been lackluster at best. Texas’ Medicaid program spends less than the
national average per enrollee, and reimburses doctors, hospitals and other
providers less than the national average. In many areas, the Texas program pays
for only the minimum standards required by the federal government. One in four
Texans—6.1 million people—lack health insurance, the highest percentage in the
country.
Now another Democratic president wants to expand Medicaid, under
the Patient Protection and Affordable Care Act, or “Obamacare.” Even a modest
expansion would mean that an estimated 1.5 million working adults who earn 133
percent of the federal poverty level or less (about $14,856 a year for an
individual) could have health insurance starting in 2014.
But there’s one big snag. The U.S. Supreme Court ruled in June
that states have the right to refuse to expand Medicaid. Texas Gov. Rick Perry
is among several governors, mostly southern and Republican, who are resisting.
To make the expansion more palatable, the federal government will pay for all
the people added to Medicaid rolls until 2017; after that, it will reimburse 90
percent of the costs. In effect, Americans around the country would help pay
for the health insurance of more than a million Texans.
If Texas doesn’t expand Medicaid, it will reject more than $100
billion in federal money the first decade, according to the state’s own
figures. To get that sizeable federal reimbursement, the state would have to
spend about $16 billion over 10 years. The governor’s refusal to take the
federal government’s billions puts him in an awkward position opposite some of
the state’s most powerful economic players: hospital chains, local governments
and chambers of commerce. Given that political pressure, Perry might strike a
deal with the Obama administration, or the Texas Legislature could push for a Medicaid
expansion.
Beyond the economics and
politics, lives are at stake. Lack of insurance will certainly mean more
deaths. How many more? Approximately 9,000 a year, according to Dr. Howard
Brody, director of the Institute for Medical Humanities at the University of
Texas Medical Branch in Galveston. Brody calculated that figure by
extrapolating from a recent Harvard University study published in The
New England Journal of Medicine that found that states that expanded Medicaid saw a 6.1 percent reduction in the death rate among adults below 65 who qualified for the program. In a recent op-ed in theGalveston Daily News Brody
wrote, “This means that we can predict, with reasonable confidence, if we fail
to expand Medicaid . . . 9,000 Texans will die each year for the next several
years as a result.”
Too often the political debate around Medicaid expansion is
about dollars and cents, Brody told me recently. “It’s presented as if it weren’t
about life and death,” he said. Brody teaches ethics to medical students at
UTMB, so for him, the issue of Medicaid expansion, when you cut through the
rhetoric and endless policy discussions, is a deeply moral question: Should
Texas allow people to die simply because they can’t afford health insurance?
“Whose life and death are we talking about?” said Brody, who treated Medicaid
patients for decades before becoming a professor at UTMB. “Politically, the
Medicaid population are simply invisible folks. Most Americans may not care
very much, because they think, ‘I’m not in that group of people and that’s
somebody else and so it’s somebody else’s problem.’”
Perry has contributed to this attitude by arguing that uninsured
Texans can receive health care in emergency rooms. “Everyone in the state of
Texas has access to health care, everyone in America has access to health
care,” Perry said at a New Hampshire campaign event in November 2011, according
to the liberal website ThinkProgress. “From the standpoint of all people in
this country, our government requires that everyone is covered.” Perry is
correct that anyone can get treated in an emergency room—but it’s expensive.
And not everyone in Texas has access to health care. People with chronic
conditions—especially those with cancer—face a bleak future without health
insurance. They are among the thousands of Texans whose lives could be saved by
Medicaid expansion.
Jen Reel
The Reyes family in front of the
Methodist Healthcare Ministries clinic in San Antonio.
For 15 years, Mario
Reyes, a diabetic, bounced from one emergency room in San Antonio to the next.
On some days his blood sugar was so high he feared he might black out while
driving to the hospital.
A commercial painter by trade, he’d worked his entire life, but
had never been able to afford health insurance. For years, like nearly 400,000
other uninsured residents in Bexar County, he’d relied on the local emergency
room for treatment. Most months he would visit the ER at least twice for his
diabetes. Then, two years ago, at the age of 52, he developed a constant,
debilitating pain in his lower back. After a few excruciating weeks, Reyes
finally went to the hospital. He felt numb when the doctor gave him his
diagnosis. Reyes had kidney cancer.
For Reyes, the diagnosis felt like a death sentence. “I couldn’t work and I had no money and no health insurance,” he says. For Reyes, uninsured and living in Texas, a diagnosis like cancer meant he was at the mercy of a charity organization, or possibly a county indigent program. Reyes was more fortunate than most. He found Methodist Healthcare Ministries, a church-based charity health-care system, which referred him to a specialist who removed his cancerous kidney. Methodist Healthcare Ministries underwrote almost all of the costs of Reyes’ surgery and care.
“My husband wouldn’t be here today if it wasn’t for them,” his
wife Mary said. But Reyes and his wife believe that he wouldn’t have gotten so
sick to begin with if he’d had health insurance all those years. “I’m surprised
he’s still here, because his sugars were always so high,” Mary says. “I feel
blessed he’s here next to me.”
Reyes received life-saving treatment because he happened to live
in a large metropolitan city with significant charity care for those without
insurance. If he had lived in a rural county, we probably wouldn’t have had our
recent conversation on a warm, sunny morning in San Antonio. The outcome had
been very different for a 27-year-old East Texas man with the same diagnosis
that I wrote about in a 2009 Texas Observer story (see “Sick +
Tired,” Sept. 3, 2009). Sam, who was also uninsured,
died because he couldn’t find anyone who would treat his cancer.
Reyes was lucky enough to find a charity program in his
hometown. But even with the charity and indigent health-care programs that San
Antonio offers, only a fraction of the county’s uninsured residents will get
help, said Kevin Moriarty, CEO and president of Methodist Healthcare Ministries.
“For every 2,000 or 3,000 that we cover, there are probably 20,000 or 30,000
that are not covered,” he said. “And they don’t get to us. And how unfair is
that, that somebody’s tumor that could be removed, that someone’s life that
could be extended, ends because we don’t have access to the resources to make
that happen?”
Medicaid expansion would help people like Mario Reyes, said
Moriarty, who is frustrated by Perry’s rejection of the program in Texas.
“We’re talking 1.5 to 3 million people around the state who are going to get
late care or no care,” he said. “They’re going to suffer, they’re going to be
in pain because we can’t make a better policy decision.”
Jen Reel
Patients check in at the
Brackenridge Hospital emergency room in Austin.
Perry has been a fierce opponent of the federal health-care reform bill since it passed.
“Freedom was frontally attacked by passage of this monstrosity,” he told the
media after the Affordable Care Act passed Congress in 2010. “Obamacare is bad
for the economy, bad for health care, bad for freedom.” After the U.S. Supreme
Court ruling in June upheld Obamacare but allowed states to opt out of the
Medicaid expansion, Perry fired off a letter to Kathleen Sebelius, secretary of
the U.S. Department of Health and Human Services, calling the notion of
Medicaid expansion and the creation of a state-level insurance exchange—another
element of Obamacare—a “brazen intrusion into the sovereignty of our state.”
“What they would do is make Texas a mere appendage of the
federal government when it comes to healthcare,” he wrote Sebelius. “Neither a
‘state’ exchange nor the expansion of Medicaid under the Orwellian-named PPACA
would result in better ‘patient protection’ or in more ‘affordable care.’”
Two hours after sending his letter, Perry was on Fox News
comparing the Medicaid expansion to “adding 1,000 people to the Titanic.”
Instead, Perry said, states like Texas should be given Medicaid block grants to
create their own system for health-care coverage, without elaborating further
on what that system might entail. Fox News correspondent Jenna Lee, much to
Perry’s visible annoyance, began to press him for specifics. “According to a
new federal government report—I know you’ve seen this—Texas has ranked last
when it comes to health services provided by the state,” Lee pointed out. “The
facts are one out of four Texans is without health insurance. One out of four
Texans is on Medicare or Medicaid. The health crisis, the big crisis for the
country and for your state, what is one solution you are offering to the
citizens of Texas?”
Perry blinked for a moment. “The idea that this federal
government, which doesn’t like Texas to begin with, to pick and choose and come
up with some data and say somehow, Texas has, you know, the worst health-care
system in the world is just fake and false on its face.
“The real issue here is about freedom,” Perry insisted. “Every
Texan has health care in this state. From the standpoint of having access to
health care, every Texan has that. How we pay for it and how we deliver it
should be our decision.”
Health-care advocates could
only shake their heads in dismay after Perry’s Fox News performance. The job of
providing a health-care safety net has increasingly fallen on hospitals, counties and local taxpayers.
To patch together a system of care, large metropolitan counties like Bexar have
taxed themselves to create health districts and to fund public hospitals. Rural
counties, with their limited pools of property taxpayers, don’t have that
option, and provide fewer services to residents.
For at least 37 years, Kevin Moriarty has been involved in the
debate over how to treat Texas’ uninsured. For decades he worked in San
Antonio’s Department of Human Services. Then, in 1995, he became president
and CEO of the nonprofit Methodist Healthcare Ministries, which funds its
charity care from profits generated by hospitals it co-owns with HCA, a
for-profit hospital chain.
In the past two decades, Methodist Healthcare Ministries’
charity care costs have grown from $200,000 to $72 million. Each year,
Methodist Hospital and other Bexar County hospitals write off millions in
unpaid emergency room charges. In 2010 alone, Methodist racked up $221 million
in unpaid emergency room bills, according to a July 2012 report by the
Kronkosky Charitable Foundation. Increasingly, the burden of underwriting
charity care falls to the insured, who pay an average of $1,500 to $1,800 per
year per family in extra costs, according to Anne Dunkelberg, associate
director of the progressive Center for Public Policy Priorities.
Hospitals and physicians see the Medicaid expansion as a smart
business decision, Moriarty said. “Every hospital system, every health-care
provider, every physician in the state is suffering from a lack of revenue from
health care,” he said. “Now, Medicaid is not their solution. However, it will
take away what might be 10 to 20 percent of their charity care expenses. Every
physician’s office, every dentist’s office that takes Medicaid, will see
improvements to their bottom lines.”
Perry and other opponents of the expansion,
such as the conservative think-tank Texas Public Policy Foundation, argue,
however, that the expansion will cost the state too much. They contend that
Texas will be on the hook if the federal government becomes less generous with
reimbursements in the future. Or as Perry put it in a 2010 op-ed after the
Affordable Care Act passed, “Staggering costs handed down to generations yet
unborn.”
But the costs don’t seem so staggering when you look at a recent
report by economist Ray Perryman, who estimated that Medicaid expansion would
result in total cumulative gross benefits to the state economy of $270 billion
in the first decade and a boost in employment. This, Perryman wrote, would come
from health-care spending provided through expansion, reduction of
uncompensated care (and thus the local government and private funds needed to
pay for it), and reduction of chronic illness and death through better health
care, and thus more productivity.
Whether Texas expands Medicaid or not, Perryman emphasized,
taxpayers will still be paying for it. If Texas passes up the Medicaid
expansion, it will forfeit an estimated $100 billion in federal reimbursements
in the first decade. Some of this money will come from Texas taxpayers and be
redistributed to other states for their own Medicaid expansion programs. “The
relevant question at present is not philosophical, but practical,” Perryman
said. The expansion “represents one of those rare occasions where Texas can
both provide significant services for many of its least-advantaged citizens
while simultaneously stimulating the economy and taking the most fiscally
responsible course. Whether Texas opts in to this program or not, our citizens
and businesses will pay the federal taxes that support it.”
It would be foolish to reject billions, especially if we’re
paying for it anyway, Moriarty said. “Here you’ve got these very conservative
individuals arguing that we shouldn’t accept this money because of the burden
to the Texas taxpayer. But an important fact about what’s being proposed is, by
not accepting these funds, we’d be taxed twice. First of all, we won’t get our
state monies back from the federal government. And secondarily, as a property
owner, I pay hospital district taxes, and so I’m paying and subsidizing these
costs at a local level.”
The prospect of rejecting so many billions is giving county
officials heartburn. Some of the state’s biggest metropolitan counties are
looking for a way around Perry and other state leaders if they continue to block
Medicaid expansion. In August, George Hernandez, president and CEO of
University Health System in San Antonio, which runs the indigent program in
Bexar County, made national headlines after he proposed that Texas’ six most
populous counties band together to circumvent the state and apply for the
federal Medicaid expansion money on their own.
Most counties are already tapped out, having formed local taxing
districts to fund public hospitals and indigent programs. Hernandez’s
University Health System has 55,000 uninsured county residents enrolled in its
indigent program. Each person in the program costs county taxpayers $2,000 a
year, he said.
At least 26,000 of those patients could be covered under the
Medicaid expansion. “That’s a $53 million savings every year to Bexar County
taxpayers.”
When I spoke to Hernandez recently, he wanted to de-emphasize
the county-led effort and focus instead on a statewide solution. “It could
reform the inequities in the existing system,” he said. “Right now we have a
county-based approach under the Texas Constitution—254 counties provide health
care in 254 different ways. Rural counties are only putting 8 percent into
their indigent health-care programs because that’s all they’re required to do
under state law. While the urban counties, including Bexar, Tarrant and Harris,
are putting 40 to 50 percent of their budgets into health care.”
Urban counties are disproportionately carrying the load for the whole state. “When you have a health crisis and you’re in a rural county, what do you do?” Hernandez said. “You move into an urban county to get health care much the same way families move school districts to get into the right school.”
In his mind, one of the most powerful arguments for Medicaid
expansion is to equalize that expense and lift some of the burden from urban
areas and urban taxpayers. “This is what moved our chamber of commerce to
support the Medicaid expansion,” he said. “The business community knows that
there is an unequal burden that our taxpayers are paying.”
In politics as in health care, nothing is as easy as it should
be. Despite the compelling economic figures and the moral question of saving
lives, convincing some state leaders to adopt anything under the umbrella of
“Obamacare” will be a difficult task this legislative session. Perry must be
won over. Even if the Legislature passes a bill expanding Medicaid, Perry could
veto it. If Texas is going to expand Medicaid, the governor will have to change
his position.
Nearly 50 years after the birth of Medicaid, things are not as
dire for low-income Texans as during Johnson’s time. But they’re not much
better. In one of the wealthiest states in the nation, more than six million
people lack access to health care. Without Medicaid expansion, thousands of
Texans will continue to die from treatable conditions.
(Correction: The original version of this story said that Kevin
Moriarty ran San Antonio’s Metropolitan Health District. It should have
stated that Moriarty worked in San Antonio’s Department of Human Services.
The Observer regrets the error).
Melissa
del Bosque joined The Texas Observer staff in 2008. She
specializes in reporting on immigration and the U.S.-Mexico border. Her work
has been published in national and international publications including TIME magazine
and the Mexico City-basedNexos magazine. She has a master’s in
public health from Texas A&M University and a master’s in journalism from
the University of Texas at Austin.
· Health Officials Decry Texas' Snubbing Of Medicaid
Billions
May 23, 2013 5:03 PM
5 min 2 sec
Texas Gov. Rick Perry
addresses the opening session of the Texas Legislature in Austin earlier this
year.
Eric Gay/AP
The state of Texas is turning down billions of
federal dollars that would have paid for health care coverage for 1.5 million
poor Texans.
By refusing to participate in Medicaid
expansion, which is part of the Affordable Care Act, the state will leave on
the table an estimated $100 billion over the next decade.
Texas' share of the cost would have been just 7 percent of the total, but for Gov. Rick Perry and the state's Republican-dominated Legislature, even $1 in the name of "Obamacare" was a dollar too much.
"Texas will not be held hostage by the
Obama administration's attempt to force us into this fool's errand of adding
more than a million Texans to a broken system," Perry said.
Texas Republicans have moved steadily to the
right — to where the very concept of public health insurance of any kind is
looked at through narrowed eyes. Still, it's not easy to walk away from $100
billion from the federal government to help your state's poor, elderly and
disabled, especially when you have powerful stakeholders like hospitals,
doctors and cities clamoring for the state to take the money for their sakes.
Texas hospitals stand to lose about $7
billion.
Health Officials Decry Texas' Snubbing Of
Medicaid Billions
May 23, 2013 5:03 PM
Listen to the Story
5 min 2 sec
Texas Gov. Rick Perry addresses
the opening session of the Texas Legislature in Austin earlier this year.
Eric Gay/AP
The state of Texas is turning down
billions of federal dollars that would have paid for health care coverage for
1.5 million poor Texans.
By refusing to participate in
Medicaid expansion, which is part of the Affordable Care Act, the state will
leave on the table an estimated $100 billion over the next decade.
Texas' share of the cost would have been just 7 percent of the total, but for Gov. Rick Perry and the state's Republican-dominated Legislature, even $1 in the name of "Obamacare" was a dollar too much.
"Texas will not be held
hostage by the Obama administration's attempt to force us into this fool's
errand of adding more than a million Texans to a broken system," Perry
said.
Texas Republicans have moved
steadily to the right — to where the very concept of public health insurance of
any kind is looked at through narrowed eyes. Still, it's not easy to walk away
from $100 billion from the federal government to help your state's poor,
elderly and disabled, especially when you have powerful stakeholders like
hospitals, doctors and cities clamoring for the state to take the money for
their sakes.
Texas hospitals stand to lose
about $7 billion.
"I don't think we will be OK,
actually, especially when you consider the state cut us about $700 million a
year in Medicaid payments because of the budget shortfall," says John
Hawkins, a senior vice president at the Texas Hospital Association. "Now
we're dealing with sequestration, which is another 2 percent.
Shots - Health News
Texas Medicaid Debate
Complicated By Politics And Poverty
"If you look at the
president's budget, there's some additional cuts to hospitals, so I don't think
it is a sustainable business model going forward if we don't do the
expansion."
If your country has no national health insurance but your citizens don't have the stomach to watch the uninsured die on the hospital sidewalk, something's got to give. So there's a national expectation that doctors and hospitals will provide these uninsured populations mostly uncompensated care — and so they do. But few in the industry think this is the way to operate.
Tom Banning, chief executive
officer of the Texas Academy of Family Physicians, lobbied hard but
unsuccessfully for Medicaid expansion. He's beside himself with frustration.
"These people don't choose to
get sick. When they do, they're going to access our health care system at the
most inefficient and expensive point, which is the emergency room,"
Banning says. "And it's going to cost the taxpayers, and it's going to
cost employers a lot of money to care for them. And we're going to be forgoing
billions of dollars that the feds have set aside for the state to pay for and
provide this care."
This is
not about money — if it were, Texas would be taking it. This is about
Obamacare. It's widely believed in Austin that Perry is seriously considering
another run for president — this time without the "oops." His base is Tea Party Republicans
across the country. While it might cost $100 billion for the privilege, Perry
is going to be able to stand in front of them and say, "I said no to Obama
when he tried to bribe my state with health care coverage for the poor."
And since it's widely believed
that these would-be Medicaid recipients probably don't vote or, if they do
vote, they vote for Democrats, there's no political price to pay for snubbing
them.
Still, there are some Republican
legislators who feel bad about not taking the money.
Rep. John Zerwas tried to craft
some sort of compromise that never mentioned Medicaid expansion, but he
couldn't get it out of committee — because for Texas Republicans, the very
words "health care" now carry the stink of Obamacare.
Zerwas points to "the
political realities of having to run for office again in two years, and how
much explaining would I have to do as a candidate around a vote that could very
easily be framed as a supporter of promoting Obamacare."
Texas Republicans aren't worried
about the reaction from the left for voting down Medicaid expansion; they're
worried they might get a primary challenge from a Tea Party candidate if the
words "health care" pass their lips on the floor of the Legislature.
That is, if they're not already a Tea Party candidate, which many are.
For at least the next two years
and probably longer, Medicaid expansion in Texas is dead. What this all means
is that more than a million Texans who might have received health care coverage
will remain one serious illness or one bad accident away from bankruptcy. And
an estimated $100 billion that would have been spent buying health care in
Texas will now go somewhere else.
"If you look at the president's budget,
there's some additional cuts to hospitals, so I don't think it is a sustainable
business model going forward if we don't do the expansion."
If your country has no national health insurance but your citizens don't have the stomach to watch the uninsured die on the hospital sidewalk, something's got to give. So there's a national expectation that doctors and hospitals will provide these uninsured populations mostly uncompensated care — and so they do. But few in the industry think this is the way to operate.
Tom Banning, chief executive officer of the
Texas Academy of Family Physicians, lobbied hard but unsuccessfully for
Medicaid expansion. He's beside himself with frustration.
"These people don't choose to get sick.
When they do, they're going to access our health care system at the most
inefficient and expensive point, which is the emergency room," Banning
says. "And it's going to cost the taxpayers, and it's going to cost
employers a lot of money to care for them. And we're going to be forgoing
billions of dollars that the feds have set aside for the state to pay for and
provide this care."
This is not about money —
if it were, Texas would be taking it. This is about Obamacare. It's widely
believed in Austin that Perry is seriously considering another run for
president — this time without the "oops." His base is Tea Party
Republicans across the country. While it might cost $100 billion for the
privilege, Perry is going to be able to stand in front of them and say, "I
said no to Obama when he tried to bribe my state with health care coverage for
the poor."
And since it's widely believed that these
would-be Medicaid recipients probably don't vote or, if they do vote, they vote
for Democrats, there's no political price to pay for snubbing them.
Still, there are some Republican legislators
who feel bad about not taking the money.
Rep. John Zerwas tried to craft some sort of
compromise that never mentioned Medicaid expansion, but he couldn't get it out
of committee — because for Texas Republicans, the very words "health
care" now carry the stink of Obamacare.
Zerwas points to "the political realities
of having to run for office again in two years, and how much explaining would I
have to do as a candidate around a vote that could very easily be framed as a
supporter of promoting Obamacare."
Texas Republicans aren't worried about the
reaction from the left for voting down Medicaid expansion; they're worried they
might get a primary challenge from a Tea Party candidate if the words
"health care" pass their lips on the floor of the Legislature. That
is, if they're not already a Tea Party candidate, which many are.
For at least the next two
years and probably longer, Medicaid expansion in Texas is dead. What this all
means is that more than a million Texans who might have received health care
coverage will remain one serious illness or one bad accident away from
bankruptcy. And an estimated $100 billion that would have been spent buying
health care in Texas will now go somewhere
else.
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