Texas political leaders like Ted Cruz have a “hell no” approach to Obamacare. Obamacare showdown in Texas

HOUSTON — The ground war over Obamacare — the one that will determine whether people sign up — will be won and lost in places like Texas.

If Obamacare fails in the Lone Star State — that is, if a significant portion of the 6.1 million uninsured Texans don’t or can’t enroll — then the White House could miss its national enrollment targets, the new health insurance exchanges could falter and insurance rates could spike.


Obamacare could be unsustainable.

And that’s exactly what leading Texas politicians like Gov. Rick Perry and Sen. Ted Cruz would like to see happen. With the political leaders’ “hell no” approach to Obamacare, Texas may not seem like a health law battleground. But the demographics — a huge, hard-to-reach uninsured population — mean it’s a make-or-break state for making the law work.

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Advocates are banking on the idea that a grass-roots push in more liberal, urban areas of Texas, plus the demand among the uninsured to get health coverage, will overcome the state’s institutional opposition and deliver on the promise of Obamacare.

“Some of my friends on the other side of the aisle are doing as much as they can to make it difficult for this program to work,” state Sen. Rodney Ellis, a Democrat from Houston and prominent supporter of the law, said as enrollment began a few days ago. He thinks the Republican strategy will backfire. “One more election cycle and all of this is going to go away,” he predicted.

The challenge for Ellis, Houston and all of Texas is “to get the word out” about the law, he said.

Texas has the highest uninsured rate in the country — about one in four people lack coverage, and one in three Hispanics. Perry’s administration didn’t expand Medicaid under the law to cover more poor people, which the Supreme Court made optional. And it spurned the state health insurance exchanges. So here in the Lone Star State, where resentment of federal interference runs strong, the U.S. government and its allies are stepping into the breach.

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The best hope of Obamacare backers is to support the efforts of local allies in regions such as Houston, Dallas and Austin, the bluest areas of a deeply red state. That’s because these areas lean liberal and also have an existing network of progressive activists. The Obama administration sent Texas nearly $11 million — more federal grant money than any other state — to fund “navigators” who are trained and tasked with helping people through the sign-up process.

In Houston, with 1.4 million uninsured residents, city officials are modeling their efforts on hurricane-force emergency response to counter the adamant state opposition, said Stephen Williams, director of the Houston Department of Health and Human Services.

“We believe this effort is so critical that we have created an incident command structure,” Williams said. “This is the same structure that we use to respond to hurricanes and to respond to public health disasters.”

The city of Houston has provided free office space to Enroll America, a nonprofit group closely associated with the former Obama campaign that is now spreading the word about the health law. The city has provided at least 55 people to help residents enroll and created space for a phone bank. It has ordered public library computers to have links to enroll access and it’s even printing Obamacare information on local water bills “so the broader population can all be informed,” said Mayor Pro-Tem Ed Gonzalez, a Democrat.

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That stance is a striking contrast with Texans on the national stage. Cruz, for instance, helped push the government shutdown over Obamacare, and now he’s urging that the GOP link its demands for health law changes to the debt ceiling fight that will peak in mid-October.

“The debt ceiling historically has been among the best leverage that Congress has to rein in the executive,” he said on CNN’s “State of the Union” on Sunday, adding that leverage should be used with the Democratic health law.

But here, some people are eager for the promised coverage. Houston resident Reynoldo Gutierrez went on Tuesday, the first day of open enrollment, to a sign-up event. His experience was typical of the technical glitches that snarled computer systems across the country. The 55-year-old patiently tried again and again to log onto HealthCare.gov using a laptop at a Houston sign-up event. He wanted to get coverage for his wife. All he got were messages that said “please wait.”

“I’m just trying to get enrolled in this health insurance, and I have to wait,” he said matter of factly, determined to complete the sign-up process when he can. “I have no choice.”

Enroll America has made Texas a priority, too.

“Our database is sophisticated,” said Mario Castillo, who is leading Enroll America’s efforts in Houston and the Gulf Coast region. “We can target uninsured individuals, where they live, what neighborhoods, what precincts.”

The group then helps link the uninsured up with navigators or counselors who can walk them through the application process. “We don’t want anyone slipping through the cracks,” Castillo said.

In addition to Enroll America’s activities, home-grown Texas health-oriented groups are pulling together. Blue Cross Blue Shield of Texas, for instance, formed an alliance called Be Covered Texas to encourage people to check out new coverage options.

National and local groups such as the Harris County Health System, the Texas Organizing Project, the Center for Public Policy Priorities and the Children’s Defense Fund collaborated earlier this year to lobby the state to expand Medicaid. They failed — but their combined effort helped them grow the network they are now activating for enrollment. That includes holding health fairs as well as sending staff to places like food banks, church youth groups and community colleges to get out the word.

Much of the outreach is aimed at Hispanics. Many of the enrollment materials are in Spanish, and in communities like El Paso, the navigators are bilingual. That helps both the communication and the comfort level, making people feel easier about handing over personal information, said Jennifer Buschick, who is leading the navigator program there.

Arturo Aguilar, who is working on ACA enrollment for an El Paso community group called Border Interfaith, says Hispanic populations in particular really want that in-person help. He works with many religious leaders, and they keep asking him, “When can you bring navigators?”

The groups share a pro-Obamacare message: Despite what you’ve heard shouted from the political rooftops of Texas, the Affordable Care Act is here and many people will get subsidies to make insurance more affordable. And insurance companies can no longer deny you coverage because of a pre-existing condition.

Even in committed pro-health law strongholds, getting that message across is a challenge.

Ron Cookston, who runs Gateway to Care, a Houston nonprofit promoting enrollment, said that the 40-odd U.S. House votes to stop the law — and now the government shutdown to stop the law — have confused people. “So we’re finding just an awful lot of people saying, ‘Wait, it’s not going forward.’”

Cookston and other supporters of the health law say they’re battling a state government that isn’t looking after the people who need help. In addition to resisting implementation every step of the way, the Perry administration is considering new rules to require navigators — the enrollment helpers — to undergo fingerprinting and additional training.

The Obama administration “has repeatedly delayed explaining how its navigators were going to be created, how they were going to operate, and how they were going to be regulated,” Perry told the Texas Department of Insurance just before the exchanges opened.

Perry, Cruz and other foes of the health law argue that there is ample evidence that it’s bad for the economy and job creation, and bad for doctors and patients.

“The pleas from the American people, I can tell you in Texas, are deafening,” Cruz said during his 21-hour Senate speech that helped set the government shutdown wheels in motion.

But as visits to some of the enrollment centers here show, some people are eager for the coverage. It’s too early to tell how the political fight will affect enrollment — which is being hampered at the outset by the the pervasive computer problems.

Cookston says the rhetoric has distorted what Texans know about the law.

“Gov. Perry said he’s not going to let the law come to Texas so sure, people will say that — and that it was voted down by the House of Representatives. My senator’s been up there filibustering, of course we hear that,” Cookston said. “He’s a Texan and no matter what else happens, people in Texas have elected him.”

Rep. Henry Cuellar, a Democrat, represents a Rio Grande district a third of whose citizens have no insurance. He said the Republican-led onslaught has cemented in his state — and Democrats haven’t been able to overcome that. He wishes Washington had gotten its own message across, louder, clearer and earlier.

“Quite honestly, I wish the president would have done a much better job — back from the beginning, we’re talking 2010,” Cuellar said. “Republicans just did a much, much better job at [messaging] against the health care law.”

This story was produced with the support of the Dennis A. Hunt Fund for Health Journalism, a program of the USC Annenberg School of Journalism’s California Endowment Health Journalism Fellowships.