When I met Charlotte, she had suffered for years from ulcerative colitis, a disease that causes inflammation and ulcers in the colon. With modern medicine, her condition and related illnesses such as Crohn’s disease are readily treatable with injectable prescription medications. But Charlotte, a 34-year-old whose name has been changed to protect her identity, is one of the 18 percent of Texans who are uninsured.
Without basic coverage, she was unable to see a gastroenterologist when she began to suffer from bloody diarrhea, and her colon eventually became necrotic and ultimately needed to be removed. (Though surgical resection of the intestine was a common treatment for inflammatory bowel diseases until the early 2000s, over the last two decades, surgery for patients like Charlotte has become infrequent as new medicines have become available.) Like many uninsured in the state, Charlotte only received the care she needed for a chronic condition in an emergency room when she became sick enough to need acute medical care.
She received an ostomy, a procedure that created a permanent opening in the abdominal wall where stool passes from her small intestine to a bag external to the body. When I met her prior to her hospital discharge, she was emotional about everything she had been through and anxious about being able to afford her ostomy supplies. Nonetheless, she expressed relief that the surgery was a permanent fix for her disease.
The truth is, Charlotte probably would still have her colon if she lived in another state. Charlotte actually had employment-based health insurance until her ulcerative colitis got so severe that she could no longer work as an administrator for a North Texas school district; when she stopped working in the spring of 2022, she lost her insurance. Unfortunately, open enrollment to purchase insurance through the state exchange in Texas is only in the fall, and even if it had been available, she would have had a hard time affording the premium while unemployed and sick. In a state that had accepted Medicaid expansion under the Affordable Care Act, Charlotte would have had an insurance safety net to ensure access to care while she was unemployed. She would have had coverage to see a gastroenterologist and get the medical care she needed before her colon was beyond saving.
But Texas remains one of eleven states that have yet to expand Medicaid, despite federal inducements to expand eligibility for low-income Americans to receive health-care coverage. Since Medicaid-expansion provisions went into effect in 2014 and the federal government offered to pick up 90 percent of the tab for the program, states that have accepted it have decreased to an uninsured rate of 6.6 percent, about half of that in states that did not accept expansion and roughly one-third the rate in Texas. And the evidence is clear: increased coverage with Medicaid expansion is associated with better outcomes for patients, including lower risk of mortality from cardiovascular disease, earlier detection of cancer, and reduced maternal mortality.
As a primary-care physician working in a safety-net clinic in South Dallas, I take care of hundreds of patients like Charlotte. Every day, I see Texans who can’t get the best diabetes medication because, without insurance, it would cost $500 a month; who have metastatic cancer but can’t afford chemotherapy or radiation; who suffer from bone-on-bone arthritis and can’t work until they get the knee replacement that they’ll never be able to pay for. It’s a smoldering emergency that’s been normalized by years of inertia and neglect.
Republican state leaders in Texas have opposed Medicaid expansion since it was first offered in 2014. Lieutenant Governor Dan Patrick has dubbed it “a tax increase waiting to happen,” while Governor Greg Abbott has called Medicaid “broken and bloated.” Other state leaders have claimed that if Texas accepts expansion, Texans will receive worse health care.
But what does Medicaid expansion actually mean for residents and taxpayers of other states? Consider Washington, where I completed my internal medicine residency. Washington Medicaid, known as Apple Health, provides health insurance for all adults who are citizens or have been permanent residents 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 on Apple Health get regular access to primary care, specialty care, physical therapy, mental health services, addiction treatment, and other services. Some Apple Health plans will even cover massage therapy for musculoskeletal injuries and lower back pain. Washington Medicaid is so good that university students often choose it over university insurance, since it’s cheaper and often more comprehensive.
Practicing in Seattle, I would rarely think twice about whether a patient would be able to afford a medication or access a specialty referral, because Medicaid was comparable to private insurance. Medicaid patients would often see the same doctors as patients insured by companies such as Amazon, Google, and Microsoft.
Contrast this to our state. Texas Medicaid only covers adults aged 19 to 64 if they are pregnant, have a qualifying disability, or have a child on Medicaid, the latter two criteria with much narrower income requirements. More than one-third of nonelderly adults who would qualify for Medicaid in expansion states are uninsured in Texas.
So what happens when uninsured Texans get sick? For emergency needs, every Texan, regardless of coverage, has protection under the Emergency Medical Treatment and Labor Act (EMTALA), a federal statute that requires hospitals to provide stabilizing treatment prior to discharge or transfer. Safety-net hospitals bear the disproportionate cost of caring for the uninsured, and they receive partial reimbursement through a program called the 1115 Medicaid waiver. A state and federal partnership, the 1115 waiver functions as a Band-Aid for health systems to offset the debilitating costs 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 federal, 40 percent state match at the county/hospital level, compared to the 90 percent federal, 10 percent state match proposed under Medicaid expansion.
Crucially for the sick, unlike true Medicaid expansion, waivers don’t provide upstream coverage for preventive care or chronic disease management—there’s no state or federal funding for doctor visits for things like checking cholesterol levels or performing stress tests to check for heart disease. And when an uninsured Texan goes on to have a heart attack, they’ll get life-saving treatment and receive a cardiac stent, paid for by the waiver, but there’s no coverage for the cardiology visit afterwards, the medications they’ll take for the rest of their life, or the rehab sessions for them to be able to return to work and their home life.
Some experts estimate that not accepting Medicaid expansion has cost Texas about $2 billion over fiscal 2022 and 2023. As Benjamin Franklin famously said, “An ounce of prevention is worth a pound of cure.” Consider that a cardiac catheterization costs an estimated $126,000 in Texas, while a cholesterol medication costs $4 a month. Of course, there’s also the human cost of suffering a heart attack.
Funding for preventive care and chronic-disease management for the uninsured in Texas depends on where they’re lucky enough to live, down to the county level. In the absence of uniform state or federal policy, county officials dictate the thresholds for charity coverage for the uninsured and the extent of services covered. Charity coverage is funded by counties through property taxes, which leads to significant disparities in care. If Charlotte had lived just one county west, in Dallas County, she would have had coverage for outpatient visits through a safety-net hospital system staffed by academic physicians, including some of the best gastroenterologists in the state. But she lived in Rockwall County, which, like most counties in the state, does not offer such coverage.
Even the 82 percent of Texans who have insurance are impacted by the coverage gap in Texas, beyond the fact that they’re paying for charity coverage through their property taxes. Research from other states demonstrates that Medicaid expansion resulted in net fiscal benefits for state budgets (without any financial impacts on allocations for education, transportation, or other programs) and, in many states, net financial benefits due to decreased spending on mental health and criminal justice. The current poor health of the uninsured also has significant downstream effects on the Texas economy. A 2019 report from the Texas Alliance for Health Care, a nonpartisan consortium of private- and public-sector health-care stakeholders, estimated a loss of $57 billion in health-care costs and decreased lifetime earnings among uninsured Texans. Medicaid expansion could also yield significant job growth, as the program ensures the unemployed can become well enough to gain employment, bolstering the labor market.
In Texas, we’re trapped in a Groundhog Day–like experience. Polling indicates that more than two-thirds of Texans support adopting expansion, and every two years Democrats and a handful of Republicans entertain the idea of expansion, before the Legislature demurs and leaves uninsured Texans—along with an estimated $100 million in net saved state revenue—behind. This legislative session figures to be no different: Nathan Johnson, a state senator from Dallas, has sponsored a bill, SB 343, to accept Medicaid expansion, just as he did last session, but Abbott and Patrick have not changed their positions on the issue.
Meanwhile, as of 2021, all our neighboring states have now adopted Medicaid expansion, and the policy appears to be popular in even the most conservative states. In 2022, South Dakota, which went for Donald Trump over Joe Biden by a 26-point margin, approved Medicaid expansion via ballot measure. The expansion is estimated to enable coverage for 45,000 South Dakotans, or around 5 percent of the population. The uninsured population of Dallas County alone is more than ten times that size.
Even though Charlotte has had her colon removed, she’s still struggling to pay for ostomy supplies and is hoping to get staged surgeries to reconnect her intestines so she no longer needs the bag, but she doesn’t see a path to do so anytime soon. She knows that she might have gotten—and could still get—better care in a different 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, MD, is a public health researcher and works as a primary-care physician in a safety-net clinic in South Dallas.