New waiver to provide opportunity to expand health coverage, 2 lawmakers say
April 23--Two Democratic lawmakers called Wednesday for Texas leaders to explore a new type of Medicaid waiver that they say could provide health coverage to many of the state's millions of uninsured.
The waiver, characterized by the legislators as the kind of block grant that Republicans favor, is not predicated on a Medicaid expansion and would allow Texas to avoid many provisions of the Affordable Care Act unpopular with the leadership in the Legislature -- including the individual and employer mandates. The waiver, known as 1332, takes effect in 2017.
"Based on where we are now in this state, (the waiver) probably is the best chance or possibility of an agreement... toward coverage expansion," Rep. Garnet Coleman, D-Houston, said at a press briefing with Sen. Luis Rodriguez, D-El Paso.
In a letter sent to colleagues earlier this week, Coleman added that the waiver must not reduce access to care, increase costs to the federal government, or make insurance more expensive than under the current law. The waiver effectively tells states that "if they know a better, more efficient way to provide healthcare, then have at it," Coleman wrote.
The Republican response to the proposal was unclear Wednesday. Coleman said several Republicans reacted positively, though he declined to name them. Gov. Greg Abbott, Lt. Gov. Dan Patrick and a number of other Republicans did not respond to Chronicle inquiries for comment.
It also unclear how far Washington would be willing to go with the waivers because no state has been able to apply for one yet. And by 2017, when states can first apply, a new administration will be in place.
The waiver could also allow the state to waive provisions affecting other federal health programs, including the Children's Health Insurance Program and Medicare. But it would maintain many of the more popular provisions of the Affordable Care Act, including eliminating denials for pre-existing conditions, banning lifetime or annual coverage caps, and allowing dependents to stay on their parents' health plans until age 26.
Texas Republicans have resisted expanding Medicaid under the Affordable Care Act, preferring instead a lump-sum, block grant approach that would provider federal funds for low-income health care without any federal strings attached.
"This approach we're talking about, involving Section 1332 of the Affordable Care Act, gives the state of Texas and the leadership of the state the opportunity to do exactly what they were saying they would prefer to do, and that is being given great flexibility, great leeway, in determining how they are going to provide health care services to the uninsured in the state," Rodriguez said at the briefing.
Arlene Wohlgemuth, executive director of the Texas Public Policy Foundation, a conservative Austin think tank, said she had spoken to Coleman Wednesday morning about developing a 1332 waiver aligned with the principles laid out by the foundation.
"Of course, we are interested in reform of the program that truly gives flexibility to the states to provide for better health outcomes in a way that is affordable for the taxpayer," Wohlgemuth said. "Thus far, the federal government has been unwilling to give exception to the requirements in the Social Security Act (the law that embodies Medicare) that have hamstrung true reform. We are interested to see what Representative Coleman has in mind through a 1332 waiver."
Vivian Ho, a health care economist at Rice University's Baker Institute for Public Policy, said there are so many unknowns about the waiver that it's hard to know what to conclude.
"I can't believe any waiver is the answer unless the state agrees to some sort of Medicaid expansion and I don't see how 1332 is going to help that," said Ho. "It's unclear how much money it would actually supply and whether it would provide access to tax credits for people below 100 percent of the federal poverty level."
Ho added that block grants are a questionable idea unless the amount of money increases with population growth, given Texas' continual migration and growing uninsured pool.
But Ken Janda, CEO of Community Health Choice, a nonprofit health care organization, called the suggestion "a very good idea" and said it "definitely seems worth talking about." He said it answers a lot of concerns raised about Medicaid expansion and presents a possible solution to the health-care crisis that's caused the closure of some private hospitals and threatens the existence of safety-net hospitals.
Though the state cannot apply for a waiver until 2017, Coleman said discussion needs to start now. Texas is paying for the care of uninsured through a different type of waiver that will expire in September 2016. The waiver provided $4 billion for uncompensated care as well as money for various local projects to transform the state's health care delivery system.
The state must provide a final plan this September to renew that waiver, but last week federal officials told Texas and other states it would link renewal to Medicaid expansion.
"There are several options for reforming Medicaid, and we will look to the Legislature and state leadership for direction on what is the best path for Texas," said Linda Edwards Gockel, a spokeswoman for the Texas Health and Human Services Commission. In the meantime, she said, discussions on the waiver renewal would continue "in good faith."