Austin American-Statesman: Texas cities, counties could expand Medicaid locally under Doggett bill, despite state's resistance

New legislation from U.S. Rep. Lloyd Doggett, D-Austin, would allow cities, counties and other local jurisdictions to expand Medicaid coverage to more low-income individuals in states that have resisted expanding the program.

The proposal, supported by more than 40 House Democrats, represents an effort to close the so-called coverage gap, which includes adults who are not eligible for Medicaid in states that have yet to expand the program but still lack access to other affordable coverage options.

Texas is one of 12 states that has opted not to expand the joint state-federal program under the Affordable Care Act, despite repeated attempts at the state Legislature to do so. An effort to expand Medicaid in Texas during the recently ended legislative session fell short on a nearly party-line House vote, with just one Republican, Rep. Lyle Larson of San Antonio, joining Democrats.

Republicans have opposed expansion, arguing that the program does not allow for flexibility and creates dependence on government programs.

"Unfortunately they once again declined to accept federal dollars to give more of our neighbors access to a family physician through Medicaid," Doggett said Monday during a news conference at the Central Health Southeast Health and Wellness Center off Montopolis Drive in Southeast Austin. "We really have the disgraceful distinction of having more uninsured citizens, more uninsured children than any state in the United States."

Doggett filed the COVER Now Act on Thursday, along with every Democratic member of Congress from Texas and nearly all of the Democrats who represent the other 11 states that have yet to expand the program.

The measure comes as Democrats control Congress for the first time since the Affordable Care Act was signed into law and was filed on the same day that the U.S. Supreme Court overturned the latest GOP-led effort to dismantle the health care law.

"One way or the other, we need to take care of our population," said state Sen. Nathan Johnson, D-Dallas. "I can't think of a better way to break through the political inertia than what Congressman Doggett is proposing here."

Medicaid expansion

Doggett's legislation would authorize the federal Centers for Medicare and Medicaid Services to work with smaller political subdivisions to develop an expansion plan for Medicaid in their area, under the same terms applying to states that opt to expand the program. Local entities would be able to apply individually for expansion or jointly with neighboring areas to create a regional plan.

"It's all about empowering our local leaders to do just what they did in the pandemic," he said. "So often when our president failed, when our governor failed, it was our county judge, it was our mayor in city after city across Texas who came through to help people get through the pandemic and eventually help get the immunization out."

In Texas, Medicaid eligibility is limited to low-income pregnant women, children from low-income families, people with disabilities and people over 65 years of age. Some parents of qualifying children also are eligible for coverage, if their monthly income is $200 or less for a family of two or $300 or less for a family of four.

With expansion, eligibility would include adults who earn up to 138% of the federal poverty level — roughly $1,500 per month for an individual or $3,000 a month for a family of four.

Doggett estimated that by expanding coverage under his act in Houston, Dallas and San Antonio, half of the eligible population in Texas that is currently without insurance would be covered.

The latest estimate shows that 1.4 million adults in the state are uninsured and would be eligible for coverage through Medicaid if the program were expanded, according to the Kaiser Family Foundation's latest estimate.

But Anne Dunkelberg, associate director for Every Texan, said the actual count is probably much higher because the 1.4 million estimate was made before the coronavirus pandemic.

"Statewide, almost 8 in 10 of the adults who could get coverage this way are either themselves a worker or they are married and their spouse is a worker," she said. "Seventy-five percent are Texans of color; that includes Black and Hispanic Texans, as well as other Texans of color, including Asians."

State incentives, penalties

Although the proposal is intended to sidestep states that are opposed to expansion, it does require a level of involvement from state leaders, including providing access to Medicaid rolls.

Doggett said the bill has incentives for states to cooperate, such as access to additional federal dollars when local entities opt to participate, but it also has penalties for states that might attempt to block local expansion efforts.

For cities and counties that opt to expand coverage under the act, the federal government would cover 100% of the cost for the first three years. After that point, its share of the funding would slowly decrease to 90% by seven years.

"We hope the combination of carrots and sticks, hopefully just using the carrot, will make this work," Doggett said.

Ideally, he said, the act would serve as an incentive for states to consider expansion on a broader scale after seeing successes in cities and counties that choose to use the program.

But there is a risk of creating further coverage disparities between urban and rural areas of the state, as local Democratic leaders might be more amenable to expansion than their Republican counterparts, often in smaller cities and rural areas.

Doggett acknowledged that "we won't cover every single Texan who is eligible under this plan."

"The goal is to help as many people as we can right now, not once again come out of the Legislature, come out of the Congress with nothing for these millions of people that can benefit from this," he said.