Medicaid unwinding exposed a ‘crisis’ in the system as 1.7 million Texans lost coverage
Editor's note: This story has been updated to reflect the latest data from the Texas Health and Human Services Commission.
During the COVID-19 pandemic, the federal government put protections in place to make sure people could access health care, like testing, treatment, and doctors’ visits.
These protections under the Public Health Emergency (PHE) started in March 2020. The PHE also ensured people would have continuous Medicaid coverage, a comprehensive federal program that covers low-income people without having to reapply.
The PHE expired earlier this year. This meant that starting on April 1, states had to determine whether the millions of people who had been added to the Medicaid rolls in the past three years were still eligible.
The Texas Health and Human Services Commission (HHSC) manages Medicaid for the state and is overseeing this process. Since redetermination began earlier this year, about 1.7 million Texans have lost coverage—almost a million of them kids, according to KFF, a health policy nonprofit..
Stacey Pogue is the senior policy analyst with the advocacy group Every Texan and has been tracking Medicaid unwinding in the state. She said since a lot of folks have never renewed before, they’re running into a lot of issues, and the stakes are high.
“Did the state send it to the wrong address?” said Pogue. “Did the notice come in your language? Do you understand it? Are the due dates on it clear? Can you get local help if you need it?
“We have a lot of parents who are trying to jump over every barrier in the system, and sometimes it’s just too hard with too many pitfalls for some parents to make it through.”
How does Texas determine Medicaid eligibility?
States use a few different methods to determine eligibility, Pogue said, that include everything from sending letters through the mail to cross-referencing federal databases.
“One of the strongest tools that states have to keep eligible people enrolled in Medicaid”, according to the U.S. Centers for Medicare and Medicaid Services (CMS), is auto-renewals, which are also called ex-parte renewals.
This means enrollment specialists review other kinds of state data, like SNAP, state wages, Social Security and DMV records to confirm people’s details. This process helps the specialists confirm things like address, number of family members, income and other requirements needed to determine a person’s Medicaid eligibility.
Only about 10% of people who retained Medicaid coverage in Texas were renewed through this process, the lowest in the nation; the majority were done through a renewal form on the website, over the phone, or through the mail, according to KFF.
Pogue said that’s not enough.
“We have access to income data that is current, that is good, that is collected by the state,” she said. “And we just don't use it in Texas. We're dismissing most of that data and asking parents then to fax or mail or upload their paycheck stubs instead.”
She said this makes the process unnecessarily complicated for state eligibility workers and families.
“Unwinding is putting a spotlight on Medicaid renewals,” said Pogue. “[It’s] giving a chance for all of us to think, ‘How many hoops should somebody jump through? How many other things do they need to do to keep their coverage?’”
How does the Medicaid unwinding in Texas compare to other states?
Texas by far has the most people who have lost Medicaid coverage, including the largest percent of kids in the 21 states reporting data on age groups impacted by this process, according to the KFF.
Amber Ayala, the storytelling coordinator for the health policy team at Children’s Defense Fund Texas, said Medicaid is a lifeline to a lot of families. Without health insurance, some parents are forced to choose between putting food on the table or going to the doctor.
“That is not a choice families should be making, but it has become the norm, and it’s all coming to light through this whole Medicaid unwinding process,” she said.
Texas already has the highest percentage of uninsured kids in the country at 10.9%. Nationally, it’s about half that, at 5.1%. A report by the Center for Children and Families out of Georgetown University ranked Texas the worst in the nation for child health, since a lack of insurance leads to “unmet health needs…diminishing their chances to grow into healthy and productive adults.”
Texas also has a high percentage of procedural denials, which could mean anything from people forgot a signature on an application page or were late in turning in their paperwork.
For Texans who were disenrolled from Medicaid, about 67% had their coverage ended because of procedural reasons. According to an analysis by Every Texan, that's about 1.1 million Texans that the state "never confirmed whether or not they remained eligible," but they lost coverage anyways.
That’s left thousands of families “in the dark,” said Ayala, about whether their kids are still eligible.
“Our state leaders have failed families through this entire process,” said Ayala. “They could have ensured that the system was equipped before the whole process started. They could’ve invested more funding. They could have paused the entire process. But none of those things happened.”
In addition, Texas is one of 10 states that has not expanded Medicaid coverage. That means most low-income adults without children don’t qualify, and may not make enough money to qualify for an Affordable Care Act Marketplace plan.
Texas did expand coverage for pregnant people during this year’s legislative session. HB 12 extended coverage from two months to 12 months with bipartisan support.
After Gov. Greg Abbott signed the bill into law, HHSC submitted its plan for a 12-month postpartum Medicaid extension to CMS at the end of October. HHSC press officer Tiffany Young told KERA in September the extension is pending CMS approval and will most likely go into effect in early 2024.
In Texas, pregnant people might not be eligible for Medicaid coverage past this window, depending on their income level, and other options for health insurance outside of ACA plans are less comprehensive.
Recommendations to improve Medicaid in Texas moving forward
Ayala with Children’s Defense Fund Texas said she’s seen the “very preventable barriers” families have had to go through during Medicaid unwinding and wants lawmakers to prioritize fixing these issues in the coming years.
“We cannot return to the old system and the old ways because families are going to continue experiencing these barriers and continue needing assistance,” she said. “They have children. They have lives, and they shouldn't have to be paying the price with their lives as they struggle to go through this process by themselves.”
She also urges lawmakers to streamline the process to ensure families know what their health care coverage is for next year.
“We're in December, it's supposed to be a joyful season,” Ayala said. “And there are still thousands of families who are waiting to hear back on their applications for their children. It shouldn’t have to be that way.”
Stacey Pogue with Every Texan is concerned about how backlogged the system is, and what that’ll mean for families applying for benefits soon. As of November, there's about 48,000 Medicaid applications still stuck in the system from March 2023 or earlier.
“It wasn't Medicaid unwinding that caused those backlogs,” she said. “But we had backlogs in the system before Medicaid unwinding. We have a structural problem where we just don't have the streamlining or staff or investments we need to for the state to process SNAP and Medicaid paperwork on time so that families don't have to wait.”
She said it’s a “crisis” that needs to be solved for families.
“With gaps in coverage, that means kids can't pick up their inhalers at the pharmacy counter or can't go to their mental health checkups,” Pogue said. “Gaps in coverage, especially as long as our backlogs are right now in Texas…that's not good for any of our kids. We want kids from Dallas to Del Rio to be able to go to a doctor when they're sick.”
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