A New House in Texas: Is it a New Day for Health Care?
  • A New House in Texas: Is it a New Day for Health Care?

Written by Mary Ann Roser

The political tea leaves do not always foretell exactly what will happen at the Texas Capitol at the opening of a legislative session, but political insiders and analysts detect a mood shift. Predicting a swing toward compromise on major issues – and away from the rancor that marked the 2017 legislative session – leaders might be looking to assemble around unity and at the least an effort toward issues where harmony might be achieved.

Divisive issues such as 2017’s “bathroom bill,” which sought to restrict public restroom access to the user’s birth gender, won’t return. Expect instead a different conversation on substantive issues, with education funding and property tax limits getting top billing, and health care issues vying next for the spotlight.

Although some political experts think sweeping changes in health care are unlikely this session, big questions are swirling around the issue and could prompt some positive, incremental steps. The mantra to “repeal and replace” the Affordable Care Act is evolving into a discussion on how to preserve its most popular features for Texans, like protecting people with pre-existing health conditions and covering more uninsured citizens.


“There’s a reset that’s happened,” said James Henson, director of the Texas Politics Project and co-director of The University of Texas/Texas Tribune Poll.

That reset played out last year in opinion polls and surveys in which Texans ranked health care among their top three priorities. Their fellow Americans ranked health care first in a number of national polls as more people embraced the ACA than shunned it.


“We saw that as soon as the Trump administration started trying to dismantle the ACA, support for it began to rise,” said David Iannelli, a partner at Hudson Pacific, a data-driven public affairs company with offices in Austin. “People value twice as much something they already have than something new."

Even in red Texas, that aspect of human nature played out on the ACA, known commonly among voters by the “Obamacare” label.

A state survey by the Episcopal Health Foundation and the Kaiser Family Foundation published in June found Texans evenly split on whether they supported the ACA. It also found that 61 percent of Texans said “top priority” should be given to lowering the cost of care, 59 percent to reducing maternal deaths, 56 percent to lowering prescription costs, 55 percent to expanding access to health coverage and 54 percent to increasing funding for mental health programs.

“I think there’s a lot of opportunity,” said Elena Marks, president and CEO of the Episcopal Health Foundation in Houston. But she and others questioned whether the GOP-dominated Legislature has the will — and the bandwidth in a regular session — to make major changes to the health care system.

Winning on Health Care

Still, state Republicans are eager to score a win on health care, political observers said.


“Health care is a vulnerable issue for Republicans,” said Mark P. Jones, political science fellow at Rice University's James A. Baker III Institute for Public Policy. “It resonates with voters and it favors Democrats far more than Republicans. The Republicans need to do something to change their image to be seen as more compassionate and more supportive” of everyday Texans.

The November election reflected that, he said. Nationally, Democratic candidates, many of whom prioritized health care, gained control of the U.S. House of Representatives. At the statehouse in Texas, Democrats gained 12 seats in the House, giving them 67 to the Republicans’ 83, the biggest flip in House seats since huge Republicans gains in 2010.

The November elections also saw incumbent statewide Republican leaders, from the lieutenant governor on down, win by much tighter margins than four years earlier.

“The 2018 midterms election really shook things up and shattered the overconfidence of many Republicans,” Jones said. “They realize if they are going to maintain their majority status, they no longer can ignore November voters.”

The new House speaker, Dennis Bonnen (R-Angleton) has demonstrated a desire to focus on substantive issues, Jones said. “For Bonnen, compromise is not a bad word.”

Harold Cook, a former executive director of the Texas Democratic Party who’s now a political and public relations consultant, said he has detected an air of bipartisanship born of practicality in this year’s Legislature.


“The change is due mostly to the ability of legislators to accurately read the annoyance among general election voters with the past hyper-partisan obsessions on wedge issues, at the expense of other issues of broader concern,” Cook said. “The Republicans lost a lot of legislative races. Just as important, several additional Republicans, most notably in the state House, survived their general election races, but only narrowly. These factors mean that general elections matter again in Texas, and we’re already seeing the result — a renewed focus on issues of most importance to general election voters.”

Abbott's Vision

Gov. Greg Abbott comes to the session with more clout than the more conservative Lt. Gov. Dan Patrick, given Abbott’s double-digit win over a Democrat in November, according to both Jones and Henson. Additionally, two prominent Patrick allies, Sens. Don Huffines (R - Dallas) and Konni Burton (R-Colleyville), lost their seats.

“I think people overestimated Patrick’s political power,” Henson said.

In December, Abbott told The Dallas Morning News that while a recent ACA ruling undergoes an appeal, Texas will work with the Trump administration on federal waivers and other flexibility, so the state is ready with an alternative should the law be struck down. “Texas will strive to expand health care insurance coverage, reduce the cost of health care and ensure that Texans with pre-existing conditions are protected,” Abbott said.

Texas still has the nation’s highest rate of uninsured residents at 19 percent, compared with 11 percent nationally, according to a 2018 Urban Institute report.

“The question is: What does the Legislature have the carrying capacity for? How much bandwidth can you have in a legislative session?” Henson asked.

In the Episcopal Health/Kaiser survey last year, nearly two-thirds of Texans said the state wasn’t doing enough to help low-income Texans get health care coverage.

Medicaid Expansion


“It’s going to come down to the 800-pound gorilla in the room,” said David White, CEO of Public Blueprint, an Austin-based public affairs firm. “You really can’t do anything about it, because it is such large dollars (required by the state). There will be pressure, but I don’t see Medicaid expansion this session.”

Texas is now among just 14 states that have not expanded Medicaid. Rep. Garnet Coleman (D-Houston) already has filed legislation to expand Medicaid and take advantage of billions of dollars in federal support. Republican legislators, though, see it as a third rail of Texas legislative politics after many of them showed openness and willingness to consider not only Medicaid expansion in its original form, but also alternative versions like those customized through waivers in other states.

The GOP may find it more appealing to seek block grants and try to work out a deal with a friendly Trump administration, Jones said, adding, “2019 is the time to strike because, odds are, Trump won’t be there in 2021.”

Marks said that regardless of what happens in future elections, today’s timing couldn’t be better for Texas. “We have seen the current administration be extremely flexible with states that have made all sorts of proposals,” she said.

Just don’t call it “Medicaid expansion,” she said, because of its link to Obamacare.

“I have quit the using the term ‘Medicaid expansion’ because it’s so politically charged,” Marks said. “What I have started talking about instead is, is the Legislature willing to take advantage of the opportunity to bring more money into the state … for uninsured populations?”

She prefers to think of it as a coverage program, like Travis County’s Medical Access Program or the Harris Health System’s Gold Card. Similar efforts began in 2014 in preparation for the 2015 legislative session as the Texas Way program emerged. Designed by the Texas Hospital Association based on policy analysis, polling of GOP voters and communications strategies, the Texas Way proposed a framework for a private market alternative to traditional Medicaid expansion. Political winds, fueled by anti-Obamacare rhetoric, still made support for the issue impossible.

What is Doable?

Iannelli expects lawmakers to go after “low-hanging fruit,” like expansion of mental health services for high school students as a way to prevent campus violence. And with a large rural constituency, lawmakers might be compelled to discuss what they can do to stem the tide of rural hospital closures in Texas, Iannelli and Marks said.

Nineteen rural hospitals in Texas have closed since 2013, the highest rate in the nation, according to the Texas Organization of Rural & Community Hospitals.

Other pressing health issues that could fall into the “low-hanging fruit” category and are receiving a lot of attention include higher-than-average death rates of new Texas moms and shoring up support for the state’s designated trauma hospitals.

Public Blueprint’s White said the Legislature likely will look for ways to cooperate on health care.

“Speaker Bonnen wants a unified house,” White said. “He and the governor realize health care is an important issue. They’re going to have their own agenda items … but I think the Legislature as a whole, Democrats and Republicans, want to get something done on health.

“Now that the gavel has fallen, politics takes a back seat.”

Texas Hospitals magazine