More than 700,000 Texans signed up for a health plan in 2014 through the Affordable Care Act’s online insurance marketplace.
For that group, the ACA appears to be working. But an even larger number of Texans – one million or more – still have no access to affordable coverage because Texas officials opted out of a federal plan to expand Medicaid for the poorest adults.
Heights resident Terry Jordan is one of them. He spent many years working for the Harris County Appraisal District, and he had good benefits there. But when he decided to start his own landscaping business, he left behind the health coverage.
“I’ve done great. I’ve worked all these years, I’ve accomplished a lot, and I have a lot,” he said. “And everything’s paid for. But if something happened to me, a broken leg or something or other, I would have to sell my place to pay for the medical bills.”
Jordan, 56, has no major health problems. He’s always wanted a private health plan, but when he shopped for one, the prices ($400-500 a month) were too expensive.
Expenses like paying for subcontractors and equipment – he recently had to buy a new trailer for his equipment – caused his gross income to dip below the poverty level. For a single person, that’s just under $12,000 a year.
So when the Affordable Care Act marketplace opened for business, Jordan couldn’t wait to check out the health plans and government subsidies.
At first he thought he would qualify for a plan costing just $79 a month.
“I was very excited, very happy, got on the phone, called around and said, ‘I told y’all Obamacare was great. Obamacare was great,’” he said.
But then Jordan learned he was actually too poor to get a subsidized plan.
Under the law, the subsidies were for people above the poverty line, for lower-middle class and middle-class people who needed some assistance paying the monthly premium.
“I knew it was going to help me but then I was real surprised when I found out, ‘Whoa! I didn’t qualify for it, cause I didn’t make enough money!’ I was very shocked at that,” Jordan added.
Originally, poor working adults like Jordan were supposed to be added to the Medicaid program in every state. Medicaid costs are usually split between state and federal governments, but under the new law, the federal government was going to pick up most of the tab for the newly-added adults.
Anne Dunkelberg is with the left-leaning Austin think tank, the Center for Public Policy Priorities.
“It was an accidental outcome when Congress wrote the Affordable Care Act,” Dunkelberg said. “They never anticipated that the Supreme Court’s decision would make the Medicaid piece of it optional.”
But given the option, Texas and 23 other other states opted out, leaving people like Jordan in the so-called “Medicaid gap” – locked out of the marketplace system with its subsidies, but unable to access Medicaid.
Dunkelberg and other advocates want the Texas legislature to reconsider when it reconvenes in January.
A coalition of Democrats, hospitals, county officials and chambers of commerce across Texas is discussing a political compromise called the “Texas solution.”
“Several other states have gotten ‘1115 waivers’ which is a wonky term, but basically it’s a formal sort of contract with the feds to break some of the usual rules of Medicaid,” Dunkelberg said. “So there is some ability to depart from standard Medicaid policies.”
Other states have been using the waivers to make Medicaid expansion more politically palatable for Obamacare opponents, usually Republicans. For example, some states expanded Medicaid to more adults, but required them to pay a small fee for doctor visits.
Ideas like that, where patients contribute to the cost of their care, appeal to some Texas Republicans. They like the idea of patients having “skin in the game” when it comes to using expensive health services, especially when the coverage is paid for by taxpayers.
But others are skeptical that a “Texas solution” is the way to go.
“If a Texas solution is just sort of window dressing for expanding Medicaid according to the dictates of Washington DC, then we’re not for that,” said John Davidson of the Texas Public Policy Foundation, a conservative Austin think tank. “That will exacerbate problems that are already in the system.”
Davidson wants the federal government to give Texas a block grant of Medicaid money, with no strings or rules attached. But the federal government has never given a block grant like that to any state.
In the meantime, he says poor working-class adults like Jordan should continue to get care at various clinics and through county programs like Harris Health System, which is funded partially by county taxpayers.
For now, when Terry Jordan gets sick, he’ll go to Legacy Community Health Services, a safety-net clinic in the Montrose.
But it’s not comprehensive coverage, and he’s still disappointed with the Republicans in Texas.
“The poor working class is really getting left behind. Way behind,” Jordan said.
If Jordan can earn just $5,000 more in 2014 than he did in 2013, that will push him back over the poverty line.
That means next year, he could get out of the Medicaid gap and shop for a subsidized health plan online.