Legislature Faces Post-Obamacare Decisions

After nearly four years of intense national debate surrounding the Affordable Care Act (ACA), the future of this mammoth, nearly 1,000-page law now rests in the hands of the voters. 

As chair of the Senate Health and Human Services Committee, I have made no secret of my strong reservations about this ill-advised plan.  It is the wrong approach to our health care challenges.  It does more harm than good.  It will hurt our economy, eliminate jobs, balloon the state budget and, perhaps most importantly, stretch to the limit our already overburdened health care system. 

When the dust settles after the general election, the Legislature faces several decisions regarding what our health care system should look like in a post-Obamacare world.  Most notably, we must decide what to do about the now-optional ACA provision directing us to add roughly 2 million Texans — individuals earning up to 133 percent of the federal poverty level — to our Medicaid rolls. 

Supporters will cite Texas’ rate of uninsured — the highest in the nation.  They point to the 100-percent federal match for services over the first three years of the program.  They suggest that it is cheaper to treat this population in Medicaid than in the costlier emergency room setting.  These are true statements — and we must continue our efforts to address these issues, regardless of what happens with the ACA.

What they leave out is that Texas would still be responsible for half of the administrative costs — $1.3 billion through 2017.  The federal match will be gradually reduced to 90 percent by 2020.  Because federal funds are never guaranteed, if a future Congress changes course, Texas could get stuck with an expanded program we could never afford on our own.

Regardless of whether we expand, the state faces additional costs of $1.8 billion through 2017 due to the so-called “take-up rate,” meaning that Medicaid-eligible Texans not currently in the program will enroll under the individual mandate.  The state will be required to increase our Medicaid reimbursement rates, which will cost Texas taxpayers an estimated $595 million through 2017. 

These additional costs must be considered as the Legislature stares at our own version of a fiscal cliff — a $4.7 billion Medicaid shortfall.  Unlike the federal government, Texas is constitutionally bound to balance the state budget.  Medicaid spending has grown from 14 percent of the state budget in 2001 to 20 percent in 2011 and could potentially be as high as 37 percent by 2023.  If we are to continue meeting the needs of Texans who rely on these services, we have a responsibility to put this program on a path to financial sustainability.

Not only are the costs a concern, access to insurance doesn’t guarantee access to care.  Texas’ 25 million residents are served by approximately 18,000 primary care physicians, and only 31 percent of Texas physicians are accepting new Medicaid patients, an all-time low.  We face critical shortages of qualified doctors, nurses and other health care professionals who play an indispensable role in the delivery of health care.  The coverage promised by Obamacare is meaningless without enough health care providers to provide treatment.

Texas is a large, geographically diverse border state with challenges that are unique from other states. The one-size fits all approach of Obamacare is wrong for Texas.  If given the opportunity, we can design an efficient system that better meets the needs of our citizens.

Last session the Legislature approved SB 7, which I authored to eliminate waste and improve outcomes in our health and human services.  One of its provisions directed the Health and Human Services Commission to apply for a Medicaid waiver giving Texas greater flexibility over our Medicaid program.  To make the system work, we need permission from the federal government to do things like charge co-pays, promote access to private health insurance, and encourage personal responsibility. 

Expanding Medicaid under the terms of Obamacare without serious reform to the system is not a legitimate option for Texas.  To be fair to those who disagree, neither is the status quo. If the federal government is truly serious about helping Americans access affordable health care, it will work with — not against — the states as we work to save Medicaid, no matter who is in the White House.

Senator Jane Nelson represents District 12, including portions of Tarrant and Denton Counties. She is Chairman of the Senate Committee on Health & Human Services.


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