A pandemic-era policy under the Trump and Biden administrations has led to a sharp increase in the number of Texans now covered under Medicaid.
The number of Texans covered by the program — which provides health care to people with low incomes — grew to 5 million people as of October 2021, according to the latest data from the Texas Health and Human Services Commission. That's an increase of about 1.2 million from February 2020.
For the past two years, the COVID-19 public health emergency, a federal declaration that opens up funding, resources and emergency powers, has allowed Americans to keep their Medicaid coverage, even if they no longer meet their state’s requirements to stay in the program.
That's been a major benefit to people in Texas, a state with some of the strictest eligibility requirements in the country and which has not expanded Medicaid eligibility under the Affordable Care Act.
"Some of the largest increases in Medicaid enrollment have occurred in non-expansion states like Florida and Texas," said Melissa McChesney, a health policy advisor at UnidosUS. "They typically have more opportunities for people to lose Medicaid. Texas is keeping them enrolled in a program that they would have otherwise become ineligible for."
In the Houston and Beaumont regions, around 300,000 people have been able to keep these health benefits during the pandemic, according to local health care nonprofit Community Health Choice.
Earlier this month, the Biden administration extended the public health emergency for another 90 days, but it's unclear whether federal officials will continue to renew the declaration later this year.
If not, the state would then need to determine if millions of people are still eligible for the program, which could lead to a paperwork pileup and gaps in coverage for Texans that still qualify. Those deemed ineligible would need to be ushered to other state programs or the federal marketplace.
"The system right now is experiencing a lot of strain from a reduced workforce," McChesney said. "We're hearing from the ground that there are long holds on the call center, the applications are taking longer to process than they had been historically. Trying to redetermine millions of people's coverage all at once would overload an already overloaded system."
The agency’s recent workforce challenges were amplified when applications for SNAP, the state food stamp program that is managed by the same system, faced delays in October and November. The agency allowed for six months of continuous renewals as they dealt with a backlog of applications.
Before the pandemic, Texas had some of the sharpest declines in Medicaid enrollment among shrinking numbers nationwide. That's due in part to fear of the public charge rule -- which makes it harder for legal immigrants to get a visa if they use or are likely to use certain public benefits -- in immigrant communities, as well as processing delays and incomplete paperwork, McChesney said.
The Texas Health and Human Services Commission says it’s already preparing for the end of the public health emergency by "developing comprehensive resources to share with families, providers, advocates and contract partners," according to an email from an agency spokesperson.
Community organizations have already begun outreach, despite not knowing when exactly continuous enrollment will end. When it does, Medicaid recipients should receive time-sensitive marked envelopes with renewal instructions from Health and Human Services, said Lisa Wright, President and CEO of Community Health Choice, a nonprofit that helps Southeast Texans sign up for Medicaid. The extension is currently set to end in mid-April.
"We're starting to go ahead and educate people because if (the public health emergency) does end, we want people to be prepared," Wright said. "We're in that gray area with everybody else with whether it's going to get extended, so what we're doing is just planning for both."
Wright said this declaration has benefited pregnant people in particular. Pregnant Texans usually lose Medicaid benefits 60 days after giving birth. National and state medical experts stress the importance of postpartum care in the 12 months following childbirth.
“It's allowing the mom to not only get her postpartum (care), which from a quality standpoint is something that we want the mom to do, but it's also allowing her to continue preventative care and those well woman checks, ensuring her health and her well being,” Wright said.
The public health emergency has meant people are accessing health care well after the fourth trimester. Researchers at the Parkland Center for Clinical Innovation have been studying the policy's impacts on parents in the Dallas area from the start of the pandemic. They compared postpartum people who continued to receive Medicaid benefits during the public health emergency and those who just missed the cutoff.
Postpartum patients who maintained Medicaid were 50% more likely to utilize preventative care. The use of mental and behavioral health services doubled. Pregnancies within the first year after childbirth, which are typically higher risk for the baby and parent, were also less common in this group.
"There are underlying needs that are not being met and not even being seen when Medicaid is interrupted or discontinued after 60 days," said Dr. Yolande Pengetnze, the head researcher on the project. "I think policymakers need to realize the impact when Medicaid is extended for pregnant women. At least one year would be a good enough coverage to not only help the mother get through the postpartum period, but also so the baby has a healthy mother that could take care of him for the first year of life, at least."
A law passed during last year’s legislative session will soon extend Medicaid coverage to 6 months postpartum. The initial version of the bill pushed for Medicaid to be extended a full year after childbirth.
However, in a non-legislative year, advocates are focused on the immediate effects of the end of the public health emergency, which will impact more than just pregnant people on Medicaid. They’re pushing for Texas to anticipate possible challenges and avoid Medicaid-eligible Texans from falling through the cracks.
Melissa McChesney, with UnidosUS, wants the state to be persistent in updating contact information, provide clients 30 days to provide any requested information and to create a staggered renewal plan, instead of processing millions all at once.
"We are largely talking about children of color and families disproportionately impacted by the pandemic, both economically and from a health perspective," McChesney said. "If they were to also then lose access to their coverage, we're talking about deepening existing racial and ethnic disparities.”
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