A Medicaid Bill With HSAs and No Entitlement. Show the Math.

A Medicaid bill landed in Austin today.

It talks about health savings accounts, private insurance, and personal responsibility.

And it says, in plain words, this is not an entitlement.

Plain English summary

HB 1089 was filed November 12, 2026 by Rep. Suleman Lalani. The caption calls it a "Texas Way" to reform Medicaid. FACT (bill history)

It does two big things.

First, if Washington ever lets Texas run Medicaid on a block grant, the state would run it through managed care and hand eligible people a sliding scale subsidy to buy a private health plan. Choose a high deductible plan with a health savings account and the subsidy gets bigger. FACT (bill text)

Second, it orders the Health and Human Services Commission to go ask the federal government for a waiver to use federal matching money to put low income Texans on private coverage. FACT (bill text)

Why it matters

The record on coverage in this state is ugly.

Texas Public Radio reports new Census numbers put the Texas uninsured rate at 16.5% in 2025, almost double the national rate of 8.4%, with almost 5.2 million Texans uninsured. DOCUMENTED INFERENCE (TPR)

The same report says the enhanced marketplace tax credits expired at the end of 2025, and an advocacy group says more than 850,000 Texans picked a 2026 plan and never activated it. DOCUMENTED INFERENCE (TPR)

Uninsured people still get sick. They show up at the emergency room. Somebody pays. Usually it is your county and your property tax bill.

The bill itself names that. One stated goal is "relieving local tax burdens." FACT

The receipt

Here is what is in the introduced text. FACT (bill text)

Block grant Medicaid (new Chapter 532A, Government Code)

Only kicks in if the federal government approves a block grant or waiver. Acute care eligibility: household income at or below 100% of the federal poverty level; kids under 19 on SSI or in foster care; or anyone eligible under the rules in effect August 31, 2027. Sliding scale subsidy to buy a private plan, based on the average premium and "a realistic assessment" of what the person can pay. A bigger subsidy for a high deductible plan with a health savings account. Leftover subsidy can go into the health savings account. Any insurer licensed in Texas can take part.

Private market program (new Chapter 545A)

Under 65, at or below 133% of poverty, and not already on Medicaid. The deal with Washington must be cost neutral to Texas, using premium tax revenue and cost savings. Coverage must "emphasize personal responsibility," with cost sharing, wellness incentives, and "disincentives for noncompliance." Pay for performance for the insurance companies. Section 545A.0004: "This chapter does not establish an entitlement."

Effective September 1, 2027. Agencies can wait on any piece that needs federal approval. FACT

What Ryan says

RYAN STATEMENT

I do not care whose name is on the bill. I care what is in it.

Health savings accounts. Private plans. You pay a share. Insurers get paid for results. It says in black and white it is not an entitlement.

That is not a handout. That is a ladder.

But the word "neutral" is cheap.

Cost neutral to Texas. Show me the math. How much premium tax revenue? How much in savings? Who scores it? Put the fiscal note on the table before anybody votes.

And notice what moves this bill. Washington. The block grant piece only works if the federal government says yes. The waiver piece only works if the federal government says yes. Texas families should not be waiting on a phone call from D.C. to fix a Texas problem.

Here is the other question I want answered. "Disincentives for noncompliance." What does that mean for a working man with a bad back who misses a wellness check? Write it down. Rules made later by an agency are rules nobody voted on.

Same county, opposite rule? Not here. One rule. If it is good policy, it is good policy. If the numbers do not hold, it is not.

What this does not prove

It does not prove the bill will get a hearing or a vote.

It does not prove the federal government will approve a block grant or a waiver.

It does not prove the program would actually be cost neutral. The bill sets that as a requirement. It does not show the numbers.

It does not prove how many Texans would be covered. The bill gives no count.

The uninsured figures come from news reporting on Census data, not from the bill. DOCUMENTED INFERENCE

What it does prove

A bill is on file in Austin today that ties Medicaid reform to private plans, health savings accounts, cost sharing, and a written line that it is not an entitlement. FACT

It caps the new program at 133% of poverty and requires any federal deal to be cost neutral to the state. FACT

And it leaves the hard details, including penalties for "noncompliance," to agency rules. FACT

The bottom line

Five million Texans without coverage is a real problem. Your county pays for it either way.

A private market answer deserves a real look.

But no vote on "cost neutral" without the receipts.

Show me the evidence.

Do not threaten anyone. Do not harass anyone. Do not contact anyone in my name. Read it. Share it. Send receipts, evidence, witnesses. Put eyes on the record.