As the state with the highest number of uninsured people in the U.S., Texas is looking at ways to increase coverage. Health professionals discussed the challenges Texans face and a variety of options to increase coverage at the 2024 Texas State of Reform Health Policy Conference last month.
Texas 2036, a public policy think tank, conducted a multi-year study called Who Are The Uninsured? in order to examine the state’s low insurance coverage ranking.
Texas is one of 10 states that has not expanded Medicaid. The study found that 15.6 percent of the uninsured population would be covered by expansion.
Charles Miller, a senior policy advisor at Texas 2036, said Medicaid expansion is currently not a politically-viable option.
Miller said the key takeaway of the study was that 30 percent of the uninsured population in 2022 was eligible for an entirely free health insurance plan under the Affordable Care Act (ACA). He added that Texas 2036 is looking at ways to cover a greater portion of the eligible-but-unenrolled population.
Lack of awareness is a primary reason some eligible people aren’t covered, Miller said. Most uninsured Texans are working, but oftentimes their jobs do not offer health insurance, and they are unaware of other options for affordable coverage. He added that technological barriers are another obstacle to getting coverage.
“There are some technocratic issues that could be improved in terms of making that enrollment process easier,” Miller said. “They are not the super exciting issues—they are things like making sure that you have a web page up front that shows all the documents you’re going to need before you go through the enrollment process.”
Sonia Lara, the outreach, enrollment, and special populations director at the Texas Association of Community Health Centers, said “enrollment assisters” and eligibility workers are vital to helping people navigate complicated health insurance systems.
Eligibility workers typically work at the association’s health centers, but many switched to application processing roles during the Medicaid unwinding.
Brittney Taylor-Ross, a senior policy analyst with Every Texan, said the post-pandemic Medicaid unwinding has become another barrier for Texans needing access to care.
During the pandemic, all states had to pause Medicaid eligibility checks, so nobody was removed from Medicaid, even if their eligibility status changed. In April last year, states were required to restart eligibility checks after three years of continuous coverage.
Over two million Texans have been disenrolled from Medicaid since redeterminations began, and 66 percent of disenrollments were due to procedural reasons, so their eligibility was not checked.
Almost one million children have been procedurally disenrolled, Taylor-Ross said.
Children have a higher income eligibility threshold for coverage than adults, and Taylor-Ross said that Every Texan estimates that as many as three in four of procedurally-disenrolled children are still eligible for Medicaid or Children’s Health Insurance Program (CHIP) coverage.
One in four children in Texas also has a non-citizen parent, so some parents may not realize they can get coverage for their child without risking their immigration status, Taylor-Ross said.
“Outreach to these families is more important now than ever before,” she said.
That is where the enrollment assisters come in. They can help ineligible parents find coverage for their eligible children.
“[Enrollment assisters] are actually the ones that are holding these parents’ hands and getting them through all the challenges and barriers that are set up getting them enrolled in coverage.”
—Lara
Taylor-Ross noted that automatic, or ex parte, renewals would help Texas relieve some of the administrative burden that the Texas Health and Human Services Commission (HHSC) is experiencing.
“Fixing this data-driven renewal process would really help, not only with HHSC staffing and workload—we know that they’re very overburdened right now with checking eligibility for so many millions of people—but it would increase efficiency [and] also just reduce that administrative burden on HHSC’s staff and families that are trying to access coverage,” Taylor-Ross said.
She said HHSC has been transparent about the unwinding, and has provided more data and statistics than federally required to by the Centers for Medicare and Medicaid Services.
As Texas works to increase its rate of insured individuals, panelists discussed the options.
Lara noted that, due to the Medicaid unwinding, Texans should be aware that the federal marketplace is open to enrollments longer than it typically is. The open enrollment period usually runs from Nov. 1 to Jan. 15.
Anybody that has lost Medicaid coverage during the unwinding “are still eligible to apply for marketplace coverage, and they can do that anytime until July 31,” Lara said.
Lara also highlighted the low-income special enrollment period, which allows people who make less than 150 percent of the federal poverty level to apply for ACA plan coverage at any time.
Lara would like to see the state strengthen its enrollment assistance network so more people can be aided by enrollment assisters.
Miller discussed a promising bill from last session that passed in the House but stalled in the Senate. House Bill 1599 aimed to add an express lane option to check children’s Medicaid and CHIP eligibility, which would strengthen the state’s ability to do data-driven automatic renewals.
“I really think that [bill] got caught up more in a battle of personalities than in any sort of policy problem last session, and I think we should be looking for that to come back,” Miller said.
Miller said two possible options to increase coverage include a reinsurance pool for small groups and a state healthcare exchange. The reinsurance pool would allow more small businesses a chance to affordably offer health insurance to their workers.The state healthcare exchange could help solve some of the user interface issues present within the federal exchange.
“If we were to take over the operation of that [healthcare] exchange, it’s possible we could improve [user experience issues]. It’s also possible that we could make them worse. There is a risk-reward opportunity there. But the other part of that state exchange effort that is really interesting is the potential for revenue to do all the other things we’re talking about.”
—Miller
Miller acknowledged that a state exchange could be a contentious topic, and all parties—such as health plans, providers, and advocacy groups—would need to be aligned in order to make it a viable option.
Taylor-Ross said Every Texan is excited to track the implementation of HB 12, which passed last session. The bill went into effect March 1, and extends postpartum Medicaid coverage from two to twelve months.
The past year has seen a record number of Texans (3.3 million) enrolling in the federal marketplace, Taylor-Ross said.
“That was an increase of almost 37 percent from the last open enrollment period,” she said.
Going into next year’s legislative session, Taylor-Ross said Every Texan will be advocating for the streamlining of the state’s eligibility and enrollment system, investments in eligibility outreach, and Medicaid expansion.
“I just think there is really no other single policy lever that we currently have at our disposal right now that could cover so many people so quickly, increase access to care, hopefully reduce medical debt, and increase affordability and utilization of healthcare across the state,” Taylor-Ross said.