One could suggest that Medicaid actually began in Texas. A young middle school teacher working in Cotulla, Texas was truly aghast at the living conditions and lack of healthcare access of his Mexican-American students. He did all he could to improve conditions and the memories of this inequality never left him. Almost 40 years later this same teacher, now President of the United States, did do something about it. As a part of his “Great Society” initiative and “War on Poverty”, Lyndon Baines Johnson (LBJ) signed the legislation that created Medicaid.

Since then, Texas has not made a solid effort to ensure Medicaid, a state run government entitlement, is performing as it was intended. How so? Texas spends less than the national average per enrolled member for healthcare and pays doctors and hospitals less, again, than the national average for Medicaid reimbursement. In large areas of the state, Texas provides only the minimum healthcare requirements as prescribed by the federal government. And, one in four, Lone Star state residents, some 6.1 million people lack health insurance, the largest percentage per capita of any state (26.2%).

With the signing of the Affordable Care Act or ACA, in 2010, some in Texas saw reason for hope when discovering part of the ACA would expand Medicaid. The Supreme Court eventually ruled states could decide if they would expand Medicaid striking down one of the legs of the Triple Aim for healthcare. Only 15 states agreed to expand Medicaid, Texas not being one of them. Governor Perry categorically refused to participate in any effort that even suggested an acknowledgement of the Affordable Care Act.

Per the ACA, the federal government would pay for 100% of the Medicaid expansion bill for 2014 – 2016 and then 90% of the expenses for the next 8 years. Despite this potential financial windfall, Texas remains vehemently opposed to Medicaid expansion. Analysts estimate this could cost the state of Texas over $100 billion over 10 years in federal monies.

But, beyond the economics and politics of this battle, lives are in the balance. According to a recent Harvard University study published in the New England Journal of Medicine, failure to expand Medicaid in Texas could ultimately result in 9,000 deaths a year. This published study used data from states that expanded Medicaid who saw a 6.1% reduction in deaths for enrolled Medicaid patients under the age of 65. Using this metric, Texas healthcare researchers can build a prediction model based on the number of uninsured, which is exactly what the University of Texas Medical Branch in Galveston did to arrive at the stunning end result of 9,000 lives lost.

The most recent economic data just published is from 2013, where as a percentage of the Texas budget, Medicaid accounted for 26.2% or roughly a quarter of the state’s financial obligations. The actual cost was estimated to be $33 billion. The average number of Texans covered each month was 3.57 million in 2013. And one statistic that was eye opening to your author was 82% of Texas Medicaid enrollees are under the age of 21. This indicates that the Texas Medicaid program is essential for unwed mothers and young children. Without this entitlement, the poor and underprivileged go without healthcare. Exactly what LBJ saw in 1929.

Now 85 years later, Texas has come full-circle bearing witness to both the genesis of Medicaid and delivering the reality of the weakness of state government to enact the law itself.

If he were here today, I am confident LBJ would take steps to provide hope and relief with Medicaid as the head of his spear of action. Our current leaders will have to answer for their failure to act for generations to come. And the state grade for Medicaid performance can only be quantified with an Incomplete.