Texas House Appropriations Committee – Subcommittee on Article II
via email Appropriations@house.texas.gov
RE: Information responsive to Charge #2, Healthy Texas Women waiver
Dear Chairwoman Davis and Members of the Subcommittee:
Every Texan (formerly Center for Public Policy Priorities), appreciates the opportunity to submit information in response to your RFI regarding the Healthy Texas Women Section 115 Demonstration Waiver:
Interim Charge 2: Review how Texas is preparing for state and federal budgetary changes that impact the state’s health programs, including: … the Healthy Texas Women Section 1115 Demonstration Waiver.
As requested, our responses to other HAC charges/topics will be submitted in separate documents.
At Every Texan, we envision a Texas where people of all backgrounds can contribute to and share in the prosperity of our state. Texas faces long-standing challenges to optimal health, including the nation’s highest uninsured rates, and steep financial and systemic barriers for those who have insurance. We work to improve public policies to make affordable, comprehensive care a reality for every Texan.
Texas women’s health programs cover critical, but very limited services
Healthy Texas Women (HTW) and the Family Planning Program (FPP) provide access to limited yet vital health care services that help Texans plan the timing and size of their families, including contraception and well-woman exams. HTW also provides limited treatment for hypertension, high cholesterol, and diabetes in a primary health care setting (not through specialists) and, for postpartum women only, provides limited benefits for postpartum depression, cardiology, and substance use disorder treatment.
Texas’ family planning programs help increase economic and social opportunity for women, improve health outcomes for women and babies, and save money for the state. These programs are not, however, a substitute for full health coverage, such as through Medicaid expansion. Unlike Medicaid and other comprehensive health insurance, Texas’ family planning programs do not cover many services women need to stay healthy, like cancer treatment, hospitalization, emergency services, medications for most medical conditions, and much more.
Barriers to enrollment planned under the new waiver
As part of the new federal waiver, Texas Health and Human Services is planning to end two current HTW policies that streamline enrollment and reduce burdens on women, clinic staff, and state eligibility workers:
- Ending adjunctive eligibility. Since implementation of HTW’s precursor program in 2007, Texas has used adjunctive eligibility to accurately confirm income eligibility by checking enrollment in other state-administered, means-tested programs instead of requiring income documentation from applicants.
- Ending auto-enrollment of new moms transitioning off of Medicaid for Pregnant Women 60-days after childbirth. This process was included in the design and launch of HTW in 2016 and is part of the reason HTW enrollment has been increasing since then. The state will replace auto-enrollment with its currently poorly-functioning administrative renewal process.
Ending these two successful strategies to streamline enrollment seems certain to lead to a decrease in enrollment in HTW, which could increase state costs in two ways:
- Reduced access to effective contraception leads to increases in unintended pregnancies and associated Medicaid spending, and
- When clinics that contract with HHS in the Family Planning Program are unsuccessful at enrolling an applicant into HTW, they often charge the services to FPP instead. Any barriers to HTW enrollment will decrease HTW services that generally get a 90% federal match, and increase FPP services, which are fully GR-funded. FPP services are consistently in high demand and program funds routinely run out before the end of the funding cycle. We urge you to guard against any policies that would more quickly deplete critical FPP funding.
On top of increasing costs, ending auto-enrollment of new moms will undermine the goal of Senate Bill 750 from last session, which added limited postpartum benefits to HTW, now called HTW Plus.
HHS should immediately take three steps to mitigate the elimination of these policies, to help maintain program enrollment and maximize savings to the state:
- Fix the administrative renewal process, so that more new moms can transition to HTW without having to submit documentation to the state on a tight timeline. Needed fixes include allowing the use of Texas Workforce Commission (TWC) wage data from the most recent two quarters. Current system design allows the use of TWC quarterly wage data in only four months of the year. HHS should also end the redundant step of checking New Hire reports at renewal, since they are already checked monthly.
- Allow the use of post-enrollment verification for both applicants seeking family planning services (who have access to traditional HTW benefits) and new moms transitioning from Medicaid (who can also access HTW Plus benefits). This policy would allow a woman to submit pay stubs or other required verification during a temporary, 90-day window after she is enrolled. Texas already uses post-enrollment verification in Texas Medicaid for Pregnant Women, and it does not require a waiver from CMS.
- Immediately request a waiver amendment to continue using adjunctive eligibility. CMS allows adjunctive eligibility for certain MAGI-based eligibility groups. For example, CMS allows “express lane eligibility” for children’s Medicaid when they are enrolled in SNAP or WIC.
For more detailed information on proposed program barriers to enrollment and available solutions, we point you to comments submitted by the Texas Women’s Healthcare Coalition.
Progress on avoiding budget cuts to women’s health services, but harms remain
Over the last few sessions, the Texas Legislature has increased its investment in the state’s women’s health programs, which has helped to rebuild the state’s family planning network and increase the number of women served. It also saves General Revenue (GR). Together, in 2019 HTW and FPP generated a net GR savings to the state of $19.6 million. Texas sought and recently received an 1115 waiver to get a 90/10 federal Medicaid match for HTW services – the same federal matching rate available for Medicaid expansion. With the enhanced federal match, net savings to GR will increase moving forward.
We applaud legislators’ efforts that took direct cuts to HTW and FPP off of the table after state leadership directed agencies to make budget cuts in the current biennium totaling 5%. HHS’ revised proposal continues to call for reduced or delayed hiring of 742 eligibility and enrollment staff positions. As the agency notes, these cuts will harm clients by causing delays in enrollment into HTW, including by new moms, and other essential programs. Cuts to health care programs are harmful at any time, but would be particularly harmful now in the middle of a pandemic and as the state’s worst-in-the-nation uninsured rate climbs even higher.
Thank you for studying how the new Healthy Texas Women Medicaid waiver will affect access to critical women’s health services in the state. We stand ready to help as you consider legislative options to ensure that every Texan has access to affordable and comprehensive health care.
Senior Policy Analyst, Every Texan
 Texas Health and Human Services. Women’s Health Programs Saving and Performance Report Fiscal Year 2019. May 2020, file:///C:/Users/spogue/Downloads/tx-womens-health-programs-report-fy-2019%20(1).pdf.