The online federal insurance marketplace opened for business Sunday. It鈥檚 the third year of open enrollment for these subsidized plans, established by the Affordable Care Act. Many Texans still oppose the law, even though the state is home to the most uninsured people in the country.
For the moment, Texas Republicans still consider the Affordable Care Act to be political kryptonite. Sen. Ted Cruz continues to criticize it. Attorney General Ken Paxton just filed attacking part of it. Gov. Greg Abbott has said he won鈥檛 consider the Medicaid expansion, because he considers Medicaid a dysfunctional entitlement program that should not be allowed to expand.
But the story on the local level is different. Harris County is home to Houston, where Judge Ed Emmett, a moderate Republican who is chief executive for the county, has supported it for years. The CEO of the taxpayer-supported Harris Health System,, says he needs the revenue that Medicaid expansion would bring. He鈥檚 had to lay off more than 100 employees and cut back on charity care.
鈥淲hat is even more profound is that money is going to other states that expanded Medicaid, like New York, California, Connecticut,鈥� Masi says. 鈥淎nd so the taxpayer of Texas is being penalized, if you will, for not taking advantage of that option.鈥�
By emphasizing the impact on taxpayers, Masi and others are framing the issue in terms of economics rather than humanitarian concerns.
鈥淲e call it a paradigm shift,鈥� Masi added. 鈥淚t鈥檚 a different way of thinking.鈥�
Government leaders and health advocates from across Houston point out that the costs of caring for the uninsured fall heavily on local institutions. Those patients strain the budgets of hospitals, first responders and even jails.
Last week, Masi welcomed Health and Human Services Secretary Sylvia M. Burwell to Houston, where she toured a Harris Health clinic.
Burwell said she鈥檚 willing to work with state leaders to craft a unique Medicaid plan for Texas. She鈥檚 done that with other Republican governors.
She, too, dangled the economic benefits of accepting more federal money under the law. She pointed to Kentucky, which expanded Medicaid.
鈥淚n Kentucky alone, which is obviously a much smaller state than the state I鈥檓 now visiting, the expectation is we will see an increase of 40,000 jobs by 2021 and $30 billion into the state鈥檚 coffers,鈥� Burwell said. 鈥淪o that鈥檚 something.鈥�
In 2013, the Texas Legislature took no action on Medicaid expansion. The same thing happened this year.
But more voices are starting to push for change, according to Ken Janda, who runs Community Health Choice, a not-for-profit insurance company in Houston.
Janda says the Texas Medical Association and the Texas Hospital Association are both being more vocal on the issue, as is the Texas Association of Business. The federal Medicaid funds would help the state budget and inject revenue into the medical sector of the economy.
鈥淒octors鈥� offices are able to hire more people,鈥� Janda says. 鈥淧harmacies are able to hire more people. That becomes an economic multiplier.鈥�
County budgets would benefit as well, because they support safety-net clinics and public hospitals such as Ben Taub, part of the Harris Health system.
鈥淚f Texas expanded Medicaid, we would be able to look at reducing local property taxes across the board in all counties, or use those dollars for something besides health care,鈥� says Janda.
Janda says the new emphasis on economics could eventually bring the parties together. 鈥淭here is some interest now by some Republican state senators because of the potential to reduce local property taxes,鈥� he adds.
Janda isn鈥檛 naming names yet. He also says don鈥檛 expect to see any movement on this issue until after the 2016 presidential election. But he says he is 鈥済uardedly optimistic鈥� that Republicans will be willing to discuss a possible Medicaid expansion after that.
鈥淭he burden is particularly acute in states that have not expanded Medicaid,鈥� says Beth Feldpush, the senior vice president of policy and advocacy for America鈥檚 Essential Hospitals.
Feldpush says the organization has not surveyed its members to find out how many other public hospitals have tightened eligibility as a way to induce patients to enroll in ACA plans.
But Feldpush says she is sympathetic to the budgetary pressures facing Harris Health.
鈥淲hen you look at the states that haven鈥檛 expanded Medicaid, hospitals there are really facing a double whammy,鈥� she says. 鈥淭hey鈥檝e got cuts coming at them that are cooked into the law, and yet they don鈥檛 see any increase to revenue from Medicaid expansion because it hasn鈥檛 happened.鈥�
This story is part of a reporting partnership with , 补苍诲听Kaiser Health News.