Democrats looking to expand Medicaid, address maternal, reproductive, and mental health during the 88th Texas Legislature


Boram Kim


Democratic lawmakers have filed a series of health-related bills in the upcoming legislative session that aim to improve maternal, reproductive, and mental health access and equity for Texans. 


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Texas has both the highest uninsured rate and the largest uninsured population in the country. Nearly 12% of children and a quarter of adults aged 19-64 (24.3%) in Texas were uninsured in 2021. Expanding the Medicaid threshold to 138% of the poverty level would bring $15.3 billion in federal incentives to the state and qualify an additional 1.7 million uninsured residents for coverage. 

The Democrats have been pushing for that expansion in Texas since the ACA’s passage in 2010 but repeatedly met opposition from Republicans who argued in past sessions that the program’s poor management and financial unsustainability promotes poor health outcomes and dependence on the government. Texas remains one of 11 states that have opted not to expand Medicaid programs under federal law.

The legislature can expand Medicaid coverage through one of 3 options: a state plan amendment, 1115 Medicaid waiver amendments, or putting the issue before Texas voters, which requires two-thirds majority legislative approval.  

Sen. Nathan Johnson (D – Dallas) and Rep. Julie Johnson (D – Carrollton) have led legislative efforts on Medicaid expansion in recent years. Both lawmakers have independently filed Senate and House bills for the upcoming session that propose again to create a “Live Well Texas” program. The state-customized approach to expansion would utilize Medicaid waivers to provide incentives to working adults to manage their healthcare responsibly. 

Speaking to State of Reform about his outlook for the next session, Johnson said he would pursue each of those three options this session. He added that while the level of engagement in Texas around expansion is vastly different than it was four years ago when he began advocating for it, his optimism that progress could be made is tempered. 

“… if [Republicans] can find a way to announce to the public that we’re gonna take this federal money, and here’s why it’s consistent with our ideals and objectives … they have to be able to explain why this moment is distinct,” Sen. Johnson said.

“From the past 10 years of rejecting Medicaid expansion, why is it okay now and it was not okay 10 years ago? They can’t say, ‘Well, because we were wrong.’ So it has to be that we’re in a different place today.

The fact is, we are. We are because the public support is vastly higher. They are because we’re not wondering whether or not the system is going to work. We’ve got data from 10 years of experience in other states. We’ve got financial incentives at levels that we’ve never seen asking Texas to do it. Speaking of finance, [expansion] actually increases our state budget. So is it going to be something that subjects Texas to the whims of the federal government? And I think that’s where Texas gets hung up. We don’t want the Feds telling us what to do.”

The Health and Human Services Commission (HHSC) recently published a report that said the state had met important milestones this year in the transition to value-based care. 

This year the state rolled out several quality and value-based incentive programs for Medicaid and CHIP that reward MCOs and providers for achieving high results on important health outcomes, including efforts to improve access and quality in rural areas and the Comprehensive Hospital Increase Reimbursement Program (CHIRP), which provides increased Medicaid payments to hospitals for inpatient and outpatient services provided to persons enrolled in STAR and STAR+PLUS. 

Sen. Johnson noted that while there are still issues with the Medicaid program, he believes its managed care organizations are for the most part well-run. 

“It would be consistent for any Republican who opposed Medicaid expansion in the past to say our Medicaid system wasn’t ready to take on that next level. But we have fixed it and now it is. If all that happens, we pass it this session. Is it likely? No, but I’ve got to keep pushing.”

Several Democratic lawmakers have filed bills (Senate Bill 73 and House Bills 56 and 487) that call for extending postpartum Medicaid care from the current 6 months in Texas to 12 months and beyond. 

Concerns over maternal health equity have amplified after the Department of State Health Services (DSHS) delayed its report on maternal mortality in September. DSHS officials are expected to release portions of the data and their recommendation to lawmakers on maternal health at the Maternal Texas Maternal Mortality and Morbidity Review Committee’s (MMMRC) December 8th meeting. 

In response, Rep. Shawn Thierry has filed several measures that address maternal health equity, including the creation of an Office of Health Equity within HHSC and the addition of another community member to the MMMRC. 

Thierry has proposed creating a maternal mortality and morbidity data registry that would protect patient confidentiality while sharing pertinent maternal mortality information. 

Rep. Julie Johnson is sponsoring HBs 755, 756, and 757, which all relate to prior authorization restrictions by health plans for prescription drugs related to chronic diseases, utilization review requests, and certain health benefits respectively. 

“Not only do we have an uninsured problem, but we have an access problem for people who actually have insurance, but they’re not able to really access and utilize the benefits,” Rep. Johnson said. “There’s a lot of wrongful denials, and so I think those are very important for people with chronic health issues in order to be able to access and get care in a timely manner.”

On the behavioral healthcare front, Sen. José Antonio Menéndez (D – San Antonio) filed SBs 112 and 113, which propose the inclusion of a mental health course in the public school curriculum as well as the provision of on-campus mental health services by school districts that are Medicaid-reimbursable. 

The mental and physical well-being of children and youth in Texas remain in focus following the tragic events in Uvalde. 

“There is an acknowledgement without regard to ideology, that mental health is at a crisis level in our state, that [it] is underfunded in our state, particularly among young people,” Sen. Johnson said. “Evidence bears that out. So I think there will be a concerted serious effort by the legislature to supply funding to mental health efforts but also work with the mental health community that has been doing research that has been on the ground in the smaller scale to try and make resources more available.”

Sen. Johnson said he would also be introducing measures that improve the school psychologist-to-student ratio and ensure school counselors are not bogged down by substitute teaching or administrative tasks but can instead focus on students. 

Democrats have also filed proposals addressing women’s reproductive health and rights. Senate Joint Resolution 21 proposes a state constitutional amendment establishing an individual’s right to personal reproductive autonomy, while HB 722 would establish employment discrimination protections for those who make medical decisions related to their reproductive health. 

Rep. Donna Howard (D – Austin) has filed HB 214, which would reestablish the Women’s Health Advisory Committee (WHAC). Howard says the committee was instrumental in ensuring programs aimed at women’s health were effective. Despite attempts to extend it by Howard last session, WHAC was decommissioned. 

“Having people who are providers on the ground delivering services and having communications with the agency has allowed them to actually ensure that the programs are meeting the needs that we intend them to meet, and identifying obstacles that can be addressed,” Howard said. “It was an extremely important committee, which was not allowed to continue despite the fact that I had filed legislation previously to extend the life of a committee because it was so valuable.

Unfortunately, that didn’t take into account the effectiveness of this particular committee. So we have been in communication with providers over these past several years, who have continued to say they have issues, they need opportunities as a group to talk with the agency and clear these up to make sure that we put policies in place that will allow them to do their jobs.”

Howard said multiple providers and family clinics across the state have reported running out of funding for these programs since committee oversight was dissolved and having to deny services and lay people off. She said some of the programs were only serving 20% of community members who qualify for women’s health services due to the lack of resources.

“Clearly, it shouldn’t have gotten to this point,” Howard said. “Having regular communication that also includes public comment and allows the public to be involved in [women’s health] is really critical. We are proposing again that this group be reestablished in order to provide the necessary feedback to the agency so that we can actually meet the needs of moms and babies in our state, which is what probably every legislator will tell you that they support. Especially those who plan to be pro-life, we need to be there protecting the lives of these moms, especially those that we’re now going to be forcing to carry their pregnancies.”

The Texas Legislature officially convenes on January 10th, 2023.