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Texas and the ACA’s Medicaid expansion

2.6 million people in 18 states are in the coverage gap. More than a quarter of them are in Texas.

texas Medicaid guide

Texas has not expanded Medicaid under the Affordable Care Act (ACA). And they’re tied with Alabama for having the most stringent eligibility guidelines in the country for non-disabled adults. As a result, Texas has the biggest coverage gap in the country, with 684,000 residents ineligible for Medicaid and also ineligible for premium subsidies to offset the cost of private coverage in the exchange. There are more than 2.6 million people in the coverage gap across the 19 states that have not yet expanded their Medicaid programs, and more than a quarter of them are in Texas.

As the ACA was written, it called for Medicaid expansion in every state for legally-present residents with incomes up to 133 percent of poverty (138 percent, with the build-in 5 percent income disregard). But in 2012, the Supreme Court ruled that states could not be penalized for opting out of expansion, and Texas is one of 19 states that has chosen to keep their pre-2014 Medicaid eligibility rules.

2017 and beyond

Political leaders in Texas have remained mostly uninterested in expanding Medicaid. Instead of pushing for legislation to expand Medicaid, Texas officials have been negotiating with CMS in an effort to secure ongoing funding to cover uncompensated care in the state.

But under the Trump Administration, many aspects of the ACA are likely to change, including Medicaid expansion. The timeline for the change is likely to be protracted; repeal legislation is expected early in 2017, but with a delayed implementation schedule during which Congressional leaders will ready their ACA replacement.

In many states that have expanded Medicaid under the ACA, residents and public health officials are worried that the proposals put forth for block grants or per-capita allotments, with fewer federal strings attached, would result in less overall funding for Medicaid, reduced benefits, and fewer people covered. In Texas, where residents never got a chance to benefit from the federal funding that was made available to expand Medicaid, the impact of repealing and replacing the ACA won’t be felt as much as it might be in states that welcomed the additional federal Medicaid funding.

But the existing Medicaid program in Texas could be impacted under the Trump Administration, depending on the degree of change that’s implemented in terms of how Medicaid is funded and controlled.

Who is currently eligible?

In addition to the aged, blind, and disabled, the following populations are eligible:

  • Adults without dependent children are not eligible at all (this is generally the case in states that have not expanded Medicaid) unless they’re disabled.
  • Adults with dependent children are only eligible if their household income doesn’t exceed 18 percent of poverty level.  This amounts to about $3,600 a year for a family of three, and is tied with Alabama as the lowest threshold in the country.
  • Children are eligible for either Medicaid or CHIP if their household incomes are up to 201 percent of poverty (this is among the lowest limits in the country, although there are a handful of states with lower eligibility thresholds for children’s Medicaid and CHIP).
  • Pregnant women are eligible for Medicaid if their household income does not exceed 198 percent of poverty.

The state also offers Texas Health Insurance Premium Payment (HIPP) which is a program that lets people with at least one Medicaid-eligible family member opt for employer-sponsored health insurance if it’s available, and receive assistance with the premiums through the Medicaid program (premium assistance programs are available in most states).

How do I enroll?

  • You can enroll through, either online or by phone at 1-800-318-2596.
  • You can enroll through the Medicaid website maintained by the Texas Health and Human Services Commission.
  • You can also download and print a paper application, or request that one be mailed to you, by using this page on the Texas Medicaid website.

Enrollment numbers

Despite the fact that Texas opted against using federal funds to expand Medicaid (the federal government would have fully funded the cost of covering newly-eligible enrollees through 2016), the state still enrolled 141,494 people in Medicaid and CHIP through from October 2013 through April 2014.  These people were eligible under the state’s existing guidelines, but hadn’t enrolled prior to October 2013.

From late 2013 to September 2016, total Medicaid/CHIP enrollment in Texas grew by only 7 percent, adding a net 306,365 people to the program. Texas has nearly 4.75 million people enrolled in Medicaid/CHIP – second only to California, where nearly 11.8 million people are enrolled (California expanded Medicaid under the ACA, and enrollment there grew by 52 percent from 2013 to 2016).

If Texas were to expand Medicaid, it’s estimated that 1,186,000 people would be newly eligible for coverage.  Of those people, 684,000 are currently in the coverage gap and have no realistic access to health insurance at all.  They don’t qualify for Medicaid, but their incomes are under the poverty level which means they are not eligible for subsidies in the exchange.

Prior to 2014, Texas had the highest uninsured rate in the country, and that is still the case. According to U.S. Census data, 22.1 percent of Texas residents were uninsured in 2013. And while the state’s uninsured rate had fallen to 17.1 by 2015, that was still by far the highest in the nation (the second-highest was Alaska, at 14.9 percent of the population, but Alaska expanded Medicaid in the fall of 2015, and their uninsured rate is likely to have declined sharply since then).

Planned Parenthood

Since October 2015, Texas has been threatening to cut Medicaid funding for Planned Parenthood. In December 2016, the state notified Planned Parenthood that funding would be cut off in 30 days, and that Planned Parenthood had 15 days to request an administrative hearing with Texas Health and Human Services.

On December 31, Planned Parenthood filed an injunction in federal court, asking the court to prevent the state from eliminating Medicaid funding for Planned Parenthood. The situation has not yet been resolved.

Missing out on billions in federal funding

By refusing Medicaid expansion under the ACA, Texas has already missed out on billions in federal funding that would otherwise have flowed to the state to provide medical care for their low-income residents. And in addition, the state’s emergency rooms are providing $5.5 billion in uncompensated care each year, treating patients who don’t have health insurance. If Medicaid had been expanded, uncompensated care would have dropped considerably, so hospitals and business groups across the state have been pressuring lawmakers to relent on their opposition to Medicaid expansion.

Because Texas has refused to expand Medicaid, the federal government has warned the state that continued access to federal funding to help cover uncompensated care is in jeopardy (since Medicaid expansion would solve much of the uncompensated care problem). But Governor Greg Abbott has continued to reject Medicaid expansion, and described the federal government’s tactics as “coercive.”

Since residents in states not expanding Medicaid still have to pay federal taxes, there has been a significant outflow from Texas residents to fund Medicaid expansion in other states. Over a decade (starting in 2014, and assuming Medicaid expansion continued for ten years, which is now unlikely under the Trump Administration), Texas residents will pay $36.2 billion in federal taxes that will be used to pay for Medicaid expansion in other states.

This is by far the highest of any state – the next highest is Florida, where residents will pay just over $20 billion to pay for other states’ Medicaid expansion by 2022 (this data was compiled in 2014, when it was estimated that Texas would miss out on $65.6 billion in federal funding over a decade of refusing to expand Medicaid; updated information indicates that Texas is actually leaving $100 billion on the table over a decade by rejecting Medicaid expansion. But again, this is all likely to change in the coming years, as Congressional Republicans will probably implement a new structure for providing federal Medicaid funding to states).

Legislative and executive actions regarding Medicaid expansion

During the 2013 legislative session, Republican John Zerwas sponsored HB3791, which would have directed the state to craft a “Texas solution” to Medicaid expansion. But it did not pass. The bill called for reforming the state’s Medicaid system while also accepting federal funding to expand the program. It also included “personal responsibility” measures like copays and deductibles, and would have included premium assistance programs to help people purchase private insurance as a preferable alternative to traditional Medicaid.

But also in 2013, Republican lawmakers in Texas passed a measure that requires the state Health and Human Services Commission to receive approval from the legislature before any future Medicaid expansion decisions could be made.  So ultimately, even if a governor were to support Medicaid expansion, and even if the Trump Administration were to leave Medicaid expansion intact (unlikely, but possible) the decision rests with the Texas Legislature. This makes expansion very unlikely in the near future, given lawmakers’ general rejection of the idea.

As long as Medicaid eligibility continues to be unchanged from 2013 guidelines, the cost of uncompensated care in Texas hospitals is roughly $5.5 billion a year, and it’s largely paid by tax dollars and higher health insurance premiums for people who do have coverage.

Former Governor Rick Perry repeatedly rejected Medicaid expansion. During the 2014 Governor’s race, Republican Greg Abbott (who won by a significant margin) agreed with Perry and expressed his opposition to accepting federal funding to expand Medicaid (both men claimed that the eventual 10 percent of the cost that the state would pay by 2020 would be too much for the budget). Democratic candidate Wendy Davis was in favor of Medicaid expansion in Texas, but she lost the election.

In late 2014, Abbott expressed interest in Utah’s Medicaid expansion waiver (two years later, Utah’s legislature still has not come to an agreement on Medicaid expansion). And while that instilled hope that Abbott might soften on his stance towards Medicaid expansion, he remains opposed to it as of 2016.

But in November 2014, a 15-member board of medical professionals appointed by Governor Perry recommended that the state move forward with Medicaid expansion. The Texas Institute of Health Care Quality and Efficiency board has recommended Medicaid expansion as a solution to what they called an “unacceptable” number of people without health insurance in Texas.

The Texas legislature only meets in odd-numbered years, and while numerous bills were introduced in 2015 in an effort to expand coverage, none were successful. And as noted above, it’s not looking likely that expansion will happen during the 2017 legislative session, particularly given the uncertainty surrounding the ACA under the Trump Administration.

Texas Medicaid

How to apply

You can enroll through or the state Medicaid website. You can enroll by phone at 800-318-2596.

Who is eligible

The aged, blind, and disabled.  Also, parents with dependent children are eligible with household incomes up to 15% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 201% of FPL, and pregnant women are eligible with household incomes up to 198% of FPL.

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