Uninsured Texans: Challenges & Policy Solutions

This is Part 2 of a blog series examining the 2022 Census data and providing insight into Texas’ uninsured rate. Read Part 1 here. 

Policy Solutions 

All Texans, no matter our race, income, or hometown, deserve to be able to see a doctor when we get sick. When Texas leaders fail to invest in our people and the programs that keep us fed and healthy, Texans and our families suffer. There are several policy solutions available at the state level to increase access to health care for all Texans.   

Medicaid Expansion

Texas is one of ten U.S. states that has not expanded Medicaid to cover low-income adults. The federal government has offered billions of dollars to Texas to provide Medicaid coverage to both low-income parents and adults without dependent children in the home. Experts estimate about 1.4 million of Texas’ uninsured would qualify for coverage if the state would take this step, the majority being people of color. 

Improving the Eligibility System

At least 495,000 uninsured Texas children were eligible for Medicaid or CHIP coverage in 2021 but were not enrolled. The Texas legislature and Health and Human Services Commission (HHSC) must work to remove barriers to enrollment for qualified children and adults. In order to ensure all individuals eligible for Medicaid and CHIP are able to easily enroll and stay enrolled, the state must staff the eligibility system adequately, increase efficiencies through system streamlining and use of reliable data sources for coverage renewals, enact express lane eligibility for children, and invest in modernizing the website and mobile app people use for public benefits in Texas (Your Texas Benefits).

The Texas legislature had an opportunity to address the high number of eligible-yet-uninsured children during the 88th Legislative Session with HB 1599, which would have allowed HHSC to use already verified information from other state programs to enroll eligible children in Medicaid and CHIP using an “express-lane” option. This bill overwhelmingly passed out of the House, but later died in the Senate without ever receiving a hearing. It’s hard enough to get Medicaid coverage in Texas, but keeping it comes with its own battles. No state does a worse job of using data matching to reduce red tape for families renewing Medicaid. Texas has only been successful in matching verified data to expedite renewals 3% of the time during unwinding, a mere tenth of the national average. This means that parents have to fax, mail, or upload their paycheck stubs in almost every renewal, even in some cases when HHSC already knows what the family earns from the state payroll data it has on hand. Lack of data-matching and streamlining not only burdens families, it places an unnecessary burden on an already overloaded state eligibility system.

In addition to barriers for families enrolling in Medicaid and CHIP, for years, HHSC’s Access and Eligibility Department has struggled to process Medicaid and SNAP applications without delays and backlogs. During the 88th session, lawmakers appropriated an additional $123 million to HHSC, a portion of which was meant to increase staffing during Medicaid unwinding. HHSC recently reported its eligibility workforce vacancy rate is down to 3.9% in September of 2023 (from 21.1% in March 2022). However, only 318 of the 642 temporary unwinding staff positions were filled as of this month. Even with this increase in staffing and pay raises, wait times and backlogs for Medicaid and SNAP paperwork are currently growing, highlighting the need for system streamlining in addition to staffing efforts.

Maintain Enrollment Increases in Marketplace

Texas has seen record-breaking enrollment in the Affordable Care Act Marketplace (HealthCare.Gov) in recent years thanks to increased federal investments in subsidies for families, enrollment assistance, marketing campaigns, and state action that made Marketplace coverage more affordable at the beginning of the year. According to 2023 estimates, about 2.4 million Texans are insured via the Marketplace, a 31% increase since 2022. Roughly 2 of our 5 million  uninsured are eligible for Marketplace subsidies, suggesting even more robust outreach and marketing could drive enrollment in the coming years. It is important to continue these enrollment increases as the unwinding process kicks Texans off of their health insurance. 


Unwinding Fallout

Earlier this year, Texas HHSC began the monumental process of re-checking Medicaid eligibility for everyone currently enrolled following the end of the pandemic-era coverage protections. This process is referred to as Medicaid unwinding and will largely be completed in December for Texans. Despite warnings from advocates several months prior to the unwinding process, the process has been chaotic and harmful. About 1.2 million Texans have been disenrolled from their Medicaid coverage since this process began, two-thirds of whom lost coverage without HHSC determining whether or not they remain eligible (called a “procedural denial”). We expect the number of Texans losing Medicaid to continue to climb. Alarmingly, about 500,000 Texas children have been removed from Medicaid, even though they were not determined to be ineligible. There are several reasons why this already challenging process is going so poorly in Texas, namely the state’s breakneck speed without adequate staffing or technology to do the job correctly and the failure to adopt best-practice streamlining measures that could have eased the strain on the already overburdened and backlogged eligibility system. The 2022 uninsured data discussed in Part 1  do not reflect the large numbers of Texans that will be removed from health care coverage in the coming months despite remaining eligible during unwinding. The effects of this chaotic process on Texas’ uninsured rate will likely not be seen until the 2023 U.S. Census data is released next year. 

Chilling Effect on Immigrant Populations & Mixed-Status Families

One in four U.S. citizen children living in Texas has a parent who is not a U.S. citizen (of any immigration status, lawful or undocumented). Parents often have questions about enrolling their U.S. citizen or lawfully present immigrant children into available coverage. Ensuring robust Medicaid outreach that addresses concerns of mixed-immigration-status families will help ensure all eligible children are successfully covered. 

HHSC’s outreach information should include updated materials that clearly explain eligibility rules for both non-citizens and their citizen and eligible immigrant family members. Outreach should also clarify that eligible children’s use of health care services will not harm a parent’s immigration status, as fear of accessing government services within the immigrant community has caused families to drop coverage for tens of thousands of U.S. citizens  and lawfully present children in recent years. Without solid, accurate information going out to lawfully present immigrant families, eligible children will remain uninsured. 

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