Medicaid expansion remains unlikely in Texas

• But there's evidence that the political winds are changing in holdout states as leaders court rural voters, assess new financial incentives and confront the bipartisan popularity of extending health care coverage.
• In Texas, the state with the highest percentage of uninsured residents per capita, some Republicans have co-sponsored Medicaid expansion bills. That indicates "cracks" in Republican opposition, Luis Figueroa, legislative and policy director at progressive think tank Every Texan, told Axios.

Yes, but: Proposals to expand Medicaid did not even get a committee hearing in 2021 — let alone a vote on the Texas House or Senate floor.

• What they're saying: Based on the history of the state's Republican leadership, there's no reason to think 2023 — the next time the legislature convenes in Austin — will be any different from 2021, David Balat, a former hospital administrator who now runs the health care initiative at the conservative Texas Public Policy Foundation, tells Axios.

State Sen. Nathan Johnson, a Dallas Democrat who has led the push for Medicaid expansion, said he doesn't expect to see it pass this session, but noted he was optimistic about last session's shift, where it became "a subject at the forefront of the state."

• "I think a lot of Republican members would like to extend Medicaid even more than they will say it," Johnson added.

Bucking expansion, Texas Republicans have tried their own approach to improve health care in the state.

• House Speaker Dade Phelan last session pushed a slew of health care measures on telehealth, drug savings and expanding Medicaid coverage for new mothers.
• Phelan told Axios he would "prioritize improvements to health coverage," but did not indicate that he would support Medicaid expansion. Instead, he said he would push for Medicaid expansion for new mothers to one year after birth, which the Senate watered down to six months before its passage in 2021.
• Federal regulators are expected to reject the plan to extend Medicaid for new mothers over its eligibility restrictions, which leave out women who terminate their pregnancies, even in medical emergencies, the Dallas Morning News reported.

Between the lines: To fill in some of those gaps, the Texas Hospital Association plans to lobby for measures to further expand postpartum Medicaid, in-patient behavioral health care and ensure that eligible Texans aren't removed from Medicaid rolls next session.

• "We will continue to strongly advocate for Medicaid expansion," said Jennifer Banda, senior vice president of advocacy and public policy for the group. "At the same time, these are also things we can do that will continue to move us forward in terms of people having the best possible access to care."

Short of an outcry over health care issues and enough electoral surprises in gerrymandered Texas House races in November to put the scare into Texas Republicans, overcoming the opposition of the top GOP leadership will be "big obstacles to overcome," Figueroa says.

• And if there are surprises: "When you're a legislator and these races did not come out the way you wanted them to come out, a vote for Medicaid expansion helps put you a little towards the middle without any real harm, so that you're not as vulnerable as next time around," he says. "Medicaid expansion is a pretty easy one, because it's revenue-supported, it's popular and it helps rural hospitals."

What we're watching: The midterm elections. In the unlikely scenario that both Beto O'Rouke beats Gov. Greg Abbott and Mike Collier unseats Lt. Gov. Dan Patrick — both sitting Republicans are opposed to Medicaid expansion — the whole ballgame changes.

The future of Medicaid expansion in other red states