BROWNSVILLE, Tex. --When the sun rises over the Rio Grande Valley, the cries of the urracas – black birds – perched on the tops of palm trees swell to an unavoidable cacophony.
That is also the strategy, it could be said, that local officials, health care providers and frustrated Valley residents are trying to use to convince Gov. Rick Perry and state Republican lawmakers to set aside their opposition and expand Medicaid, a key provision of the federal health law.
To the struggling counties that stretch along the border with Mexico, where unemployment hovers above 10 percent and the local tax base often cannot fund basic government services, the roll-out of President Barack Obama’s health care overhaul and its promise to open up Medicaid to all low-income adults is akin to eyeing a winning lottery ticket. In Cameron County, for example, where Brownsville is the county seat, it will mean $7 billion added to the local economy over a decade. In neighboring Hidalgo County where some 800,000 people live, the windfall is even more impressive: some $12.6 billion, according to an analysis by Ray Perryman, a Texas economist well-regarded by both political parties.
“It’s a big number,” said Carlos Cascos, a Republican judge in Cameron County elected to oversee the commissioners and budget in the county that is home to 414,000 people.
Texas has the highest rate of uninsured residents in the country – one in four Texans has no health coverage – and the rate in the Rio Grande Valley is even higher, at about 38 percent. Counties are required by state law to pay for basic health care for destitute residents, and last year Cameron County paid $6 million for so-called “indigent care.” The program is closed to anyone earning more than $196 a month, leaving many working adults ineligible and without coverage. And since there are no public hospitals in the Valley, private hospitals end up with millions in unpaid bills when residents seek emergency care.
That has led a number of counties in the Rio Grande Valley, and elsewhere in Texas, to begin squawking, just like the black birds, by passing resolutions stating their support for the Medicaid expansion. It is an act of public defiance against a powerful, combative governor. Perry, who has been in the governor’s office since George W. Bush left Austin for the White House in 2000, has been one of the most outspoken critics nationally of the federal health law.
All of which makes Cascos something of an unlikely – and cautious – rebel with a cause.
“It’s contrary to what the leadership in Austin is recommending,” said Cascos of his vote on the Cameron County board in support of the expansion. “But we thought it was important enough to take a position – just to show the governor and the administration that there is support out there from the local municipalities, the local county government and other officials.”
Across the Border
It is easy to see why this struggling South Texas county would yearn for more dollars. In Brownsville, across the street from Casco’s office in an ornate former courthouse are abandoned wooden buildings, their paint peeling from ceilings to cellars. And many of those who live here – including poor Latino immigrants, both legal and undocumented -- suffer from diabetes and lack of insurance. Some of those uninsured diabetics, including American citizens and others living here legally, used to go across the border to Matamoros, Mexico for insulin. But now with the fear of brutal drug violence and tougher border restrictions, families share their insulin shots rather than risking the crossings.
“People aren’t going anymore,” said Lupita Sanchez, a community health worker who does diabetes education at Proyecto Juan Diego, a health outreach program in downtown Brownsville and a short walk to the border.
Sanchez said that many of those who used to cross the border would qualify for Medicaid under the expansion offered by the health care law. And the state of Texas wouldn’t have to pay for it, at least not initially: the law directs the federal government to pay the entire cost of expanding Medicaid for the first three years for newly eligible enrollees, and 90 percent in subsequent years.
But Perry has called the expansion “foolish” and has said he is leery of Obama and Congress, both eager to balance the federal budget, pushing more of the costs onto the states in the future. Whether that is likely is unclear: to change the funding formula, Congress would need to change the law. And there would be fierce Democratic opposition to doing that. As it stands, Texas would have to spend about $1 billion a year over the next three years, say Democrats, to receive $27 billion in federal matching funds.
Meanwhile, as health care providers in South Texas watch Republican governors in Arizona, Ohio and New Jersey moving to expand their state Medicaid programs, patience is running out.
Health care providers and community activists organized a 700-mile bus trip earlier this year for Valley residents to lobby lawmakers in Austin over the Medicaid expansion. Mike Siefert, a former Catholic priest who lives in Brownsville, rose at 3:25 a.m. to make the bus trip. He said the effort seemed fruitless, no matter how loudly Valley residents and local officials, Democrats and Republicans alike, make the case for expansion. “We are totally ignored,” Siefert said. “It’s not only speaking into the wind. It’s speaking into a deep dark hole.”
Looking For Buy In
“If Texas doesn’t buy in in the next three months, shame on us,” said Paula Gomez, the executive director of the Brownsville Community Health Center. “I think we’re derelict in our responsibilities to our residents in this great state.”
Sitting at her desk at the Brownsville Community Health Center, Gomez pulls up on her computer a list of some 4,000 uninsured patients seen at her clinic who would be eligible, based on their income, for the Medicaid expansion. Perry has argued that adding more people to the state’s Medicaid program would be akin to adding people “to the Titantic,” he said, since so few Texas physicians accept Medicaid because of the paltry reimbursement rate set by state lawmakers. But Gomez said for safety-net clinics like hers, those added Medicaid dollars would go a long way.
“You’re talking huge bucks,” said Gomez, who estimates that her clinic alone could receive up to $1 million per year in additional Medicaid payments under an expansion.
For now, those uninsured patients pay what they can for basic medical care at the clinic, but specialty care is a problem.
“Once you diagnose a cancer, then what?” said Dr. Henry Imperial, the clinic’s medical director. “How are you going to give me chemotherapy or surgery or radiation therapy? It goes out of our hands.”
Those complications can make for some intense arm-twisting among Brownsville’s medical ranks. Imperial said he often plies fellow doctors in town with beer to see his uninsured patients. “When they see me approaching them, they start running away,” he joked before turning somber. “It’s just tough. I could not do an appendectomy. I cannot operate on gall bladders. I need a surgeon.”
Most specialists, including surgeons, in Brownsville, accept Medicaid, said Imperial. “It does pay for services that otherwise the patient does not receive.”
Perry’s position that Texas will not expand Medicaid remains unchanged. According to his website, “Texas will continue saying ‘no’ to Medicaid.” At a press conference at the state Capitol in April, Perry said, “Texas will not be held hostage by the Obama administration's attempt to force us into the fool's errand of adding more than a million Texans to a broken system.”
Waiting For Care
Sitting in the clinic’s waiting room as the energetic hosts of a Spanish-language morning show laugh and strut on the television, Mark Buitron, 22, is sweating and looks miserable. He suspects he has the flu, and he called in sick to his job tearing apart old cruise ships at the Port of Brownsville. “We take apart boats from the bottom, removing shelves, desks, beds,” he said, his hands tucked into the pockets of a boiled-wool green varsity letter jacket from his days playing soccer at a local high school.
Buitron is fit, with a chiseled jawline and dark brown eyes, and he works full time with no sick pay or health insurance. His yearly income is less than $15,000 which is low enough to qualify for the expanded Medicaid should Texas lawmakers decide to expand the program.
He has been to the hospital only once since he became uninsured after he aged out of Medicaid for children. The hospital sent him a bill for $11,000. “I still have it,” he said. For today’s visit, he’ll pay $25 in cash to see the doctor. But should he need medical care beyond basic services or if he gets sick in the future, he asks, “How much are they going to charge me then?”
Paula Gomez says the clinic often has to send patients with serious illnesses to the emergency room knowing they’ll get bills they can’t pay.
“I can blame Perry all day long, but he’s just one man,” Gomez said. “I think we’ve got a whole mess of other people who should be pushing. And he’s not God in this state. He’s just the governor.”