Medicaid in Texas covers close to , everyone from cancer patients to pregnant people to kids across the state. That coverage means people have access to doctor鈥檚 appointments, hospital visits, nursing facilities and birth centers, without having to worry about the cost of care, according to the .
But 13 years after the expanded Medicaid, Texas is now that has yet to adopt it.
Almost shows , and about would be eligible. So why hasn't Texas expanded Medicaid?
Impact on health outcomes
Adam Searing, , has been working on Medicaid issues at the university since 2014. He said it鈥檚 one of the 鈥渕ost studied health policy issues in history鈥� because of the stark differences between states that have expanded coverage and states that have not.
鈥淭he idea with Medicaid [is] that the people who are really in the lowest income category can still be able to get decent health coverage, and that has lots of good implications for them and for their ability to work,鈥� Searing said.
Research shows the impact of Medicaid expansion is widespread: People have better ; teens have , which reduces their chances of unintended pregnancy; pregnant people have access to , which contributes to lower maternal mortality and morbidity rates; and children who age out of the Children鈥檚 Health Insurance Program (CHIP) are .
鈥淏y and large, there are just huge benefits to people who get coverage,鈥� Searing said. 鈥淗ealth is a building block for a lot of success, whether it's in work, family, society, your job.鈥�
Beyond health impacts, people in states that have expanded Medicaid experience less financial pressure. For example, showed lower rates of evictions in counties with Medicaid expansion.
鈥淲hen you expand Medicaid, the increase in financial security for many families goes up significantly,鈥� Searing said. 鈥淭hat means they can make their car payments. They can pay their rent. They can continue to go to the restaurant down the street or buy toys for their kids at the local toy store.
鈥淪o, there are all these ripple effects in the economy, too.鈥�
Reasons states haven鈥檛 expanded Medicaid
Historically, Searing said, arguments against Medicaid expansion fall into two categories: differences in political ideology, and not wanting to grow an already broken system.
鈥淢any legislators in the states that haven鈥檛 expanded say, 鈥榃ell, we just don't feel that the government should be in the in the business of helping provide health coverage for folks, they should get it through their work,鈥欌�� Searing said. 鈥淎nd I've heard legislators say, 鈥榃ell, our Medicaid system is a government system, it doesn't work very well. And we don't think it can take more people being in the system.鈥欌��
The eligibility requirements for Texans under Medicaid are some of the strictest in the United States: For parents and caretakers of kids who are covered by Medicaid, a family of four with two parents has to make at or below to be eligible. In comparison, the same family in Tennessee can and the caregivers can still qualify for Medicaid coverage.
Adults in Texas who aren鈥檛 caregivers, pregnant, have a disability or are 65 years or older . They can access insurance through the Affordable Care Act marketplace, but they must make above the federal poverty income level.
According to the advocacy and policy organization , 鈥渢his leaves most working-poor Texas adults uninsured, because [the] state鈥檚 Medicaid program is closed to them, and they cannot get sliding-scale ACA coverage[,] either.鈥�
Texas Republicans have opposed Medicaid expansion for years. Back in 2015, Gov. Greg Abbott said writing in a news release that the program is 鈥渁lready broken and bloated.鈥� Beto O鈥橰ourke, who ran for governor against Abbott in 2022, made Abbott鈥檚 refusal to expand Medicaid a .
Most Texans support Medicaid expansion
But most Texans support wider access to health care coverage. A 2020 poll by the Episcopal Health Foundation showed nearly seven in 10 Texans
鈥淭exas is a state that has the largest number of people who would benefit from expansion,鈥� Searing said. 鈥淲hen you get down to ordinary people who are trying to live their lives, they are generally very supportive of expansion, regardless of what side of the political spectrum they're on. So, we really need to focus on the leadership in the states that haven't expanded. And political leadership is where the roadblocks are.鈥�
He points to North Carolina as an example of despite the fact that 鈥渇or much of the past decade, Republican legislative leaders opposed expanding the Medicaid program to more than 600,000 new recipients.鈥�
Searing said he 鈥渢ook a lot of hope鈥� from seeing previous opponents of expansion discuss the benefits to people like young mothers, students and uninsured children.
If lawmakers in North Carolina, a state with a Democratic governor but 鈥渧ery, very conservative leadership in the state legislature鈥� could change their minds about Medicaid expansion, Searing said other states can, too.
鈥淓ven in states like Texas, that have a lot of ideological opposition still, there is this potential for change,鈥� he said. 鈥淎nd I hope eventually that will happen. I think it will.鈥�
Impact of not expanding Medicaid on accessing health services
Kailey Horne, a recent graduate who lives outside Houston, knows firsthand the impact of not having insurance. She was on Medicaid as a kid, but lost it when she aged out. She qualified for Medicaid again when she was pregnant, but lost it a few months after she gave birth to her son.
鈥淚t just became a cycle of not being able to go to the doctor,鈥� Horne said.
In her twenties, she started having seizures and , where she had trouble understanding people and responding to them.
鈥淚 went probably like three or four years just getting worse,鈥� Horne said. 鈥淚 knew I needed to go to doctor and figure out what was wrong, but I just didn't have the means to do so.鈥�
Horne made too much money to qualify for Medicaid at the time but didn鈥檛 make enough to afford a plan through the insurance marketplace.
In early 2022, she had a when she was out at the movies. She fainted and was taken to the hospital, where she was finally diagnosed with epilepsy. She applied for Medicaid again, even though she鈥檇 been denied after her pregnancy, because she wasn鈥檛 sure how she was going to pay for the cost of her medication or visits to specialists.
鈥淭his time, whenever I applied, it felt a lot more serious,鈥� she said. 鈥淭his was a very stressful time for me. My life had completely changed. I needed the insurance. It was just this piece of hope that I was holding on to鈥攎aybe I can finally get some help if they would just reply to me.鈥�
After a few months of waiting, she was approved. But the whole process made her feel like 鈥渁 pawn in the health care system, to learn how to navigate all of this stuff when at the same time trying to deal with the life changes that I was having.鈥�
Horne often wonders what her life would have been like if she could have accessed health insurance after her pregnancy, or when she started experiencing seizures for the first time.
鈥淢y struggle to get good insurance and to find providers that will accept it, in a way it's prolonged my recovery, prolonged my success with epilepsy treatment,鈥� she said.
If she could talk to lawmakers, she would encourage them to expand access to Medicaid.
鈥淭here are a lot of people in the same gap that I was in,鈥� Horne said. 鈥淚 was working, and I was bringing in money, but apparently it was too much to qualify for Medicaid. I was also going to school, so I wasn't able to work full time to qualify for insurance. The eligibility needs to change.鈥�
鈥淚t's a human issue.鈥�
State Rep. , co-authored a Medicaid expansion bill in 2021 to try to close this coverage gap in Texas. House Bill would have established the 鈥淟ive Well Texas鈥� program, expanding Medicaid access to adults and offering job training and financial assistance.
鈥淗ealth care is not a Republican or Democratic issue,鈥� Johnson said. 鈥淚t's a human issue.鈥�
But in Texas, much like other states, support for Medicaid expansion falls along party lines 鈥� Democrats for, Republicans against. Johnson said she and her Senate colleague, Sen. , spoke with Republicans to try to 鈥渕ove the needle鈥� on Medicaid expansion when they first introduced the bill in 2021.
鈥淭here's a lot of Republicans who represent rural Texas whose hospitals are closing,鈥� Johnson said. 鈥淭hey have constituents that have to drive three, four hours to get to the nearest emergency room. They understand the significance of Medicaid expansion to their districts.鈥�
From 2013 to 2020, Texas had the most rural hospital closures in the country, according to by the U.S. Government Accountability Office. The report found that over time, doctors continued to leave areas with hospital closures, giving people even fewer options for care.
Medicaid expansion alleviates some of the reasons for closures by improving 鈥渉ospital finances by extending coverage to uninsured patients who would otherwise qualify for hospital charity care or be unable to pay their bills,鈥� .
Ultimately, , but the bill failed to pass either chamber. This year, Johnson鈥檚 鈥淟ive Well Texas鈥� bill didn鈥檛 make it out of committee. She said it鈥檚 mystifying to her why, with so much evidence on the benefits of Medicaid expansion, Republicans refuse to support it.
鈥淚t absolutely makes no sense,鈥� Johnson said. 鈥淭his is politics. This is an uninformed, far-right Republican base, making a policy decision that is not based in truth, but it's based in myth, and an inaccurate belief structure.鈥�
The state and future of Medicaid in Texas
Policy groups and health associations have long been discussing the benefits of expanding Medicaid in Texas, but the discussion took on new meaning in 2023 as hundreds of thousands of people lost the coverage they had for three years under the federal COVID-19 public health emergency declared in 2020. Continuous Medicaid enrollment under this provision ended March 31.
The groups impacted most likely include kids 19 or older who aged out of the program, new parents, and kids whose families have made more money than the monthly requirements.
But it鈥檚 hard to tell exactly who鈥檚 been impacted, said Stacey Pogue of the , because states aren鈥檛 required to submit demographic data to the federal Centers for Medicare and Medicaid Services (CMS). Pogue spoke during a press conference in early August on the impact of Medicaid unwinding thus far in Texas.
Before continuous enrollment, pregnant people who recently gave birth would lose Medicaid coverage after two months, which led to higher rates of maternal mortality and morbidity. This year, Texas lawmakers passed HB 12 extending coverage to 12 months postpartum. The law goes into effect Sept. 1.
But Pogue said Texas still must submit a plan to CMS, and have the plan approved before people can access extended coverage.
鈥淲hat that means is new [parents] anywhere from two to 11 months postpartum are going to start losing coverage in September and October during unwinding, despite HB 12,鈥� she said.
New parents have limited coverage options beyond a year since Texas has not expanded Medicaid.
According to data from the Texas Health and Human Services Commission, , more than 785,000 people who previously had coverage either were now ineligible, their applications were denied, or they had incomplete applications.
, an advocacy and policy organization, that 鈥渢he high percentage of procedural denials should be setting off alarm bells.鈥�
鈥淲hen you see this many procedural denials, it means that the process is not working properly, whether the state is sending renewal information to the wrong mailing addresses or parents are running into bureaucratic delays with the state when they try to renew their children鈥檚 health insurance,鈥� said Diana Forester, the director of health policy at the organization.
Since Aug. 1, about 3.8 million people have been disenrolled from Medicaid nationally, according to analysis by the . Texas has the largest number of people disenrolled in the country, said Pogue, and it鈥檚 only going to get worse as time goes on.
鈥淭he problems with eligible folks losing coverage are huge,鈥� she said. 鈥淲e need the governor to ensure no eligible [person] loses coverage on his watch.鈥�
For Rep. Johnson, now is the time to consider Medicaid expansion. She says it鈥檚 about giving more people the chance to live a healthy life.
鈥淲hen the person you love most on this earth鈥攜our child, your parent, your spouse鈥攏eeds health care and can't get it, that is very, very frustrating, sad, emotional, and heartbreaking,鈥� Johnson said. 鈥淲e as a state can do better by our residents, by the people of Texas. Our elected leaders need to step up to the plate and pass Medicaid expansion.鈥�
Got a tip? Email Elena Rivera at erivera@kera.org. You can follow Elena on Twitter .
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