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Texas leaders have shown a decadeslong antipathy toward Medicaid, the federal-state health insurance program that covers millions of low-income and vulnerable residents.
They declined additional federal money that, under the Affordable Care Act, would have allowed Medicaid to offer health care coverage to more low-income families. The state was among the last to insure women for an entire year after they gave birth. And when the federal government last year ended a policy that required states to keep people on their Medicaid rolls during the coronavirus pandemic, Texas officials rushed to kick off those they deemed ineligible, ignoring persistent warnings that the speedy process could lead to some people being wrongfully removed.
Come January, when Donald Trump assumes the presidency for the second time, Texas leaders could get another opportunity to whittle down the program — this time with fewer constraints.
Trump has not shared any plans to cut Medicaid, which covers about 80 million Americans, and his campaign did not respond to requests for comment. Health care advocates and experts, however, say that his past efforts to scale back the program, as well as positions taken by conservative groups and Republican lawmakers who back him, indicate that it would likely be a target for severe reductions.
“We expect the Republicans to move very quickly to cut Medicaid dramatically and indeed end its guarantee of coverage as it exists today,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families in Washington, D.C.
Currently, the federal government picks up, on average, nearly 70% of Medicaid spending, with states assuming the remaining costs. (A state’s share varies based mostly on what percentage of its residents are impoverished.) Any decisions to cut federal spending would likely lead states to shrink the number of people they deem eligible and the care that enrollees are entitled to receive, Alker and other experts said.
That would be particularly devastating in Texas, which already has one of the country’s lowest percentages of residents covered through Medicaid and where officials lack the political will to make up the difference in funding with state money, experts say. Parents with two children, for example, must earn less than $285 monthly to qualify for Medicaid for themselves.
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“Our elected officials would have to decide whether they want to cut health care for pregnant women, kids, people with disabilities, or seniors because that is essentially who Medicaid covers in Texas,” Adriana Kohler, a policy director for Texans Care for Children, a statewide nonprofit that advocates for families, said in a statement.
Spokespeople for Gov. Greg Abbott, a Republican, and the state’s Health and Human Services Commission did not respond to repeated requests for comment. During Abbott’s prior role as the state’s attorney general, he helped to lead a successful lawsuit against the federal government, ensuring that states did not risk losing Medicaid funding entirely if they didn’t want to cover more residents as part of the Affordable Care Act.
Even when Texas does offer Medicaid coverage to its most vulnerable residents, state officials enabled a system that creates often insurmountable barriers to receiving care. A 2018 Dallas Morning News investigation found that some of the insurance companies Texas hired to administer Medicaid benefits systematically denied expensive and, at times, life-saving treatments to bolster profits. Critics say problems with the system persist despite legislative reforms spurred by that series of stories.
Texas insures more than 4 million residents through Medicaid, which amounts to a smaller percentage of its total population than almost any other state. But given its sheer size, the state still covers the third most people in the nation, behind only California and New York. The program provides health care for 3 in 8 children, 3 in 5 nursing home residents and 2 in 7 people with disabilities in Texas, according to KFF, a national health policy research organization. It is the top funder for nursing homes and long-term care services for the disabled and elderly, and it pays for nearly half of all births in the state.
Michael Morgan, a 75-year-old retired nurse who lives in Fort Worth, is among those who worry that if Trump caps or cuts the amount of money the federal government spends on Medicaid, the state could make it even harder to get coverage for his daughter Hannah. She has Down syndrome and schizencephaly, a brain malformation, and she is deaf and partially blind, she doesn’t speak, and she needs assistance to walk and eat.
Morgan is depleting his limited savings to pay for Hannah’s health care expenses after she lost Medicaid coverage earlier this year when she turned 19. He submitted a new application for her in May — she should qualify for Medicaid because of her disabilities. State officials denied her coverage in November, arguing that Morgan did not meet the deadline to return a form providing his consent for the agency to access his daughter’s medical and financial records. Morgan, who plans to appeal the denial, said in an interview that he received the form a day before the deadline.
“I don’t know how much more they can cut it,” he said of Medicaid in Texas.
During his first term, Trump tried unsuccessfully to repeal the Affordable Care Act, which provides health coverage to 45 million Americans. His administration also repeatedly supported spending caps for Medicaid, including block grants that would give states a fixed amount of federal funding, no matter how many people needed the insurance or how much their health care cost. Currently, Medicaid covers all people who qualify, no matter the expense.
While those efforts did not significantly advance during Trump’s first term, Republicans will hold majorities in both the House and the Senate come January, and they have signaled an openness to impose caps on spending and establish requirements that most adults in the program hold jobs. They argue that Medicaid spending is unsustainable and that the program is susceptible to waste, fraud and abuse.
Republicans who have supported such measures include U.S. Sen. John Cornyn and U.S. Rep. Jodey Arrington, a Lubbock Republican who leads the House Budget Committee.
GOP policy primers — including Project 2025, published by the conservative think tank The Heritage Foundation, and one from the Republican Study Committee, a conservative congressional caucus — have also called for cutting Medicaid.
Arrington, whose spokespeople did not respond to repeated requests for an interview, told reporters last month that he supported a “responsible and reasonable work requirement.” Harvard University health professors who studied a previous work mandate in Arkansas that Trump allowed during his first term found that most adults using Medicaid were already employed or qualified for an exemption, but thousands of residents still lost health care, at least in part because of the onerous process of continuously proving their eligibility.
This is not the first time Arrington has pushed work requirements and sought to lower the share of health care costs that the federal government pays to states. He previously proposed cutting federal Medicaid spending by more than a quarter, or $1.9 trillion.
Cornyn, whose spokespeople also repeatedly declined to comment, said last month that he would not support cuts to Medicare, the federal health insurance program for seniors and the disabled, or to Social Security. Still, he suggested that Medicaid cuts were on the table.
“We can’t just keep doing things the way we’ve been doing them,” Cornyn told Politico Pro, adding that “block grants make a lot of sense.”
William T. Smith, a 65-year-old retired construction worker who lives along the U.S.-Mexico border in Brownsville, said that he voted for Trump partly because he agrees that “there’s too much fat” and supports cutting some federal programs.
Smith has chronic obstructive pulmonary disease, which affects his lungs and makes it difficult to breathe. He said he also has bipolar disorder, sleep apnea and chronic pain after decades of performing manual labor.
Smith said Medicaid, which he has been trying to get since the summer, should not be where the federal government looks to reduce expenses. Instead, he said, the federal government should take savings from cutting other programs and put the money toward more people’s care.
“I don’t think they’re going to yank health care away from people,” he said. “If they do, I’d be really angry.”
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