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Benson Kumenda 1
How has the Affordable Care Act impacted the economically disadvantaged population in
Texas compared to California?
In 2010, President Barack Obama signed the Affordable Care Act, also known as Obama
Care to the vast majority of Americans, into legislation. When this piece of legislation was going
through Congress Republicans and Democrats could not uniformly agree. This piece of
legislation was one of the most bi-partisan and complex pieces of law to ever pass through
congress. During the time many news outlets were reporting very polarizing information on this
important piece of health reform leading to not many Americans not having a full understanding
of the Affordable Care Act and what it is designed to do and help. After this health reform was
signed into office certain aspects of this reform were implemented differently across different
states. This research paper will compare and contrast how the implementation of the Affordable
Care Act has affected the economically disadvantaged people in Texas versus California. Texas
and California are very opposite states so it will be very important to see have this piece of the
law affected those in a very liberal state versus those in a very conservative state.
Benson Kumenda 2
The construction of the Affordable Care Act was meant to provide a way for middle-class
Americans to be able to afford health insurance. This health reform was meant to target
Americans who were too rich to be placed on their state's Medicaid program and weren't
receiving enough health coverage from their jobs. What made the Affordable Care Act such a
bi-partisan issue was the fact that “the ACA addressed health care issues, but the two most
controversial were these: an individual mandate that all uninsured Americans purchase health
insurance and a requirement that all states expand their Medicaid programs to meet a new and far
more generous nationwide eligibility standard or lose existing federal Medicaid dollars. While
many commentators hailed the ACA as a landmark on the path to universal health insurance,
others bitterly criticized the individual mandate and the expansion of Medicaid. The law, vilified
by conservatives, has survived numerous attempts at outright repeal by the House of
Representatives, but it has endured Supreme Court challenges less than fully intact, and many
states have simply refused to comply with the bill’s expectations. This last problem, state
non-participation, has brought state choice into scholarly focus”(Meyer and Kenter and Morris
2015, 1). The constitutionality of this was questioned heavily on whether the federal government
had this right to force all Americans to receive health insurance and if they had the power to
make all states expand their Medicaid programs. Medicaid is a state-run program funded by
individual state governments. The federal government making states expand their Medicaid
programs were seen as a overstep in their given power. Many cases went to the supreme court
regarding the affordable care act but no real issues could be found with the health reform.
Because this was such a partisan piece of the legislature, it could be argued that there was
a shift from it being a piece of public reform meant to help a neglected group of Americans to
partisan politics. Studies have shown “states with the greatest Tea Party influence happen to be
Benson Kumenda 3
home to some of the poorest and unhealthiest populations in the country, populations that the
ACA was designed to assist. Brill, on the other hand, has cited general public disdain for the
health care system as a whole — a system which, compared to the systems of other developed
nations, is among the most expensive, among the least supportive of public-health programs,
judged by outcomes, among the middle-ranking” ( Meyer and Kenter and Morris 2015, 1). Also,
“many early studies assumed the decision not to expand Medicaid was a function of partisan
politics underscored by ideological cleavages. Partisanship would make the balancing of conflict
and incentive difficult, even futile. Reference Haeder and Weimer Emanuel suggested that the
intense political partisanship around the early implementation of the ACA created the most
poisonous political environment in the United States since the Civil War” ( Meyer and Kenter
and Morris 2015, 1). This piece of health reform is meant to help uninsured Americans receive
health insurance. Not having health insurance in the U.S can lead to an accumulation of crippling
debt or forgoing needed health care because of how much the costs outweigh the benefits in their
situation. It is scary to think how much partisan politics can play a prohibiting a group of
Americans from receiving needed health reform to a health system that has neglected them.
Shifting from a piece of health reform designed to help Americans to play into politics can lead
to the true agenda being lost, ultimately affecting the American people in the end.
Many states were given incentives under the Affordable Care Act to expand their
Medicaid programs, Medicaid is a state-run program that issues health care to the lower class
populations in the state. Since each state has its regulations and requirements to meet Medicaid
the federal government can’t force the expansion of a state-run program as seen in Texas. Texas
governor Greg Abbot chose to not expand Medicaid under the Affordable Care Act saying
“Medicaid is wrong for Texas,” and he called the ACA a “massive expansion of an already
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Benson Kumenda 4
broken and bloated Medicaid program. Republican leaders may be misreading voter sentiment
because respondents’ third highest priority for the state legislature was expanding Medicaid
under the ACA. The literature has indicated that the states that chose to expand Medicaid have
higher coverage rates than do those that did not expand Medicaid.8,11,19 Texas’s proportion of
Hispanics is higher than that of the United States as a whole, so insurance coverage may have
increased more in Texas than in other non-expansion states.”(Pickett and Marks and Ho 2016, 1).
Not expanding Medicaid in a state that has the second-highest population while also
simultaneously having “the lowest coverage rate in the country before the implementation of the
ACA Marketplace” with “22.1% of all Texas residents lacking coverage (5 748 000 people)”
compared to the national rate of 14.1% (Pickett and Marks and Ho 2016, 1). Having a large
population of residents uninsured means that some of those residents don't have the opportunity
to put their health first because of the risk of going into debt due to the rising cost of healthcare
in America. Because this piece of legislature was so complex and controversial, Governor Abbot
may have been playing into partisan politics rather than the health interests of his people. Having
an uninsured population will lead to overutilization and unnecessary visits to the expensive
hospital emergency rooms.
Although Texas choosing not to expand its Medicaid program under the Affordable Care
Act, this federal health reform still had a positive impact on the economically disadvantaged
population. Upon implementation, the Affordable Care Act was meant to “ provide much-needed
financial relief to millions of lower- to middle-income individuals and families through a robust
new tax credit to assist with the cost of health insurance premiums. These new premium tax
credits will offset a significant portion of the cost of health insurance premiums. The unique tax
credit will be calibrated to ensure that individuals and families do not have to spend an excessive
Benson Kumenda 5
share of their income on premiums. The limit for each family will be between 2 and 9.5 percent
of income, on a sliding scale ”( Basiley and Stoll 2011, 8). This means that when a person is
shopping for health insurance there will be cheaper and more affordable monthly premiums for a
health plan. Saving the financial pockets of the financially disadvantaged texas residents will
help them in more ways than one and ease the stress of having to pay high medical bills. The
Affordable Care Act still helped lower class texas residents but choosing to not expand the
Medicaid program in Texas is still going to leave a large amount of the poor population without
valuable health insurance denying them the opportunity to seek medical help if needed or forcing
this population to make constant emergency room visits when an illness progresses too far.
In California, Governor Arnold Schwarzenegger elected to expand the Medicaid program
in Califonia called Medi-Cal to encompass more lower-income residents. Overall, “changes to
insurance regulations, the creation of health insurance marketplaces, and the expansion of
Medicaid in California have reduced the number of uninsured individuals substantially”(Roby et
al. 2014, 1). California expanding its medicare program had a direct effect in lowering the
number of uninsured residents in the state. After the implementation of this health reform a
“significant 1.8 percentage-point increase in public coverage among low-income adults in the
first full year following the expansion, with larger increases found among Latinos and
individuals with limited English proficiency. We found a 2 percentage-point decline in the
uninsured rate among adults below 200 percent FPL in expansion counties, compared to control
counties” ( Sommers et al. 2016, 1) Lowering the uninsurance population in California will
greatly help ensure that healthcare in the state is equal and available for all residents.
Low-income residents in California can worry less about their health and take the initiative to
seek preventative care through annual PCP checkups to ensure they are healthy and able to
Benson Kumenda 6
promptly address any health issues of concern. This will cut the overutilization of the emergency
rooms by the uninsured because with health insurance they can seek help through a primary care
doctor rather than going to the hospital for flu-like symptoms and having to pay a large medical
bill for that emergency room visit.
The Affordable Care Act benefited both low-income residents in Texas and California
in providing a market for more affordable healthcare that helped get a lot of people who couldn't
afford health insurance due to the high premiums. While also being able to “improve quality and
bring down the growth in health care costs. The Affordable Care Act authorizes programs that
improve the ways that doctors and hospitals coordinate care, programs that promote preventive
services and practices, and programs that will develop and disseminate better information about
new drugs and treatments to both patients and doctors. In addition, the Affordable Care Act will
promote transparency, accountability, and competition among health insurance companies
through both the new state exchanges and new standards for reviewing how premiums are set by
insurers. By promoting greater competition and accountability, the Affordable Care Act will
motivate 2 The Bottom Line insurance companies to hold down health care costs and premium
increases while improving quality of care” ( Basiley and Stoll 2011, 3 ). This is important due to
the worry that the cost of healthcare was rising at such a rate that eventually it’ll be unaffordable
for most and still be needed by all Americans. This rise in price is partly due to the “hidden
health tax”, which happens when not many uninsured patients can cover the full cost of their
healthcare so to cover the costs insured patients have to pay higher premiums. Lower premiums
also will mean that more people can afford to purchase coverage. As more people move from the
ranks of the uninsured to the insured, premiums should further decline as the hidden health tax is
reduced. In 2008, this hidden health tax raised family health premiums by more than $1,000
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Benson Kumenda 7
( Baisley and Stoll 2011,3 ). Having a higher insured population makes it possible for health care
to be more affordable for all, not just the low-income residents. The biggest difference between
Califonia and Texas is the fact that Medicaid was not expanded under the Affordable Care Act in
Texas which would have made it easier for those who still couldn’t afford the new insurance
marketplace to be covered. Similar to trickle-down economics if Texas had expanded Medicaid
which would have lowered the uninsured rate and eventually helped lower the overall cost of
healthcare while also leading to better utilization of healthcare.
Many may argue and wonder how Texas will be able to financially cover the residents if
Medicaid were to be expanded under the ACA. When the Texas government was considering
expanding Medicaid, “Texas received a Medicaid 1115 waiver from the Center for Medicare and
Medicaid Services that provided $29 billion in funding between 2011 and 2016 to reimburse
hospitals for uncompensated care and pay health care providers a delivery system reform
incentive payment to transform and improve indigent and Medicaid health care systems. The
Center for Medicare and Medicaid Services recently agreed to extend the 1115 waiver funding
through December 2017. But in 2018, it will not reimburse Texas for uncompensated care that
could be provided through a Medicaid expansion. In addition, funds for the delivery system
reform incentive payment pool, an estimated $3.1 billion in 2016, will be reduced 25% in 2018
and an additional 25% each year after This loss of funds would likely cause the closure of
multiple facilities across Texas, which may force legislators to act on the Medicaid expansion.”
(Pickett and Marks and Ho 2016, 1). If Texas had approved this health reform then many people
who still lack health insurance will be covered today. Making health insurance available for
those who are of low income will positively help all Americans. In America, lifesaving
healthcare is not denied to anyone even if they can’t afford the care. This care is always given
Benson Kumenda 8
but is very costly and still needs to be paid for in the end. When large sums of patients don't pay
their hospital bills, hospitals have to cost shift to cover those lost expenses onto the paying
patients, leading to increased healthcare costs for everyone. California expanding its Medicaid
program will lead to lower overall healthcare costs in the state.
Texas and California implemented certain aspects of the Affordable Care Act very
differently and that had a direct impact on the lower-income residents being able to receive
health coverage. Residents in California had more of an opportunity to receive healthcare
through the expansion of the Medicaid program compared to residents in Texas, a state with
already one of the highest uninsured rates, not having that same opportunity to receive health
insurance.
Benson Kumenda 9
Works Cited
Bailey, Kim, and Kathleen Stoll. “Bottom Line: How the Affordable Care Act Helps Texas
Families” : Bottom Line:
How the Affordable Care Act Helps America’s Families
;2012
SRIR4865-75.45.(2012).https://statistical-proquest-com.libproxy.utdallas.edu/statisticalinsight/re
sult/pqpdocumentview.pqppanelgroup_1.gispanelfour:pdfLinkUri?pdfLinkUri=%2Fftv2%2F4c4
e0000011cb59e.pdf&docUri=%2Fcontent%2F2012%2FR4865-75.45.xml (Accessed February
28, 2022).
Mayer, Martin, Robert Kenter, and John C Morris. “Partisan Politics or Public-Health Need?:
An Empirical Analysis of State Choice During Initial Implementation of the Affordable
Care Act.”
Politics and the life sciences
34, no. 2 (2015): 44–5
https://www-cambridge-org.libproxy.utdallas.edu/core/journals/politics-and-the-life-scien
ces/article/partisan-politics-or-publichealth-need/97B32C146ABBC61F619E12671679F5
86 (Accessed February, 28th).
Pickett, Stephen, Elena Marks, and Vivian Ho. “
Gain in Insurance Coverage and Residual
Uninsurance Under the Affordable Care Act: Texas, 2013-2016
.” American journal of
public health (1971) 107, no. 1 (2017): 120–126.
https://ajph-aphapublications-org.libproxy.utdallas.edu/doi/full/10.2105/AJPH.2016.303510
(Accessed February, 28th).
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Benson Kumenda 10
Roby, Dylan et al. “
Health Care Reform in the US: An Analysis of Implementation of the
Affordable Care Act in California.
” BMC health services research 14, no. S2 (2014):
P103–P103.https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/1472-6963-14-S2-P1
03.pdf (Accessed February, 28th).
Sommers, Benjamin D et al. “California’s Early Coverage Expansion Under the
Affordable Care Act: A County-Level Analysis.”
Health services research
51, no. 3
(2016):h825–845.https://go-gale-com.libproxy.utdallas.edu/ps/i.do?p=HRCA&u=txshrac
d2602&id=GALE|A454361538&v=2.1&it=r (Accessed February 28, 2022).