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Celebrating 60 Years of Food Assistance

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As a centerpiece of his War on Poverty, President Lyndon B. Johnson signed the Food Stamp Act of 1964 on August 31 of that year. Now known as the Supplemental Nutrition Assistance Program (SNAP), more than 3.3 million Texans currently rely on this program to provide food for their families. In a state as great as ours, too many families experience food insecurity and face difficulties meeting basic food needs. When Texas families struggle to make ends meet – juggling finances to cover rent, utilities, and transportation – often little is left for food. 

Texans who provide kinship care to the children of family members are particularly in need of food assistance programs; nearly 42% of Texas children in state care are placed with relatives after being removed from their homes by Child Protective Services. Many more are living away from their parents in informal or voluntary kinship care placements, though the vast majority of those children live with grandparents. Often on fixed income, grandparents who take in grandchildren are at greater risk of experiencing poverty and food insecurity. 

President Johnson understood and addressed these struggles by creating a permanent food assistance program, which has evolved significantly in the last 60 years. Initially, people would purchase “stamps” at a level similar to what the family would spend on food and then receive a bonus, or benefit, based on income level. The Food Stamp Act of 1977 eliminated the need to purchase “stamps” to receive the benefit while also establishing national eligibility for participation. As a result, the amount of benefits a family receives is based on the household’s size, income, and expenses. 

In the early 2000s, Electronic Benefit Transfer (EBT) cards – similar to credit or debit cards – started to replace paper stamps. The transition to EBT cards reduces stigma for the families using food stamp benefits while also reducing costs and fraud within the program. The program was renamed SNAP in the 2008 Farm Bill. 

While the federal government fully funds SNAP benefits, the state and federal governments share the administrative costs. Health and Human Services Commission (HHSC) administers SNAP and is charged with making accurate eligibility determinations, issuing payments, overseeing participating retailers, and preventing fraud. 

Unlike the 38 states that do not count assets, Texas chooses to impose a vehicle asset test (VAT) on all SNAP applicants in addition to income limits. That means our state factors in a car’s value when determining if a family is eligible for SNAP benefits. In 2001, Texas set a resource limit of $5,000 in countable cash, a first vehicle worth up to $15,000, and any additional vehicles could be worth up to $4,650 (any excess vehicle value counts towards the cash resource limit). Those limits were never indexed to inflation, so they’ve lost purchasing power over the decades and no longer reflect the cost of safe and dependable family cars or trucks. Fortunately, in 2023 the Legislature updated Texas’ SNAP VAT to $22,500 for first vehicles and $8,700 for each additional vehicle. This change will help thousands of Texans – including families with young children, the elderly, and kinship care providers – who face hunger every month simply because they need a car to survive.

In 2023, HHSC formally recognized food security as a significant, non-medical component of individual, family, and community health. HHSC’s 2023 Non-Medical Drivers of Health (NMDOH) Action Plan includes ways to build on the foundation laid by the 1964 Food Stamp Act by assessing current HHS SNAP enrollment and utilization data to enhance the program’s use. By increasing the number of people enrolled in SNAP and ensuring that eligible community members are able to use the program to its fullest, Texas can improve health outcomes and stabilize access to healthy food.

However, Texas is currently experiencing an eligibility system crisis that requires legislative intervention. SNAP benefits have lapsed for anywhere from tens to hundreds of thousands of eligible Texans due to paperwork backlogs at HHSC. These failures not only expose Texas to the threat of federal financial sanctions and/or the loss of federal funds, but far more importantly, these failures cause real suffering. Failure to take immediate action to address the eligibility system crisis amounts to an explicit decision to increase financial hardships and human suffering among low-income Texas children, the elderly, and individuals with disabilities today and for years to come. 

An effective eligibility and enrollment system forms the foundation for meeting the needs of eligible, low-income Texans. Its most basic function is to process eligibility accurately and without delay. Maintaining a system that can do that consistently takes meaningful investments. 

When the Legislature goes back into session this January, they should reflect on the vision of President Johnson and ensure no Texas family goes hungry due to an inadequate eligibility system and unnecessary barriers to participation.

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Testimony

Testimony on Harris County’s Guaranteed Income Program in the Senate Committee on Local Government

Read this testimony as a PDF here.

Unlocking the Potential of Guaranteed Income for Every Texan 

Every Texan deserves the opportunity to thrive and ensure a bright future for themselves and their families. 

In recent years, guaranteed income (GI) programs have been invaluable for many families. These piloted and means-targeted programs have enabled individuals to afford groceries, ease housing costs, cover medical expenses, and better care for their families. The immediate, tangible benefits of guaranteed income have garnered strong support nationwide. 

Guaranteed income has deep U.S. roots, gaining traction in the 1960s through civil rights leaders like Dr. Martin Luther King and President Nixon’s negative income tax proposal that would have provided a minimum income to low-income families. It is a proven approach used for decades in Alaska, where direct cash transfers from the state’s oil and mineral revenues are distributed to all residents annually.

Harris County’s GI pilot program joins at least 150 initiatives across the country, including cities like Austin and San Antonio. Many of these programs are at least partially funded using federal funding from the American Rescue Plan Act (ARPA).

Meeting the Demand to Address Our State’s Economic Precarity 

The immediate demand for Harris County’s GI program is clear: despite our state’s economic power, working Texans and their families are not reaping the benefits of the booming economy we create. Texas’ widening economic gap has resulted in one of the nation’s highest poverty rates, with nearly two in five Texans struggling to meet their basic needs. This disparity is particularly acute among Black, Latino, and rural communities.

The lack of economic security and concern over insufficient family budgets is driven by stagnant wages created by an outdated minimum wage, underpaid jobs, and a tax system that overburdens low-income Texans. This affects people’s ability to save. In Houston, about 43% of Houstonians cannot cover a $400 emergency from savings, with Black (67%) and Hispanic/Latino (53%) residents more than twice as likely to face this challenge than other racial and ethnic groups.   

Leveraging Local Governance for More Resilient Communities 

Localities have a deep understanding of their communities’ needs and are best positioned to allocate resources effectively. Investing in direct cash policies using ARPA funds is not just an opportunity—it’s a necessity. These federal dollars must be spent, or they will be forfeited, missing a critical chance to support those who need it most. Direct cash investments empower families during uncertain times, providing immediate relief that can drive long-term stability.  

Harris County’s GI program would establish a minimum income level to prevent participants from falling below it. This is a rare opportunity to invest in their future; letting these funds go unused would be a missed opportunity for meaningful change. Evidence shows that direct cash transfers are spent prudently on necessities, and over time, participants can use this support to build toward long-term goals. GI programs can:  

  • Help workers invest in themselves and their communities: Guaranteed income programs empower individuals to take risks and pursue better jobs by providing financial stability. In Austin’s pilot program, participants used guaranteed income to invest in education at times by adjusting their work hours and having better access to transportation options, all of which helped them advance in their careers.
  • Nurture stronger families with time to care for loved ones: Guaranteed income programs strengthen families by relieving financial stress, giving caregivers the time and support they need to care for loved ones. This financial stability enhances access to quality food and medical care, helping families meet their basic needs and fostering a healthier, more supportive environment for everyone.
  • Improve family budgets to meet rising living costs: Guaranteed income programs help families keep up with rising living costs and offer crucial relief during financial crises. By providing a steady income, these programs help cover unexpected expenses, such as emergency care or unforeseen bills. Participants also experienced better housing affordability, with fewer late rent payments and reduced eviction rates.

Read this testimony as a PDF here.

 

 

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Blog

Gov. Abbott’s Executive Order Will Increase Distrust in Texas Health Systems, Diminish Health Outcomes, and Harm State Economy

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On August 8, 2024, Texas Gov. Greg Abbott  issued Executive Order GA-46, which requires the Texas Health and Human Services Commission (HHSC)  to direct public hospitals in the state to collect demographic information on patients that will enable hospital staff to determine how many inpatient and emergency care patients at the hospital are undocumented. HHSC must also direct hospitals to collect and report back to HHSC the health care costs that those undocumented patients incur. The processes outlined in the Executive Order begin Nov. 1, 2024, also the date DACA recipients around the U.S. will first be able to enroll in Marketplace health insurance through the Affordable Care Act.

The governor seeks to use hospital reports to justify his understanding that “the federal government may and should be obligated to reimburse the State of Texas for the costs” of treating undocumented patients. However, statewide public health systems are not appropriate environments for testing out policies that the governor believes “may and should” exist. 

Abbott’s Executive Order will lead to fewer Texans and their families seeking medical care when they need it, even when dire medical needs make expensive health care necessary at the emergency room. These are Texans who generally already avoid less expensive medical care in settings like clinics and health centers because they are uninsured and often concerned about the cost and documentation requirements. The well-documented “chilling effect” of policies like this one will further marginalize undocumented individuals and their family members  – even those who are lawfully present – from enrolling in health coverage programs and seeking out necessary medical care.

Texas’ economy — particularly our construction, agricultural, and service sectors — will suffer as a result, as injured and sick workers are unable to  return to work. Meanwhile, Texas families will suffer the governor’s policies as he threatens their rights to seek medical care in emergencies. 

The Federal Government Already Funds Most Charity Care 

Just over 64% of the public funds used to reimburse hospitals for the health care they provide to people without health insurance comes from federal dollars. Therefore, most health care services for which hospitals are uncompensated already get reimbursed by federal funds, not by state or local dollars.  

The federal government requires public hospitals to provide funds – called “charity care” – to uninsured patients in exchange for tax breaks. Thus, the uncompensated care that Abbott is concerned about is already part of established funding relationships and tax structures that exist to improve community health. 

In Texas, other federal funding reimburses the state for uncompensated care; some of those funds are codified in one of the state’s 1115 waivers granted by the federal Centers for Medicare and Medicaid Services. It provides directed payment programs to hospitals that are providing care to uninsured patients. The waiver allows for the federal government to pay Texas hospitals for treatment that no one can pay for, since so many uninsured people seek emergency medical care in the state.

Because pregnant citizens and adults with qualified immigration status do qualify for Medicaid in Texas, the state does accept Social Security Act’s Title XIX Grants to States for Medical Assistance Programs for undocumented pregnant people in emergency rooms for labor and delivery. Those undocumented pregnant people are also currently eligible for CHIP-Perinatal, which covers unborn children. In these circumstances, the federal government does contribute billions to Texas health programs and hospitals for providing coverage and care to undocumented residents. Every Texan supports that federal funding and initiatives designed to increase coverage and affordable care for Texans – regardless of immigration status. When more people have access to affordable health care, entire communities have improved health and economic outcomes.

By persistently rejecting the interests and preferences of their constituents, the Texas Legislature continues to avoid passing legislation that would close the health insurance coverage gap in the state by making low-income adults eligible for Medicaid. This refusal to expand Medicaid eligibility to low-income citizen adults and adults who are qualified immigrants prevents Texas hospitals from receiving federal Medicaid dollars made available by SSA Title XIX/Medicaid funds. These dollars would fund the emergency room costs of people who are not U.S. citizens — both undocumented and lawfully present people — and would qualify for Medicaid were it not for their immigration status. By refusing to close the health insurance coverage gap, state lawmakers have cost Texas billions of dollars of federal aid for undocumented Texans’ emergency room care since 2014.

The current system is costly and inefficient. Abbott’s order will only increase expenses and worsen community health outcomes by deterring undocumented Texans from seeking emergency care.  

Executive Order Adds Administrative Burden on State Agency 

While HHSC is currently under federal oversight and potential financial sanctions for its processing time of Medicaid, CHIP, SNAP, and TANF applications, and while the agency avoided implementing summer food security programs for children who receive free school meals specifically due to its lack of capacity, the governor’s Executive Order requires HHSC to have somehow the capacity to implement another program. Although the staff hours and infrastructures necessary for carrying out this hospital reporting program are less intensive than processing benefits applications and administering summer food benefits, Every Texan encourages the governor’s office to decrease the administrative strain HHSC is already operating under by rescinding GA-46.  

Importantly, the Executive Order does not require hospitals to subtract from the dollar amount of health care costs incurred by undocumented patients the amount of bills those patients themselves reimburse with out-of-pocket payments directly to hospitals. Whether the governor’s office will require hospitals and/or HHSC to track these direct payments is unclear. 

Conflicts with Texas and Federal Privacy Standards 

Abbott’s Executive Order acknowledges that public hospitals must treat patients regardless of their coverage or immigration status. However, it does not acknowledge the conflicting messages from state and federal offices, legal services programs, and community-based organizations that will confuse community members and ultimately increase distrust in Texas’ health systems. 

For example, the Texas Department of State Health Services (DSHS) posted a flyer from national immigrant rights organization Protecting Immigrant Families (PIF) on its website until Sunday, Aug. 11 – just three days after Abbott announced the Executive Order — which confirmed to Texas patients that “health care workers should not ask for immigration status information.” 

Although DSHS removed that flyer from their website as of Monday, Aug. 12, Every Texan refers advocates, analysts, and members of the media to the same “YOU HAVE RIGHTS: PROTECT YOUR HEALTH” flyer  on a California United Way office website. Shifting messaging and conflicting positions among federal, state, and local offices and organizations will increase hesitance to visit hospitals/clinics not only for people with noncitizen immigration status but for  mixed immigration status families as well. We anticipate concerns and potential lawsuits about patient HIPAA violations from federal oversight offices and national legal partners in the coming weeks.

Messaging to Community Members 

Every Texan encourages community partners, immigration attorneys, hospital staff, and members of the media to share widely that accessing public health and/or benefits programs – including charity care at public hospitals, sliding fee-scale programs at federally-qualified health centers, Medicaid, CHIP, CHIP-Perinatal, SNAP food benefits, and Marketplace health insurance – has NO EFFECT on public charge admissibility tests and WILL NOT affect immigration applications for legally permanent resident status.

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We urge the governor’s office to rescind GA-46. While some states are expanding access to affordable health care for people without current immigration status, Gov. Abbott strives to further marginalize those taxpayers from programs that would not just save lives and money for Texas families, but also benefit hospitals and local and state governments.

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Blog

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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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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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.