Health law ruling leaves uninsured Texans in limbo [Houston Chronicle]

June 29--The 6.5 million Texans without health insurance faced a future of hope tempered with uncertainty Thursday, as the U.S. Supreme Court ruled that most of the health care reform law was valid but left a key provision up to the states.

"I'm so proud to be an American," said Jennie Johnson, a self-employed grant writer who lives in Missouri City. "This is what the founding fathers envisioned. I am so proud of the Supreme Court."

But the ruling left plenty of questions unanswered, including whether Texas will participate in a program to expand Medicaid coverage -- if it doesn't, as many as 1.5 million low-income people will remain uncovered -- and whether, and how quickly, it will set up the health insurance exchange intended to make it easier to shop for insurance.

Texas did little to prepare for the law.

"Texas gambled the law would be ruled unconstitutional and lost," said Pauline Rosenau, a professor at the University of Texas School of Public Health in Houston. "It is now ill-prepared to implement health-care reform as it goes forward."

Gov. Rick Perry called the ruling "a stomach punch to the American economy" and a "shocking disappointment to freedom-loving Americans."

And he had plenty of company in everyday citizens, many of whom said they found the 2010 law, known derisively as "Obamacare," to be overly intrusive.

Elisabet Montano, 23, who works at Memorial Hermann Hospital, said she didn't like the decision.

"The law should not make someone have insurance even if they don't want to," she said.

Medicaid expansion

It will be weeks, or maybe months, before state leaders decide what the state will do next.

Advocates for uninsured Texans celebrated the moment.

At 25 percent, Texas has the highest rate of people without health insurance of any state in the country, and Anne Dunkleberg, associate director of the left-leaning Center for Public Policy Priorities, estimated about half of those people would gain coverage fairly quickly.

If Texas chooses not to participate in the Medicaid expansion, it would forgo an estimated $164 billion in Medicaid funding the federal government would provide from 2014 to 2023, according to the Texas Health and Human Services Commission. The agency estimates Texas would have to provide $27 billion in Medicaid costs over that period.

Dunkelberg said it was equally important that people are assured of benefits that have already taken effect, including a popular provision that allows people to keep adult children up to age 26 on their parents' policies.

Medicare beneficiaries get a discount on prescriptions when they fall into the gap for drug coverage. Children can't be denied coverage for a pre-existing condition.

But most of the law will take effect in 2014.

Alternatives provided

Even if Texas were to participate in the Medicaid expansion, not all of its 6.5 million uninsured would qualify for coverage; between Medicaid and private insurance, most experts estimate at most about 4.1 million would gain coverage.

"But at least it begins to provide alternatives," said Ron Cookston, executive director of Gateway to Care, a collaborative of 167 clinics and other organizations in Harris and surrounding counties.

"There's incredible pressure on a public and private health care systems to serve that uninsured population," Cookston said. "The opportunity to level the playing field will be life-changing for hundreds of thousands of people."

The Harris County Hospital District may be ground zero.

District president and CEO David Lopez said that even if millions of Texans gain coverage, the need will remain overwhelming. Even if the Affordable Care Act is fully implemented, about 500,000 Harris County residents will remain uninsured, Lopez said.

If Texas opts out of the Medicaid expansion, its needs will be greater.

Worry over expenses

The law calls for everyone earning up to 133 percent of the federal poverty level -- about $25,390 for a family of three -- to qualify for Medicaid. Until now, it has mainly covered only children and pregnant women, along with very poor people over 65, in Texas.

The federal government will pay 100 percent of the law's cost for the first three years, through 2016, and gradually add state responsibility until, by 2020, the state is responsible for 10 percent.

But Texas and other states are worried that the law will become too expensive.

Stephanie Goodman, spokeswoman for the state's Health and Human Services Commission, said it probably will be up to the Legislature to decide on the expansion.

People who would have qualified for the Medicaid expansion would not be eligible for subsidized insurance through the exchange, Dunkleberg said.

"We would be leaving 1.5 to 2 million of our poorest without any option if we didn't take that option," she said.

Peggy Fikac and Mayra Cruz contributed to this story.

jeannie.kever@chron.comtodd.ackerman@chron.com

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