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Undocumented Texans Paid $4.9 Billion in State and Local Taxes in 2022

Undocumented immigrants are essential contributors to Texas’ economy and robust job growth. Regardless of their citizenship or immigration status, immigrant families pay state and local taxes to support vital public services that benefit all of us, such as schools and colleges, roads, parks, and libraries. A new report from the Institute on Taxation and Economic Policy (ITEP) confirms in 2022 1.9 million undocumented Texans paid a hefty $4.9 billion in state and local taxes. 

Undocumented Texans pay their fair share of state and local taxes. 

Without a state income tax, Texas’ state and local tax system relies heavily on sales and property taxes. Most revenue (58%) contributed by undocumented Texans (nearly $2.8 billion) was paid in sales and excise taxes, while 37% (about $1.8 billion) was paid in property taxes that support public education and local government services. Because Texas relies so heavily on its “two-legged stool” tax structure, undocumented Texans are even more likely to pay the same taxes as other Texas residents when compared to those undocumented in other states. 

The ITEP report estimates the effective tax rate — the percentage of annual income paid in taxes — for undocumented immigrant families. In Texas, the effective tax rate for undocumented Texans is 8.9%, the 15th highest in the nation. Given the regressive nature of Texas’ tax system, it is unsurprising that undocumented immigrants’ effective tax rate is higher than most. For perspective, the state’s wealthiest taxpayers (the top 1%) pay an average effective tax rate of just 4.6%, half of what undocumented Texans pay. 

Texas is one of six states that raised more than $1 billion in tax revenue from undocumented immigrants. On average, undocumented Texans pay $2,615 in state and local taxes per person. This means that public services receive an additional $1.3 billion in tax revenue for every half a million undocumented immigrants living in Texas. 

Undocumented immigrants pay federal taxes too but are denied many benefits.  

Undocumented Texans contribute to federal taxes and may help lower the federal deficit by a net $0.9 trillion over the next 10 years. Yet a substantial portion of their contribution goes to payroll taxes, which fund the major social insurance programs they are barred from accessing. In 2022, undocumented immigrants nationwide paid $25.7 billion in Social Security taxes, $6.4 billion in Medicare taxes, and $1.8 billion in unemployment insurance taxes. Despite contributing nearly $34 billion to the U.S. social safety net, undocumented Americans are unable to access that support. 

Undocumented immigrants also can face higher income tax payments than U.S. citizens due to laws that deny them and their U.S. citizen family members significant tax credits, such as the Earned Income Tax Credit and Child Tax Credit. Many do not claim tax refunds at all because of lack of awareness, fear of immigration consequences, or limited access to tax preparation help. 

Granting legal status to undocumented immigrants would not only raise their wages, but also enable them to claim more credits and refunds to which they are entitled. It also would mean more state revenue. If all current undocumented immigrants received work authorization, their annual state and local tax contributions would increase by $474 million, reaching $5.3 billion. This new revenue would include an additional $215 million from sales and excise taxes, $157 million from property taxes, and $102 million from other taxes. 

Undocumented Texans are critical contributors to the so-called “Texas Miracle.” Every Texan wants to provide for their family and improve the state — regardless of their legal status. This study reminds us how important our undocumented family, friends, and coworkers are to the economic productivity of Texas communities from Amarillo to Brownsville.  

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Blog

Why “Food is Medicine” Initiatives Are Important in Addressing Food Insecurity

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Lawrence Robinson was a Health and Food Justice Policy Intern from September 2023 to May 2024

The food we consume is a crucial determinant of health, as quality nutrition prevents and manages chronic diseases. However, 1 in 8 Texans experience food insecurity and rising rates of diet-related conditions. These data mirror the national average and contribute to the 117 million Americans who have at least one preventable chronic disease; the story is even more devastating for Texans of color. As food access plays a key role in public health and wellness, we must understand the root causes of food insecurity in order to promote healthy living. This report examines the current state of food insecurity in Texas while exploring how public health programming and policy can address these issues. 

View this report as a PDF.

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Blog

Another Year of Record Affordable Care Act Marketplace Enrollment

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Texas saw record enrollment growth in both new and returning customers on the Affordable Care Act (ACA) Marketplace for 2024. A number of factors drove these historic gains, including an extension of federal subsidies supporting low-cost coverage and mass coverage loss due to Medicaid unwinding.  

By the Numbers

More people enrolled in better plans for this year. 

Almost a million new Texans have Marketplace coverage this year, meaning enrollment gains are about the same as the city of Austin’s population. Marketplace enrollment in Texas grew an astounding 44.5% between 2023 and 2024. 1 in 9 Texans are now insured through the Marketplace. 

Most Texans signed up for gold plans, and as a state, we had higher-than-average enrollment in gold plans and lower-than-average enrollment in bronze plans compared to the rest of the United States. Bronze plans have lower premiums on average but much higher deductibles and other cost-sharing, which can lead people to put off care or forgo it altogether in fear of high costs. Federal subsidies over the past few years have made gold and silver plans an accessible and attractive option for more people. 

Most Texans benefitted from cost-reduction policies and federal subsidies. 

Congress has repeatedly funded different financial supports for people using the Marketplace. These subsidies typically fall into two categories: 

  • Advanced premium tax credits (APTCs) apply to the monthly premium paid to the insurance company to maintain coverage. These are refundable credits applied to federal income taxes.  
  • Cost sharing reductions (CSRs) apply to the amounts paid when using insurance, such as a copay or coinsurance paid to a provider for care. CSRs are only available to people enrolled in silver plans.  

The  Inflation Reduction Act extended the subsidies provided by the American Rescue Plan Act, making APTCs and CSRs available again for the 2024 plan year. This extension made these benefits available to more people and resulted in more plans with low or no-cost premiums. These extended subsidies were likely a major driver of the huge Marketplace enrollment in Texas this year. In 2024, 96% of Texans got coverage supported by federal premium subsidies; nearly half (49%) of that 96% also got CSRs they could apply to deductibles, copays, or coinsurance.  

Most users comparison-shopped for coverage to find the best deal. 

Texans overwhelmingly used Healthcare.gov to compare plans and find the best price and fit for their health care needs. 72% of Texans on Marketplace coverage updated information and shopped to compare plans. This led around half of Texans using the Marketplace to switch plans from last year. Only about a quarter of Texans automatically renewed their coverage without first looking at other available options. In many cases, this is because a consumer knows ahead of time which plan reliably covers a preferred provider in their area.  

While federal policies and funding are in place to make gold plans a best option in most cases, for some, a silver plan would lead to better savings and comparable coverage because they qualify for CSRs. Annual changes to federal policy and funding can make choosing a plan daunting, which is why there is federal support for free assistance in navigating the Marketplace.  

Better access to enrollment assistance should be funded. 

Finding health coverage is stressful. Even navigating employer-sponsored insurance options or choosing the right Medicaid managed care plan can be difficult. How insurance works and what a plan will pay for is variable and confusing. This reality makes the availability of expert help — without financial interest in enrollment outcomes — a vital part of every state’s insurance ecosystem. Though Texas used to fund enrollment assistance support, the state stopped years ago for political reasons and left Texans to rely on the network of federally-funded  enrollment assisters in communities across the state. These wonderful groups can help individuals and families assess coverage options, enroll in coverage, and untangle access issues. More funding for more such support across Texas is a key step toward reducing Texas’ highest-in-the-nation uninsurance rate:  a staggering 16.6%. 

These Numbers Could Change. 

There are several threats to Texas’ coverage gains on the Marketplace, including: 

  1. The potential expiration of federal subsidies supporting access to coverage; 
  2. A lack of state funding for qualified enrollment assistance programs;  
  3. Fraud by bad actor agents and brokers illegally leaving people enrolled in more than one plan with limited options to fix their situation; and  
  4. “Junk” insurance-like products offering non-comprehensive coverage mistaken for true, ACA-compliant health insurance.  

State and federal funding is necessary to continue to support this progress. Comprehensive health insurance is expensive and health care costs are high — especially when accounting for high inflation. Congress must reauthorize the subsidies that make APTCs and other CSRs more broadly available in order to ensure people can afford coverage. Texas should invest state funds to support enrollment assistance programs to help Texans navigate comprehensive coverage options and find the best plan. Enrollment assistance and coverage information should be available in multiple languages, accessible to people with disabilities, and navigable by households with different eligibility for different programs, including food access programs.  

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Blog

New Policy Removes Barrier to Health Access for DACA Recipients

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A  new federal policy ensures people with “Deferred Action for Childhood Arrival” (DACA) status are no longer barred from participating in the Affordable Care Act (ACA) Marketplace. For years, a different legal definition of people who are “lawfully present” improperly excluded DACA recipients, who do have legal status across other federal programs. The Centers for Medicare and Medicaid Services estimates 100,000 DACA recipients across the U.S. may have been barred from accessing the Marketplace coverage because of it.  

The new final rule clarified technicalities of the definition of “lawfully present” as it relates to people eligible for ACA Marketplace plans and cost-sharing support to now include DACA recipients. This means things like advanced premium tax credits and cost-sharing reductions are now available to DACA recipients purchasing Marketplace coverage. No changes were made to similar definitions in Medicaid or the Children’s Health Insurance Program (CHIP).  

The new rule takes effect in November 2024. DACA recipients who would like to purchase a plan on the Marketplace will have a Special Enrollment Period (SEP) that allows coverage to begin the month after enrollment. This SEP will last through January 2025 to ensure overlap with the national ACA Open Enrollment period. 

Every Texan looks forward to working with national, state, and local partners  to ensure DACA recipients are made aware of this change and have the tools — including enrollment assistor help — to take advantage of this new avenue to coverage and care. 

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Testimony

Testimony on Senate Health and Human Services Committee Interim Legislative Charge: Health Insurance

View this testimony as a PDF 

Every Texan (formerly CPPP) appreciates the opportunity to comment on the 2024 Senate Interim Legislative Charges. The Benedictine Sisters of Boerne, Texas, founded Every Texan in 1985 to advance public policy solutions for expanding access to health care. We became an independent, tax-exempt organization in 1999. Today, we prioritize policies that will measurably improve equity in and access to health care, food security, education, and financial security. We are based in Austin, Texas, and work statewide. 

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 as well as 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. Every Texan has had the privilege of working directly with enrollment assistors over the last several years, convening workgroups and providing technical assistance to enrollment assistors who are on the frontlines with families across Texas of all incomes. It is our goal to maximize enrollment in health care coverage for all Texans and ensure all Texans have access to comprehensive and affordable coverage. 

Most Texans Can Access Quality, Affordable, Comprehensive Coverage 

A record number of Texans signed-up for health insurance on Healthcare.gov or the ACA Marketplace this year. 3.5 million Texans enrolled for 2024, compared to 2.4 million in 2023, a 36.5% increase. The number of Texans enrolled in plans through HealthCare.gov has nearly tripled over the last three years. These numbers show that HealthCare.gov is working well for many across the state of Texas. 

Data also show nearly 75% of Texans returning to the Marketplace comparison shopped successfully to find the best plan. Texans are empowered to find and access coverage on the Marketplace because of an increase in the availability of cost-saving options. The increased enrollment follows a significant nationwide investment by the federal government in HealthCare.gov affordability, outreach, and enrollment. Federal investments in subsidies – first through the 2021 American Rescue Plan Act and then the 2022 Inflation Reduction Act – have saved Texans in the Marketplace an average of $560 in premiums per year. 

Comparison shopping for products to protect your family’s health and safety can be complicated. This is true for buying a car or a house or finding the right school for your children. It is also unfortunately true in the United States that we have to find the best health coverage for what we need. In other states, there is a funded network of experts available to assist families in finding the right plan on the Marketplace. 

Texas chooses not to fund a program like this, even though it did years ago with success. Texans have to rely on federally-funded programs to get help enrolling in coverage. Since 2021, the federal government has awarded $13 million in navigator grant funding to 10 Texas organizations, substantially increasing enrollment assister capacity for Texans who need help signing up for plans. It is crucial that funding for navigators is increased by our state legislature as more Texas families access the ACA marketplace. Navigating the health insurance market can be difficult for families and enrollment assistors are a critical lifeline for families. 

We know there is bipartisan understanding in our legislature of the value of this access to coverage—SB1296(87R) by Senator Nathan Johnson and Representative Tom Oliverson makes certain Marketplace plans more affordable by boosting the impact of federal subsidies. 96% of Texans got help from subsidies to lower their premiums. Almost half of that enormous percentage also got cost-sharing reductions that lower all out-of-pocket costs. 

The Affordable Care Act is great for Texas businesses, too. Since its passage, the uninsured rate for small business employees has dropped by almost 10 points. For smaller employers who offer health coverage as a part of a competitive benefits package to attract the best talent, premiums have almost halved because of the law. Health coverage means healthier Texans, and healthier Texans leads to a healthier Texas economy (especially as a big deterrent to starting a new venture is loss of health coverage). Things that harm access to the Marketplace also harm our small businesses and community of entrepreneurs — around half of Marketplace enrollees are entrepreneurs, run a small business, or work for a small business. 

Parts of the Private Insurance System are Not Working for Texans and Can be Addressed by the Legislature 

Evidence shows the Marketplace is working well in Texas despite a rising trend in fraud by certain bad actor agents and brokers (which would not be as big an issue with state-funded enrollment support to help consumers) who are enrolling some people in multiple plans without their consent. The US Department of Health and Human Services is investigating this, but in the interim more support for Texas families would be a help in protecting consumers from this fraud. 

Another threat to Texans having comprehensive medical coverage are plans that are simply not comprehensive medical coverage. In the same way a moped would be an alternative to a car, these products are cheaper but have far fewer protections for the people relying on them. It is far more confusing to navigate health coverage options if products that are not actually comprehensive health coverage are not well-regulated and look a lot like major medical insurance — until someone in the family actually needs care. These may be simpler to buy, but the products themselves are not simple to understand when consumers try to use them and realize things, like pregnancy care or hospitalization, are not covered. These plans can lead to negative financial outcomes, such as medical, debt and negative health outcomes. 

To help ensure Texans can navigate the private insurance market better, we recommend: 

  • Re-instituting and re-allocating funds to our state navigator program; 
  • Requiring consumer disclosures on association health plans, short term plans, farm bureau plans, and standalone/excepted benefits plans; 
  • Investigating agent and broker fraud allowing bad actors to double-dip and get fees by enrolling unsuspecting families in multiple plans and finding policy solutions to prevent this harm; and 
  • Setting up programs targeted to self-employed Texans and small business owners and employees who rely on Marketplace coverage to ensure a healthy Texas economy. 

Some Texans Still Cannot Access Comprehensive Coverage Because of Texas Law and Policy 

When the law is a barrier to accessing better health, the law should be changed. Providing an alternative to that good or service is not the same thing as providing access to it. Up to 726,000 Texans cannot access real, comprehensive insurance because of Texas failure to expand Medicaid to cover low-income adults. The unwinding of the Medicaid continuous coverage requirement following the end of the federal public health emergency saw 2 million children, people with disabilities, and pregnant women lose coverage because of state-level policies that make it difficult to get and keep coverage. The uninsurance rate in Texas does not look like that of any other state, and this can and should be addressed by our legislature using what we know are best practices used in virtually every other state. 

Despite the record enrollment in the ACA Marketplace, many Texans still do not have a door to health care coverage and Texas continues to have the highest uninsured rate in the U.S, with 4.9 million Texans uninsured in 2022. Unfortunately, the enhanced federal subsidies referenced above are not available for Texans caught in the Medicaid coverage gap. This gap consists of adults who earn too much to qualify for Texas Medicaid but too little to qualify for these subsidies. 

It is estimated that there are 726,000 uninsured Texans currently in the coverage gap. 73% of Texans in the coverage gap are in families with at least one worker and 77% are people of color. Many Texans caught in this gap work in lower-wage jobs such as food service, child care and home health providers, and construction. It is no accident most Texans in this situation are also members of workforces we are struggling to maintain and that the rest of the state relies on to live and work well. The best policy solution we have available right now to cover more Texans is to expand Medicaid to adults with incomes up to 138% FPL. Expanding Medicaid would increase the use of preventive care, reduce utilization of emergency care, and improve health outcomes for many Texans while ensuring more Texans have access to consistent care. 

The Medicaid Public Health Emergency Unwinding is Unwinding Progress in Texas 

Unfortunately, many Texans, particularly children, have lost access to health care coverage during the Medicaid “unwinding.” As Texas re-checked the eligibility for over 5 million Texans on Medicaid and CHIP over the last year, about 1.35 million children were removed from Medicaid and CHIP. Because income eligibility for children is much higher than adults, most of the children who have lost coverage are likely still eligible. We’re concerned that many children who have lost their Medicaid/CHIP health coverage do not have access to healthcare. 

Even short gaps in coverage cause children to miss vital prescriptions or not be able to see a doctor when they are sick. Texas has the worst uninsured rate in the nation for kids, and these data indicate that an increasing number of Texas children are likely going without the protection that health coverage provides. To help ensure eligible Texans are able to enroll in health care coverage through Medicaid and CHIP and keep their coverage, we recommend: 

  • Investigating why the state has such a low rate of data-driven automatic renewals (also known as ex parte renewals) that reduce paperwork by using other databases the state has on family income and other data; 
  • Removing unintended barriers that families face when attempting to apply for or renew their coverage. Specifically, invest additional funding in upgrading the technology within the Texas Medicaid eligibility system, the 2-1-1 call system, and the state’s YourTexasBenefits website and app; 
  • Investigating why the computer systems supporting the program drawing the largest share of federal dollars to our state is malfunctioning to the degree it is and assessing the administrative costs of the repeated, continued errors shouldered by Texas taxpayers; 
  • Investing in community partners who are help Texans enroll in Medicaid;
  • Investing in additional funding in maintaining a stable, experienced workforce of state eligibility workers; 
  • Improving language access and Medicaid outreach that addresses concerns of mixed-immigration status families. One in four Texas children lives in a mixed-status household. To ensure meaningful language access to Medicaid/CHIP, the state should make applications, notices, and outreach materials available in multiple languages, not just English and sometimes Spanish; and 
  • Passing “Express Lane” enrollment for kids who are already eligible for Medicaid or CHIP. The proposal would allow the Health and Human Services Commission to use already-verified information, such as a child’s enrollment in SNAP, as an indicator for Medicaid and CHIP eligibility. 

Thank you for the opportunity to provide written testimony on this important topic. Please feel free to reach out to our team with any questions at taylor-ross@everytexan.org. 

View this testimony as a PDF 

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Blog

New Federal Updates to Affordable Care Act Marketplace Policy

The Centers for Medicare and Medicaid Services (CMS), the federal agency in charge of regulating most types of health insurance, just released a final rule that makes changes to the ACA Marketplace. The new final rule, called “Notice of Benefit and Payment Parameters for 2025,” includes many wins for Texas families who rely on care from the health plans governed by the Affordable Care Act (ACA). These changes will be in effect for the 2025 plan year, with some of the more complex changes phasing in through 2027. 

It is more important now than ever that Texans be able to find affordable, comprehensive coverage after the mass coverage losses from Medicaid unwinding. Last year, a record number of adults and children enrolled in Marketplace plans, and CMS has been working to strengthen both consumer protections and the coverage offered since. This rule is filled with policies that make it easier for people to find and receive the right health coverage and for states to set their own policies to facilitate that. 

Following are highlights of policies states can or must adopt over the next few years:

Dental care for adults can now be added as an Essential Health Benefit (EHB) by states. Each state can create what is called a “benchmark plan” with certain EHBs within parameters set by the ACA. This change will apply to most plans governed by the ACA, including those sold on ACA Marketplace Exchanges. Before this new rule, only pediatric dental care was allowed to be a part of EHBs; even if a state wanted to have a requirement to cover these vital services, it was unable to do so. We hope Texas takes advantage of this new allowance by adding adult dental care to its Benchmark Plan. 

The rule also makes a few updates to how prescription drugs are chosen and treated as EHBs. In order to ensure consumers’ voices are considered in the process, a representative from the patient community must now be on the state committee designing these benefits. The new rule also extends patient protections to prescription drugs health plans cover in addition to those listed as EHBs. This means if a plan covers prescription drugs that are not drugs the plan must cover, the ACA’s protections such as the bar on annual and lifetime limits also apply to those non-EHB drugs. 

CMS made some fairly technical changes to how health plans are designed and marketed so that consumers can have an easier time picking the right plan for themselves and their families. Consistent with changes made over the past couple of years, CMS made tweaks to its framework for standardizing plans; more standardization means fewer options and variables for consumers to consider, which in turn makes it easier for families to find the best-suited health coverage plan. There are also new lower-cost plans tailored to people with certain chronic or expensive-to-manage conditions a state can choose to offer.

Other parts of the rule are designed to make it easier to enroll in coverage. For example, new policy will make a “Special Enrollment Period (SEP)” available to certain consumers using Advanced Premium Tax Credits toward their premiums. These consumers are projected to make at or under 150% of the Federal Poverty Level in a year and to have a higher-than-zero percentage applied when their share of the premium is calculated. This SEP can be used at any time – not just when coverage is lost.  

Finally, the rule includes changes to how a state-based marketplace can be launched and operated. The ACA allows states to use the federally-facilitated marketplace – which is what Texas does – to either host a state-specific marketplace on the federal platform, or to have their own marketplace and system. The new rule requires states moving toward their own marketplace and system to have a full year of operation on the federal platform first; this will make sure the state is prepared and will avoid potential coverage losses. State-based marketplaces will also be required to host a “Healthcare.gov-type” enrollment system where eligibility can be checked across different coverage types and household members.  

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Blog

CMS’ New Rules Govern “Junk” Short-Term Health Coverage and Insurance-Like Products

As if navigating health coverage options isn’t hard enough for most Texans, a multitude of health plans  not required by federal law to comply with the consumer protections in the Affordable Care Act (ACA) have proliferated the marketplace in recent years. Intended to be short-term, stopgap coverage for emergency situations, these plans are not regulated the same way other health plans are. They can discriminate against people with preexisting health conditions — which includes ever having been pregnant — and can refuse to pay for indispensable health care. Yet, these short-term, limited-duration insurance (STLDI) plans are often marketed in the same way as ACA-compliant plans and during the same Open Enrollment period. 

Most people who enroll in these plans believe they are low-cost, comprehensive coverage or catastrophic major medical insurance. They do not realize the lower prices are a result of far fewer essential health care services being covered. This can lead people to forgo essential health care. It also commonly leads to unexpected, life-altering medical debt burdens. Medical debt continues to be a major challenge and barrier to economic stability and mobility for families in the United States and Texas. More than 40% of American adults  experience the burden of medical debt, which disproportionately affects families of color, parents, women, and households with low incomes.  

Despite polls showing an overwhelming majority of Americans believe the government should be responsible for regulating these plans and protecting consumers, the Trump Administration made changes that allow more of these STLDI plans to be sold for longer contracts. That leaves more Americans  stuck with junk coverage with no way out. Since then, Every Texan and our patient and consumer advocate partners have been working on state-level measures while appealing to the Biden Administration for more urgency in closing these harmful loopholes. Unfortunately, many of these products cannot be banned and can only be regulated more closely with more consumer protections.  

For Texas families who must find their own health coverage, these new guardrails around insurance-like products are a major win. The biggest changes include requiring short-term plans to notify consumers of what is not covered under the plan and direct consumers to comprehensive coverage as a part of this disclaimer. The changes will go into effect in September 2024 — a critical time as we ensure the hundreds of thousands of Texans who lost coverage during the Medicaid unwinding are finding comprehensive coverage during Open Enrollment of the ACA Marketplace this year.  

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Blog

New Federal Policies Help Eliminate Barriers to Medicaid and CHIP Access for Texans

The Centers for Medicare and Medicaid Services (CMS), Texas’ partner in administering Medicaid and Children’s Health Insurance Program (CHIP), released a final rule to better streamline the application, eligibility determination, enrollment, and renewal processes it regulates across states and public insurance coverage types. Overall, the goal of these policies is to reduce the “churn” of people moving on and off insurance coverage due to issues with paperwork, agency processes, and gaps in data-sharing. This rule is a collection of tweaks that will have enormous impacts on all Texans — even those who have other kinds of insurance.  

Medicaid is a cooperative state and federal program, meaning CMS and the Texas Health and Human Services Commission (HHSC) set the policies for the program while the state and federal governments fund it. Though CHIP and Medicaid are separate programs in Texas, changes to CHIP policy also require cooperation between the states and federal government. In some cases, changes to federal policy — like this final rule — create options and flexibilities for states. Other times, CMS policy requires states to make changes.  

A unique aspect of this final rule — and the basis for all of the policy changes in it — is a reminder that preserving the “integrity” of these programs does not just mean being vigilant about fraud and abuse; it means stewarding the program in a way that ensures people we know are eligible (or should know based on data we already have) are enrolled in and can keep their coverage.  

This final rule requires that changes be made to the systems and processes states use to determine whether a person is eligible or not for Medicaid and CHIP. The highly anticipated — if belated — policy changes were strongly encouraged by Every Texan and our partners, and even largely supported by HHSC as well.  

Medicaid  

The fallout of Medicaid unwinding in states like Texas clearly shows the connection between eligibility and enrollment policies and access to coverage and care. As of March of this year, 1.37 million Texans — mostly kids — have lost their access to health care without having their eligibility determined. Several policies in the new CMS rule will help people enroll in and better retain their Medicaid coverage because states will lose the ability to opt out of commonsense administrative fixes.  

States must now use a specific procedure when mail is returned and it’s clear the notice did not reach the intended person or family. This includes checking other sources, like the United States Post Office, for changes of address as well as using text messages and emails to reach Texas families. HHSC began reporting its use of emails, texts, and robocalls to reach people as they approached the end of the unwinding process, and we hope the agency continues to employ these methods to complete successful redeterminations and future enrollments.  

Federal law now requires states to use certain “ex parte” data in determining eligibility, which includes income eligibility. Ex parte data is information the state or federal agency already has access to without needing more information or evidence from the person or family applying for Medicaid coverage. In many states, there is a long list of data the state Medicaid agency can use to determine eligibility automatically so no one has to send in a paper packet or pay stubs. This, in turn, makes it less likely for applications to get denied, as there’s less manual mistake opportunity. In Texas, the list of data that can be used for ex parte renewals is comparatively short, and it’s only as long as it is now because the state is allowing some flexibility during unwinding. This is why Texas has the lowest ex parte renewal rate in the country and also why HHSC staff have to work overtime to do manually what most states handle automatically.  

The rule also sets a new minimum response time states must allow for people trying to enroll in or remain on Medicaid coverage. In cases where HHSC needs more information from a person or family trying to enroll, Texans will now have 15 days to respond to requests. Current Texas policy gives 10 days to respond. In order to ensure fewer people lose coverage we know they are likely eligible for, there is now a 30-day window for people to respond to agency information requests during an eligibility redetermination. 

Other policies in the rule are designed to enable better ex parte renewal rates by improving record and data storage, retention, and sharing. This should reduce the administrative burden on agencies as well as the likelihood that a person or family will have to provide more information as a part of their application. Ideally, state agencies will now have better information and systems to complete eligibility determinations. 

The Children’s Health Insurance Program (CHIP) 

Texas ranks last in the United States for children’s insurance coverage rates. Key pieces to closing this coverage gap are a better system for eligibility determination, easier enrollment, and ways to maintain CHIP coverage. Since CHIP covers children* from families with higher incomes versus the children covered by Medicaid, there have historically been allowances for more restrictions on access and use of CHIP coverage compared to Medicaid. These barriers to access have long been controversial because the enrollees we’re talking about are children and because many of these types of policies have previously been banned by different laws across other types of insurance. The new rule gets rid of several such restrictions, including: 

  • Arbitrary waiting periods before coverage begins after other coverage is lost (something that no other health insurance program requires). 
  • Lockouts from the program — previously, if a family did not pay their share of costs on time, the child covered by CHIP could get locked out of their health coverage.
  • Annual and lifetime limits. These are caps on what a CHIP plan would spend on a child enrolled on either an annual or lifetime basis (meaning the duration of the child’s coverage on that plan) regardless of whether a child had more health needs. A ban on these types of limits is a popular provision of the ACA, and we are glad to see this same protection applied to CHIP plans.  

Texas currently has a three-month waiting period for children who lose their coverage and want to apply for CHIP coverage that will now have to be phased out. Texas does not currently use lockouts but does have a cap on what it will spend on a child’s dental care, though a family can request these caps be waived in special circumstances. Texas also cuts kids off from CHIP coverage if their family fails to pay a fee when trying to enroll.  

The rule also requires states to create and bolster the process for transitioning children between Medicaid and CHIP when there are changes to income in order to prevent coverage termination. These new processes include a single notice delivered to a household letting the members know who is or could be eligible for what kinds of coverage, including ACA Marketplace coverage and tax credits. Kids shouldn’t lose health coverage just because a rise or decline in family income makes them ineligible for Medicaid or CHIP when Texas has data to show they are eligible for the other program. Coverage loss is fairly common, and it has become a larger issue in many states during the unwinding because there has been no federal requirement for states to create a good, predictable process for transitioning kids between coverage types.   

*CHIP also covers some non-minors under certain circumstances, such as some pregnant adults.  

People Eligible for Both Medicare and Medicaid  

Though Medicare is a federal program, some state eligibility and enrollment processes can impact eligibility and ease of access to Medicare benefits for many Texans with lower incomes and/or disabilities, as a person can be “dually-eligible” for both Medicaid and Medicare (there is no way to qualify for Medicaid based on Medicare eligibility, however). The new rule ensures barriers to enrollment, such as an interview requirements, multiple eligibility checks in a year, and waiting periods, are not applied to programs that do not factor the income and assets limits of an enrollee into the eligibility determination.  

In the same way CHIP, with its higher income eligibility limits, has made enrollees jump through more hoops to enroll and stay enrolled, other groups whose incomes are not a factor in applying for coverage have also faced a daunting process to sign up. These groups are low-income seniors, people with disabilities, and people with medically complex care needs. In these cases, higher income eligibility or the absence of an income check has led to more requirements, such as in-person interviews, designed to make people prove they qualify for coverage the state already knows they should have. Unsurprisingly, these extra steps often translate to barriers to coverage and access. Elimination of these barriers in the final rule is especially important for these populations, as Medicaid and Medicare sometimes pay for different types of care in specific settings. In these cases, losing Medicaid eligibility can have a major impact on a person and their family. Removing these barriers to Medicaid coverage is a vital step to ensuring all Texans have access to all of the types of coverage they need. 

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Blog

What Makes ‘El Paso Strong’?

Having been born and raised in El Paso, it’s clear to me that inclusion – regardless of race, income, or nationality – lives at the heart of our city’s culture. Following a tragic mass shooting in 2019 when a white supremacist murdered 23 people and injured another 24, the phrase “El Paso Strong” emerged as a demonstration of our community’s ability to unite against adversity. Now, our city is facing another challenge: deadly, anti-immigrant policy spearheaded by Greg Abbott and other extremist Republicans. 

While El Paso’s local government, religious centers, and community groups are working diligently to implement a humanitarian process for migrants, extremists in our state’s government continue to impede that progress by perpetuating the false ‘invasion’ rhetoric seen in Operation Lone Star and bills like SB 4. As bad actors continue to implement harmful legislation across the state, it is more important now than ever to recognize the power that exists in community. “El Paso Strong” is not just a phrase; the community’s bond can act as a catalyst for change to bring about proactive policies in the state government. 

A large part of what makes “El Paso Strong” is the city’s ability to accept people regardless of where they come from. Nearly 25% of El Paso residents were born in a different country. Countless residents have banded together to feed, clothe, and shelter migrants who are crossing through the southern border. The organizers spearheading these efforts are not asking for harsher policies or to further militarize the border. On the contrary, these advocates want state investments in education, infrastructure, and housing.

Ivonne Diaz, the Regional Program Coordinator for the nonprofit Texas Rising, has spent the last few years volunteering to help process asylum seekers in El Paso. She has also made numerous trips to Austin to testify that instead of investing in health care, a new electric grid, or better pay for teachers, state legislators “focus on things that don’t advance our community, like spending money on barbed wire and law enforcement and more prisons.” Unfortunately, it’s fallen on deaf ears, as Texas is now spending more than $5.5 billion this biennium on failed border security measures.   

Instead of implementing a proactive agenda, extremist Texas Republicans have opted to score cheap political points at the expense of migrant families and border residents including an attempt to run the Annunciation House that provides basic housing to migrants out of business. This political game has a significant, tangible cost to Texas families. Over the last decade, state spending on border militarization has reached $6 billion. Meanwhile, state spending on education has remained roughly stagnant over the same period of time. 

It’s not just that these extremist policies fail to benefit border communities, they actively hurt them.

“Legislation like SB 4 is the definition of counterproductive policy,” said advocate Manuel Guzman, who was raised in both El Paso and neighboring Ciudad Juárez. “Those who are most impacted by these bad bills aren’t asking for them in the first place. People who live on the border don’t want to live in a place that is over-militarized and overpoliced. They want access to health care and funding for quality education, and they want migrants to be treated with dignity and respect. Texas has failed to provide any of these things.” 

Extremist legislation, like those proposed, serves to propagate an out-of-touch agenda that wrongfully villainizes migrants while ignoring the critical issues border communities are actually facing. For instance, even though a quarter of nonelderly Texas border residents are uninsured, the Texas government fails to expand Medicaid, which would pay for itself. Every dollar spent on deterrence policies without evidence of effectiveness is a dollar lost on education, health care, and other underfunded public services. 

Though the state government is failing to adequately address the needs of migrants at the border, people can still take action. Diaz notes that El Paso’s residents hold extreme power in the effort to ease conditions for asylum seekers and migrants: “It’s important [for people] to connect to organizations that are doing the work and to educate ourselves, not just believe what’s shown on TV.” 

As migrants come to seek refuge in the United States, Texas should follow El Paso’s lead. The city continuously demonstrates that inclusion makes communities stronger. Instead of hampering El Paso’s progress with divisive, unhelpful legislation, Texas leadership must bolster funding for the humanitarian programs that the city’s community centers have implemented. Border residents know best and have made their position loud and clear: less barriers, more resources.

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Comments Testimony

Comments on the Healthy Texas Women Section 1115 Medicaid Demonstration

View these comments as a PDF.

Every Texan appreciates the opportunity to comment on the Texas Health and Human Services Commission’s (HHSC) application to the Centers for Medicare & Medicaid Services (CMS) to extend the Healthy Texas Women (HTW) demonstration under Section 1115 of the Social Security Act. 

Every Texan is a nonpartisan, nonprofit 501(c)(3) public policy organization that uses data analysis to advocate for solutions that enable Texans of all backgrounds to reach their full potential. Improving access to health care for Texans has been at the core of our mission and activities since our founding more than 30 years ago. Every Texan is a vocal advocate for improving access to publicly funded, quality family planning services because making sure that all Texans have access to the tools they need to plan the timing and size of their families is a critical piece of the puzzle in building equal economic opportunity for Texans. 

We urge HHSC to amend its waiver application, as outlined below, before submitting it to CMS, to ensure that the program can maximize access to quality family planning services for Texas enrollees. 

We echo comments made by the Texas Women’s Healthcare Coalition, including requesting the use of a short form family planning only application, opting-in to presumptive eligibility, and ensuring network adequacy and expedited provider credentialing when moving HTW into Managed Care. 

While we are supportive of the HTW program and the coverage it offers to enrollees in Texas, we are concerned that the extension application would continue to exclude access to certain well-qualified family planning providers, which will continue to needlessly harm access to health care. We recommend that HHSC remove the request to waive federal freedom of choice protections in Section1902(a)(23) with respect to providers that do not adhere to Texas Human Resources Code 32.024(c-1) or any similar consideration of services provided (or by affiliates), before submitting the waiver extension application to CMS. 

The current extension application seeks to continue to waive Medicaid’s freedom of choice of provider protection – excluding qualified providers who provide clients with the full spectrum of reproductive health services or affiliate with providers who do so from participating in the HTW demonstration. Continuing this authority holds no experimental purpose and its negative consequences directly conflict with the purpose of 1115(a) waivers in Medicaid. Excluding providers for reasons unrelated to their qualifications does not further the objectives of the Medicaid program because it severely reduces low-income women’s access to family planning and other preventive services. 

Based on current Texas state law, there is no longer a basis for waiving freedom of choice based on services providers are now largely prohibited from legally providing in Texas. Following the Dobbs v. Jackson Women’s Health decision in June 2022, abortions became inaccessible in almost every case in Texas beginning in August 2022. There is no demonstration value, if there ever was one, to waiving freedom of choice to exclude certain providers now in Texas. It is only restricting access to care, including preconception services that can help promote healthy pregnancies. 

At this time, we do not oppose a waiver of freedom of choice that is solely intended to implement managed care networks and does not restrict access to providers based on the range of services they (or their affiliates) provide. We would not support any freedom of choice waiver if the state uses its managed care contracts to limit or impede access to providers (or those with affiliates) that offer the full range of reproductive health services. We also urge the state, in its managed care contracts and contracting process, to set strong requirements ensuring that contractors have robust provider networks that include the community-based providers that have the most experience providing reproductive health services to low-income populations. 

In conclusion, we urge HHSC to restore freedom of choice in the HTW demonstration waiver with respect to providers that provide a full range of services. We appreciate Texas’s recognition of the need to support access to women’s health care services. However, the current waiver extension application continues to exclude well-qualified providers which will limit eligible women’s ability to receive important services. Restoring Medicaid’s freedom of choice protection for providers that offer the full range of services is critical to ensure access to needed care. 

View these comments as a PDF.