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2.5 million Texans face loss of coverage under the AHCA; lawmakers approve high-risk pool in case federal funding becomes available

They say everything’s bigger in Texas, and that commentary extends to the state’s uninsured population—even in the age of Obamacare. Health disparities in Texas are significant, and the state has maintained a firm stance against the Affordable Care Act, including Medicaid expansion. Despite having a long ways to go, the state continues to have the third highest exchange enrollment in the country, following California and Florida.

During the 2017 open enrollment period, 1,227,290 people enrolled in private plans through the Texas exchange. That was a 6 percent drop compared with 2016’s enrollment, when 1,306,208 people signed up (average enrollment totals declined by about 5 percent across the states that use HealthCare.gov, while average enrollments increased slighly in states that run their own exchange platforms).

Texas and the AHCA

The future of healthcare reform under the Trump Administration is uncertain. House Republicans passed the American Health Care Act (AHCA) in May 2017. The Senate is working on their own version of the bill, and hoping to vote before the 4th of July.

The Congressional Budget Office has estimated that the uninsured population in the US will grow by 23 million people over the next decade if the House version of the AHCA is enacted. An analysis by the Center for American Progress indicates that more than 2.5 million of those people are in Texas. Currently, 4,377,000 Texans are uninsured. Under the AHCA, the total could reach 6,927,000.

Lawmakers approve a temporary high-risk pool, pending federal funding

The House Version of the AHCA includes $138 billion in new federal funding for various programs that could be used to stabilize health insurance markets and/or reduce premiums and increase benefits. This includes $100 billion for the Patient and State stability fund, $15 billion for maternity, newborn, mental health and substance abuse care (ie, the programs most likely to be under-covered if states can waive essential health benefit requirements), $15 billion for an “invisible risk sharing program” and $8 billion (the Upton Amendment) to offset premiums for people in states that allow insurers to base premiums on medical history when an applicant has had a gap in coverage.

Some of this money could be used to fund high-risk pools, which used to be the default last resort coverage option in most states when people couldn’t get private insurance as a result of their medical history. Texas had a high-risk pool (the Texas Health Insurance Pool), but coverage through the pool terminated in March 2014, as medical history was no longer an obstacle to obtaining health insurance in the private market under the ACA.

In May 2017, lawmakers in Texas overwhelmingly approved S.B.2087. If approved by Governor Greg Abbott, the bill would allow Texas to create a temporary high-risk pool if and when federal funds become available. The text of the legislation specifically prevents the state from using the pool to expand Medicaid. But the pool could be used to either directly insure people with pre-existing conditions in coverage separate from the private individual market, or to offset costs for private insurers so that people with pre-existing conditions could still obtain affordable private health insurance.

Nothing would happen under S.B.2087 if federal funding doesn’t become available, so if the AHCA or a similar measure is not enacted, Texas will not create a new high-risk pool (nor would they need to, since private coverage would continue to comply with the ACA absent a federal legislative change).

It’s noteworthy that health policy experts have generally said that the money provided by the AHCA would not be sufficient to create functional high-risk pools or otherwise adequately ensure that people with pre-existing conditions could obtain high-quality, affordable health insurance in the individual market if the AHCA were to be enacted.

Texas health ratings

The Lone Star state continues to founder in national healthcare rankings across the board. Though seeing slight improvements, the state’s large population of uninsured surely impacts its performance in many health dimensions.

In 2015, The Commonwealth Fund’s Scorecard on State Health System Performance ranked Texas 40th out of the 50 states and the District of Columbia, consistent with its 2014 ranking.  In 2017, the state dropped slightly, to 41st place. The Lone Star state came in last for access, performing at 51st and 48th for uninsured adults and children, respectively. Texas adults placed 50th for the percentage of adults who went without care in the past year due to cost (18 percent). But the state scored well in terms of relatively low rates of smoking, suicide, and tooth loss due to dental decay.

If Texas were to improve to the level of the best-performing state, more than 3 million adults would be insured and more than 2 million fewer adults would go without needed health care because of cost. Review the 2017 Texas scorecard for more details on where the state’s health system succeeds and where it could use the most improvement.

In the 2016 version of America’s Health Rankings, Texas placed 33rd overall. For many years, the state has placed poorly in Policy measures, repeatedly ranking 50th for its high percentage of uninsured. According to US Census data, Texas had the highest uninsured rate in the country in 2013 (22.1 percent), and still had the highest uninsured rate in 2015, at 17.1 percent.

Trust for America’s Health provides another look at overall public health in Texas in their 2016 listing of Key Health Data About Texas, which includes information on specific diseases and health outcome predictors. Since the 2009 report, Texas has ranked No. 1 for the number of uninsured adults. However, in that time, the percentage of uninsured adults has dropped from 24.5 to 19.1. The state ranks second for the number of children under age 18 who are uninsured (11 percent).

The Robert Wood Johnson Foundation has also compiled health factors and outcomes data in Texas on a county level. The state’s uninsured population is as low as 16 percent in its best-performing county for this health factor and as high as 39 percent in its worst-performing county. You can use this interactive map to see how the counties in Texas compare with one another.

Has the ACA helped Texans?

Before the ACA was implemented, according to US Census data, Texas had the highest uninsured rate in the country in 2013 (22.1 percent). It’s gone down since then, but Texas still had the highest uninsured rate in 2015, at 17.1 percent.

According to Census data, 1 in 5 uninsured U.S. children live in Texas; only Alaska fared worse. However, Texas officials have stated that they are pushing to reach more families who may be eligible to apply for the state’s Medicaid and Children’s Health Insurance Program.

Texas leaders have been vocally opposed to the ACA, and the state has thus far refused to expand Medicaid, so a cornerstone of the law’s ability to reduce the uninsured rate is unavailable in Texas. Of the 2.6 million people who are in the coverage gap in 18 states that have refused Medicaid expansion, Texas has by far the largest share, with 684,000 people unable to realistically access any health coverage at all.

Rates and carriers for 2017 Obamacare plans

Entering 2017 open enrollment, Texans saw higher health insurance rates and fewer options, as was the case for consumers nationwide. UnitedHealthcare, Aetna, Scott & White, Cigna and Allegian all ceased to offer individual health plans through the Texas exchange, leaving 10 exchange carriers remaining for 2017. The remaining carriers offering plans through Texas’ federally facilitated exchange and their approved average rate increases are as follows:

  • AmBetter (Celtic) – 15.38 percent
  • Blue Cross Blue Shield of Texas – 44 to 48 percent, depending on the plan
  • CHRISTUS Health – 17 to 30 percent, depending on the plan
  • Community Health Choice – 21 percent
  • FirstCare (SHA) – 48.45 percent
  • Humana – 45.35 percent
  • IdealCare (Sendero) – 28.9 percent
  • Molina – 10.3 percent
  • Oscar – 17 to 25 percent, depending on the plan; coverage area is being reduced, and plans will not be available in the Dallas area in 2017
  • Prominence Health First – 31.2 percent

While these rate increases were substantial, premium subsidies increased to offset these increases for eligible enrollees. 83 percent of Texas exchange enrollees are receiving premium subsidies that reduce their average 2017 premiums from $404/month to just $130/month.

Humana will exit the individual market in all of their remaining states, including Texas, at the end of 2017. So far, no other insurers have indicated plans to leave the exchange for 2018.

Texas enrollment in qualified health plans

Texas went into the 2014 open enrollment with a much larger uninsured population and pool of potential exchange enrollees than most states. In November 2013, the Kaiser Family Foundation estimated that 3,143,000 Texas residents were potential exchange customers, and that 2,049,000 of them would qualify for premium subsidies.

By mid-April 2014, when the first open enrollment period ended, 733,757 Texans had finalized their enrollment in qualified health plans through the exchange, and HHS reported that 84 percent of them had their premiums reduced with subsidies.

At the end of 2016 open enrollment, more than 1.3 million Texans had selected a qualified health insurance plan through HealthCare.gov. At the end of the first quarter of 2016, effectuated enrollment was 13 percent higher than it was in 2015. Marketing efforts by the Texas Hospital Association have been given credit for this improvement.

Enrollment declined slightly in 2017, but there were still 1,227,290 enrollees in private plans through the Texas exchange by January 31, 2017.

Obamacare in the Lone Star State

In 2010, Texas’s U.S. Sens., John Cornyn and Kay Hutchison, Republicans, both voted no on the ACA. In the U.S. House, 20 Republican representatives from Texas voted no, while 12 Democrats voted yes. Ted Cruz has since replaced Hutchison in the Senate, and is one of the country’s most outspoken opponents of the ACA. In the House, representatives from Texas currently include 11 Democrats and 25 Republicans.

Former Texas Gov. Rick Perry was also staunchly opposed to the ACA and had a state legislature with a strong Republican majority. The state opted to let HHS run the exchange, has refused to expand Medicaid, and has even worked to make it more difficult for navigators to do their job in Texas.

In January 2015, Greg Abbott took office as Texas’ governor. He has voiced his opposition to expanding the current Medicaid system. However, he would like to see Texas use federal Medicaid funds in the form of block grants, but the Obama Administration opposed that possibility with other governors. It’s much more likely that the Trump Administration would approve, although a lot is up in the air in terms of the future of the ACA under the Trump Administration and a Republican Congress. The AHCA, as passed by the House, would convert all federal Medicaid funding to block grants or per-capita allotments, but it would also prevent any additional states from expanding Medicaid, and would roll back the enhanced federal funding for new Medicaid expansion enrollees after 2019 in states that have already expanded Medicaid.

Texas Medicaid/CHIP enrollment

The ACA would have expanded Medicaid to cover all legal residents in Texas with incomes up to 138 percent of the federal poverty level, but a Supreme Court ruling in 2012 allowed states to opt out of Medicaid expansion. As stated above, Texas remains among the states who declined to expand Medicaid under the healthcare reform law.

Texas is currently one of 19 states that has not yet expanded Medicaid and has no pending plans to do so. Researchers at New York University estimate that if the state has still not expanded Medicaid by 2022, Texas will be forfeiting $9.6 billion in federal funds that year (the state’s portion of Medicaid expansion in 2022 would be just $1.2 billion – federal funding for Medicaid expansion will always cover at least 90 percent of the cost of covering people newly eligible based on Medicaid expansion).

Because the state refused to expand Medicaid, Texas has 684,000 people in the coverage gap, with no access to financial assistance with their health insurance. This is far more than any other state that has not expanded Medicaid – the next highest is Florida, with about 467,000 people.

These residents would be eligible for Medicaid if the state were to accept federal funds to expand coverage. But for now, there is no financial assistance available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing stringent guidelines.

Between 2013 and March 2017, Texas’ existing Medicaid/CHIP program saw an increase of about 7 percent, despite the very strict eligibility guidelines that the state uses: Non-disabled adults without dependent children are ineligible regardless of income, and parents with dependent children are only eligible if their household income doesn’t exceed 15 percent of poverty (less than about $3,000 annually for a family of three). Medicaid and CHIP enrollment is open year-round.

Medicare in the state of Texas

Texas Medicare beneficiaries make up 13 percent of the Lone Star State’s total population, compared with 17 percent of the U.S. population enrolled in Medicare.

Of these enrollees, 84 percent qualify based on age and 16 percent qualify based on disability. The state spends about $10,549 annually per recipient – 18 percent more than the national average of $8,970 per recipient.

Texans who qualify for Medicare can select Medicare Advantage plans instead of Original Medicare as a way to gain more health benefits. In 2015, about 31 percent of Texas Medicare recipients selected a Medicare Advantage plan instead of traditional Medicare, consistent with the national average

Additionally, 44 percent of Texas Medicare enrollees selected a Medicare Part D stand-alone prescription drug plan.

State-based health reform legislation

Here’s a summary of recent Texas bills related to healthcare reform:

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