Death by Ideology: How Texas’s Refusal to Expand Medicaid Is Killing Rural Texans and Destroying Healthcare

View the Texas Watchdog article Death by Ideology: How Texas’s Refusal to Expand Medicaid Is Killing Rural Texans and Destroying Healthcare here. 

The refusal to expand Medicaid in Texas has left hundreds of thousands of low-income Texans, particularly in rural areas, without access to affordable healthcare. This decision, led by the state's conservative political leadership, has had catastrophic consequences for healthcare facilities, patients, and communities across the state. With Texas leading the nation in the number of uninsured residents, the absence of Medicaid expansion has worsened the already precarious situation for rural hospitals, working-class families, and healthcare providers. Rural Texans, who are disproportionately affected by this policy, find themselves trapped in a broken system that seems to care more about ideology than human lives.

This investigation examines the impact of Texas's Medicaid non-expansion policy on rural communities, based on the reporting by KERA News, Texas Tribune, and ruralhealthinfo.org, and will delve into the political motivations behind this decision, the devastating economic and health outcomes, and the preventable deaths that have resulted from this ongoing healthcare crisis.

The Political Ideology That Abandoned Rural Texans

The heart of this crisis lies in the refusal of Texas’s political leaders, spearheaded by Governor Greg Abbott and Lieutenant Governor Dan Patrick, to expand Medicaid under the Affordable Care Act (ACA). Despite overwhelming evidence of the benefits Medicaid expansion could provide—including a $5.4 billion influx of federal funds annually—Texas Republicans have doubled down on their ideological opposition to the ACA, often branding it as “Obamacare” to stoke political resentment among their conservative base.

Abbott has called Medicaid expansion a “massive expansion of an already broken and bloated Medicaid program,” choosing instead to stick with the status quo. This rhetoric may play well with conservative voters who fear government overreach, but it leaves nearly 800,000 Texans in a coverage gap—earning too much to qualify for Medicaid but too little to afford private insurance. This ideological grandstanding leaves rural Texans, who often don’t have access to the same wealth of healthcare options as urban areas, struggling to access even basic medical care.

The irony here is palpable. Texas, with its reputation for self-reliance and independence, is sacrificing the health and well-being of its residents, especially in rural areas, on the altar of political ideology. And it’s not just a few people suffering—nearly 15% of Texas’s population lives in rural areas, and many of them are uninsured.

Rural Hospitals on the Brink of Collapse: Closing Doors on Care

If there’s one visible consequence of Texas’s refusal to expand Medicaid, it’s the closure of rural hospitals. In the last decade, 21 rural hospitals in Texas have closed, and another 26% are at risk of closure, according to a 2022 report from Kaufman Hall. These hospitals serve as lifelines for communities spread out over large distances, often with no other healthcare options for miles. Without them, routine medical care, emergency services, and life-saving treatments are out of reach for many rural Texans.

This isn't just a healthcare problem; it's an economic disaster. Rural hospitals are often some of the largest employers in their communities. When a hospital closes, the economic ripple effects are devastating. Jobs are lost, families leave, and local businesses that relied on the hospital’s staff and patients for revenue also suffer. It’s a downward spiral that pushes already struggling rural economies even closer to collapse.

But why are these hospitals closing? One of the biggest reasons is the amount of uncompensated care they provide. Without Medicaid expansion, many rural Texans remain uninsured and cannot afford to pay for medical services. As a result, hospitals are forced to provide care for free, but they still have to cover the costs of staff, equipment, and supplies. In 2019, rural hospitals in Texas faced uncompensated care costs of 3.81% of their operating expenses, compared to 3.12% for urban hospitals. In Medicaid expansion states, this figure is even lower—2.55%—which highlights just how much Texas is losing out on by refusing to expand coverage.

Texas hospitals are hemorrhaging money because the state refuses to take federal funds that would help cover these uninsured patients. It’s as simple as that. And as these hospitals continue to close, more rural Texans are left without access to the care they desperately need.

The Working Poor: Caught in the Coverage Gap

Texas’s Medicaid eligibility criteria are among the most restrictive in the nation. To qualify for Medicaid as a parent in Texas, your income must be less than 17% of the federal poverty level—around $3,733 annually for a family of three. Childless adults, regardless of income, don’t qualify for Medicaid at all. This leaves a huge number of working Texans—people in low-wage jobs, many of whom are essential workers—without access to affordable healthcare.

In industries like construction, food services, and home healthcare, workers often make too much to qualify for Medicaid but not enough to afford private insurance. These are people who are vital to Texas’s economy, yet they are being left behind. Around 77% of those in the coverage gap are in families where at least one person works, and 42% are women of reproductive age.

Without Medicaid expansion, these workers are less likely to have a regular source of healthcare, more likely to delay or avoid necessary treatment, and at higher risk of medical debt and bankruptcy. For them, an unexpected illness or injury can be financially ruinous, pushing them further into poverty.

The fact that Texas’s leaders continue to deny these people healthcare while they work for low wages is not just a policy failure—it’s a moral one. These are the people who keep Texas’s economy running, and they are being abandoned by a state government that values ideological purity over human lives.

Community Health Centers: The Last Line of Defense

With rural hospitals closing and Medicaid expansion off the table, Federally Qualified Health Centers (FQHCs) have become the safety net for many uninsured Texans. These centers provide care for underserved populations, but they are also stretched to their limits. About a third of patients at FQHCs in Texas have Medicaid, while nearly a quarter are uninsured. The demand for services far exceeds the capacity, and with limited resources, these health centers are struggling to keep up.

For uninsured patients, the cost of care is often prohibitive. A visit to an FQHC might cost $350, but an uninsured patient might only be able to pay $30-$40, leaving the center to absorb the rest. This means fewer resources for expanding services, fewer staff to handle the growing number of patients, and longer wait times for care. As a result, uninsured Texans often don’t seek care until their condition becomes severe, which leads to more expensive and complicated treatments down the line.

The lack of Medicaid expansion also impacts the ability of these centers to recruit healthcare providers. Working in a community health center can be financially unstable, and providers may prefer to work in urban settings where salaries are higher and there are more opportunities for career advancement. This staffing shortage exacerbates the already limited access to care in rural areas.

The Health Toll: Preventable Deaths and Poorer Outcomes

The consequences of Texas’s refusal to expand Medicaid are not just financial—they are fatal. Between 2014 and 2017, an estimated 2,920 Texans aged 55-64 died prematurely because the state refused to expand Medicaid. These are deaths that could have been prevented if these individuals had access to regular healthcare.

Chronic conditions like diabetes, hypertension, and heart disease go untreated or poorly managed when people don’t have access to care. Without insurance, people are less likely to take medications regularly, less likely to see a doctor for check-ups, and more likely to end up in the emergency room when their condition worsens. The result is a healthcare system that spends far more on emergency care and hospitalizations than it would on preventive care, but with far worse outcomes for patients.

Maternal and infant health in Texas is also a significant concern. The state has one of the highest maternal mortality rates in the country, and uninsured women are at significantly higher risk. Expanding Medicaid would provide prenatal care and reduce the risk of complications for both mothers and babies. Yet, Texas’s leaders continue to deny this coverage, putting the lives of women and children at risk.

What Could Medicaid Expansion Do?

The refusal to expand Medicaid is costing Texas billions of dollars in federal funding—money that could be used to improve healthcare access, keep rural hospitals open, and provide insurance for hundreds of thousands of Texans. Expanding Medicaid would bring in an estimated $5.4 billion per year in federal funds, money that could cover the cost of care for low-income Texans and reduce the financial strain on healthcare providers.

The economic benefits of Medicaid expansion are clear. It would create jobs, strengthen rural economies, and ensure that more Texans have access to the care they need. States that have expanded Medicaid have seen significant improvements in health outcomes, including lower mortality rates, earlier detection of cancer, and better management of chronic diseases. Yet, Texas continues to reject these benefits, leaving its most vulnerable residents to fend for themselves.

Conclusion: Ideology Over People

At the heart of Texas’s Medicaid crisis is a simple truth: the state’s leaders care more about maintaining their ideological opposition to “Obamacare” than they do about the lives of rural Texans. The decision not to expand Medicaid is not based on sound economic reasoning or concern for the state’s healthcare system—it is a political stance that sacrifices the well-being of millions of Texans for the sake of partisan purity.

Rural Texans, the backbone of the state’s economy, are the ones paying the price. They are losing their hospitals, their access to care, and, in many cases, their lives. Until Texas’s leaders put people over politics, this crisis will only continue to worsen.