MARLIN, Texas — Texas has more uninsured people, per capita, then any other state. The number is $4.7 million, according to the Urban Institute.

In 2013, when Rick Perry was governor, Texas had a chance to drastically expand health care coverage to 1.5 million of the poorest Texans. 

As part of the Affordable Care Act, Obamacare, this expanded health care coverage would come at no additional cost to Texas taxpayers.

“We care about our poorest Texans. We want them to have the best care possible,” Perry said during a speech that year.

Under the deal, the federal government would pay 100% of the cost, until 2020. And then 90% after that. Texas lawmakers said no, they just didn't trust Washington.

“It tries to blackmail the states into taking this money now and then a couple of three years down the road the money’s not there. You’re going to have to pay for it.” Perry told WFAA-TV in a 2013 interview.


What we’re talking about here is known as Medicaid expansion. And now that six years have passed, I want to know if the decision not to participate in the program was good for Texas..

What is Medicaid? It’s a government program that provides health care for low-income children and families and people with disabilities. 

The Affordable Care Act expanded who qualifies for Medicaid to millions more poor or working poor families who don’t have health care coverage.

Back in 2013, an economist in Waco, Dr. Ray Perryman, produced this economic report, weighing the pros and cons of Medicaid expansion on Texas. He predicted, with expanded health care coverage, Texans would be healthier and more productive, and this would spur an economic expansion.

For example, mothers getting pre-natal care would have healthier babies who lived longer lives and enjoyed longer working careers.

“You’re talking about an enormous amount of economic benefit that could have occurred as a result of this,” Perryman told me.

“In terms of a policy, not taking that money at the time, you felt what?” I asked.

“It was a big mistake,” he said.

Perryman also believed refusing the funds would lead to an economic drag on the state from people who got medical treatment but could not afford to pay for it.

“I’m not saying Medicaid was perfect. Not saying the Affordable Care Act was perfect. But given the rules that it set out that it didn't make any sense for Texas to do anything but expand Medicaid. We chose not to,” Perryman said.


That drag that Perryman predicted in 2013 can be felt today at rural hospitals across Texas which are closing their doors at a record pace.

I'm at Falls Community Hospital in Marlin now, between Dallas and Austin.  And I'm getting a tour from Jeff Lyle, who runs the facility. He’s taking me to a health clinic where the front door is locked.

“Why is it dark in here?” I ask.

“This clinic has been closed because we don't have providers to staff it.  And we've had to lay off staff that supported those providers," Lyle says.

“To be in this clinic that is totally empty, not providing care for your community, how do you feel about that? 

“It bothers me much like it bothers all the other rural communities that are in the same situation we are in,” says Lyle.

A research study in the journal Health Affairs compared states that did expand Medicaid to ones that did not, like Texas. It found, in the states without expansion, rural hospitals are closing at a rate eight times faster.

In Texas, 21 rural hospitals have closed since the state declined to expand Medicaid. More than any other state, according to the Texas Organization of Rural Community Hospitals.

One reason is that it's common for people without insurance to show up in the ER when they’re sick, which is the most expensive way to see a doctor.

“Because so many people in Texas don't have any kind of insurance, is this kind of like their doctor’s office?” I ask Jeff, as we tour his emergency room.

“17 percent use the ER as their primary care physician,” he says.

“And you can't turn them away?” I ask.

“No. We probably wouldn't anyway. That's why we do what we do. Some communities no longer have that option because their hospitals are closed,” Jeff adds.

The year Texas declined Medicaid expansion this hospital provided $3.6 million in free care to patients without insurance. Last year, $5.5 million. A 53 percent increase. Jeff calls it bad debt.

“Why is your bad debt growing?” I ask.

“Because we have less people that have insurance,” he says. “Most rural hospitals in this country work off a margin that's between zero and one percent. That's not a book of business you necessarily want to go into,” he finished.


On the other end of the hospital spectrum is the massive John Peter Smith. JPS is run by Tarrant County.

I'm talking to Glen Whitley, the Tarrant County Judge about the decision not to expand Medicaid.

“Has that decision been in the best interest of taxpayers?” I ask.

“I would say that's hard to determine. I am comfortable with the decision that was made,” he says. 

But not everyone is.

The Commonwealth Fund says not expanding Medicaid "has left many low-income Texans less able to afford their medical bills, to pay for needed prescription drugs, and to obtain regular care for chronic conditions.

The year Texas turned down the expansion, JPS Hospital provided $809 million in care to uninsured patients. Today, it's $983-million, a 22 percent increase.

But Whitley says JPS is financially healthy and property taxes here are under control.

And he still has a healthy mistrust of Washington.

“Trust me, one of the things I think we all need to understand is that if the federal government were to balance their budget, they like the state sometimes, how do they balance that budget? They stop paying for it and force local folks to pay for it,” Whitley is saying.

“And you're worried that's what's going to happen?” I ask.

“I’m worried that’s going to happen,” he says.


So, six years after declining Medicaid expansion where are we?

Well, 1.5 million poor Texans did not get health coverage, rural hospitals are struggling, and local taxpayers are paying the bills for uninsured patients at county hospitals.

Texas leaders believe Washington will shift the cost back on you. While that could happen, it hasn't yet.

So, when you ask if it was good for Texas to decline Medicaid expansion, the answer is no.

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