Texas Battles Health Law Even as It Follows It
http://www.nytimes.com/2010/07/28/health/policy/28texas.html?_r=1&hp
July 27, 2010
By KEVIN SACK
AUSTIN, Tex. — There are more uninsured residents of Texas — 6.1 million and counting — than there are people in 33 states. The state’s elected officials might be expected, therefore, to cheer a federal health care law that is likely to deliver billions of dollars from Washington to Austin and cover millions of low-income Texans.
Instead, the Republican political leadership has greeted the law and its anticipated costs with open hostility, leaving policy makers to move forward with a complex set of changes even as the governor, attorney general and ranking legislators rage against it. The same awkward dichotomy exists in many of the 21 states that are challenging the health reform act’s constitutionality, but are nonetheless required to follow it while their lawsuits meander through the courts.
In Austin, legislative hearings and agency planning sessions proceed despite Gov. Rick Perry’s vow to fight “on every front available” against a law that he characterizes as “socialism on American soil.” Bureaucrats apply for federal grants and collaborate with the Obama administration at the same time that Attorney General Greg Abbott strategizes to eviscerate the law in court.
“Sometimes it seems a little schizophrenic,” acknowledged State Representative John M. Zerwas, a Republican who favors the law’s repeal but also leads a House committee that seeks to maximize its benefits to Texas. “There are plenty of laws out there that I might not agree with. But if the law of the land says we have to do it, the last thing I want is for Texas to not be prepared or not put things in place to comply.”
The antipathy toward the law in Texas is rooted in deeply conservative politics that have been further stirred up in a gubernatorial election year. Because one in four Texans is uninsured, the highest ratio in the country, the law’s advocates argue that Texas stands to gain as much as any state. But leaders in Austin are focused on the fiscal threat it poses, which they estimate could cost the state $27 billion in the 10 years beginning in 2014.
“You can say a chicken in every pot, a car in every garage and health care for all, if taken in isolation,” said Mr. Abbott, a leader among the Republican attorneys general who are suing the federal government in Florida. “But none of those are good things if it requires breaking the Constitution and breaking the bank to do it.”
States share in the cost of Medicaid, the government insurance program for the poor, and the new health law will vastly expand eligibility by offering coverage to childless adults
State agency leaders said politics had not interfered to date with that task, or with new requirements to create a health insurance exchange and oversee strict regulations on health insurers.
“I don’t have any sense that I’m being held back in any way,” said Billy Millwee, the state Medicaid director.
That view was echoed by Thomas M. Suehs, the commissioner of health and human services, who said the governor “expects me to implement the federal law in the most cost-effective, efficient manner.”
Mr. Perry, who is seeking re-election to a third full term after filling George W. Bush’s seat, declined to be interviewed.
Obama administration officials, while noting the incongruity, said they had been impressed that politically antagonistic states like Texas were complying with, and taking full advantage of, the new law. The Texas Department of Insurance, for instance, has applied for a planning grant to create a more muscular process for reviewing proposed premium increases, a White House priority.
“That’s sort of the operational norm in Texas,” said F. Scott McCown, executive director of the Center for Public Policy Priorities, which advocates for safety-net programs in the state. “Your leadership may be railing against Washington, but federal supremacy still requires that the people in the trenches get the work done.”
That dynamic may be tested down the road as states decide how aggressively to market the Medicaid expansion that begins in 2014, when most Americans will be required to obtain coverage.
Texas traditionally has set among the country’s most restrictive Medicaid eligibility thresholds. This has limited its Medicaid rolls, as have burdensome application requirements, outmoded computers, inadequate staffing and difficulties in signing up children born to illegal immigrants.
Mr. Perry, whose antagonism toward Washington is central to his political persona, would seem to be in tune with public opinion. Sixty percent of Texans questioned in May for a University of Texas/Texas Tribune poll said they opposed the health care law. Only 28 percent said they liked it.
The Democratic nominee for governor, Mayor Bill White of Houston, has not made an issue of Mr. Perry’s approach. He said in an interview that he also opposed the health care law because of its potential impact on the federal deficit.
In late April, Mr. Perry announced that Texas would not establish the temporary high-risk insurance pool required by the law, leaving that task to the federal government. Twenty other governors made the same choice, arguing that the new law did not provide enough money for the pools, and that states would be left holding the bag.
Some Democrats find the position inconsistent. “You can’t run around saying the federal government wants to take over Texas, but then when we have an opportunity to do it ourselves leave it to the federal government,” said State Representative Garnet F. Coleman, a Democrat.
Democrats also accuse the Perry administration of producing a sticker-shock cost estimate for the state’s share of Medicaid expansion. To come up with his 10-year projection, Mr. Suehs skipped the law’s first four years, when states bear little cost. He also assumed an increase in enrollment that some analysts say is inflated.
The commissioner projects that 2.3 million people will be added to the Medicaid rolls by 2023, nearly doubling the current enrollment of 3.1 million. Thanks largely to job losses during the economic downturn, enrollment has surged 12 percent in the past year.
Mr. Suehs and other state officials worry about a severe shortage of doctors who are willing to accept low Medicaid payments, which the state is about to cut by 1 percent. They also are concerned about the continuing strain on hospitals from treating an estimated 800,000 uninsured illegal immigrants, who will not be eligible for subsidized coverage under the new law.
But among the reasons the law could be expensive for Texas is the state’s past failure to enroll many of those already eligible for Medicaid. Going forward, Washington will pay a much smaller share of the cost for those recipients than for those who gain coverage because of expanded eligibility.
The federal government would still pay nearly 90 percent of the state’s total costs. But that is providing little comfort in a tax-averse Capitol that faces an $18 billion shortfall in its budget over the next two years.
