State sees renewed calls to expand Medicaid eligibility, increase coverage as Texas leads nation in percent uninsured

Policy leaders point to Texas’ hesitancy to expand Medicaid eligibility, as outlined by the Affordable Care Act passed in March 2010, as a likely contributor to the large uninsured population statewide. (Courtesy Adobe Stock)
Policy leaders point to Texas’ hesitancy to expand Medicaid eligibility, as outlined by the Affordable Care Act passed in March 2010, as a likely contributor to the large uninsured population statewide. (Courtesy Adobe Stock)

Policy leaders point to Texas’ hesitancy to expand Medicaid eligibility, as outlined by the Affordable Care Act passed in March 2010, as a likely contributor to the large uninsured population statewide. (Courtesy Adobe Stock)

Texas leads the nation in its percentage of uninsured residents with 17.4% of Texans, or 4.76 million residents, uninsured in 2018, down from 22.8% in 2013. By comparison, the U.S. rate totaled 9.4% 2018, according to census estimates.

Policy leaders point to Texas’ hesitancy to expand Medicaid eligibility—as outlined by the Affordable Care Act passed in March 2010—as a likely contributor to the large uninsured population statewide. Other factors could include a large number of small businesses and independent contractors, the second-highest noncitizen population in the U.S. and a growing population choosing to go without health insurance.

"I think part of that is probably related to people who ... are uninsured because they may be ineligible for existing programs, but I also think it's partly related to the fact that there's a growing number of people that are not finding the value in insurance," said Rep. Tom Oliverson, R-Cypress.

An April 27 report from the Kaiser Family Foundation, an independent health care information nonprofit, shows that 36 states as well as the District of Columbia have adopted Medicaid expansion, and 14 states, Texas among them, are not yet opting to expand Medicaid eligibility.

"The idea under [the ACA] was you would subsidize coverage in the private market on a sliding scale for this really ‘working poor.’ The folks—they’re not deadbeats; they’re not homeless people. They’re just working folks, probably working two, maybe three jobs and just can’t afford health insurance," said John Hawkins, senior vice president for advocacy and public policy with the Texas Hospital Association. “I do think the current situation really changes the playing field [for Medicaid expansion] for a variety of reasons. ... This [legislative] session would be a really good chance to tee that issue up again.”

According to a report from the Kaiser Family Foundation, 1.5 million currently uninsured, nonelderly adults could be covered if Texas expanded Medicaid eligibility. Policy leaders anticipate this figure could still grow amid recent job losses.

“If we were to do Medicaid expansion right now, we would not only pick up a million and half of those adults who are already uninsure, but potentially, the million or more who may have found themselves on the uninsured rolls in the last month or so would have an option,” said Anne Dunkelberg, associate director of the Austin-based Center for Public Policy Priorities, which she said has supported Medicaid expansion since 2012.

Most residents who live in states that have expanded Medicaid and who earn less than 138% of the federal poverty level are covered by Medicaid, according to the Kaiser Family Foundation. In states like Texas that have not chosen to expand Medicaid eligibility, select groups may be covered under Medicaid. In Texas, this includes low-income individuals who are pregnant, who are a parent or relative caretaker of a child under age 19, who have a disability or a family member in the household with a disability or who are age 65 or older, according to Texas Health and Human Services.

Not expanding Medicaid eligibility means residents may find themselves in a coverage gap in Texas but could otherwise be insured in a state that has opted to expand Medicaid, said Adam Johnson, a report analyst at Quote Wizard, which compiled a report on COVID-19 unemployment and its impact on uninsured rates.

“To qualify for Medicaid in an expansion state, it's 138% of the federal poverty line. But in other states, that's typically right at the poverty line, so you do have quite a large population [in] Texas [that] would qualify in another state like New York, but they are left out of Medicaid in Texas but also still have incomes that may not be able to afford them a marketplace insurance policy, as it may be too expensive," he said.

Hawkins said while many states have expanded Medicaid with no strings attached, leading to a straight-up entitlement program, more conservative states have opted to expand eligibility with a working requirement or a small out-of-pocket payment—flexibility that comes via states using a Section 1115 Medicaid waiver to expand eligibility and customize it a bit.

“It’s almost going to be super subsidized, but even if it’s a $5-a-month premium, their argument is [that] at least now, folks have some skin in the game,” he said. “That’s good—for beneficiaries to have skin in the game—because then, they’re going to show up to appointments. They’re going to be better [users] of health care.”

The cost of caring for the uninsured

Hawkins also said expanding health care coverage by significantly subsidizing low-income individuals to purchase health insurance from the private market is better for health care providers, as private companies reimburse health care providers at a higher rate than Medicaid.

"Those rates are negotiated with those health plans, as opposed to the Medicaid program, where we’re at the mercy of the legislature setting rates. That’s why Medicaid rates are typically pretty low, and providers struggle with [the cost of Medicaid patients]," he said.

Additionally, Hawkins said the cost of caring for the uninsured is high, as hospital emergency rooms are often their only option. With patients having little ability to pay and no insurance provider to reimburse the hospital for a portion of the cost, hospitals take on an uncompensated care burden. State and federal supplemental payments help alleviate some of that burden, and hospitals are required in Texas to reserve a portion of revenue for charity care, but it is not enough, Hawkins said.

“There’s $5 billion or so to help offset uncompensated care, but we report, I think, north of $7 billion to the state, so those funds aren’t able to cover all of the burden," he said.

The cost of uncompensated care, then, can be translated to an increased tax rate if the hospital is part of a hospital district that levies a tax, such as Harris Health System, he said.

Hawkins said he believes expanding health care coverage using subsidies for the private marketplace would benefit health care providers, patients and the state's bottom line.

“It is a big issue for hospitals in Texas. The fact that we lead the nation in the number of uninsured is a fiscal challenge," he said.

Looking ahead

Oliverson, a lawmaker and anesthesiologist, said that while he anticipates Medicaid expansion will be discussed in the upcoming legislative session—slated to resume Jan. 12, 2021—he anticipates redistricting, unemployment and fiscal matters will get more of the focus.

“It's a big-ticket item, and the question is, philosophically, whether or not it's appropriate for the state government to be providing free- or reduced-cost health insurance for able-bodied adults who don't currently have coverage through their employer vis-a-vis the Medicaid expansion,” Oliverson said. “I actually think that the biggest problem we have with health care in Texas is not the availability of health care—it's the affordability of health care. ... That's not necessarily a problem that Medicaid is designed to solve because if ... you expand Medicaid, all you've done is basically change who's paying the bill. You haven't done anything to address the cost.”

Oliverson said concerns with the traditional expansion of Medicaid include that fewer than half of Texas physicians accept Medicaid and that expansion of Medicaid would be costly for the state, particularly amid the pandemic and economic downturn, when the state has few funds to spare.

"What happens if you expand Medicaid and you essentially double the number of people who are now on the Medicaid rolls and 50% of your health care workforce doesn't accept those patients? Where are those people going to go?" Oliverson said. "While I do think that there's going to be a strong conversation about health care [in the upcoming session], remember that Medicaid expansion—traditional Medicaid expansion like a lot of my colleagues like to talk about—requires a match, and we're not going to have any money for a match."

However, Dunkelberg, with the CPPP, said she believes the ongoing coronavirus pandemic changes the Medicaid discussion.

“The shape of this disaster may help ... because you have literally millions of Texans who maybe have never been jobless before suddenly overnight being thrown into that situation,” Dunkelberg said. “So when millions of Texans suddenly discover that because they have no income, they don’t qualify for anything, you may have a change in the political pressure."

Adriana Rezal and Hannah Zedaker contributed to this report.
By Anna Lotz

Editor, Tomball | Magnolia

Anna joined Community Impact Newspaper as a reporter in May 2016 after graduating with a degree in journalism from Cedarville University in Cedarville, Ohio. In July 2017, she transitioned to editor. Anna covers education, local government, transportation, business, real estate development and nonprofits in the Tomball and Magnolia communities. Prior to CI, Anna served as editor-in-chief of Cedars, interned with the National Journalism Center in Washington, D.C., and spent time writing for the Springfield News-Sun and Xenia Daily Gazette.


A total of 35 COVID-19 deaths were confirmed between July 10-12, the largest three-day total since the pandemic began. (Community Impact Staff)
Harris County coronavirus count: After three weeks of surging cases, death toll starts to rise

A total of 35 COVID-19 deaths were confirmed between July 10-12, the largest three-day total since the pandemic began.

Texas Commissioner of Education Mike Morath announced in a June 30 State Board of Education meeting that students will be taking the STAAR in the 2020-21 school year. (Courtesy Pixabay)
Education organizations call for STAAR requirements to be waived another year

Gov. Greg Abbott waived the State of Texas Assessments of Academic Readiness, or STAAR, testing requirements in March of earlier this year in response to the coronavirus pandemic.

With a clinical background in internal, pulmonary and critical care medicine, Corry has been with BCM for 20 years. He now focuses primarily on inflammatory lung diseases, such as asthma and smoking-related chronic obstructive pulmonary diseases. (Graphic by Ronald Winters/Community Impact Newspaper)
Q&A: Baylor College of Medicine's Dr. David Corry discusses immunity, vaccine production amid COVID-19 pandemic

Rapid development and distribution of a vaccine worldwide and successful achievement of herd immunity will be key players in determining the lifespan of the COVID-19 pandemic, said Dr. David Corry, a professor of Medicine in the Immunology, Allergy and Rheumatology Section at Baylor College of Medicine.

The county's active case count rose July 10 after three straight days of declines. (Community Impact staff)
Montgomery County adds 40 active COVID-19 cases, reaches 3,000 cumulative cases July 10

Five new hospitalizations and 87 new recoveries were also reported July 10.

The new partnership will provide on-site, same-day testing and results for assisted-living facility staff and their residents. (Courtesy Adobe Stock)
State announces partnership for increased COVID-19 testing for patients, staff at assisted-living facilities, nursing homes

These test sites will help the state work toward the goal of processing up to 100,000 tests in the first month.

Pet Supplies Plus opened a new location on FM 1488 in May, and will hold grand opening events July 11-12. (Courtesy Pet Supplies Plus)
Pet Supplies Plus opens new FM 1488 location north of The Woodlands

The national pet supplies chain opened the store in late May.

Texas Medical Center reports only 4% uptick in ICU bed use despite continued COVID-19 case increases

Compared to 1,350 total intensive care units in use June 30, Texas Medical Center has seen only a slight uptick in occupancies since then, with 1,394 reported July 9.

When interest rates are low, homeowners may look to save money by refinancing, which means getting a new mortgage with a better term or interest rate to lower payments. (Source: Matt Frankel/Community Impact Newspaper)
Refinancing a home, police departments address protests: Popular news this week from Greater Houston

Read popular stories from the Greater Houston area on Community Impact Newspaper’s website.

Tomball ISD's plans include continuing to provide bus transportation to all families who desire it—although district officials encourage families to provide their own transportation if possible—lunch procedures varying by campus, and limiting large group activities, including recess. (Courtesy Adobe Stock)
Here’s what bus transportation, lunch and recess will look like this fall for Tomball ISD students

Families who can provide transportation for their student to and from school are encouraged to do so, Chief Operating Officer Steven Gutierrez said during the meeting.

Lone Star College had almost 3,000 foreign students attend in the spring semester this year. (Andrew Christman/Community Impact Newspaper)
Immigration and Customs Enforcement rules could affect thousands of Lone Star College students

Lone Star College is currently unsure how a recent ICE rule will be affected its foreign student population.

Coronavirus cases continue to rise in Harris County. (Community Impact Staff)
Harris County coronavirus count: 907 cases, 12 deaths confirmed July 9

The 12 deaths—the largest single day total in Harris County since the pandemic began—brings the total COVID-19 death count in the county to 423.