Riojas, who was working in an embroidery store when she was diagnosed in November 2010, said, “I thought, if I can’t pay, I’m going to die even sooner from this than I have to.”
A local burden
More than half of the state’s population lives in one of the large hospital districts offering generous health care programs. Some of the counties, such as Bexar, cover illegal immigrants.
Under the federal health law, the Medicaid expansion would begin in 2014, and would cover people with incomes of up to 133 percent of the poverty level. The federal government would pay the entire bill for the first three years and 90 percent thereafter. If there were a county-backed expansion in Texas, the local hospital districts would tax residents to come up with the 10 percent state share. Texans living in counties that participated in the expansion would be eligible for Medicaid under the less restrictive rules, while those living in the rest of the state would not.
An official from the U.S. Department of Health and Human Services declined to comment on the idea, but said, “We look forward to continuing our dialogue with states . . . as we work to meet the law’s goals.”
Alan Weil, executive director of the National Academy for State Health Policy, said that the idea, despite its challenges, “is certainly not far-fetched.”
Weil noted that there is precedent for a federal waiver of this type: After California declined to take advantage of a provision in the health-care law that allows states to accelerate their Medicaid expansion, the leaders of several counties got permission from the Obama administration to do so on their own.
The Texas proposal, of course, represents more than a temporary bridge to statewide expansion; it could be a permanent arrangement.
“And federal authorities might feel differently about that,” Weil said. “But as a general proposition, could you have different counties with different eligibility standards? I think the answer would be yes.”
In many ways, Medicaid would be better for the poor than the county programs. For instance, the county programs do not technically function as health insurance. That means eligible residents can get care only at the public hospitals and facilities affiliated with their hospital districts.
Also, the county programs often require patients to shoulder more of the cost of their care — by making monthly payments based on their income, or paying co-payments such as the $10 that Christopher Mitchell handed over on a recent afternoon after stopping by JPS’s Center for Cancer Care for a check of his hemochromatosis — a debilitating blood disease.
Still, Mitchell, 31, who works in sales at a salvage yard, is grateful for the county program. He said his co-pays were “no problem” — nothing compared to the roughly $45,000 per year his parents paid to cover his medical bills before his family qualified for county help after his wife lost her job.
Christann Vasquez, chief operating office of San Antonio’s University Hospital System, is proud of the county programs but insists they are not a substitute for Medicaid. Even in Bexar, only about one-seventh of the low-income uninsured people who are eligible for the county program are actually served by it, partly because University Hospital System doesn’t have adequate resources to promote the program and sign people up. Often, patients find out about the program from hospital staff once they are already so sick they seek treatment at the emergency room.
“We know we are not capturing anywhere near everybody we need to right now,” Vasquez said. “With Medicaid, [low-income people] would know they can access the system and go to see a doctor so much sooner.”
Riojas is a case in point. For years, she didn’t get routine checkups because she assumed she could not afford them. Had she done so, a doctor might have learned that she had an aunt who died of colon cancer in her 40s, and suggested that Riojas get regular colonoscopy exams. But by the time doctors discovered her disease, her illness was so advanced that she was hemorrhaging blood.