Soon the state of Texas will offer another incentive: cash.

Lawmakers this year created a program —at a cost of nearly $3 million over the next two years — that will help pay off mental health professionals’ student loans if they practice in an underserved area. The loan forgiveness program seeks to alleviate the state’s shortage of mental health professionals — including social workers, psychologists, counselors and psychiatrists — by luring them to parts of the state that have significant need for health care but may not beÌýattractive to graduates of expensive professional schools.

Health agency officials acknowledge there is a “” of the state’s mental health workforce. Watchdogs call it a public health emergency: Of the state’s 254 counties, roughly 200 are designated as Mental Health Professional Shortage Areas. That’s a federal classification meaning there are more than 30,000 people per psychiatrist — the threshold at which it becomes nearly impossible for the average person to get a referral to a mental health specialist, experts say.

“We really do have special challenges in rural areas, because you go to school, you get a couple hundred thousand dollars of debt, you feel like you should at least have a Starbucks near you,” said Andrew Keller, executive vice president of policy and programs for the Meadows Mental Health PolicyÌýInstitute for Texas. “But there’s a statewide dearth across the board. It’s psychiatrists, it’s social workers — it’s everybody.”

The idea is that if the state spends money so that people with serious mental illness can easily access health care early on, it is cheaper and more effective than waiting for them to turn up in an emergency room or jail.

Bill Kelly, director of government affairs and public policy at the advocacy group Mental Health America of Greater Houston, said Schwertner’s bill would help Texas professional schools be more competitive in attracting students in the mental health field. Neighboring states like Louisiana and New Mexico already have loan forgiveness programs, he said.

A statewide from April conducted by physician recruiting firm Merritt Hawkins found that 185 of Texas’ 254 counties lacked a single psychiatrist. The Texas Medical Association estimates the state would need about 1,100 more mental health doctors to bring Texas up to the national average of psychiatrists per capita.

It’s an aging workforce as well. The average male psychiatrist in TexasÌýwas 57 years old in 2011, and his average female counterpart was 50, according to an analysis by the Hogg Foundation for Mental Health.

Meanwhile, the state’s population is growing rapidly, expected to .

“If you’ve got an aging workforce that isn’t growing, combined with a population that’s booming, you’re really setting yourself up for some hard times,” Kelly said. “If your demand is increasing and your supply is decreasing, it doesn’t take an economist to know that scarcity is going to have some very bad effects.”

Some research suggests that the demand for mental health services is highest in areas where the supply of professionals is low. A March study published in the Journal of the American Medical Association found that the youth suicide rate in rural areas was as in cities.

Meanwhile, the state receives federal money to help it more effectivelyÌýleverage the mental health workforce it already has. More than one-fourth of the roughly 1,500 projects in a federally approved programÌýmeant to spur innovation in the health care systemÌýdeal with behavioral health care, according to state health officials. That is sending $11.4 billion to Texas over five years.

Rebecca Wells, a professor with the University of Texas Health Science Center at Houston School of Public Health who has studied the mental health projects, said clinics in underserved areas that integrate mental health services with physical care often struggle to find primary care doctors who are willing to work with people with serious mental illness.

“It turns out that virtually every area I look at in Texas is medically underserved,” she said. “Mental health shortages come up over and over and over again. There just don’t seem to be a lot of Upper East Sides in Texas, with a superfluity of psychiatrists.”

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Facing a $338 million unpaid bill for Medicaid, the state’s health insurance program for the poor and disabled, lawmakers on the House Appropriations Committee voted Tuesday to help pay for it with a $102 million cash infusion that cameÌýfrom the feds under President Obama’s signature health law. But that’s not how lawmakers say the information was presented to them.

“No one indicated that it had anything to do with the ACA,” said state Rep. , D-Houston, the committee’s vice chairman. “Many individuals are running away from the ACA, but then we’re taking the benefits, and we’re using the benefits, at least at this point, to pay down on the unfunded Medicaid bill.”

“That was under the ACA,” said Stephanie Goodman, a spokeswoman for the Health and Human Services Commission, the state’s largest health agency. “We were not sure we were going to get it.”

It had previously been unclear, Goodman said, whether Texas would qualify for the , which was designed with the assumption that the state would expand its Medicaid program to cover low-income adults. Texas’ Republican leadership has consistently opposed Medicaid expansion, a central tenet of the health law, criticizing the public insurance program as inefficient.

The $102 million was apparently the single largest Easter egg state officials found in the health budget. In total, the five health and human services agencies reported $278 million in unspent funding for various programs.

That included money intended forÌýservices for low-income Texans, like the Children’s Health Insurance Program, which had $15.3 million left over, and the Texas Women’s Health Program, with $4.5 million unspent. Both programs saw lower-than-expected enrollment, which the health commission attributed in part to the Affordable Care Act.

The women’s health program in particular saw lower-than-expected enrollment, according to the agency, because more women were purchasing subsidized Obamacare plans on the federal exchange. Federal data show roughly 1.2 million Texans signed up for coverage.

But the leftover money from CHIP and the women’s health program, plus surplus funding earmarked for mental health services, will not go toward paying down the state’s Medicaid deficit, state Rep. , R-Dayton, told the appropriations committee, which he chairs.

Last week, Democrats wondered why budget writers would leave health funding on the table in a state that has the highest rate of people without insurance.

“No one can argue there are tremendous unmet needs dealing with health and human services, often more needs than we have money to appropriate,” Turner said in an interview. Otto did not return a phone call seeking comment.

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Over the objections of the medical community, state Rep. , R-Kaufman, has filed a bill that would prohibit doctors from asking patients whether they own a firearm and makes theÌýTexas Medical Board, which licenses physicians,Ìýresponsible for doling out punishment.

“Pediatricians are asking children away from their parents, ‘Do you have guns in your house?’ and then reporting this on the electronic health records, and then the federal government, frankly, has access to who has guns and who doesn’t,” Spitzer said in a recent interview. He said he experienced the phenomenon firsthand when he took his daughter to the doctor, who asked her whether there were any guns in the house.

“We, as physicians, ask all sorts of questions — about bike helmets and seat belts and swimming pool hazards, dangerous chemicals in the home, sexual behaviors, domestic violence. I could go on and on,” said Gary Floyd, a Fort Worth pediatrician andÌýÌýof the Texas Medical Association.

“All of that’s geared mainly to how we should direct our advice,” he said. “As a pediatric [emergency room] doc, one of the worst things you have to do is sit down with the family and explain that the child has died, or may never be the same, because of an unintended gunshot wound.”

Spitzer said his bill would still allow psychiatrists, who are more likely to encounter suicidal patients, to ask about gun ownership. But for most physicians, he said, asking about gun ownership is “not appropriate.” He suggested they could instead ask more “open-ended” questions about a person’s means to harm himself.

Florida passed a similar law in 2011. Challengers, including the American Academy of Family Physicians, challenged the law in court arguing that it infringed on doctors’ free-speech rights. The 11thÌýU.S. Circuit Court of Appeals in Atlanta last year upheld the law as constitutional.

“The Act simply informs physicians that inquiring about a private matter irrelevant to medical care isn’t part of the practice of good medicine and that, as always, a physician may face discipline for not practicing good medicine,” Judge Gerald Tjoflat wrote in theÌý.

Spitzer’s billÌýwas referred Monday to the House Public Health Committee.

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“Any expansion of Medicaid in Texas is simply not worth discussing,” state Sen., R-Georgetown, chairman of the Senate Committee on Health and Human Services, said at a press conference.

Schwertner andÌýLt. Gov. Ìýboth told reporters that the federal-state healthÌýinsurance program for the poorÌýand disabledÌýwas on an “unsustainable trajectory” of growing costs. In a letter, they asked the federal government for more wiggle room to administer the program, requesting cost-cutting changes to its benefits packages and seeking to require that Medicaid beneficiaries have or seek employment to get health coverage.

Similar requests by former Gov. for flexibility in spending Medicaid dollarsÌýfailed under both Democratic and Republican presidents. About 4.1 million Texans are on Medicaid, which constitutes about 29 percent of the total state budget.

In 2008, Perry health officials under President George W. Bush for a waiver allowing the state to limit its number of Medicaid beneficiaries and create a less generous benefits plan. That request was rejected.

“We should be following the example of other Republican states who are finding fiscally responsible solutions to closing the coverage gap rather than increasing it,” Coleman said in a statement.

Twenty-eight states and the District of Columbia Medicaid under the federal law.

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For Perry, accepting federal money to create a state insurance exchange would have meant acquiescing to yet another of the Obama administration’s “brazen intrusions into the sovereignty of our state,” he wrote inÌýa in 2012Ìýto the president’s then-health czar, Kathleen Sebelius.

Nearly 1 million Texans have now signed up for health insurance on the federal marketplace, known as healthcare.gov. But Texas, and 33 other states that did not create their own exchanges, will be the most vulnerable ifÌýthe U.S. Supreme Court rules against the Obama administration in the latest lawsuit challengingÌýthe Affordable Care Act, health policy experts say.

At issue are federal tax subsidies, a cornerstone of the law, given to people who cannot afford the full cost of insurance premiums.ÌýThe lawsuit, known asÌýKing v. Burwell, questions whether the Internal Revenue Service can give tax credits to people who purchased plans on the federal exchange. The challengers say no, pointing to a provision of an IRS rule that links subsidies to an “exchange established by the State,” wording that some of the health law’s authors have described asÌý.

Not surprisingly,ÌýTexas’ Republican leadersÌýsay they supportÌýthe case against President Obama’s signature health law. But spokesmen for Gov. and Lt. Gov. declined to sayÌýwhether they oppose the creation of a state exchange, as Perry did.

“This lawsuit highlights more evidence that Obamacare is a broken law that is bad for patients, doctors and taxpayers,” said John Wittman, an Abbott spokesman. “Gov. Abbott believes that Texas should be able to address our unique health care situation without federal interference, putting patients and doctors in charge of health care decisions.”

Oral arguments in the case are scheduled for March, and the high court’s decision could come as early asÌýJune.ÌýIf the high court rules that subsidies are not allowed for Texans and others in states without their own exchanges, the ripple effects could be striking. OneÌýinsurance industry group, in a court brief supporting the subsidies, said eliminating them would trigger a “death spiral” of premium increases and market destabilization.

Without assistance from the federal government, many young and healthy enrollees “are simply going to drop” their health plans, while the sickest people would remain in the market, said Nicholas Bagley, a professor at the University of Michigan Law School. That would expose insurers to greater risk, causing them to hike their rates for all customers, not just those who entered the system through Obamacare plans.

“Holy shit, that’s chaos,” said Robert Laszewski, a health policy consultant in D.C.Ìý“What’s ironic here is not only will the Republicans be screwing up the insurance for poor people on the Obamacare exchange, they’ll be screwing up health insurance for rich people in Texas who happen to be in the individual market.”

Now, Democrats and other advocates for the uninsured say Texas should prepare for the worst-case scenario by setting up its own exchange.ÌýState Rep. , D-Grand Prairie, has filed two bills to do so.

“My motivation was to say that we ought to create a state exchange so that even if the court rules with the plaintiffs, Texas citizens will not see a tax increase or will not have to lose their health insurance policy,” he said. “I hope that my colleagues and leadership will look at this not as a referendum on the Affordable Care Act. It’s simply a bill that says it’s a good thing for Texans to be able to buy health insurance.”

Eighty-six percent of Texans who purchased insurance on the federal exchange received a tax credit.ÌýThe average subsidy was $242 per month, or about a 72 percent reduction to their health insurance premium.

So far, state leaders have been tight-lipped about what, if anything, they are doing to prepare for a high court ruling. John Greeley, a spokesman for the Texas Department of Insurance, referred questions about King v. Burwell to “state leadership.”

“We’re not gonna weigh in,” he said. As for the state’s decision to create an insurance exchange, he said, “that has not been our call, from the very beginning.”

Representatives for Texas’ largest health insurers also declined to comment.

“Blue Cross and Blue Shield of Texas is waiting for further guidance from the federal government as this situation plays out,” company spokeswoman Margaret Jarvis said in a written statement, though a trade group representing the insurer in support of the subsidies.

The hesitancy for state leaders to act is based on red-state political opposition to the Affordable Care Act, Bagley said.

“There are formidable political obstacles in Texas, because there are so many people who have been elected on a strident anti-Obamacare platform,” he said. “I think it’s going to be very hard for Texas legislators to take the votes to actually fix this problem.”

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And then there are the approaches to helping poor people get medical care.ÌýInÌýArkansas, lawmakersÌývoted in 2013Ìýto expand the state’s Medicaid program, takingÌýfederal money to buyÌýprivate insurance for low-income adults. Texas, by contrast, has steadfastly refused to expand its Medicaid program.

SoÌýin Texarkana, access to free health care can beÌýdetermined byÌýtheÌýside of the street on which someone lives.

Shortly after Arkansas launched its “private option” plan expanding coverage for the poor, advocates for the uninsuredÌýbegan pushing Texas lawmakers to followÌýthe lead and devise a “Texas way” to expand coverage.ÌýBut in its first year, the Arkansas plan isÌýcosting more than expected, andÌýa growing chorus of Texas Republicans isÌýsaying “I told you so.”

Backed by the influential Texas Public Policy Foundation, a conservative think tank, they now citeÌýthe neighboring state’s experience as a cautionary tale against Medicaid expansion in any form.ÌýThree other states also have received federal permission to try alternative forms of coverage expansion.

“What I’m seeing in a lot of those states is the illusion of flexibility,” said state Sen. , a Republican and chairman of the upper chamber’s Health and Human Services Committee. “You’re aware that Arkansas is over budget?”

Arkansas has enrolled about 213,000 people in its program, dropping the state’s share of uninsured roughly 10 percentage points between 2013 and 2014, according to state records. In Texas, by comparison, about 1 million people would be eligible for health coverage under an expansion.

When Arkansas lawmakers negotiated the three-year plan, they agreed to spend no more thanÌý$477.63 per person each monthÌýin 2014. But at the end of the year, the actual per-person-per-month cost was $489.85, according to the state.

If Arkansas still exceeds the spending cap after three years, the state will be on the hook for the extra cost, but state officials say they are not concerned.

“There’s a caveat,” department spokeswoman Amy Webb said. “We have not yet reconciled with the insurance carriers related to cost-sharing reduction or medical necessity. At the end of our three-year waiver, we feel like we will be within the limit.”

That has not stopped the critics. John Davidson, a health policy analyst at the Texas Public Policy Foundation, said Texas cannot afford the risk ofÌýcost overruns jeopardizingÌýother priorities, likeÌýeducation.

“When you put a population that’s eligible for Medicaid into private coverage like Arkansas did, you’re going to end up paying more because you’re paying premiums on a private plan, and those are just more expensive,” he said. “At the very least, they’re nondisabled people who are working age, so the idea for a lot of conservatives is that for folks who are able-bodied and working age, what they really need is a full-time job, not Medicaid expansion.”

The future of Arkansas’ program is itself unclear. After sweeping Republican victories at the polls in November, state lawmakers there are threatening to repeal the expansion altogether. Newly elected Republican Gov. Asa Hutchinson has said he will give a speech on the future of the program next week.

Twenty-seven states and the District of Columbia have expanded Medicaid, and seven others are considering it, according to the Kaiser Family Foundation.ÌýArkansas would be the first state to drop out of an expansion.

In Texas, Medicaid covers 3.7 million poor, disabled and elderly people, including children, and costs roughly $40 billion per year, of which the federal government pays about 60 percent. Under the Affordable Care Act, the federal government offered to cover all of Texas’ Medicaid expansion costs for three years, eventually reducing its contribution to 90 percent.

Republican lawmakers considered an alternativeÌýto Medicaid expansion during the 2013 legislative session that would have drastically reformed the program. That proposal, led by state Rep. , R-Richmond, failed. The Legislature ultimately approved a requirement that the Health and Human Services Commission receive legislativeÌýÌýbefore expanding Medicaid eligibility.

Texas’ Legislature has only moved further to the right since then. Whether Zerwas will stick his neck out again this year remains to be seen, he said.

“There needs to be kind of a sense from the highest levels of leadership whether there’s interest and support for that,” he said. “I don’t have any sense of where the new governor’s office is on this, where the lieutenant governor is on this, or the speaker, for that matter.”

Gov.-elect , who campaigned fiercely against Obamacare as federal overreach, has not publicly appeared receptive to Medicaid expansion. “Fear not — Governor-elect Abbott has fought Obamacare and will continue to fight against it,” Abbott spokeswoman Amelia Chassé recently told the conservative National Review.

But he has not categorically ruled out an alternative form of expansion, either. This week, in an interview with The Wall Street Journal, he gave advocates for such a program a sliver of hope.

Though he is against the expansion of Medicaid as it exists, Abbott said, “like anyone with an inquiring mind, we’ll look at any idea anyone has.”

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The 15-member Texas Institute of Health Care Quality and Efficiency recommended that the state’s health commissioner be authorized to negotiate a Texas-specific agreement with the federal government to expand health coverage to the poor, “using available federal funds.”

“We’re trying to look at actions whereby more Texans can be covered,” said board chair Steve Berkowitz, the president and founder 0fÌýSMB Health Consulting. “We’re trying to take the politics out of it.”

Under the Affordable Care Act, President Obama’s signature health law, the federal government has offered to foot more than 90 percent of the bill for states that expand their Medicaid programs to cover adults living in poverty. Perry and other Republican leaders have criticized the program, which could insure more than 1 million currentlyÌýuncoveredÌýTexans, as inefficient.

Lawmakers considered an alternativeÌýto Medicaid expansion during the 2013 legislative session — an initiative that would have called on the state’s health agency to seek a waiver from the federal government to draw down funds to cover the uninsured. That proposal failed. Ultimately the GOP-led Legislature approved a requirement that the Health and Human Services Commission receive legislativeÌýÌýbefore expanding Medicaid eligibility — an effort to ensure that they held the keys to any possible agreement with the feds.

Members of the Institute of Health Care Quality and Efficiency — which was established by lawmakers in the 2011 legislative session to identify evidence-based approaches to improving health care and cutting costs — said Wednesday that Texas’ rate of uninsured was “unacceptable,” and that state leaders should look for an alternative way to expand health coverage. The board’s recommendations are not binding and any such decision is up to the Legislature.

“We should be maximizing available federal funds through the Medicaid program to improve health care for all Texans,” said Joel Allison, a board member who is chief executive of theÌýBaylor Scott & White Health System.

Ìý

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Hughes, who is HIV positive, has struggled to find insurance coverage, because HIV is considered a pre-existing condition. But even under the new law, Hughes said her care providers had advised her not to enroll in the federal health care exchange yet. It is unclear, they said, how the law will affect HIV care when marketplace coverage begins Jan. 1.

“Right now we get good care, and I’m not interested in having my stuff all shifted around,” she said from her Houston home.

Minister Freedom Gulley led a candlelight vigil in recognition of World AIDS Day on Dec. 1, 2013, in Houston (photo by: Michael Stravato).

Hughes and her husband, Daniel, also HIV positive, receive some health coverage under the Ryan White Care Act, a federal health care program for HIV and AIDS patients. Community advocates expected the Affordable Care Act to provide nearly universal health coverage for HIV patients, freeing up funding from the Ryan White program to cover services beyond primary care.

But many HIV patients in Texas live below the poverty line and are therefore ineligible for subsidies on the exchange. Add Texas’ decision not to expand Medicaid to cover poor adults, and the bulk of low-income HIV patients are missing out on expanded health coverage.

Dena and Daniel Hughes, who have four dependent children, recently started a home repair business and do not know how much they will earn next year.

The stakes are high. If their income is below $31,590 — the requirement for a family of six to receive tax subsidies on the federal exchange — they will rank among the thousands of HIV-positive Texans whose incomes are too low for subsidized private insurance but too high for Medicaid. Roughly 14,000 Texans with HIV used assistance from the Ryan White program to pay for antiretroviral medication in 2011, while nearly 19,000 were not receiving any HIV-related medical care, according to the Department of State Health Services.

Daniel Hughes receives medical care at Legacy Community Health Services, a federally qualified health center in Houston. Katy Caldwell, its executive director, said she had struggled to advise HIV patients about the marketplace with certainty that their health plans would cover all their medications. “You’ve got people on some complicated drug regimens that you want to make sure people stay on, and it’s not as easy as it sounds,” she said.

Referring to patients living below the poverty line, she added, “One of the hard things to explain to people is you’re actually too poor to get help.” At Legacy, 58 percent of patients are uninsured.

Texas’ Medicaid eligibility requirements are among the country’s strictest. For a family of six, adults without a disability must earn less than $4,608 per year to qualify for coverage.

But Gov. has adamantly opposed Medicaid expansion, citing worries about the program’s efficiency.

“The fact is that Medicaid is a broken system in need of fundamental reform,” Lucy Nashed, a spokeswoman Perry, said in an email. She added that “Texas has a proven history of providing services and effective HIV medications to HIV-positive Texans through the HIV-STD Program and the Texas HIV Medication Program.”

Katherine Record, a senior fellow at Harvard Law School’s Center for Health Law and Policy Innovation, directed a project that modeled how health reform would affect HIV patients in Texas. She roughly 65 percent of Texans who received assistance from the AIDS Drug Assistance Program, a Ryan White program, would be eligible for Medicaid under the expansion.

By comparison, “Pre-ACA, you could only qualify for Medicaid if you proved you were disabled, which pretty much meant having your HIV progress to full-blown AIDS,” she said.

For Santiago Estrada, a 53-year-old patient in Abilene, AIDS allowed him to enroll in Medicare, which covers his antiretroviral medication. He said the drugs alone would have cost him $2,000 per month out of pocket.

Estrada visits the Big Country AIDS Resources center in Abilene for care. He says the “wraparound” services the center provides with Ryan White funding, like assistance with nutrition and transportation, are paramount for his well-being.

Betty Sims, the center’s executive director, says the Affordable Care Act could mean big changes for many of her clients’ access to coverage. But for the 48 percent of her clients who live below the federal poverty line, most have never qualified for Medicaid “and are really left out in the cold,” she said.

Advocates say demand for transportation services ranks highly among the wraparound benefits that Ryan White money could assist with, if more HIV patients had primary care coverage under the Affordable Care Act. For Sims’ clinic and others that serve large rural populations, patients’ lack of access to a vehicle is a significant obstacle to HIV care. “There’s only one infectious disease specialist in the 19 counties we serve,” Sims said. The center has partnered with infectious disease physicians at Texas Tech University to consult with patients electronically.

“The Ryan White services that we provide are going to continue to be needed here no matter whether people have access to insurance or not,” Sims said.

One way states have sought to make the most of their Ryan White money under the new health law is to use the AIDS Drug Assistance Program funds to pay for HIV patients’ insurance premiums, rather than purchasing expensive drugs directly. Because the Affordable Care Act requires insurers to cover pre-existing conditions like HIV, “in almost every case now it will be cost-effective” to spend the money on HIV patients’ insurance premiums, even if they do not qualify for subsidies, said Ann Lefert, director of policy and health care access at the National Alliance of State and Territorial AIDS Directors.

Christine Mann, a spokeswoman for the Texas Department of State Health Services, said the agency was looking into such a measure.

Many advocates expect Texas to expand its Medicaid program eventually. But in the meantime, Ryan White funding will continue to shoulder primary care costs for the majority of impoverished Texans with HIV.

“They call it payer of last resort,” Dena Hughes said of that coverage. “But for some people, it’s the payer of first hope.”

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