For the third time, Texas state Sen. Nathan Johnson, a Democrat from Dallas, is trying to get a Medicaid expansion bill through the Legislature.
Senate Bill 232 would create Live Well Texas, a state-specific approach to extending Medicaid coverage to over 1 million Texans.
But unless Republican sentiment toward the federal program changes, Johnson said, his chances are, in a word, “grim.”
Most Republican lawmakers have repeatedly rejected efforts to expand Medicaid in Texas – and it’s likely they will again this year without a push from leadership.
Lt. Gov. Dan Patrick listed addressing barriers to health insurance among his priorities during the state legislative session. However, in a 2022 speech to the conservative think tank the Texas Public Policy Foundation, he said the Affordable Care Act harmed the U.S. health care system.
“We are one of the states that did not go along with that Medicaid expansion and thank goodness, because I wouldn’t say we’d be bankrupt now but a lot of the states that did are in deep fiscal trouble,” Patrick said.
Arguments for, against expansion
Texas is one of the 10 states that haven’t expanded Medicaid.
Of the 1.2 million Texans who could be covered under expansion, around 617,000 people are in a coverage gap, according to the health policy nonprofit KFF. In other words, they make too much to qualify for Medicaid but not enough to afford government-subsidized insurance in the ACA Marketplace.
Research in publications including the Journal of the American Medical Association and Health Affairs has attributed expansion to better health outcomes, including dental health, postpartum coverage and maternal mortality and morbidity.
However, groups such as the Texas Public Policy Foundation have pushed instead for Medicaid reform; they say the program is bloated, fosters government dependence and does not guarantee more or better coverage.
Dr. Cliff Porter, a senior fellow with the foundation, said administrative costs and bureaucracy have caused some providers to opt out of accepting Medicaid.
“What if you have the best Medicaid plan in the world?” he said. “Well, if there’s no doctors in the county, there’s no doctors. Expanding Medicaid on its own without really fundamental reforms is throwing money at the problem.”
At the federal level, members of the U.S. House Republican caucus have put forward proposals to cut funding to Affordable Care Act marketplace subsidies, the Children’s Health Insurance Program AND Medicaid, according to analysis of the Republican Study Committee’s 2025 budget plan.
The proposal also recommends changes to the way the federal government administers Medicaid funding.
Those changes would constrict funding in Texas and force state legislators to find ways to shore up the difference, according to Erin O’Malley, a senior policy analyst with the group Every Texan.
“Our legislature would have to turn around and either come up with the money ourselves or they would have to cut health care for people, mostly children and people with disabilities and seniors in the state, which is really scary, and I don’t think anything that our legislature really wants to do,” O’Malley said.
Sen. Johnson said cuts to funding would be “disastrous.”
“I think what worries me most is that (Trump will) just go in and say, do more with less, as if that can happen,” he said. “Well, as if that can happen without planning.”
Outlook
Johnson said he considers his bill a plan that could appeal to his colleagues across the aisle with its inclusion of health savings accounts, employment assistance and rewards for healthy behaviors.
“(Conservatives) can say 10 years ago, this was an unproven plan. The kinks hadn’t been worked out,” Johnson said. “We’ve allowed other people to make the mistakes. We can learn from their mistakes and tailor the program in a way that we know works. That’s conservative.”
Nine Republicans in 2021 signed onto the House version of a Live Well Texas bill, but the proposal did not make it out of either chamber. The legislation was also unsuccessful in 2023.
Democratic U.S. Rep.-elect Julie Johnson sponsored the bills during her time as a state representative. She said she worries about the future of Medicaid expansion.
Johnson pointed to the seats Republicans gained in the state House in November, as well as both Lt. Gov. Dan Patrick and Gov. Greg Abbott’s longstanding opposition to expansion.
“I think as long as it is dead in the Senate, it’s not going to happen in the House,” Johnson said.
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