The Affordable Care Act's online health insurance exchanges go live on Oct. 1, which is where many people without health insurance can pick a plan and enroll.
One out of four Texans do not have health insurance -- the largest percentage of uninsured in the nation -- and leaves the state with over 6 million potential customers for the health insurance exchanges.
With so many people potentially signing up for health care, Texas could make a strong case for the ACA's success, but it could also be the best place for opponents to discourage enrollment in the exchanges in order to collapse the system.
State leaders are unabashed about doing all they can to hobble the new law's rollout, but they can only do so much.
At an ACA community information meeting recently held in on San Antonio West Side, community organizer Sevi Laura of the Texas Organizing Project addresses a room crowded with people looking to learn more about the roll out of the affordable care act.
"Today we’re here to give information about the exchanges that will be happening in October," Laura said. "To make sure everyone has the correct information and knows all the avenues to be able to receive health care."
People took turns telling their personal stories about life without health insurance -- stories about budget-busting premiums, denials of coverage due to preexisting conditions and the frustration that Texas refused to expand the federally funded Medicaid that would have helped many of the poorest in the room,
Enrique Maydon, who said he has diabetes, arthritis, was hurt on the job and now can't work and has no health insurance, said he needs Medicaid to be expanded.
Texas Gov. Rick Perry decided not to expand Medicaid and is one of the nation’s loudest opponents of the ACA. He made that clear while being interviewed on Fox News.
"We’re not going to expand Medicaid we’re just not going to be a part of – again – socializing health care in the state of Texas and going in direct conflict with our founding fathers’ wishes and freedom for that matter," said Perry.
Recently Perry took another step to hinder the ACA by directing the Texas Department of Insurance to establish strict rules to regulate the ACA navigators, people hired across the country trained to help people enroll in Obamacare. Many are focused on going into Spanish speaking neighborhoods and helping minorities.
Josh Havens, who works in the governor's press office, said most of the requirements have to do with competency:
"Including requiring navigators to complete a certain amount of hours of state training in addition to the federal training -- we've asked that they pass an exam based on that training. Refrain from influencing a customer’s decision or a consumer’s decision on which insurance to choose," Havens said.
Fourteen other states are also regulating the navigators but Texas announced its intentions just days before the start of enrollment and the new Texas regulations won’t be in place until Jan. 1, which will keep the navigators from doing their jobs for three critical months of the enrollment window.
Is this the blueprint for ACA collapse?
Jose Ibarra is a Texas coordinator for Enroll America and said not having those navigators is going to make his job tougher.
"The navigators play an integral role in this whole process," Ibarra said, "they are there to help folk enrolling in insurance step by step. Help them find an insurance plan that’s best for them and best for their family that they can afford so without a navigator it will be difficult for the public."
If fewer people sign up in Texas that could strike at the heart of what is supposed to make the ACA economically viable.
"The entire scheme of these exchanges in Obamacare depends upon as many people as possible signing up for coverage to dilute the risk pool and the theory is the more people who sign up the more it will drive prices down," said John Davidson, a health care policy analyst at the conservative Texas Public Policy Foundation.
Davidson said the opposite also works. If not enough people sign up, then the ACA could go into a death spiral.
"This happens in insurance markets when not enough healthy people sign up and there’s too many sick people in the insurance pool with too high of an insurance claims -- premiums go up, more healthy people drop out, premiums continue to go up until the market collapses," he said.
State Rep. Mike Villarreal, D-San Antonio, claims that’s exactly what the state’s Republican leadership wants.
“What they are attempting to do is to discourage – make it harder – make people jump through more hoops who are particularly younger to sign up and participate in the health care market places and that’s not helpful for anyone.," Villarreal said.
