Over the years, as members of the Health and Public Policy Committee (HPPC) of the Texas chapter of the American College of Physicians (ACP), we have focused on advocacy for what we believe is the most important health policy issue in our state, Medicaid expansion under provisions of the Affordable Care Act (ACA). Our efforts, and the work of many others, have had no discernable impact on state policy.

In the summer of 2023, we conducted a survey on Medicaid expansion advocacy by HPPCs of the nine other non-expansion states, hoping to discover effective strategies to pursue in Texas. The survey revealed a profound sense of frustration, resignation, and burnout leading several chapters to abandon expansion advocacy. Representative statements included:

“Advocating for Medicaid expansion is problematic in our state as the legislative leadership has signaled strong opposition.”

“As to the loss of hundreds of millions of federal health care dollars, this is falling on deaf ears. Several years ago, the House of Delegates of our medical association passed a resolution to support Medicaid expansion, but after the legislative committee saw how much political ammo would be required—and the unlikelihood of passage—they have abandoned any efforts. Our ACP health and public policy committee has chosen not to pursue Medicaid expansion support until the current legislature has been overturned.”

“We share your same struggles! This past legislative session, Medicaid expansion was not seriously considered. I don’t think any amount of lobbying or money would have changed that based on the current legislature. We did donate to an organization whose main goal is advocating for Medicaid expansion; however, some of our members thought we shouldn’t even donate because the return on investment is so poor—meaning, again, no amount of money is changing the minds of the current legislature.”

“Discussion on Medicaid expansion has been a complete non-starter over the years.”

“Not sure we have made much headway on Medicaid expansion. I think we are all fighting a significant uphill battle.”

In short, non-expansion states’ leadership is unmoved by the overwhelming evidence that expansion results in better health and longer lives for citizens of their states, including children. It also reduces health care costs, for example, by reducing the number of expensive emergency department visits. Inflicting all of this hardship is also expensive, but apparently a price these states are willing to pay by declining an enormous amount of federal funds—money that is available, in part, because of their own taxpayers.

The UC Berkeley social scientist George Lakoff would say that our advocacy is misguided in ways that are characteristic of progressives. For example, his research indicates that argument by evidence is not convincing in the political sphere. What is compelling, as conservatives understand, is framing your position as an unshakable moral principle. Progressives, on the other hand, tend to be embarrassed by “moral” assertions and appeals to emotionality. Anti-abortion partisans persisted for almost 50 years before Roe was overturned. Lakoff would also decry our lack of perseverance. The frustration expressed in the state survey is understandable. But waiting for a change in the composition of the state legislature—assuming that if you just wait long enough, political sentiment will move in your preferred direction—is not a strategy. It is wishful thinking.

Expansion is favored by 70 percent of Texans. Although not controversial, expansion is adamantly opposed by the governor and most state legislators. Why? We can think of three possible explanations:

Political self-interest. In a one-party state, most incumbents are not concerned about the general election. They care about being “primaried” by more extreme challengers from their own party. Therefore, legislators may not want to advocate expansion, assuming they are untroubled by the impact on constituents’ health and longevity or by the increased rate of rural hospital closures seen in non-expansion states. (Texas is the most rural American state.)

Aversion to “generosity” to the “undeserving.” This applies to those unaware, sometimes willfully, that most Medicaid recipients already work unless they are children, elderly, or disabled.

“… government is not the solution to our problem; government is the problem.” The words of President Ronald Reagan have become a cornerstone of conservative ideology. Legislators are in a position to make this a self-fulfilling prophecy by undermining program implementation, traditionally by underfunding. Expansion is an especially inviting target because of antipathy to President Obama and the ACA, derisively called “Obamacare” by opponents to the legislation.

Regrettably, there is one more possible explanation, described in a widely quoted article in The Atlantic by Texas-based journalist Adam Serwer in 2018. The title of the article summarizes his argument: “The cruelty is the point.”

Under provisions of the ACA, states could expand Medicaid coverage to include anyone earning up to 138 percent of the federal poverty level beginning in 2014. The cost of expansion was initially covered in full by the federal government. Since 2020, the states have had to pay 10 percent of the cost. Expansion has generally remained a net positive for state budgets.

Because funding for states is so generous, the framers of the ACA legislation did not anticipate that any state would decline to participate. In some states that chose not to expand Medicaid, income eligibility thresholds remain significantly below 133 percent of the poverty line, and able-bodied adults may not be eligible for Medicaid at all. Some of these states do not make Medicaid available to non-pregnant adults without disabilities or dependent children, no matter their income.

In non-expansion states, this policy has caused the “coverage gap,” where millions of people have an income too high to qualify for Medicaid but too low to receive subsidies to pay for private health insurance from the ACA marketplace, making insurance unaffordable. There is no other source of funds sufficient to raise non-expansion states like Texas and Mississippi above their last-place status for health outcomes. Newly released census data show that Texas has the worst uninsured rate in the United States. In Lakoff’s language, Medicaid non-expansion is morally indefensible. State legislators across the political spectrum habitually endorse improving health care “access” for the underserved. Those who express this opinion but do not support Medicaid expansion do not, in fact, favor better access. They just like talking about it.

David M. Auerbach is an internal medicine physician. Alex Gajewski is an internal medicine resident. Fabrizia Faustinella is an internal medicine physician.