DAVID GREENE, HOST:
We're digging deeper into the debate over the Affordable Care Act. A key part of that law has been expanding Medicaid to extend health coverage to more uninsured adults. Mostly it's working-poor Americans who don't make enough to participate in the health insurance exchanges.
RENEE MONTAGNE, HOST:
In all, 29 states have expanded Medicaid. But when the U.S. Supreme Court ruled in 2012 that the federal government could not compel them to do so, many Southern and Midwestern states opted out.
GREENE: And one of them is Texas. A quarter of low-income adults without insurance in this country live in Texas - more than a million people. Here's NPR's Wade Goodwyn.
WADE GOODWYN, BYLINE: For 121 years, Parkland Hospital has been the heart of Dallas's health care system. On a November day in 1963, emergency room doctors at this county hospital frantically tried to save an American president who could not be saved. These days, emergency room doctors frantically try to treat 240,000 patients every year.
DR. JOHN PEASE: Let me bring you out to where it all happens. These are the triage rooms.
GOODWYN: Dr. John Pease is the chief of emergency services. Parkland Hospital divides its emergency department into five different pods separated by symptoms and acuity.
UNIDENTIFIED ANNOUNCER: Patient, last name Aniyaku, first initial L, please return to Pod 5 for treatment.
GOODWYN: By federal law, the county's hospital emergency room cannot turn sick patients away, no matter their ability to pay. And so Parkland opens its arms.
PEASE: So you can see we have every treatment area filled up, beds along the hallways and rooms are all full.
GOODWYN: Last year, it cost Parkland Hospital a staggering three quarters of a billion dollars to provide what is called uncompensated care - mostly treating patients without health insurance. Parkland is hardly some 90-pound weakling, but $765 million of red ink will strain any-sized hospital. Dallas County judge, Clay Jenkins, oversees the county hospital. He says it doesn't have to be this way.
JUDGE CLAY JENKINS: A huge chunk of that could be paid for. It's about $580 million a year that would be brought in by the Medicaid expansion monies.
GOODWYN: Statewide, Texas hospitals had to eat 5.5 billion dollars in uncompensated care last year. The reason is this - after the Affordable Care Act passed, the amount of money the federal government provides to hospitals for uncompensated care was significantly reduced. It's cause and effect; if 9 out of 10 Americans have health insurance, the amount of uncompensated care hospitals have to provide goes down. But when the U.S. Supreme Court gave the individual states the option to opt out of part of the Affordable Care Act, then-Texas Governor Rick Perry could not opt out fast enough.
(SOUNDBITE OF ARCHIVED RECORDING)
RICK PERRY: Thank you all for being here. And the first day of April seems to me an appropriate April Fools' Day - makes it perfect to discuss something as foolish as Medicaid expansion.
GOODWYN: In 2013, while contemplating a second run at the presidency, Perry had a message for Tea Party conservatives across the nation.
(SOUNDBITE OF ARCHIVED RECORDING)
PERRY: And to remind everyone that Texas will not be held hostage by the Obama administration's attempt to force us into this fool's errand of adding more than a million Texans to a broken system.
GOODWYN: Perry's speech that day was a clear message to the Republican-dominated state legislature - Medicaid expansion is part of Obamacare, and Texas hates Obamacare. The problem is in hating the Affordable Care Act, the state is leaving on the table as much as $100 billion of federal money over 10 years - money that would pay for health insurance for more than a million of its working poor. This is driving many in the state's business community bonkers.
BILL HAMMOND: It's our money that we are sending to Washington, D.C. We are not getting it back.
GOODWYN: Bill Hammond is the CEO of the Texas Association of Business, which includes many of the state's richest and most powerful business owners.
HAMMOND: We pay for it with corporate income tax. We pay for it with our personal income tax, and we pay it in the fact that our premiums are higher than they would be if everyone was insured.
GOODWYN: Texas has the second-highest health insurance premiums in the country, right behind Florida. And Texas has the third-highest property taxes in the country. In Dallas, for example, more than half of property owners' county tax bill goes to reimburse Parkland Hospital for the uncompensated care it has to provide. And guess who's paying those high property taxes and buying that expensive health insurance for their employees?
HAMMOND: Texas businesses pay almost 63 percent of all state and local taxes.
GOODWYN: Hammond says if the state participated in Medicaid expansion, it would save Texas businesses billions of dollars a year that could then be invested in upgrading equipment, hiring new employees, providing raises and rewarding shareholders. Economic studies have shown that for every dollar the state would pay into Medicaid expansion, it would earn back $1.30 from the economic activity created. That economic activity is estimated to top out at $3 billion over a 10-year period, creating 300,000 jobs each year. Ray Perryman is a Texas economist who authored a comprehensive study about Medicaid expansion in 2013.
RAY PERRYMAN: It's infused in some areas that have direct impacts on the economy in a lot of fundamental ways 'cause you extend beyond the year in which it occurs, you may be prolonging someone's work life for 10 or 15 years or you may be solving a chronic illness problem that's going to drain hundreds of thousands of dollars from the system over time that's avoidable if people get health care earlier. There's a lot of things that play into it.
GOODWYN: For the last 30 years, Perryman has served as an economic adviser to the state legislature and six Texas governors, including George Bush and Rick Perry. Perryman says the economic benefits from taking billions of dollars of federal money to provide health insurance to Texas' working poor are multifaceted.
PERRYMAN: Forget all the other positive benefits you're having. Forget you're helping people's health care. Forget all that, just look at the numbers. And you look at them, you say this is a no-brainer. We need to be doing this. It's really in apolitical situation. It's just math.
GOODWYN: But it's much more than just the math. As the 84th session of the Texas legislator comes to a close, there's been no debate at all about Medicaid expansion. The issue seems settled, and the answer is an unqualified no. Wade Goodwyn, NPR News, Dallas. Transcript provided by NPR, Copyright NPR.
