Gov.-elect Hinojosa wants to expand Medicaid in Texas. An executive order won’t make that happen.

A week ago, expanding Medicaid health insurance coverage to more low-wage Texans was the quixotic dream of health policy advocates in a state where conservatives have soundly blocked it for years. 

Writing it off as a wasteful expense, Gov. Greg Abbott once called Medicaid expansion “a tax increase waiting to happen.” But Abbott last week was swept out of office, along with every other Republican on the statewide ballot. Expanding Medicaid could bring up to $10 billion a year in federal funds to Texas and mean health care coverage for more than 1 million additional Texans.

Such an expansion has been a top priority for Gov.-elect Gina Hinojosa and Lt. Gov.-elect Vikki Goodwin. And even though the Texas House will also be controlled by Democrats next year, getting a Medicaid expansion through a state Senate still controlled by Republicans could be a thorny battle.

During Abbott’s 12-year tenure, the state’s stubborn uninsured rate never substantially dropped. Today, 16% of Texans lack health insurance, leading the nation in the share of uninsured residents. Since 2015, the number of uninsured Texans has climbed to more than 5 million residents who can’t afford coverage or work for an employer who does not offer it. In Texas, unlike in many other states, Medicaid is an insurance program restricted to low-income children, new mothers and the elderly. No childless working-age adult can currently qualify.  

“Opting in is a gamechanger for people to have access to a healthcare system that their tax dollars pay for,” said Lynn Cowles, the health and food justice policy director for Every Texan, a left-leaning policy group.

Before last week’s Democratic sweep, it took two legislative sessions (2021 and 2023) for lawmakers to allow poor mothers an additional 12 months of Medicaid coverage after giving birth. For more than a decade, Republicans in Texas have criticized the program saying it creates an overdependence on government and, like Abbott, have said that the best way to be insured is to be employed. 

But a flat resistance to any type of expansion may now be a tougher position to hold onto. The minimum wage has been frozen at $7.25 for 17 years, not everyone’s employer offers health insurance and voters’ frustrations over their rising cost of living is viewed as a major driver in last week’s stunning partisan flip.  

Governors in some states like Louisiana, Kentucky and West Virginia expanded Medicaid through executive orders. Hinojosa could run into a roadblock because Texas law prevents the state from altering the eligibility requirements of Medicaid without legislative approval. It’s not clear if that law prevents Hinojosa from unilaterally directing state officials to file an expansion plan with the Centers for Medicare and Medicaid Services. 

Either way, there are more challenges ahead even if Texas were to expand tomorrow. 

Cutting the Texas coverage gap

Beginning in January, states that expanded Medicaid access now face more administrative costs because they have to monitor new Medicaid work-reporting requirements, imposed a year ago by H.R. 1, the One Big Beautiful Bill Act of 2025. 

Under the act, Medicaid recipients under the age of 65 must be employed at least 80 hours a month and make at least the federal minimum wage (about $580 a month) to keep their government-issued health coverage. States that have to comply are already complaining about the added cost to them. For some, the added staff needed to keep up with the restrictions is as high as an extra $15 million. 

As a result, if Texas were to expand this minute, the new January restrictions could add millions to the 10% share of expansion costs Texas must foot to get access to 90% in federal funding, said state Rep. Donna Howard, D-Austin. 

That’s why one option discussed this week is a Texas “trigger” bill, that would activate Medicaid expansion but only if the incoming Democratic majority in Congress is able to repeal some of the harshest and costly federal restrictions put in place by H.R. 1. 

Until that happens, Howard said lawmakers are looking for ways to increase healthcare access and remove obstacles in other ways. 

“We can’t pass something that is going to not achieve our goals,” she said of passing expansion sooner instead of waiting until after the incoming Congress gets to work. 

Howard said she wants to see more things — more mobile health clinics, more investment in federally qualified health clinics, removing administrative obstacles that keep more doctors from accepting Medicaid or keep them from getting paid in a timely manner. 

“We need providers, and yet, we have an onerous system that has delayed payments for, you know, up to a year,” Howard said.

Since 2014 under the Affordable Care Act, states have had the option to expand Medicaid health insurance coverage to low-wage, working age adults and more children whose parents and guardians did not previously qualify. Before the ACA, Medicaid was mostly a health insurance program for poor children and the elderly, and conservative Texas leaders have kept it that way. Today, Texas is one of only 10 states that have refused to expand Medicaid access. 

According to Cover Texas Now, an umbrella organization whose members include several health advocacy groups, expanding Medicaid in Texas would give U.S. adult citizens in a family of four making between $4,000 and $44,000 per year, health insurance coverage. 

States can expand Medicaid access one of two ways. A governor can ask its state agency to submit an expansion plan to the federal government or a state legislature could approve the expansion and the plan is sent to Washington. 

Hinojosa has clearly said that Medicaid expansion is a priority. One day after her historic win, she reiterated her commitment to expanding Medicaid in Texas. 

“What my healthcare position is to ensure every Texas child has quality healthcare. We have the most children without health insurance of any state in America. It is a sin,” Hinojosa told KPRC last week in Houston after Tuesday’s election. “We are a world economic powerhouse and we can take care of our kids. The way we do that is expanding Medicaid and that’s my position.”

However, it’s not clear yet, almost a week after her election win, how she and her administration would do it.  

There is a Texas law that prevents the state from altering the eligibility requirements of Medicaid without legislative approval. But it’s not exactly clear if that effectively blocks the governor-elect from bypassing the Texas Legislature and directing the Texas Health and Human Services Commission from submitting a plan to Washington. 

One thing is certain. Even with new Trump-directed restrictions on Medicaid put in place a year ago, expanding access would still work to cut what is known as the Texas coverage gap — the swath of residents who make too little to qualify for a subsidy to help buy an ACA health plan but make too much to qualify for Medicaid. 

“The number of people who would gain coverage … it would remove the concept of the coverage gap,” said Charles Miller, director of Health & Economic Mobility Policy at Texas 2036, a nonpartisan policy think tank. “As people gain coverage, they tend to seek out more care. They gain protection against medical debt.”  

Texas benefits, cost, to expanding Medicaid

For years, Abbott and other Republicans have rejected expansion, brushing away concerns of lower wage earners who can’t afford health insurance. 

“The best way to get health care insurance is through an employer,” Abbott said in 2022. “Since I was re-elected, Texas has added more new jobs than any other state … Medicaid was created to serve the most vulnerable, not able-bodied adults who can and should get healthcare through an employer.”

Although most workplaces with over 50 employees offer health insurance because they are required to, only 38% of small employers have health insurance for their workers. 

Cowles said this one policy switch up could mean so much savings for hospitals and local governments who have had to pay for years to help their uninsured residents access low-cost or free care. Expanding Medicaid would offer regular health visits for people who never had such access. “They would have the backing of comprehensive coverage from a state-based program that for decades in this state, leaders have said: “ ‘No, not for you.’ “ 

In turn, Texas local governments could finally repurpose funds they have had to budget for years to help their uninsured residents get medical treatment. Currently, Texas’ local public health infrastructure, locally-funded hospitals and nonprofits spends hundreds of millions of dollars each year to help residents who have no access to health insurance.

“One of the positive benefits (of expansion) is improved operating margins for hospitals, because they have fewer uninsured patients, less uncompensated care,” said Dr. Edwin Park, a Georgetown University research professor at the McCourt School’s Center for Children and Families. “They’re more able to keep their doors open, avoid cutting staff and services.”

While Texas’ current Medicaid recipients have not had to face new work restrictions placed on expansion states, mainly because the program here covers children and the elderly, if Texas expands Medicaid access, its newer working age recipients would have to prove they are working 80 hours a month to keep the coverage. 

And in a year where under Abbott, agencies have been asked to slash their budgets by 3% it’s not clear how the incoming Democrats would pay the 10% cost to expand Medicaid access. 

But Cowles said the large overall impact this one policy change would make is worth the investment. 

“We owe it to people in Texas to do something with this moment,” she said. 

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