When I met Charlotte, she had suffered from ulcerative colitis for many years, a disease that causes inflammation and ulcers in the colon. With the help of modern medicine, her condition and related diseases such as Crohn’s disease are easily treated with injectable prescription drugs. But Charlotte, a 34-year-old woman whose name has been changed to protect her identity, is one of 18 percent of uninsured Texans.
Without basic medical care, she was unable to see a gastroenterologist when she developed bloody diarrhea and her colon eventually became necrotic and eventually had to be removed. (While surgical resection of the bowel was a common treatment for inflammatory bowel disease until the early 2000s, surgeries for patients like Charlotte have become infrequent over the past two decades as new drugs become available.) Like many uninsured people in the state, Charlotte received the care she needed for her chronic illness in the emergency room only when she became so ill that she needed emergency medical care.
She had an ostomy, a procedure that created a permanent opening in her abdominal wall to allow stool to pass from her small intestine into the sac outside her body. When I met her before leaving the hospital, she was excited about everything she was going through and worried about affording stoma care. However, she expressed relief that the operation had permanently cured her of her illness.
The truth is, Charlotte would probably still have a large intestine if she lived in another state. In fact, Charlotte had health insurance at her place of work until her ulcerative colitis became so severe that she could no longer work as an administrator in the North Texas School District; when she stopped working in the spring of 2022, she lost her insurance. Unfortunately, open enrollment to buy insurance through the Texas Public Exchange is only open in the fall, and even if it were available, it would be difficult for her to afford insurance while unemployed and sick. In a state that passed Medicaid expansion under the Affordable Care Act, Charlotte would have had an insurance network guaranteeing access to health care while she was unemployed. She would have had insurance coverage to see a gastroenterologist and get the medical attention she needed before her colon could not be saved.
But Texas remains one of eleven states that have yet to expand Medicaid, despite federal incentives to expand low-income Americans’ eligibility for health insurance. Since Medicaid expansion regulations went into effect in 2014 and the federal government offered to take on 90 percent of the bills for the program, the states that adopted it have dropped to 6.6 percent of the uninsured, about half as much. than the states that did. did not take the extension and approximately one third of the speed in Texas. And the evidence is clear: Expanding Medicaid coverage is associated with better patient outcomes, including a lower risk of cardiovascular death, earlier cancer detection, and reduced maternal mortality.
As a primary care physician working at a social care clinic in South Dallas, I care for hundreds of patients like Charlotte. Every day I see Texans who can’t buy the best diabetes drug because without insurance it would cost $500 a month; who have metastatic cancer but cannot afford chemotherapy or radiation; who suffer from arthritis of the bones and cannot work until they get a knee replacement for which they can never pay. It is a smoldering emergency that has been normalized by years of inertia and neglect.
Texas Republican state leaders have opposed expanding the Medicaid program since it was first proposed in 2014. Lieutenant Governor Dan Patrick called it “tax hike pending” and Governor Greg Abbott called Medicaid “broken and overblown.” Other state leaders said that if Texas agreed to the expansion, Texans would receive worse health care.
But what does the expansion of Medicaid really mean for out-of-state residents and taxpayers? Take Washington DC, where I completed my residency in internal medicine. Washington Medicaid, known as Apple Health, provides health coverage for all adults who are citizens or permanent residents of the country for at least five years and whose income does not exceed 138 percent of the federal poverty level ($3,192 per month for a family of four). . Washington residents enrolled in Apple Health receive regular access to primary health care, specialty care, physical therapy, mental health services, addiction treatment, and more. Some Apple Health plans even cover massage therapy for musculoskeletal injuries and lower back pain. Washington Medicaid is so good that university students often prefer it to college insurance because it’s cheaper and often more comprehensive.
Working in Seattle, I rarely thought twice about whether a patient could afford to buy a drug or get a referral, because Medicaid was like private insurance. Medicaid patients often visited the same doctors as patients insured by companies such as Amazon, Google and Microsoft.
Compare this with our state. Texas Medicaid only applies to adults aged 19 to 64 if they are pregnant, have a qualifying disability, or have a child receiving Medicaid, the last two criteria have much narrower income requirements. In Texas, more than a third of non-elderly people who can qualify for Medicaid in expanding states are uninsured.
So what happens when uninsured Texans get sick? In an emergency, every Texan, regardless of insurance coverage, has protection under the Emergency Medical and Labor Act (EMTALA), a federal law that requires hospitals to provide stabilizing treatment prior to discharge or transfer. Social care hospitals incur a disproportionate cost of caring for the uninsured, and they receive partial reimbursement through a program called the 1115 Medicaid waiver. A state-federal partnership, the 1115 waiver acts as a band-aid for health systems to offset the debilitating cost of caring for the uninsured, but this funding is generally limited to hospital services, local health departments, and some mental health services. The funding stream for Medicaid waivers has a 60 percent overlap at the federal level, 40 percent at the state level at the county/hospital level, compared to 90 percent at the federal level and 10 percent at the state level proposed under the Medicaid expansion.
Most importantly for patients, unlike a true expansion of Medicaid, insurance waivers do not provide primary coverage for preventive care or chronic disease management—there is no state or federal funding for doctor visits for things like checking cholesterol levels or doing stress tests. to check for heart disease. And when an uninsured Texan has a heart attack, they will receive life-saving treatment and receive a cardiac stent paid for by the waiver, but a follow-up visit to a cardiologist is not covered, medications they will take for the rest of their lives, or rehab sessions so they can get back to work. and family life.
Opposition to the Medicaid expansion cost Texas about $2 billion in fiscal year 2022 and 2023, some experts estimate. As Benjamin Franklin said, “An ounce of prevention is worth a pound of cure.” Consider that a cardiac catheterization in Texas costs approximately $126,000 and cholesterol treatment costs $4 per month. Of course, there is also the human cost of a heart attack.
Funding for preventive care and chronic disease management for the uninsured in Texas depends on where they happen to live, down to the county level. In the absence of a unified state or federal policy, county officials dictate thresholds for charitable coverage for the uninsured and the amount of services covered. The charity is funded by counties through property taxes, resulting in significant disparities in care. If Charlotte lived just one county to the west, in Dallas County, she would have insurance for outpatient visits through the hospital insurance system, which employs academically trained doctors, including some of the best gastroenterologists in the state. But she lived in Rockwall County, which, like most counties in the state, doesn’t offer that kind of coverage.
Even the 82 percent of Texans who have insurance suffer from the insurance gap in Texas, on top of the fact that they pay for charitable insurance with their property taxes. Studies in other states show that the expansion of Medicaid resulted in net financial benefits for state budgets (without any financial impact on spending on education, transportation, or other programs), and in many states, net financial benefits due to the reduction mental health spending and criminal prosecution. justice. The current poor health of the uninsured is also having a significant impact on the Texas economy. A 2019 report by the Texas Health Alliance, an unbiased consortium of private and public sector health stakeholders, estimated a $57 billion loss in health care spending and a decline in lifetime earnings among uninsured Texans. An expansion of the Medicaid program could also lead to a significant increase in jobs, as the program ensures that the unemployed can become healthy enough to get a job, propping up the job market.
In Texas, we fell into a trap similar to Groundhog Day. The poll shows that more than two-thirds of Texans support passing the expansion, and every two years Democrats and a handful of Republicans push the idea of an expansion before the Legislature objects and leaves uninsured Texans — along with roughly $100 million in net government revenue saved. -per. This legislative session is no different: Nathan Johnson, a state senator from Dallas, sponsored SB 343 to pass the expansion of Medicaid, as he did in the last session, but Abbott and Patrick have not changed their position on this issue. .
Meanwhile, as of 2021, all of our neighboring states have adopted the expansion of Medicaid, and the policy seems to be popular even in the most conservative states. In 2022, South Dakota, which preferred Donald Trump over Joe Biden by a 26-point margin, approved Medicaid expansion by vote. The expansion is estimated to reach 45,000 South Dakotas, or about 5 percent of the population. The uninsured population of Dallas County alone is over ten times that.
Despite having her colon removed, Charlotte is still trying to pay for ostomy supplies and is hoping for a staged operation to reconnect her bowel so she doesn’t need a bag anymore, but she doesn’t see an option to do so anytime soon. She knows she could get – and could get – better care in another state, but Texas is her home and she doesn’t want to leave. It’s mine too, and I think we should do better for Texans like her.
Anisha Ganguly is a public health researcher working as a primary care physician at a social care clinic in South Dallas..