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Kansas lawmakers know they are late to the Medicaid expansion party, but they appear determined to show up anyway.

“I feel like now is as good a time as any,” says Anthony Hensley, the leader of the Democratic minority in the state Senate.

For the past three years, Republican Gov. Sam Brownback and legislative leaders were able to block debate on expanding health care for the disabled and working poor via Medicaid, a component of the 2010 Affordable Care Act.

Not anymore.

In last year’s primary and general elections, Kansas voters — frustrated by chronic budget problems caused in large part by income tax cuts that Brownback pushed through the Legislature — replaced several conservative incumbents with moderate Republicans and Democrats who promised to stabilize the state’s finances, fund public education and push for Medicaid expansion.

Coalitions energized by the influx of new lawmakers wasted little time in making good on those promises. The Kansas House recently passed an expansion bill by a margin close to what would be needed to override a Brownback veto, should it come to that.

A Kansas Senate committee is holding hearings on the expansion bill and may vote on Thursday to send it to the floor. That is the same day the U.S. House of Representatives has scheduled a vote on a Republican proposal to replace the ACA.

The replacement bill before Congress would phase out federal funding, starting in January 2020, for expansion programs in 31 states and the District of Columbia as well as any others to implement programs between now and then. But it would not immediately close the expansion window for states that have not acted, says Tom Bell, president of the Kansas Hospital Association.

“From our perspective, this provides some encouragement for states to expand their programs prior to that Jan. 1 of 2020 date,” Bell says, noting that the bill would continue funding 90 percent of expansion costs for people enrolled by the deadline.

David Jordan, executive director of a Kansas coalition pushing for expansion, is making a similar pitch to lawmakers.

“This is really an invitation to states like Kansas to expand their Medicaid programs,” Jordan says. “We have everything to gain by taking this step and nothing to lose.”

To date, Jordan says, the failure to expand Medicaid has cost health care providers and the Kansas economy an estimated $1.7 billion.

Currently, Kansas limits Medicaid eligibility to children and pregnant women in low-income families, people with developmental and physical disabilities, and seniors who cannot afford nursing home care. Parents are eligible only if they earn less than a third of the federal poverty level, or about $9,200 annually for a four-person family.

Single adults without children are not eligible.

Expansion would qualify all Kansans earning up to 138 percent of the poverty level, annually about $16,642 for individuals and $33,465 for a family of four.

An estimated 300,000 Kansans would qualify for coverage under expansion, though only about half that number are expected to initially enroll.

Senate President Susan Wagle, a Republican, says she expects the Kansas Senate to pass the expansion bill next week, perhaps by a vetoproof margin.

But even if Kansas lawmakers are able to advance an expansion plan to the U.S. Department of Health and Human Services, she is not convinced federal officials would give it serious consideration.

“The timing is wrong,” Wagle says. “It could just sit there because what I see the feds doing is winding that program down.”

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In this corner of Appalachia, poverty takes a back seat to art galleries, country clubs, golf course communities, five-star restaurants, and multimillion-dollar houses.

From this perch in Highlands, N.C., Congressman Mark Meadows, a real estate entrepreneur who capitalized on the area’s transformation to a prosperous retirement and vacation community, rose to political power quickly. Now, Meadows leads the House Freedom Caucus, controlling about 30 votes and showing few qualms about endangering his party’s best chance to repeal the Affordable Care Act.

Meadows, who has called the GOP health bill replacement “Obamacare Lite,” said Thursday on MSNBC: “I am willing to invest the political capital to get it right. The next week is critical.”

And on Saturday, Meadows went to President Trump’s Mar-a-Lago club in Florida to negotiate over the bill with Trump aides, along with with Sen. Ted Cruz, R-Texas, and Sen. Mike Lee, R-Utah.

Meadows’ confidence is warranted.

His gerrymandered district covers 17 counties and spans 150 miles of western North Carolina. The populous liberal bastion of Asheville is mostly carved out of his district like a bite from a cookie. What’s left is a retiree-rich constituency of 750,000 people that is heavily Republican, mostly white, and lives mainly in small, rural towns amid pockets of extreme wealth. Its survival, however, could hinge on a Supreme Court ruling expected this year over whether racial bias tainted how the state legislature drew North Carolina’s congressional map.

Elected in 2012, Meadows, 57, has rebelled against the establishment Republican Party. He helped shut down the government in 2013 and oust John Boehner from his House speakership in 2015.

While Democrats and even moderate Republicans decry House Speaker Paul Ryan for cutting federal aid to help get people insured in the GOP bill, Meadows says the cuts don’t go deep enough. He vows to oppose any ACA replacement that does not bring down health costs for people and government. No such plan is on the table, however.

Meadows wants to cut off all 10 million Americans who today get federal subsidies to buy health coverage, which he says the country can ill afford. With enough support, Meadows could either block the House leadership from passing its plan or force it to approve a more conservative replacement that would face little chance of getting through the more moderate Senate.

Meadows’ potential role as “Trumpcare” spoiler is stirring concern in the White House and Congress. By Thursday, Meadows seemed to have gotten that message.

“The last thing I want is for the president to be mad at me,” Meadows told Politico. “He asked me to negotiate in good faith, so I have been working around the clock.”

But his hard line doesn’t bother most folks back in his part of North Carolina, where the ACA, also known as Obamacare, is unpopular. Only about 5 percent of those in his district receive government-subsidized health plans made available by the law.

Meadows is revered by most constituents.

Even the local hospital industry — which typically opposes any effort to scale back the health law — remains firmly in Meadow’s corner.

“We are big fans of Mark. He’s a man of integrity and he has the heart,” said Jimm Bunch, CEO of Park Ridge Health, a 103-bed hospital in Hendersonville. He heaps praise on Meadows even as the congressman fights to eviscerate the law that helped the hospital achieve one of its best financial years ever. As more patients got insurance, Park Ridge gained $600,000 a year in funding it used to provide free care to other patients.

Because North Carolina did not expand Medicaid under Obamacare, many poor adults there remain uninsured. But many residents did gain coverage. The state’s uninsured rate fell from 20.4 percent in 2013 to 13.6 percent in 2016 — about three points higher than the national average, according to Gallup.

Small-business owners, who provide most jobs in the district, are reluctant to take on Meadows, even if they’ve benefited from the ACA.

At Sanctuary Brewing in Hendersonville, co-owner Joe Dinan said the Obamacare coverage helped him get surgery for skin cancer on his head. “I don’t want to see the subsidy end,” Dinan said. He won’t say anything critical about Meadows, though.

Meadows insists no one will get left behind.

He wants to allow people to buy less-expensive policies with fewer benefits than now required under the ACA. His tax help would be in the form of year-end deductions or a break on their payroll taxes — different than both the current law and the GOP replacement plan now before Congress.

That infuriates Kent Loy, a thrift-store volunteer in Hendersonville.

“It’s an attack on the poor,” said Loy, 71. “This should disqualify him from office.”

But it won’t, said Chris Cooper, professor of political science at Western Carolina University. Meadows drew 65 percent of the vote in November. “Taking out Asheville turned the district from being the most competitive district in the state to the most conservative,” Cooper said.

The political climate is challenging for cultivating grass-roots opposition to Meadows, according to activist Susan Kimball, of Waynesville, N.C., who is part of Progressive Nation WNC, a group pushing to retain the ACA.

She moved to Waynesville from South Florida four years ago, and the area’s conservatism has been an eye-opener.

“We were just moving to the mountains and we didn’t know the region would become Tea Party central,” Kimball said.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Steve Inskeep talks to Robert Laszewski, a health policy consultant, about how the Republican’s plan to reform health care would effect insurers. Laszewski had a long career in the insurance industry.

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For years, Republicans in Congress have promised to repeal and replace the Affordable Care Act, claiming that its requirement for nearly everyone to buy insurance or pay a fine is burdensome and costly, and it doesn’t give people enough flexibility to get the coverage they need.

Now that they’re in charge, the bill they’ve released as an alternative (the American Health Care Act) would effectively eliminate the requirement to buy coverage, and it could open up more health care choices, but it’s under fire because it may cause millions of people to lose their coverage. According to the nonpartisan Congressional Budget Office, up to 24 million more people could be without insurance by 2026 if it passes.

So what are the differences between the ACA and the GOP alternative, and what does it all mean to you and your health care? We put some of your questions from our Twitter chat (#ACAchat) earlier this month to Alison Kodjak, NPR health policy correspondent, and Julie Rovner, chief Washington correspondent for Kaiser Health News.

Many questions came in about the elimination of the requirement to buy insurance, known unflatteringly as “the mandate,” and how the lack of one might impact the health insurance market.

Is the mandate in the GOP bill? It won’t work if people only sign up when they are sick.

Kodjak: The mandate is technically still written into the law, but since no one will enforce it under this new bill, it’s unlikely to have any impact. In fact, the Internal Revenue Service has already issued some guidance that suggests it may not enforce the mandate very actively even now, before this bill becomes law. The result? People who think insurance is too expensive and don’t expect to need it are unlikely to sign up for a health plan.

Rovner: It’s true that GOP the bill technically preserves the mandate, but it eliminates the penalties. Instead, the bill would require those with a lapse in insurance of more than 63 days to pay an insurance premium that’s 30 percent higher for one year. Analysts say that could actually serve as a disincentive for healthy people to purchase insurance if they’ve had a break.

Can someone can wait until they are sick to buy insurance, knowing that they would have to pay a 30 percent fine?

Rovner: Not exactly. There will still be standardized open enrollment periods once a year, and you will only be able to buy insurance outside of those windows if you have a life change, like moving or losing a job. But if you’re willing to wait as long as 11 months, then yes, you can wait and buy insurance after you get sick.

Kodjak: It’s not without risk. The Department of Health and Human Services has already proposed regulations that would reduce that open enrollment period to six weeks from the current three months. So a patient may incur some health care costs while awaiting the open enrollment, and then face the 30 percent penalty when they do buy a health plan. However, if the individual has a health issue where treatment can wait, then they certainly can enroll at the correct time and then seek medical care.

We also got a lot of questions about the new tax credits to help people buy insurance that are in the GOP bill, and how different they would be from the structure of purchasing help in the ACA.

Explain the difference between tax credits and subsidies, and will tax credits will be distributed quarterly or at the end of the year?

Kodjak: Both the ACA and the AHCA use advanceable, refundable tax credits. That means the government each month sends the tax credit amount to your insurance company.

We refer to the Obamacare financial assistance as a “subsidy” in part because the amount fluctuates and is based on your income – the idea is to limit your health costs to a specific percentage of your income. In addition, under the ACA, there are payments to insurers to help cover the co-payments and deductibles of lower-income people.

Rovner: The tax credits differ in how large they are and how they are calculated. The ACA tax credits are based on income and how much insurance costs in a given area. The GOP credits, by contrast, are based primarily on age and do not vary according to the cost of insurance in an area, so in low-cost parts of the country they will go farther than in very high-cost areas.

In addition, the ACA has a series of subsidies that help those with low incomes (under 250 percent of poverty; about $50,000 for a family of three) pay their deductibles and other out-of-pocket expenses in addition to the tax credits to help pay for premiums.

Why does the GOP bill provides age-based tax credits instead of income-based ones?

Kodjak: The basis for age-based tax credits is that people who are younger tend to have fewer health costs, so insurance policies are likely to be lower priced for them than for older people.

Republicans prefer the fixed credits in part because they are cheaper, and more predictable, than the income-based credits under the Affordable Care Act. That’s because those ACA credits rise as premiums rise, giving insurers little incentive to keep their premiums low. Republicans hope that by restraining the government’s financial help to patients, insurance companies will offer cheaper policies that better match the cost of the tax credits.

Rovner: Younger adults, on average, need less health care than older adults. The ACA limited the differential in premiums for older adults to three times more than the amount charged to younger adults. The GOP bill would change that so older adults could be charged five times more. The change would make insurance less expensive for younger people, likely enticing more of them to enroll, and lowering premiums for all, at least marginally, according to the Congressional Budget Office. But it would dramatically increase premiums for older adults, particularly those aged 55-64, just under the age to qualify for Medicare.

Which brings us to this question, which represents several we received about how the ACHA appears to disproportionately impact people ages 55-64.

Do I face a penalty for waiting to buy health insurance until I’m eligible for Medicare in three years? I’m concerned that I’ll be stuck with an expensive plan.

Kodjak: No 30 percent penalty if you wait for Medicare, but remember, if you get sick while you’re waiting, you could be in financial trouble.

Rovner: That is correct. Also, remember if you fail to sign up for Medicare when you first become eligible at age 65, you would also pay a premium penalty. It’s 10 percent per year, forever.

Got more questions? We’ll keep answering them as the GOP bill moves through Congress. Send them to us via Twitter at #ACAchat.

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Designing skateboards is just one of Luke Franco’s gigs. He has just enough time before his next shift to chat at a café in downtown Providence, R.I.

“I work at the YMCA Monday through Friday with kindergartners through fifth graders. It’s split shift; seven to nine, two to six daily,” he says. “With the rest of my day, I also work at a local pizza place. And in addition to that, I also own and operate a small skateboard company.”

But none of his jobs offers health insurance. I ask him if he worries about that.

“Yes, especially being an avid skateboarder,” the 26-year-old says. “That’s constantly something in the back of my head now — before I try this trick, what happens if I get hurt?”

So he’s looking for a full time job with benefits. Until then? Franco hasn’t really explored his options. He’s a member of the millennial generation. They represent more than a quarter of the nation’s population. These are people 18 to 34 years old, and we’re hearing a lot about them in the health care debate. How they fare under the GOP health care bill going through Congress is complicated.

Franco doesn’t know whether he qualifies for Medicaid or a subsidy to buy coverage on the exchange set up under the Affordable Care Act, also called Obamacare.

If the Republican plan to repeal and replace the ACA goes forward, his options might be more limited than that.

“I’m assuming that paying full price for it [health care] would be completely unaffordable for me,” he says.

The GOP plan would offer Franco a tax credit of $2,000 a year — that’s the amount for which 26- to 29-year-olds would be eligible. The amount goes up to $2,500 for those ages 30 to 39. But even if Franco could buy a plan for a few hundred dollars a month, he wants to hold on to what little pocket money he has for dinner or drinks with friends.

Jen Mishory heads an organization called Young Invincibles, a tongue-in-cheek name for millennials who think they’re too healthy to need health insurance. But the organization is serious about advocating for young people. Mishory says the ACA helped this generation.

“You’re starting pre-ACA with an uninsurance rate of about 29 percent for young people. We see that uninsurance rate drop, over the course of the last five, six years to about 16 percent,” she says. That’s thanks to many factors, the expansion of Medicaid, for one, and children being able to stay on their parents’ insurance until age 26.

But coverage on the exchange is still expensive for some millennials. Even with subsidies, they didn’t sign up for the ACA exchanges in the numbers insurers were hoping for.

Mishory points out the GOP proposal to roll back Medicaid expansion could hurt some young, single adults. The proposed tax credit might help others.

“For some young people [the tax credit] may be more than what they received under the ACA,” she says. “But for a lot of the low-income young people, they could see reductions in that subsidy.”

What concerns Mishory most is the Republican provision that insurance companies could charge customers 30 percent more for a plan if their coverage lapses.

“Young people are the most likely to see gaps in coverage,” she says. That’s because young adults move and change jobs a lot. They also tend to have lower incomes, so the penalty might discourage millennials, especially healthy ones, from enrolling in coverage again.

Molly Tracy says she’ll buy insurance, penalty or not. She’s 25 and works at a charter school.

She worries the Republican model won’t be affordable.

“I’m not rich! I work in public education. So even if I do have coverage, having a $3,000 medical bill … that’s going to pose a significant challenge for me,” she says.

Right now, Tracy is covered by her father’s health insurance. But her 26th birthday is coming soon, she says, “So I’m trying to get a tonsillectomy before my insurance lapses. That’s one of the issues. The other issue is scheduling, having enough time to recover.”

When Tracy does get her own health insurance through work this fall, she wants to know what she will be getting. Will birth control remain affordable? Will mental health care be covered? A Congressional Budget Office analysis finds people like Tracy might end up paying much more out of pocket for those benefits than they would now.

This story is part of a partnership with NPR, Rhode Island Public Radio and Kaiser Health News.

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David Higginbotham contracted hepatitis C more than 35 years ago. He’d like to rid his body of the virus, but Colorado’s Medicaid program says he’s not sick enough to justify the cost.

And he’s not alone.

Since 2013, when Gilead Sciences Inc. released Sovaldi, the first medication that can reliably cure hepatitis C, health insurers and state Medicaid programs have been coming up with ways to limit access to it and a sister drug, Harvoni, because they’re priced so high — more than $80,000 for a 12-week course of Sovaldi at the outset.

Both drugs are produced by Gilead, and their price has dropped some, as competitors have hit the market, but Higginbotham still hasn’t been able to get the cure.

Gilead isn’t the only company that produces expensive drugs. Prices for prescription medications for various conditions have been rising faster than inflation for years.

President Donald Trump says the pharmaceutical industry is “getting away with murder,” and he’s vowed to do something about it.

So what could he do in the case of hepatitis C medications?

One solution that’s been proposed is to buy the company. Specifically buy Gilead Sciences Inc.

Dr. Peter Bach, the director of health policy and outcomes at Memorial Sloan Kettering Cancer Center in New York, says the U.S. government could save money and treat everyone in the nation who has hepatitis C if it bought Gilead Sciences, rather than just buying Gilead’s products.

Hepatitis C kills more Americans than any other infectious disease, according to the Centers for Disease Control and Prevention, and it leads to a liver transplant more often than any other condition.

A year after Gilead got FDA approval for Sovaldi, it launched Harvoni, — a combination medicine that includes Sovaldi’s key ingredient and a second medication that attacks the hepatitis C virus in a different way. Sovaldi and Harvoni are the first drugs to consistently eradicate the virus, which has infected an estimated 2.7 to 3.3 million people in the U.S.

Bach says that in the three years since the drugs hit the market, only about 600,000 people have been treated — a low number considering there is a cure available.

“We’re doing a pretty poor job right now of finding patients with hepatitis C,” he says.

The slow uptake, Bach says, is because of the drugs’ price. When Harvoni came on the market, it was listed at $94,000 for a course of treatment that cures most patients. The price has since dropped to about half that, but is still out of reach for most people.

Medicaid programs are limiting access and many insurance companies list it as a specialty drug and cover only a percentage of its cost.

“Because nobody can afford Gilead’s prices, there really isn’t much sense in investing to go find these patients and get them into treatment,” Bach says.

He says the U.S.government, however, could cut the cost of treatment by almost two-thirds by buying Gilead on the open market – its market capitalization on March 17 was about $90 billion — and selling off all its assets except the U.S. rights to Sovaldi and Harvoni.

The savings would be three-pronged, he explains. The cost of treatment would decline. The disease would stop spreading. And the number of liver transplants prompted by hepatitis C infections would drop significantly.

“There’s a queue right now for liver transplants, so it will free up those livers for other people who have other diseases that we can’t cure who otherwise will die,” Bach points out.

That would help states like Colorado, for example, which is limiting access to Medicaid patients because the costs of treating everyone at once would be too high. If the state were to treat every Medicaid beneficiary who is diagnosed with hepatitis C, it would cost an additional $500 million.

So to get the drug, Higginbotham has to wait until his liver is more damaged that it is today.

Bach says if the federal government treated hepatitis C as a public health issue, rather than as a Medicaid budget problem, buying Gilead would make sense.

Gilead’s senior vice president, Gregg Alton, says Bach’s idea is thought-provoking. What it really demonstrates, Alton says, is that the system to pay for prescription drugs isn’t equipped to deal with quick, expensive cures.

“Because we have a cure, the costs are paid in a short period of time,” he says. “Our payment systems have a real tough time with that because they’re used to these sorts of long-term, chronic therapies that pay a little bit at a time – but, over time, cost a lot more.”

In other words, it can cost a lot more to treat diabetes or multiple sclerosis over a lifetime than to cure hepatitis C in three months.

From a public health perspective, buying Gilead isn’t a bad idea, says Sara Fisher Ellison, an economics lecturer at MIT.

But that assumption rests on the notion that the government would buy the company’s shares at full price on the open market. That would avert any reaction from drugmakers or other companies who would fear that the government could use its power just to force them to lower prices.

“The reason this proposal could work is that right now the drugs are only serving a fraction of the potential patients,” Fisher Ellison says, “and there’s a big public health benefit to serving all of the patents. That’s something that Gilead doesn’t take into account in its pricing policy, but it’s something that a government does take into account.”

The idea is a long shot of course.

But Higginbotham, who is still waiting in Colorado for his chance to take the hepatitis C drug, sees an opening with Donald Trump in the Oval Office.

“With our present administration,” he says, “a hostile takeover might be just up his alley.”

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This Friday is Match Day, an annual rite of passage for seniors in medical school, when they find out at noon if they’ve “matched” with a residency in the specialty and location of their choice.

But many of those being matched will be happy to go pretty much anywhere. They are international medical graduates — either U.S citizens who’ve attended school out of the country (think the Caribbean or Mexico) or doctors who are citizens of other countries and want to train here.

Though getting into medical school in the U.S. is highly competitive, the simple fact of the matter is that there aren’t enough graduates of those medical schools to fill all of the residency training slots, especially in the less-desired primary care fields. It’s been this way for decades, and we’ve depended on foreign-born doctors to fill out our training cohorts.

Nationwide, 24 percent of medical residents are graduates of foreign medical schools, many of them at urban hospitals that serve low-income patients or hospitals in rural areas.

Throughout my medical career, I’ve benefited greatly from working with doctors from other nations. Regardless of their country of origin, doctors who come to the U.S. to train and work are ambassadors of humane values, learning the mores of American culture while sharing their skills and knowledge. A recent study even suggests that patients do slightly better when treated by doctors born and educated outside of the United States.

In my days as a medical student in Cleveland, my favorite rotations were at our county hospital. There the mission was clear: Treat any patient who walked through the door. There were no insurance requirements or other barriers to patients seeking help. Another benefit was that as a student, I could get the most hands-on experience.

As a third-year medical student, I had to learn to draw blood from patients, usually the ones with the hardest-to-find veins that the regular lab techs and nurses couldn’t get. I was blessed to work with a resident named Ahmad who was originally from Pakistan, where he’d trained as a surgeon.

Ahmad gave up his dreams of performing surgery when he obtained a student visa and matched in internal medicine in Cleveland. He moved his family to Ohio, where they shivered through their first experience of real winter.

Ahmad’s dexterity skills were in high demand among his American-born fellow residents, who were happy to learn procedures like intubation and inserting central lines from him.

One night on call, a patient with an IV drug habit had a fever, which made us worry that he had a bloodstream infection. The problem was that his veins were so scarred that drawing blood to verify our hunch was a real challenge.

It was no problem for Ahmad. He coached me through a couple of tricks like obtaining blood from a leg vein and the external jugular vein in the neck. And he did all of this while talking the patient through it to distract him from the unpleasantness. Ahmad’s skill made it easier for both of us — the patient, who didn’t even flinch, and me, a wet-behind-the-ears student.

Residents like Ahmad who train in the U.S. often decide to stay here, where physician incomes are higher and educational opportunities for their children are more abundant. Because of their visa requirements, doctors like Ahmad often move to locales that find it hard to attract health care professionals, including rural and low-income areas.

I see this as a win-win: highly skilled foreigners move along the pathway to becoming permanent residents or U.S. citizens, and areas with a shortage of health professionals get doctors willing to ply their trade and become members of the community.

Such is the American melting pot in the medical profession. However, the recent rise in anti-immigration sentiment in our country threatens to undermine this balance — which leaves us vulnerable to worsening doctor shortages in smaller cities and community health centers.

The president’s revised immigration executive order, which was slated to go into effect Wednesday, would cloud the picture for those who would come here to train. Foremost are those from the six countries that are temporarily banned. But other visa holders, while still allowed to travel to the U.S., may find a less welcoming environment, too.

Foreign medical graduates already undergo rigorous screening as part of the visa process, notes Darrell Kirch, CEO of the Association of American Medical Colleges. He said of the executive order in a statement: “This order will not only have short-term negative implications, but will have a lasting impact on our nation’s patients, particularly those in rural and urban underserved areas.”

Here’s hoping that Friday’s match brings more Ahmads to our country’s training programs. The medical profession could sure use more of that skill, worldliness and wisdom.

John Henning Schumann is an internal medicine doctor and serves as president of the University of Oklahoma’s Tulsa campus. He also hosts Studio Tulsa: Medical Monday on KWGS Public Radio Tulsa. You can follow him on Twitter: @GlassHospital.

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Many in Texas are keeping a close eye on the Republican bid to replace the Affordable Care Act. One of the big changes is how it would affect low-income people, seniors, and people with disabilities who get help from Medicaid. And people on both sides of the political spectrum say the Lone Star State is not going to fare well.

As the GOP bill, the American Health Care Act, works its way through Congress, Anne Dunkelberg with the left-leaning Center for Public Policy Priorities in Austin says she’s a little stumped.

“I have worked on Medicaid and uninsured and health care access issues in Texas for well over 20 years,” she chuckles. She says this bill leaves the fate of some current funding streams unclear and there’s one pot of money she’s particularly concerned about. Texas has struck deals with the federal government to help reimburse hospitals for the cost of caring for people who don’t have insurance. And Texas has more uninsured residents than any other state.

“About half of what Texas hospitals get from Medicaid today comes through payments that are outside from the regular Medicaid program,” she says, which adds up to $4 billion in federal funds every year.

But even if Texas gets to keep all that money, there’s another whammy — the GOP plan caps how much money states get for Medicaid from the federal government for every person they cover. It’s called a per-capita cap, and the payments under that formula would start in 2020, but would be based on how much the state spends this year.

Adriana Kohler with Texans Care for Children, an advocacy group based in Austin, says Texas already leaves too many people without care.

“Last legislative session there were cuts to pediatric therapies for kids with disabilities enrolled in Medicaid,” she says. The cuts caused some providers to shut their doors, which left some children without services, she says. “That’s why these cuts coming down from the ACA repeal bill are very concerning to us.”

She says in Texas, children, pregnant women, seniors, and people with disabilities will bear the brunt of any belt-tightening. These populations make up 96 percent of people on Medicaid in Texas. That’s why Dunkelberg says the program as is should not be the baseline for years to come.

“They could lock Texas into a lot of historical decisions that were strictly driven by a desire to write the smallest budget possible,” she says.

Some on the right agree Texas is getting a raw deal. Doctor Deane Waldman with the right-leaning Texas Public Policy Foundation says there are things he likes in the bill. But in general he says, “It’s bad deal for Texas. It’s a bad deal for the American people.”

He says it was the right thing for Texas not to expand Medicaid, but this bill punishes Texas for it. Under the GOP bill, states that expanded Medicaid would get more money. And because the Republican bill leaves the door open for states to expand Medicaid before 2020, he thinks more states will do that to get in on the deal.

“It’s going to be a huge rush — an inducement to drag in as many people as they can drag in, because the more they can drag in, the more federal dollars they can get,” he says.

That, in turn, will make Medicaid spending skyrocket, he says. But if Texas still refuses to expand, it will have to share a pot of $10 billion over five years with other non-expansion states, per the GOP bill. And that would be just a drop in a bucket for a state as big as Texas.

This story is part of a reporting partnership with NPR, KUT and Kaiser Health News.

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