Texas Coverage Gap Project

Objections & answers

Serious objections deserve serious answers, including the parts where critics are right.

“Texas can't afford it, and the federal match could be cut.”

What the evidence shows: Expansion adults are matched at 90%.1 Studies of expansion states found no significant rise in state-funded spending.2,3

What we concede: The state share is real, and current estimates don't exist.4,5 A law can include a trigger that ends expansion if the match falls.

“The 2025 federal law makes expansion bad for Texas hospitals.”

What the evidence shows: Hospitals would see less uncompensated care.6

What we concede: Expanding would also trigger tighter provider-tax and directed-payment limits.7 This is the strongest Texas-specific objection, and its net effect hasn't been modeled publicly.

“It discourages work.”

What the evidence shows: Most rigorous studies find no significant employment drop.8,9

What we concede: Some people do work for insurance.10 Federal work requirements would apply anyway; in Arkansas they mostly cut coverage.11,12

“People will drop private insurance.”

What the evidence shows: No measurable crowd-out of employer coverage was found.13

What we concede: People at 100–138% of poverty on Marketplace plans would shift to Medicaid.

“Medicaid is full of fraud.”

What the evidence shows: The 6.12% improper payment rate is mostly documentation problems, and CMS says it is not a fraud rate.14

What we concede: Eligibility errors happen, and federal penalties now apply to states with high error rates.

“Doctors won't take Medicaid anyway.”

What the evidence shows: Coverage still reduces financial harm and increases regular care.15,16

What we concede: Texas physician participation is below the national average.17 Coverage alone doesn't solve access.

“Coverage doesn't improve health.”

What the evidence shows: Strong studies found lower mortality and less depression.18,19,20

What we concede: Oregon saw no 2-year change in blood pressure or cholesterol, and some mortality studies are underpowered.20,21

“It will raise ER use and spending.”

What we concede: Yes. ER use and total spending rose in Oregon.22,23 The argument is about value and financial protection, not savings.

“Paperwork will churn people off anyway.”

What the evidence shows: Renewal design matters: automatic data checks can keep eligible people covered.

What we concede: Texas had high procedural disenrollment during the unwinding, and six-month renewals are now required.24,25

“We already have rural grants, hospital pools, and county indigent care.”

What the evidence shows: None of these is insurance. County care stops at 21–50% of poverty.26

What we concede: Rural grants are temporary, and the hospital pool is shrinking.27,28

Sources for this page

  1. Federal Register FMAP notice for Oct 1, 2026-Sep 30, 2027 (2025-11-28). https://www.federalregister.gov/documents/2025/11/28/2025-21332/federal-financial-participation-in-state-assistance-expenditures-federal-matching-shares-for [evidence L10]
  2. Sommers & Gruber, Health Affairs 2017, doi:10.1377/hlthaff.2016.1666 (2017-04). https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1666 [evidence P1]
  3. Markell & Meiselbach, Health Serv Res 2024, doi:10.1111/1475-6773.14331 (2024-05-28). https://pmc.ncbi.nlm.nih.gov/articles/PMC11366958/ [evidence P2]
  4. Legislative Budget Board staff estimate (Mar 4, 2013); HB 3376 fiscal note (Apr 16, 2013) (2013). https://capitol.texas.gov/tlodocs/83R/fiscalnotes/html/HB03376I.htm [evidence P3]
  5. Fritz, Pitts & Pitts (Sept 2020); Dague & Hughes, Texas A&M Bush School (Sept 2020), both for Episcopal Health Foundation (2020-09). https://episcopalhealth.org/wp-content/uploads/2020/09/Fritz-Pitts-Pitts-Sept-2020-Impact-of-Medicaid-Expansion-on-State-Budget-1.pdf [evidence P4]
  6. Blavin, JAMA 2016;316(14):1475-83, doi:10.1001/jama.2016.14765; Dranove, Garthwaite, Ody, Health Affairs 2016, doi:10.1377/hlthaff.2015.1344 (2016). https://jamanetwork.com/journals/jama/fullarticle/2565750 [evidence R2]
  7. CMS Dear State Medicaid Director letter on OBBBA sections 71115/71117 (2025-11-14). https://www.medicaid.gov/medicaid/downloads/providertax_dcl_11142025.pdf [evidence L7]
  8. Baicker, Finkelstein, Song, Taubman, AER P&P 104(5):322-28, doi:10.1257/aer.104.5.322 (2014). https://pmc.ncbi.nlm.nih.gov/articles/PMC4145849/ [evidence W1]
  9. Leung & Mas, Industrial Relations 57(2):206-234, doi:10.1111/irel.12207; Kaestner et al., JPAM 36(3):608-42, doi:10.1002/pam.21993 (2018; 2017). https://doi.org/10.1111/irel.12207 [evidence W3]
  10. Garthwaite, Gross, Notowidigdo, QJE 2014, doi:10.1093/qje/qju005 (2014). https://doi.org/10.1093/qje/qju005 [evidence W2]
  11. CMS Interim Final Rule CMS-2454-IFC, 91 FR 33348 (FR Doc 2026-11094); CMS fact sheet (2026-06-03). https://www.govinfo.gov/content/pkg/FR-2026-06-03/html/2026-11094.htm [evidence L5]
  12. Sommers, Goldman, Blendon, Orav, Epstein, NEJM 2019;381:1073-82, doi:10.1056/NEJMsr1901772 (2019-06-19). https://www.nejm.org/doi/full/10.1056/NEJMsr1901772 [evidence W4]
  13. Frean, Gruber, Sommers, J Health Econ 2017, doi:10.1016/j.jhealeco.2017.02.004 (2017). https://doi.org/10.1016/j.jhealeco.2017.02.004 [evidence E4]
  14. CMS FY2025 Improper Payments Fact Sheet (2026-01-15). https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-improper-payments-fact-sheet [evidence E2]
  15. Finkelstein et al., 'The Oregon Health Insurance Experiment: Evidence from the First Year', QJE 127(3):1057-1106 (2012). https://pmc.ncbi.nlm.nih.gov/articles/PMC3535298/ [evidence F1]
  16. Sommers, Maylone, Blendon, Orav, Epstein, Health Affairs 2017, doi:10.1377/hlthaff.2017.0293 (2017-05). https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0293 [evidence H6]
  17. MACPAC, 'Physician Acceptance of New Medicaid Patients: Findings from the NEHRS' (June 2021) (2021-06). https://macpac.gov/wp-content/uploads/2021/06/Physician-Acceptance-of-New-Medicaid-Patients-Findings-from-the-National-Electronic-Health-Records-Survey.pdf [evidence R4]
  18. Miller, Johnson, Wherry, 'Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data', QJE 136(3):1783-1829, doi:10.1093/qje/qjab004 (2021). https://academic.oup.com/qje/article-abstract/136/3/1783/6124639 [evidence H1]
  19. Borgschulte & Vogler, 'Did the ACA Medicaid expansion save lives?' J Health Econ 72:102333, doi:10.1016/j.jhealeco.2020.102333 (2020). https://doi.org/10.1016/j.jhealeco.2020.102333 [evidence H2]
  20. Baicker et al., 'The Oregon Experiment', NEJM 2013;368:1713-22, doi:10.1056/NEJMsa1212321 (2013-05-02). https://www.nejm.org/doi/full/10.1056/NEJMsa1212321 [evidence H5]
  21. Black, Hollingsworth, Nunes, Simon, NBER w25568 'The Effect of Health Insurance on Mortality: Power Analysis...' (2019 (rev.)). https://econpapers.repec.org/RePEc:nbr:nberwo:25568 [evidence H4]
  22. Taubman et al., Science 2014, doi:10.1126/science.1246183; Finkelstein et al., NEJM 2016, doi:10.1056/NEJMp1609533 (2014; 2016). https://www.nejm.org/doi/full/10.1056/NEJMp1609533 [evidence H8]
  23. Baicker et al. NEJM 2013 (Oregon) (2013). https://www.nejm.org/doi/full/10.1056/NEJMsa1212321 [evidence S1]
  24. KFF unwinding analysis; Texas Tribune 2023-12-14; ProPublica (2024). https://www.kff.org/medicaid/an-examination-of-medicaid-renewal-outcomes-and-enrollment-changes-at-the-end-of-the-unwinding/ [evidence E3]
  25. KFF, 'Health Provisions in the 2025 Federal Budget Reconciliation Law' (P.L. 119-21) (2025-08-22). https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/ [evidence L6]
  26. Texas Health & Safety Code ch. 61; Texas HHSC CIHCP page; county FY2025-26 chart (accessed 2026-10-24). https://www.hhs.texas.gov/services/health/county-indigent-health-care-program [evidence L11]
  27. CMS press release 2025-12-29; Texas HHSC bulletin (Year 1 budget approved 2026-04-07) (2025-12-29). https://www.cms.gov/newsroom/press-releases/cms-announces-50-billion-awards-strengthen-rural-health-all-50-states [evidence L13]
  28. Texas HHSC 1115 waiver page; HHSC 'Future of the UC program' (rev. 05/2024, hosted by THA) (2024-05). https://www.tha.org/wp-content/uploads/2024/05/Future-of-UC-Program.pdf [evidence L14]

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