2024 Presidential Election Impact on Texas: Medicaid

This is a multipart series on the different ways the 2024 Presidential Election is likely to affect Texas.

Medicaid is the federal government health insurance plan designed to cover low-income, chronically ill, and disabled people. Unlike Medicare, which primarily covers older adults and is run entirely by the federal government, Medicaid is a joint state/federal program. That means that whoever is president can have a significant impact on how Medicaid is run in Texas.

When former President Donald Trump ran for election in 2016, he vowed to repeal the Affordable Care Act, also known as Obamacare. The ACA is responsible for a widely popular Medicaid expansion, where the federal government covers almost all the costs of insuring state residents who sign up under the expanded guidelines.

Trump tried repeatedly to repeal the ACA through both executive action and pressure in Congress, but ultimately failed. Currently, he says he no longer wants to terminate it, but only has a “concept of a plan” to improve the law.

Texas remains one of the few states that has still not accepted the Medicaid expansion. However, the winner of the election still matters a great deal to the Texas residents already on Medicaid.

The administration of President Joe Biden and Vice President Kamala Harris made reducing maternal mortality and morbidity a top priority. Biden-Harris offered Section 1115 waivers to states to expand their coverage in this area. Texas accepted, keen to address its woeful state of maternal healthcare. Because of Biden-Harris, thousands of people in Texas received extended postpartum care.

Trump also approved some waivers while president for states to expand their coverage, but they came with a major caveat: work requirements. Texas already has some of the most restrictive eligibility requirements for Medicaid coverage in the country. Most Medicaid recipients either work or have health restrictions that prevent them from doing so. Trump was the first president to narrow the eligibility field in this way. His actions were struck down by the U.S. Supreme Court and fully walked back by Biden-Harris.

Neither candidate can force Texas to accept the Medicaid expansion. The U.S. Supreme Court ruled in 2010 that acceptance was optional for states. However, a president that builds on the success of the Affordable Care Act could make it more attractive to the remaining states like Texas who have refused to go along.

There is some evidence that this is already happening. The matter of Medicaid expansion came up repeatedly in the last two Texas legislative sessions despite Governor Greg Abbott’s antipathy for the idea. The adoption of the maternal health expansion is proof that Republican lawmakers are wavering on their universal opposition to Obamacare.

Texas has over a million residents who would be eligible for Medicaid if the expansion was adopted. While it’s unlikely that Trump could completely repeal the Affordable Care Act if he won, he could continue trying to limit who is eligible through the program. It’s highly unlikely Medicaid enrollment in Texas would rise under a Trump-Vance Administration.

There is one significant black mark against Biden-Harris when it comes to Medicaid. Federal laws passed during the COVID pandemic loosed eligibility requirements on Medicaid and prevented people from being taken off the program. Because of this, millions were able to secure coverage in the most severe health crisis in a century.

Those protections ended in 2023, and states immediately began purging their rolls. Texas dropped half a million people in a single month. Though this was the result of a law expiring rather than deliberate action on the part of Biden-Harris, it was still a massive loss of healthcare for Texans, and the president did little to address it.

Medicaid in Texas remains underutilized and ineffective, thanks mostly to Republican state leadership. Biden-Harris has had some success in expanding coverage, while Trump sought specific restrictions. Whoever wins, there will be a lot of work to do.