Medicaid Expansion Returns to a Changed Capitol

Estimated Time to Read: 14 minutes

Medicaid expansion was the first item of business for the 90th Texas Legislature. On November 9, the opening day of prefiling, State Rep. John Bucy III (D-Austin) filed both House Bill 101 (HB 101) and House Bill 102 (HB 102), and State Sen. Judith Zaffirini (D-Laredo) filed Senate Bill 31 (SB 31). Each would extend Medicaid eligibility to adults for whom federal matching funds are available under the Affordable Care Act (ACA), and they were the first of 13 expansion measures filed that day.

Lawmakers have filed similar bills in every regular session for more than a decade, and none has become law. What has changed is who will hold power when the debate resumes. Following the November 3 election, supporters of expansion will hold the governor's office, the lieutenant governor's office, and a majority of the Texas House for the first time in more than two decades.

The Senate remains in Republican hands, however, and the federal terms for expansion have changed since Texas last seriously debated it.

Two Paths to the Same Expansion

The three bills share a goal but offer lawmakers two vehicles for reaching it. Both House bills would require the Texas Health and Human Services Commission (HHSC) to extend Medicaid eligibility to applicants for whom federal matching funds are available. Bucy's office estimates the change would cover roughly 1.4 million additional Texans.

HB 102 is the statutory route. It directs the HHSC executive commissioner to take all necessary actions to expand eligibility, including notifying federal agencies. New eligibility would apply to determinations made once HHSC implements the change, and if any additional federal waiver is needed, the agency may delay implementation until it is granted. Because it does not depend on a constitutional amendment, HB 102 could become law with simple majorities in both chambers and the governor's signature.

HB 101 is the constitutional route. Its expansion language is identical to HB 102, but it takes effect January 1, 2028, only if voters approve a constitutional amendment requiring Medicaid expansion; if the amendment fails, the bill has no effect. That amendment is Bucy's House Joint Resolution 21 (HJR 21), which would add Section 74 to Article XVI of the Texas Constitution and place the question on the November 2, 2027, ballot. The bill's companion is SB 31.

Both bills would require HHSC to report each December 1 to state leaders and the relevant committees on expansion's effects on the number of uninsured Texans, state health care costs including general revenue programs, local health care costs, and hospitals' charity and uncompensated care. Neither sets a spending ceiling, and fiscal notes have not yet been prepared. Neither bill outlines work requirements; instead, both tie eligibility to whoever qualifies for federal matching funds, which leaves the terms of coverage to Washington.

HB 101 and HB 102 are conventional expansions of eligibility under the ACA. They do not revive the customized, Texas-specific program design that attracted Republican sponsors in 2021.

A Crowded Field

Bucy's bills were the first of 13 expansion measures filed on opening day, and more have followed. By November 12, TPR's bill digests listed 18 measures that would expand Medicaid eligibility or create an alternative program built on expansion funding.

Four more House bills filed on opening day would require the same statewide expansion: House Bill 138 (HB138) by State Rep. Ana-Maria Rodriguez Ramos (D-Richardson), House Bill 141 (HB 141) by State Rep. Suleman Lalani (D-Sugar Land), House Bill 363 (HB 363) by State Rep. Donna Howard (D-Austin), and House Bill 855 (HB 855) by State Rep. Rafael Anchía (D-Dallas). On November 12, State Rep. Diego Bernal (D-San Antonio) added a pair that mirrors Bucy's: House Bill 1109 (HB 1109) as an ordinary statute and House Bill 1110 (HB 1110) contingent on voter approval of a constitutional amendment proposition.

In the Senate, State Sen. José Menéndez (D-San Antonio) filed Senate Bill 109 (SB 109), and State Sen. Carol Alvarado (D-Houston) filed Senate Bill 229 (SB 229) alongside Zaffirini's SB 31.

Four joint resolutions would write expansion into the Texas Constitution: Bucy's HJR 21, Zaffirini's Senate Joint Resolution 6 (SJR 6), House Joint Resolution 70 (HJR 70) by State Rep. Lauren Ashley Simmons (D-Houston), and Bernal's House Joint Resolution 73 (HJR 73). A constitutional amendment is now pending in each chamber.

Howard's HB 363 stands apart. It would prohibit work or community engagement requirements for expansion enrollees, but its substantive provisions would become operative only after Congress changes the Medicaid requirements enacted in HR 1, or the One Big Beautiful Bill Act.

In practice, HB 363 is an expansion bill that waits on Washington.

Three bills take different routes. Incoming State Rep. Chris Jimenez (D-Elgin) refiled Live Well Texas as House Bill 725 (HB 725), which would seek a Section 1115 waiver for high-deductible plans with personal health savings accounts and income-based contributions, and would end that alternative program if the federal match fell below 90 percent. Lalani's House Bill 113 (HB 113) would pursue a block grant, if federally authorized, and premium assistance with health savings accounts for adults up to 133 percent of the federal poverty level, subject to state cost-neutrality.

Bernal's House Bill 1111 (HB 1111) would let individual counties request Section 1115 waivers to expand Medicaid for their own residents, with each waiver identifying how the state's share of costs would be funded. Howard's House Bill 389 (HB 389) would take a narrower step, covering women ages 19 to 49 with household incomes at or below 133 percent of the federal poverty level. More filings are likely before the March 12 deadline.

More Than a Decade of Attempts

The U.S. Supreme Court's 2012 decision in National Federation of Independent Business v. Sebelius allowed states to decline the ACA's Medicaid expansion without losing their existing Medicaid funding. Texas has declined ever since, and expansion bills have become a fixture of each session.

The 87th Legislature (2021) came closest to a breakthrough. Then-State Rep. Julie Johnson (D-Carrollton) filed House Bill 3871 (HB 3871), the Live Well Texas program, with a Senate companion, Senate Bill 117 (SB 117), by outgoing State Sen. Nathan Johnson (D-Dallas), the Attorney General-Elect. Rather than a conventional expansion, Live Well Texas would have sought a Section 1115 waiver to create a Texas-specific program with personal wellness accounts, work incentives, and higher provider reimbursements.

HB 3871 drew 76 authors and coauthors, including 10 Republicans. Former State Reps. Lyle Larson (R-San Antonio), Steve Allison (R-San Antonio), Kyle Kacal (R-College Station), and Dan Huberty (R-Houston) signed on as joint authors. Among the Democratic coauthors was outgoing State Rep. Gina Hinojosa of Austin, the Governor-Elect. Despite majority sponsorship in the House, neither HB 3871 nor SB 117 received a committee hearing.

The limits of that coalition became clear on April 22, 2021. During the House budget debate, former State Rep. Garnet Coleman (D-Houston) offered an amendment directing the state to create coverage for adults up to 138 percent of the federal poverty level, through either expansion or a program unique to Texas. It failed 68–80. Larson was the only Republican to vote for it, and the other Republicans who had sponsored HB 3871 voted against it.

That June, 56 House members asked Gov. Greg Abbott (R) to add expansion to a special session agenda. Larson was the only Republican signer. The governor declined, though Sen. Johnson refiled Live Well Texas as SB 41 in the third called session that fall.

Later sessions followed the same pattern. In 2023, Bucy filed HJR 7 and its enabling bill, HB 132, alongside Zaffirini's SJR 6. In 2025, bills included HB 1355, coauthored by outgoing State Rep. Vikki Goodwin of Austin, the current Lieutenant Governor-Elect, and Zaffirini's SB 45. Bucy's attempt to add expansion to the 2025 budget was defeated, and he refiled the constitutional amendment as HJR 11 in the first called session.

The record holds one consistent lesson: sponsorship has never translated into the votes needed for passage. The difference in 2027 is that two former sponsors of expansion legislation will soon be governor and lieutenant governor.

New Political Will at the Capitol

The November 3 election reshaped the institutions that blocked expansion for a decade. Gov.-elect Gina Hinojosa defeated Abbott, and Lt. Gov.-elect Vikki Goodwin defeated Lt. Gov. Dan Patrick, becoming the first Democrat to hold the office since 1999. Democrats also won control of the Texas House for the first time since 2003.

Supporters are treating the results as a mandate. Bucy said Democrats are ready to pass Medicaid expansion and described it as one of the top issues the party campaigned on, from Hinojosa and Goodwin to House candidates. Goodwin released a health care plan in August that includes expansion for low-income Texans.

A new governor cannot expand Medicaid alone, however. Eligibility is set by the Legislature, and the governor's main tools are the bully pulpit, emergency-item designations that allow early votes, and the veto.

The Texas Senate is now the decisive chamber. Republicans hold 19 of its 31 seats. The lieutenant governor's power to appoint committees and refer bills comes largely from rules senators adopt at the start of each session, and the Republican majority could rewrite those rules to limit Goodwin's authority. How that rules fight resolves in January will shape whether expansion bills receive hearings at all.

The Federal Terms Have Changed

Texas would be expanding under different federal rules than those supporters cited in 2021. HR 1, the One Big Beautiful Bill Act, was signed into law on July 4, 2025, as Public Law 119-21. It rewrote several of the Medicaid terms that matter most to a state weighing expansion, and many of its changes fall on the expansion population specifically.

First, it ended the American Rescue Plan Act's (ARPA) incentive for new expansion states, a temporary five-percentage-point increase in the federal match for a state's traditional Medicaid program. That incentive sunsets on January 1, 2026. The federal government still pays 90 percent of costs for the expansion population, leaving the state responsible for the remaining 10 percent.

Second, the law requires community engagement, or work, requirements for most expansion adults ages 19 through 64. States generally must implement them by January 1, 2027, although federal officials may grant good-faith extensions through the end of 2028. The same law requires eligibility redeterminations for expansion enrollees every six months and limits retroactive coverage.

Third, HR 1 tightened Medicaid financing. It places a moratorium on new or increased provider taxes, which states use to finance their share of Medicaid costs. For expansion states only, it also lowers the safe-harbor threshold for existing provider taxes from 6 percent to 3.5 percent in steps between fiscal years 2028 and 2034, while non-expansion states keep 6 percent. Expanding would therefore narrow the financing tools available to Texas at the same time it adds a new obligation.

Finally, HR 1 ended the enhanced 90 percent federal match that expansion states received for emergency Medicaid provided to immigrants who would otherwise qualify for expansion coverage, effective October 1, 2026.

These changes reshape the 2021 debate. The work incentives and personal-responsibility features that drew Republicans to Live Well Texas are now, in part, a federal baseline. The open questions are how Texas would administer those requirements and how it would pay its share.

Implications

Which vehicle supporters choose will determine how many votes they need. A constitutional amendment requires approval by two-thirds of the members of each chamber before it can go to voters, or 100 House members and 21 senators. With 12 Democratic senators, sending HJR 21 or SJR 6 to the November 2027 ballot would require at least nine Republican votes in the Senate.

The statutory route is easier, but not easy. HB 102 and similar bills need only a simple majority of 16 senators, or at least four Republicans, though Senate floor procedure in recent sessions has required a larger bloc just to bring a bill up for debate.

The constitutional route carries a cost of its own, because a mandate written into the Texas Constitution would be difficult to reverse. A later Legislature can amend or repeal a statute, but undoing a constitutional requirement would take another statewide vote. Lawmakers who favor limited government should weigh whether an open-ended entitlement belongs in the state's founding document.

That permanence matters because the state's share of costs would be both recurring and dependent on Washington. A 10 percent share of a program covering more than a million adults is a permanent claim on general revenue, and Texas would have fewer provider-tax tools to finance it. HR 1 has already shown that Congress can change the terms after states commit.

Live Well Texas included stopgap measures in case federal funding fell, and its refiled version, HB 725, would end its alternative program if the federal match dropped below 90 percent. HB 101 and HB 102 contain no such trigger, and HJR 21 would require expansion for anyone federal matching funds cover, whatever the match rate becomes.

Given those stakes, lawmakers deserve to know the cost before they vote. The bills' annual reporting requirements are a reasonable start, but they would measure costs only after expansion begins. Consistent with the Texas Liberty Compact's commitment to transparent government, legislators should have a full fiscal note before any floor vote, including HHSC's cost to administer federal work requirements and six-month redeterminations.

The debate also need not be confined to the bills as filed. In 2021, Republican support attached to a customized program rather than a conventional expansion. During the same budget debate, the Texas Public Policy Foundation pointed lawmakers to a bipartisan House package of health care bills it argued would reach more Texans at a fraction of expansion's cost.

Senate Republicans seeking a negotiated outcome are likely to return to approaches like these rather than accept expansion as filed.

Our Assessment

The expansion measures filed for the 90th Legislature would enlarge a program that already struggles to deliver the care it promises. Expansion would add able-bodied, working-age adults to a program built for low-income children, mothers, older Texans, and Texans with disabilities. It would do so even though, as early as 2011, nearly one-third of physicians nationally said they would not accept new Medicaid patients.

Coverage is not the same as care. A Medicaid card does little for a patient who cannot find a doctor who will see them, and adding more than a million enrollees would deepen that shortage rather than resolve it.

The structure of federal financing compounds the problem. Because the federal match rises with what a state spends, it rewards enrollment growth rather than results. HR 1 shows that Washington can rewrite the terms after a state has committed.

An open-ended entitlement tied to whatever Congress decides, with no spending ceiling, no funding trigger, and no fiscal note, is inconsistent with limited government and responsible budgeting. Writing it into the Texas Constitution would make the commitment harder still to revisit. Lawmakers should reject HB 101, HB 102, SB 31, HJR 21, SJR 6, and the other Affordable Care Act expansion bills as filed.

A Better Path

The goal should be timely, affordable care for Texans of modest means, not enrollment for its own sake. The Empower Patients Initiative, published by Americans for Tax Reform (ATR) in August 2025 and written by Dr. Deane Waldman and Dr. Vance Ginn (a TPR Board Member), offers one framework. It would put health care dollars under patients' control and let providers compete for them.

For the safety net, that framework calls for fixed federal funding in exchange for state freedom to design the program, including eligibility, benefits, and work obligations. The authors model a Texas safety net in which the state funds patient-controlled health savings accounts paired with catastrophic coverage. They estimate it would cost the state less than current Medicaid over five years.

Fixed-sum federal funding requires action by Congress, but Texas can press for it and pursue the flexibility already available through federal waivers. That route would make Texas, not Washington, accountable for the results. Lalani's HB 113 suggests that interest in a block grant is not confined to one side of the aisle, even though the bill pairs it with a new coverage program.

Lawmakers can also act now on supply and price, with reforms that would lower costs for every Texan, not only those who qualify for Medicaid. They can expand direct primary care, which offers unlimited primary care for a flat monthly fee. They can protect access to catastrophic and short-term plans, and they can loosen the licensing and scope-of-practice limits that restrict how many providers can serve patients.

What to Watch

The first test comes in January, when the Senate adopts its rules, and the House elects a speaker. Those decisions will determine who refers expansion bills and whether they receive hearings. After that, watch which vehicle supporters prioritize, what the fiscal notes show, and whether Hinojosa designates expansion an emergency item.

The 2021 session showed that a sponsorship majority does not guarantee a voting majority. Texas Democrats now control most of the levers that once stopped expansion, but the Senate's Republican majority will still decide whether it passes. That makes the 90th Legislature the moment for lawmakers to choose patient-centered reform over a larger entitlement.

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