Since she was diagnosed with HIV in the 1990s, Deneen Robinson has worked as an advocate, promoting health, abortion rights and AIDS education for other Black women. But it was not until June, when her job as a policy director for a Dallas nonprofit organization was eliminated — leaving her with insurance premiums she no longer could pay — that Robinson discovered a gap she had never known existed.

Unable to find work beyond a few hours a day as a friend’s caregiver, Robinson descended into poverty. In Texas, even that scanty income is too much for adults to qualify for Medicaid. But it is too little to make her eligible for a subsidized Affordable Care Act health plan. So with a worsening endocrine problem, she cannot afford to see the cardiologist she needs as her blood pressure has spiked, threatening her heart.

“The irony is not lost,” Robinson said. “Now, I’m fighting to get the things I advocated for for everyone else.”

So Robinson has a personal reason to celebrate a few passages in the sprawling social spending plan House Democrats adopted last month. It would create a path to health coverage for her and more than 2 million fellow uninsured people in Texas and 11 other states that have not expanded Medicaid as the ACA allows.

If the plan survives a political minefield in the Senate, it would rely on ACA insurance marketplaces to close the coverage gap temporarily, offering people such as Robinson a chance for the next few years to sign up for private health plans nearly for free.

This approach is considerably less ambitious than goals for expanding access to health care that President Joe Biden carried to Washington from his campaign.


A public insurance option — something the president and liberal Democrats in Congress have long espoused — has never been seriously considered as part of this legislation. Nor would the plan create a permanent, all-federal program similar to Medicaid, the insurance system for the poor run jointly by the federal government and states, in the dozen states that have resisted expanding the program.

And the House’s approach is a tacit admission that the last way Biden and Congress tried to close the Medicaid coverage gap has not worked. As part of a coronavirus relief law passed in March, the government began offering a novel and generous financial incentive to the holdout states if they agreed to expand.

A few of the states, led by Republicans and spread largely across the South, have talked about the offer with federal health officials, although none has accepted it.

In Texas, an estimated 771,000 people fall into the Medicaid gap, more than in any other state and roughly one-third of the national total in the gap. Consumer health advocates there have concluded that filling the gap would need to be done by Washington.

Laura Guerra-Cardus, deputy director of the Children’s Defense Fund’s Texas branch, said she is not exactly happy with the plan to offer ACA marketplace health insurance plans only through 2025 — but nevertheless is “in full support” of it. Given adamant opposition from Texas Gov. Greg Abbott, a Republican, and his predecessor, to expanding Medicaid, the House’s temporary approach “represents the only realistic path forward,” Guerra-Cardus said.

The Democratic authors of the ACA did not envision any coverage gap when they created the health-care law that was enacted in 2010. Originally, the law sought to widen access to insurance in two ways. It would expand Medicaid nationwide and allow people to join even if their incomes were a little above the poverty line. And for others who lack affordable health-care benefits through a job, it offered new federal subsidies to help pay for the monthly premiums for private health plans sold through insurance marketplaces that the law created.


But in a challenge to the law two years later, the Supreme Court ruled that each state has the power to decide whether to expand Medicaid.

Since the high court’s decision, five legislative sessions have taken place in Texas, where lawmakers convene every other year. Democrats have introduced bills to expand Medicaid each time. With governors’ opposition and a strong GOP majority in the legislature, only three of the bills have even gotten as far as a hearing.

During this year’s session, grassroots advocates intensified their efforts. Dozens of organizations joined forces to implore legislators to close the gap. The state’s AARP chapter called on the governor to temporarily expand Medicaid to help poor Texans during the coronavirus pandemic.

Once again, the expansion bill did not get a legislative hearing.

As in some other states that haven’t expanded Medicaid, the views of Texas political leaders conflict with public opinion. Two polls this year showed that nearly 7 in 10 Texans say they favor Medicaid expansion.

With no sign that Texas politics will shift to more closely mirror public sentiment, Guerra-Cardus said, “at the end of the day, this country needs to ensure there is a permanent coverage option for all people.” In the meantime, she said, even temporary federal help “is a lifeline.”


The House version of the Build Back Better Act, its name drawn from Biden’s campaign theme, would allow people below the poverty line in non-expansion states to enroll in one of the private health-care plans sold on ACA marketplaces. A federal subsidy would pick up the full cost of the monthly premium, and co-payments would be small.

The help would run through 2025, with the net cost about $57 billion, according to an estimate from Congress’s budget analysts.

Republican governors and state lawmakers opposed to expansion have not spoken out against this approach, because its reliance on ACA marketplaces falls within federal control.

“I don’t think anyone is complaining about that,” said one health policy expert familiar with state government, who spoke on the condition of anonymity to describe private discussions.

Less certain is the plan’s fate in the Senate, when the chamber considers the spending bill in the weeks ahead. Senate Majority Leader Chuck Schumer, D-N.Y., has said he would like the chamber to pass it by Christmas, though it is unclear whether that timing is likely. As in the House, the Senate’s GOP members are uniformly against the legislation. With barely a majority, Senate Democrats cannot pass the bill unless every member of their caucus supports it.

Ideological fissures are already evident.

Sen. Raphael G. Warnock, D-Ga., is among the strongest advocates for the bill, contending that providing more insurance coverage to low-income Georgians is crucial to his reelection next year — and perhaps to preserving his party’s slim Senate majority.


Warnock favors a permanent expansion of Medicaid — either by states or an all-federal public program to provide the same coverage. Still, the senator worked to incorporate the temporary ACA approach — more appealing to party centrists — into a revised Build Back Better framework that Biden issued in October, Warnock’s office said.

One of those centrists, Sen. Joe Manchin III, D-W.Va., has condemned the idea of creating a federal program that would act like Medicaid to fill the coverage gap. Manchin says it would be unfair to states such as his, which have expanded Medicaid and, as the ACA requires, are footing 10 percent of the cost. Manchin does not yet have a position on the House’s ACA marketplace approach, his office said.

For states with expanded Medicaid, the plan would temporarily increase the federal share of the cost from 90 percent to 93 percent. It is unclear whether that extra help will satisfy Manchin or other senators with similar reservations.

Despite the bill’s uncertain prospects for becoming law, advocates in Texas are mobilizing, preparing for a mass education campaign to help the state’s hundreds of thousands of uninsured people learn how to sign up for ACA health-care plans.

One such person is Jahnari Ball, who lives with his grandmother on Houston’s south side and grew up on Medicaid. At 22, he is in his first semester at a community college, studying to get a real estate license, and he works part-time setting up stages for community events. He has had no health insurance for three years, once he became no longer eligible for Texas’ Medicaid as a child and did not qualify as a single adult.

In the past year, Ball has begun to have what he suspects are mental health issues, worrying whether his life is in a good lane. Some nights, he lies awake.


“It depends on how the vibe is at the moment,” Ball said. “I have different episodes, as far as the anxiety coming back.”

He wanted to have this anxiety checked out. He couldn’t afford it. So he began searching for how to get insurance, doing Google searches, asking relatives.

They had suggestions that would have helped if he were old or disabled — “nothing for me,” Ball said. Finally, he discovered he was in the coverage gap.

Ball said help from Congress “would be amazing … especially for ones in the gap, who need it the most.”

If he could get insurance, he said, he would get a physical. And he would find a mental health professional, as he began wanting to do months ago. “I was just looking for a sense of peace,” he said.

More than 200 miles to the northwest in Dallas, Robinson remembers being in the hospital in 1992, diagnosed with HIV.


“They gave me three to five years to live,” Robinson recalled. “And I’m 55. I want to keep living.”

Most of those years in between, she has had insurance. At her last job, at the Afiya Center focused on reproductive rights, the nonprofit group gave her $200 a month to apply to an ACA health-care plan. She kept paying the premiums of about $700 through August, two months after her job ended. Then she stopped, unable to keep up payments on her part-time caregiver’s income of roughly $900 a month.

With neither a full-time job nor health insurance, she can get medicine and other care for her HIV through a federally funded clinic. Still, if the federal government helped her back onto an ACA plan, Robinson said, “I’d be super-excited and very grateful. … I’d make the appointment with the cardiologist.”

She fears that if the help is not permanent, some people would not bother to apply for the coverage. For others, she said, a few years’ insurance “is just long enough to get you used to it, and then you lose it.”

Still, she said, “anything, honestly, is better than nothing. It will be enough until it’s not.”