Photo by the National Cancer Institute, public domain.
All Americans deserve equal access to affordable health care and insurance protection. Photo by the National Cancer Institute.
John Burnam

As detractors and proponents of the Patient Protection and Affordable Care Act continue to spill rivers of ink on the healthcare market exchanges and functionality of the website, quietly, one of the most critical components of “Obamacare” — the state expansion of Medicaid –has been all but stricken from the records in 25 states, including Texas.

While expanding Medicaid to all adults living at or below 138 %  of the federal poverty is moot in states like New York where the safety net already surpasses the mark, the refusal by Gov. Rick Perry and the Texas Conservative Coalition in the Texas Legislature will leave an estimated  1.5 million person coverage gap in Texas between the poorest of the poor who currently qualify for Medicaid and the working poor who will be eligible for subsidies on the open market.

Gov. Rick Perry
Gov. Rick Perry

Although every state offers Medicaid benefits to a segment of its population, eligibility in Texas is the second lowest in the country, which also has the largest population of uninsured residents.

To be eligible for Medicaid under the current state standards, an individual must have earnings 15% at or below the federal poverty line, or $275 per month for a family of three and assets under $2,000.

Single adults are not eligible for Medicaid in Texas.

These numbers represent a dire predicament for a state with approximately 18% of the population living at or below the federal poverty line.

Anne Dunkelberg, CPPP Associate Director
Anne Dunkelberg, CPPP Associate Director

“Starting in 2014, those living from 100-138% of poverty can get sliding-scale premium assistance, while those living below 100% of poverty who don’t already qualify for Medicaid, get nothing,” stated Anne Dunkelberg of the Center for Public Policy Priorities (CPPP) in a recent Austin American-Statesman op-ed. CPPP is a nonprofit, nonpartisan policy institute based in Texas.

Director of San Antonio Metro Health Department
Dr. Thomas Schlenker, Director of San Antonio Metro Health Department

While those living under 100% of the poverty line technically will be eligible to apply for the premium subsidies on the market, “these are people who have extremely low incomes and even $40 a month might be very difficult to come by. They choose to pay rent and put food on table before anything but emergency care, ” said Dr. Thomas Schlenker, director of San Antonio Metro Health Department.

While the refusal to expand Medicaid will be devastating for communities throughout the state, the challenges will be even more difficult to handle in San Antonio, where 25% of the population lives below the federal poverty line.

According to Dr. Schlenker, this means that rather than receiving $100 billion in federal subsides over the next 10 years to cover Medicaid expansion, the cost burden will continue to fall on local taxpayers and hospitals.

“We will continue to be stuck in status quo, which is a continuation a very inefficient and expensive system that only takes care of people at the last minute and all of the cost falls on Bexar County”, he said. “This is not how the Affordable Care Act was supposed to work, and it’s really sad for those people.”

Although Perry and Sen.Ted Cruz hide their disdain for Medicaid expansion behind ideas of fiscal responsibility (Perry calls the ACA “a brazen intrusion into the sovereignty of our state.”), the fact of the matter is that the federal government will cover 100 percent of the expansion costs for the next three years and then phase down to 90 percent by 2020.

The financial ramifications of such anti-Washington politics will affect every taxpayer and not only the uninsured. According to a recent study by the Rand Corp, private health insurance premiums will increase by an average of 9.3 percent for people who buy their own coverage in the state.

Uninsured population in Texas by age. Graphic courtesy of CPPP.
Uninsured population in Texas by age. Graphic courtesy of CPPP.

Coverage of these costs also fall on the tax payers in San Antonio as hospital systems write off the costs of uninsured residents seeking medical treatment.

Representatives from CPPP say the financial burden will include the loss of potential jobs and almost $500 million in business revenue each year, before accounting for the massive increase in long-term productivity that would come from a healthier population.

While the financial concern of non-expansion is great, ultimately, the real worry is for the health of the individuals that fall within this new coverage gap.

Based on numbers extrapolated from a recent study in the New England Journal of Medicine, Dr. Howard Brody, director of the Institute for Medical Humanities, stated that “if we fail to expand Medicaid … 9,000 Texans will die each year for the next several years as a result.”

If we take this number of deaths and weigh it against the fact that Bexar County contains nearly 200,000 of these 1.5 million Medicaid ineligible Texans, it means that roughly 1,200 residents of San Antonio’s poorest will needlessly lose their lives each year due to inadequate care.

Why will these individuals die?

Because emergency rooms are only required to stabilize patients and relieve pain as opposed to diagnosing and treating the underlying problem. Individuals who have to use emergency room care for treatment are less likely to receive timely diagnosis of screenable conditions such as cancer, high blood pressure, and diabetes, all of which can mitigated through access to routine doctor visits.

Photo by James Gathany, public domain.
Preventative care is key to low healthcare costs for all. Photo by James Gathany for the CDC, public domain image.

Individuals suffering from these communicable and chronic diseases who need routine and consistent care will most certainly face suffering and death. An overwhelming majority could have received the basic preventive care they needed to recover if the state had opted to expand the safety net.

San Antonio hospitals provide generous amounts of charitable care and the county programs like CareLink annually cover $52 million dollars in care for 60,000 residents. Still, city services are overwhelmed by 400,000 county uninsured residents who require emergency room treatment because they are uninsured.

In an interview earlier this year with the Texas Observer, Ken Moriarty, CEO of the San Antonio based Methodist Healthcare Ministries, put the numbers in context.

For every 2,000 or 3,000 that we cover (in charitable care), there are probably 20,000 or 30,000 that are not covered … how unfair is that, that somebody’s tumor that could be removed, that someone’s life that could be extended, ends because we don’t have access to the resources to make that happen? We’re talking 1.5 to 3 million people around the state who are going to get late care or no care. They’re going to suffer. They’re going to be in pain because we can’t make a better policy decision.”

Regardless of what one might think about the continuous stream of misinformation coming from both sides of the aisle about the ACA and its effects on middle class wallets, the ultimate “losers” are the millions of low-income Americans that must continue to sit in agony for hours at the emergency room. All because their state thought it was more valuable to show up the president than provide basic treatment to mothers and fathers earning as little as $4-5,000 a year.

John Burnam is a nonprofit consultant currently working with San Antonio Christian Dental, Eyecare San Antonio, The Louise Batz Foundation for Bedside Advocacy, and The San Antonio Non-Profit Council. He works in patient safety, community health and well-being, and nonprofit development. He graduated with a degree in Classics and Art History from Trinity University and a Masters of Theological Studies from Vanderbilt before returning to SA last summer. Interested parties can learn more at:

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John Burnam

John Burnam is the co-founder and principal of Burnam | Gray, a nonprofit consulting firm that seeks to help agencies ignite and scale best practices.