Last November, Tiayana Hardy gave birth to her first child, a baby girl named Laylani.
“She came a week before her due date, but I can’t complain about that,” said Hardy. “She was born healthy, she’s an easy baby, and motherhood is amazing.”
But Hardy has concerns about her future. She is still experiencing bleeding related to the delivery as well as continuing postpartum anxiety. And now the Garland resident is about to lose the Medicaid coverage that got her through her pregnancy.
Hardy is far from alone. An estimated 2.7 million Texans—mostly children and new moms— are at risk of losing their Medicaid insurance in the next few months, some as early as June. That’s almost half of all Texans now on the Medicaid rolls. Most of those affected had had their earlier coverage extended by the public health declaration that came during the COVID-19 pandemic. The declaration expires at the end of March.
Now the state must begin a federally mandated review of its entire 5.9 million-member Medicaid caseload. Texans who no longer qualify will lose their coverage, but so could current eligible recipients who fail to complete required paperwork for recertification.
“Advocates are very, very concerned right now,” said Jana Eubank, CEO of the Texas Association of Community Health Centers. “Families aren’t even going to know what’s going on, and they’re just going to lose coverage and show up at a doctor or a health center, and they’re going to be told, ‘Oh, you’re not on Medicaid anymore.’”
“Families aren’t even going to know what’s going on. They’re just going to show up at a doctor and they’re going to be told, ‘Oh, you’re not on Medicaid anymore.’”
For over a year, public health advocates have raised concerns about Texas Health and Human Services’ (HHSC) ability to handle this recertification process, which begins April 1 and is expected to be finished within 12 months. State officials are apparently worried, too: HHSC recently requested an additional $143 million to cover more staff to process the approaching onslaught.
“It’s probably the largest enrollment event, if not the largest enrollment event since the ACA [federal Affordable Care Act],” Eubank said.
Medicaid, a federal entitlement program administered by states, provides health insurance for low-income residents who cannot afford private insurance. Nearly half of Texas children depend on the program, as do 51 percent of moms, whose prenatal care and hospital bills are covered.
In this, the most underinsured state in the country, millions of people fall outside of Medicaid coverage due to Texas’ strict eligibility criteria and Republican leaders’ refusal to accept billions of federal dollars to expand the program. The state’s requirements around income eligibility mean the vast majority of working poor Texans make too much to qualify for coverage.
A single mother of two would need to earn less than $4,000 per year to be eligible for Texas Medicaid insurance, while childless adults are ineligible no matter how poor they are. Eligibility requirements ease for single pregnant women, who may make up to $2,243 a month, but that coverage cuts off two months after birth regardless of their care needs.
Despite Republican leaders’ past opposition to any expansion of Medicaid, Texas Speaker of the House Dade Phelan and Governor Greg Abbott both have named postpartum Medicaid expansion as a top priority for this session. But even if it passes, it won’t come soon enough to prevent confusion and distress for low-income families.
Under the national public health emergency initiated by the federal government in March 2020, no Texan who qualified and was enrolled in Medicaid could be dropped from the program. That meant Texas moms like Hardy who would have ordinarily lost their insurance two-months postpartum have been able to maintain their coverage for the duration of the pandemic. The same is true for Texas children who would have aged out of the program.
As a result, the state’s Medicaid rolls grew from 3.5 million before the pandemic to 5.9 million today. Federal dollars provided the financing for this temporary expansion.
But with the public health emergency set to expire, advocates say, families are now scrambling to find new coverage options and navigate a complicated and bureaucratic reenrollment process.
A single mother of two would need to earn less than $4,000 per year to be eligible for Texas Medicaid insurance, while childless adults are ineligible no matter how poor they are.
Of particular concern are the millions of Texas children currently enrolled in Medicaid who could miss prescription refills or have to forgo doctor’s visits if their parents are unable to complete the upcoming recertification process. According to state data, 4.2 million Texas children currently rely on Medicaid to access healthcare, up from 2.8 million prior to the pandemic.
“You’re going to go to your pharmacy to get your prescription renewed and they’re going to say, ‘Oh, you don’t have coverage anymore.’ Or you’re going to take your kids for their scheduled well-child visit to get vaccinations for school. And they’re going to say, ‘Oh, you don’t have coverage.’ That’s when they’re going to find out,” said Diana Forester, who oversees health policy at the children’s advocacy nonprofit Texans Care for Children. The organization recently launched a website to help Texans navigate the end of continuous coverage.
Based on state enrollment data, advocates estimate that as many as 1.4 million Texas children benefited from continuous coverage and may no longer qualify for Medicaid due to changes in their family’s income or because they’ve aged out. Children from low-income families who make too much to qualify for Medicaid, but cannot afford private insurance, may qualify for CHIP, the children’s health insurance plan that provides similar coverage to Medicaid but requires monthly payments and copays.
Still, a family’s ability to enroll their child in a new coverage plan such as CHIP will depend on their knowledge of the upcoming end of continuous coverage and their ability to navigate a complicated bureaucratic process.
“The average person isn’t going to really understand about the public health emergency and what this means for their insurance coverage,” said Eubank, “and there’s a real lack of public information out there about what is about to happen.”
“The sheer number of individuals that they’re going to have to process is so much greater than anything they’ve ever done before,” said Forester.
At its peak before the pandemic, the system recertified 3.5 million applications per year. Today, the agency is short by more than 300 needed employees and is already working through a backlog of about 130,000 new applications from eligible Texans awaiting approval. In February, just over half of new Medicaid applications were processed on time, according to state data.
In an email, an HHSC spokesperson said the agency is considering “strategies to increase our eligibility workforce by conducting job fairs, promoting a nontraditional or flexible work schedule and training noneligibility staff to assist with the workload.”
Even if HHSC were to hire and train 300 new workers in the next month, experts worry that the archaic recertification process will lead to many eligible Texans getting inadvertently kicked out of the program.
On April 1, state workers will start sending out renewal packets via the U.S. mail. Medicaid recipients will then have 30 days to respond, providing documentation of the recipient’s age, address, and household income.
Eubank and others say they’re concerned that thousands of eligible Texans will miss the notice.
“A lot of Medicaid recipients move around a lot. And so in three years, they are likely to have moved on,” said Eubank. “It’s likely that they’re not going to get that notice. They’re not going to get the packet.”
If a family fails to respond to the recertification request, or if their eligibility status has changed, their coverage will be dropped. State officials said they will begin removing Texans from the Medicaid rolls on June 1. If a current Medicaid recipient qualifies for a different state-administered healthcare program, such as the Children’s Health Insurance Program or Healthy Texas Women, they will be transferred.
HHSC is relying on community partners around the state to spread the news of the upcoming deadline.
“It’s definitely going to keep us busy,” said Dora Vazquez, who manages outreach and enrollment at HealthPoint, a network of federally qualified clinics in the Brazos Valley.
Vazquez and her team are organizing in-house enrollment events at their network of community clinics to help clients submit their recertification applications. She hopes the extra effort will prevent her clients from falling into a coverage gap, but she’s worried about those who miss the message.
“It’s a very trying time for the individuals that we serve and we just have to make sure that they know what’s coming,” Vazquez said. “Patients are trying to get in front of it and get it done so there’s not a big backup or delay in care.”
In addition to the millions of Texas kids who could be affected, advocates are concerned about the estimated 300,000 Texas moms who qualified for Medicaid during their pregnancy and who were able to stay enrolled thanks to the public health emergency designation.
Typically, under state law, pregnant Texans who cannot afford private health insurance are eligible for Medicaid for the duration of their pregnancy, plus two months after the baby’s birth. But the program has long been criticized for the staffing shortages that have repeatedly delayed access to that prenatal and postpartum coverage.
Under the public health emergency directive, the issue was temporarily resolved—pregnant Texans enrolled in Medicaid have been able to maintain their coverage. For some, this means they’ve had access to continuous care for nearly three years.
“I just feel like they aren’t giving me enough time to actually get things sorted out post-birth.”
For new moms like Hardy, expanding coverage from two months to 12 would be a huge relief. She was working full time at a Dallas pawn shop last year when she found out she was pregnant. She didn’t qualify for health insurance through her job and couldn’t afford private coverage.
Fortunately, she was able to enroll in pregnancy Medicaid and has benefited from extended coverage since then. “I do get worried because if something is serious and I need to go to see the doctor, I can’t do that because I won’t have insurance. I would have to pay for it, which is kind of crazy with a newborn,” said Hardy, “I just feel like they aren’t giving me enough time to actually get things sorted out post-birth.”
Advocates say that expanding Medicaid would help curb the state’s high rate of maternal mortality and morbidity, by ensuring that new moms maintain access to their doctors, specialists, and prescriptions. In Texas, rates of severe pregnancy complications continue to rise and racial disparities in maternal health persist. Black Texans are twice as likely to die from childbirth as white Texans.
Continuous coverage during the federal public health emergency provided a window into what that postpartum expansion could look like.
“This was essentially a form of Medicaid expansion that the state has contemplated but continued to deny for many, many years,” said Jason Wallace, Chief Operations Officer at HHM Health, a community health center in Dallas. The results of continuous coverage, Wallace said, are healthier patients who are taking a more active role in their health.
Eubank agreed. “We have seen patients be much more active in their own health and more willing to come in and do preventative care and primary care that’s keeping them healthier,” said Eubank, who represents a state-wide network of community health clinics. “When you have insurance, you’re more likely to go in and access primary care, go ahead and get that mammogram, go ahead and get your birth control renewed. You generally take better care of yourself.”
