Policy expert says Build Back Better Act could help fill coverage gap, but not likely to incentivize Medicaid expansion in Texas


Soraya Marashi


According to Joan Alker, executive director and co-founder of Georgetown’s Center for Children and Families, the Biden administration’s Build Back Better legislation presents a promising opportunity to help insure Texans who fall into the Medicaid coverage gap.


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A specific provision in the Build Back Better Act would temporarily close the coverage gap for uninsured people living in the 12 states that have not adopted Medicaid expansion by allowing these individuals to receive federally subsidized coverage on state-run marketplaces through 2025. 

For Texas, says Alker, this provision is especially important because Texas has the largest population (an estimated 771,000 as of 2019) that falls into the coverage gap among the states that haven’t expanded Medicaid. Moreover, Texas has the largest uninsured rate in the nation for both adults and children. 

Alker said there are many ways this legislation would benefit Texas if it passed. 

“We know that people who are uninsured have lost access to needed medical care, and that they’re exposed to medical debt and even bankruptcy when they do need health care. So, providing that financial security, as well as access to needed health care is critical for anybody’s well being … for the providers in Texas … they are carrying a big uncompensated care load today, because Texas is the number one state for uninsured rates. So providers have to pick up a lot of those costs when someone shows up in the emergency room, and those costs get shifted to everybody else in the system to some extent.”

Alker also said, despite evidence proving it to be a beneficial fiscal decision, the state most likely would not change its mind on expanding Medicaid even if the bill passes. 

“There already are additional fiscal incentives from the American Rescue Plan last year for states that expand [Medicaid]. It was already a very generous offer on the table–the federal government pays 90 cents on the dollar. The American Rescue Plan added an extra boost, so that the state for the first couple of years could actually make money, and the Build Back Better Act enhances that even more by raising the underlying match rates from 90% to 93% for all states that do expansion.”

She added that, if Texas did expand Medicaid, Build Back Better would increase the FMAP even further for the expansion group from 90% to 93%, resulting in an even better fiscal deal for Texas.

“For states that have not expanded Medicaid … it’s really an ideological, political decision at this point. It’s not a fiscal decision. It’s not a fact-based decision, because we have hundreds of studies showing how Medicaid expansion benefits people in many, many ways, and it helps state budgets and helps health care providers like hospitals. So there’s a mountain of evidence as to why states should do it. The 12 states that still refuse to do it is for political reasons. So those probably won’t change.”