Somewhere in Texas is Medicaid middle ground

Posted Saturday, Mar. 02, 2013  comments  Print Reprints

Topics: Medicaid, Texas

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Take the sound-bite version of what Gov. Rick Perry says about expanding joint state-federal healthcare to cover as many as 2 million more low-income Texans, and you have to conclude it won't happen.

"Let me go on the record here for a moment," Perry said in a Feb. 22 speech to the Texas State Society in Austin. "We're not going to expand Medicaid in Texas."

Medicaid expansion is a key part of the federal Affordable Care Act, commonly known as Obamacare. Perry opposes that law as "gross federal overreach" and says the Medicaid program itself is "on the brink of failure."

"Dumping millions more individuals into the Medicaid mix will not save it, will not cut any costs and will not improve overall access to quality care," he wrote last year in a commentary for the Washington Times.

But that's not the whole story. Perry also says he wants to help the 5.5 million people -- 25 percent of the state's population -- who have no health insurance.

Powerful members of the Legislature, Perry's fellow Republicans, would not dare cross him publicly but have not followed his hard line on Medicaid expansion. State Sen. Jane Nelson of Flower Mound, chairman of the Health and Human Services committee, has said she wants Texas to explore possible waivers on some of Obamacare's Medicaid requirements to shape an expansion particularly suited to Texas.

Sen. Tommy Williams, chairman of the Finance committee, is inching his way in that same direction (see his related commentary).

It becomes a crucially important question for Texans whether there might be common ground between what these senators are thinking, what Perry is vocally insisting and what federal Medicaid officials will allow.

Go beyond the sound bites, and there is more to what Perry has said.

In July, the governor sent a letter to U.S. Health and Human Services Secretary Kathleen Sebelius saying Texas has "no intention" of joining in Medicaid expansion under Obamacare. But a news release about his letter also stated what he wants to do to expand healthcare in Texas.

Topping the list is "the allocation of [federal] Medicaid funding in block grants so each state can tailor the program to specifically serve the needs of its unique challenges."

In other words, give us billions of federal dollars and back away. It's too much to expect the Obama administration to go along with a "no strings attached" approach. But there might be another way.

"As a common-sense alternative, Gov. Perry has conveyed a vision to transform Medicaid into a system that reinforces individual responsibility, eliminates fragmentation and duplication, controls costs and focuses on quality health outcomes."

What does that mean? Almost anything Perry wants it to mean. But it is important that he thinks about alternatives.

"This would include establishing reasonable benefits, personal accountability and limits on services in Medicaid," the news release said. "It would also allow co-pays or cost sharing that apply to all Medicaid eligible groups -- not just optional Medicaid populations -- and tailor benefits to needs of the individual rather than a blanket entitlement."

That means he would go for a plan that might not have all the benefits or services as today's Medicaid and includes "personal accountability." That gets further explanation in the next sentence: It means "co-pays or cost sharing."

"Tailored benefits" means some people might qualify for some Medicaid benefits but not all.

Some elements of Perry's alternative might even be acceptable to strong Obamacare proponents as a way to get expansion going (see related commentary from Scott McCown of the Center for Public Policy Priorities).

The case for getting Medicaid coverage for more Texans is not hopeless. Much could happen during the current legislative session. But if it does, it's not likely to be Obamacare all-or-nothing.

Texas has received important Medicaid waivers in the past. The focus now, as in all contentious public policy-making, must be on middle ground.

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