People without insurance coverage often end at emergency rooms when they have medical issues — the priciest place for them to end up. Credit: Shutterstock / hxdbzxy

On a stifling August day, hundreds turned up to an event at the San Antonio Food Bank’s pavilion, a place usually associated with feeding the community. Instead, it was full of people hungry for information on getting health insurance coverage on paychecks that rarely even cover their basic needs.

For many, especially those with chronic conditions, insurance and access to regular medical care outside of the ER are a matter of life and death, rather than a political football that’s been punted away by Texas’ state leadership for decades.

Under the pavilion, Chelsea Martinez worked on an application with a state Health and Human Services representatives to see if she qualified for Medicaid coverage after struggling with online signup for the program. The South Side mother had coverage while pregnant with her third child but fell off the rolls when her short post-partum coverage ended. Around the same time, the pandemic-era automatic re-enrollment into the insurance program also came to a halt.

“I haven’t had Medicaid in a few months, so I just try to do everything at home,” said Martinez, 28. That includes trying to cope with a diagnosis of anxiety while taking care of three children, including two with special health needs.

During the first few months of the year, she scheduled as many appointments as she could to take care of her health needs.

“I was scared they were going to cut me off so quick,” she said.

Texas’ process of “unwinding” Medicaid after three years of automatic re-enrollment during the pandemic left many dropped from the program and back in the Medicaid gap, even though they could still be eligible. Martinez said no one told her that a new state law that went into effect this spring would have extended her post-partum coverage up to a full year after the birth of her youngest, now 10 months old.

Even though Martinez is stretching a meager income that primarily consists of $800 in monthly child-support for her 8 year old, she still had an anxious wait ahead to see if she could enroll again.

Otherwise, she would fall into the so-called “Medicaid Gap” that accounts for more than 1.4 million of Texas’ 5.2 million uninsured. The makes Texas the most uninsured U.S. state, according to numerous rankings.

Texas Republicans, particularly those in leadership roles, continue to successfully run for reelection on red-meat issues that include saying no to additional publicly funded healthcare. Texas is one of 10 states, mostly in the South, which have turned down Medicaid expansion funds from the federal government. That’s not been an oversight by Lone Star State leaders but a deliberate choice by Gov. Greg Abbott, a Republican, and the GOP-dominated Texas Legislature.

As a result, the state is turning its back on $5.4 billion a year in federal dollars to fund an expansion that would offer medical coverage to far more residents. The state’s portion would run less than $600 million annually.

Attempts by Democratic lawmakers and even some House Republicans to get their colleagues, Gov. Greg Abbott and Lt. Gov. Dan Patrick to undertake an expansion have so far gone nowhere.

“We have so many working adults who have no insurance,” said Christine Yanas, vice president of policy and advocacy for San Antonio-base Methodist Healthcare Ministries. “It’s a philosophy of healthcare as a right or a privilege and that’s the sticking point.”

‘Dying in childbirth’

The stakes are high.

Advocates for better indigent healthcare and expanded coverage for the working poor say too many people without coverage, especially men, will put off getting care or not seek out services even as their untreated conditions become more perilous.

Also, some pregnant women who would normally qualify for Medicaid during their pregnancy lost coverage when the automatic re-enrollment offered during the past three years ended in April.

“Women of color are dying in childbirth,” Yanas said of those disproportionately affected by losses of coverage that can drag on for months.

Texas’ refusal to expand Medicaid and stave off unnecessary death and illness is infuriating to advocates because there’s no downside.

“This [resistance] is very much a product of first Gov. [Rick] Perry and then Gov. [Greg] Abbott presenting as conservative a face as they possibly can,” said Anne Dunkelberg, a senior fellow for health policy at Every Texan, formerly known as the Center for Public Policy Priorities.

Meanwhile, down-ballot candidates have adopted the same “ultra-conservative talking points that public [spending] for health care is bad,” she said. “We have a governor who doesn’t want to take billions and billions and billions in federal dollars.”

That refusal comes even though studies show that Medicaid expansion would reduce local and state government costs of caring for the indigent, incentivize work, create jobs in the health care sector and grow the economy.

Another benefit is that it would create a more productive workforce for the private sector, Dunkelberg said. Improved coverage would reduce complications from chronic conditions for aging workers too young to qualify for Medicare, allowing them to stay in the workforce longer.

Chelsea Martinez is struggling to find coverage as she takes care of three kids, two of whom have special needs. Credit: Travis Poling

Working without coverage

For parents to qualify for Medicaid, a family of three must earn less than $3,977 annually, or about $331 a month. Even at the federal minimum wage of $7.25 per hour, families would lose coverage starting at just 47 hours of work in a given month. Adults under 65 with no children in Texas are completely on their own even with no income.

Even a raise in a part-time job from an employer that doesn’t provide commercial health insurance can shove a working parent out of Medicaid eligibility and make their financial circumstances worse.

The coverage gap faced by 1.4 million Texans arose after the passage of the Affordable Care Act, popularly known as Obamacare.

The ACA created a sliding scale of subsidies allowing Americans to purchase coverage through health insurance companies participating in exchanges. The subsidies are generous for those with incomes starting at 138% of the federal poverty level.

The law required states to expand Medicaid eligibility up to 138% of the poverty level. Above that, individuals can qualify for a subsidized health plan.

However, a U.S. Supreme Court ruling in 2012 shot down the expansion requirement, allowing Texas to maintain the status quo.

The resulting coverage gap in Texas starts at 16% of the federal poverty level, the lowest threshold in the country for adult parents to qualify for Medicaid. Adults not raising children and parents over the Medicaid threshold can buy individual ACA insurance, but they have to pay full price because they make too little for federal subsidies.

Alamo City resident Jay Nanda has spent more than a year without coverage after falling into the gap.

Nanda is single and works three driving jobs, including a 40-hour-a-week position as an airport shuttle driver for the City of San Antonio. But because he is considered a temporary worker on the payroll, he doesn’t get any of the benefits that usually come with a full-time position — including health insurance.

The 52-year-old has been without benefits since May 2022 and the COBRA laws that would have let him pay to continue the group insurance from his previous employer would have set him back $700 a month. Even with three jobs, he remains firmly in the coverage gap and has no time to go insurance shopping.

“I’ve put off my eye exam twice now after seeing how much they wanted to charge [for the visit] with no insurance,” Nanda said. “Now it has increased and is a minimum of $179 without insurance.”

Rural hospitals struggling

Texas lawmakers justify their refusal to expand Medicaid by saying they’re being fiscally conservative and protecting taxpayer dollars. Even so, someone’s still picking up the bill to provide medical access for some of those who have fallen through the cracks. Right now, that’s happening through a combination of local taxes, other state-funded programs and nonprofits that receive federal grants.

“Indigent healthcare is not a state responsibility under the Texas Constitution. It is a county responsibility. So you have 254 ways to deal with the problem,” said George Hernandez, president and CEO of University Health in San Antonio.

He characterizes the Texas County Indigent Health Care Program as broken one, saying it doesn’t work equally well around the state.

Even though they have plenty of uninsured residents, rural counties are hamstrung on multiple fronts as they try to raise money to take care of that population. Typically, those counties are forced to have higher property tax rates — often as high as 61 cents per $100 of valuation — for health services. In part, that’s because much of the land has an agricultural exemption and doesn’t generate revenue for a rural hospital district.

In contrast, University Health, Bexar County’s hospital district, has a tax rate of 27 cents per $100 of valuation. That makes up about 18% of the revenue, while the rest comes from sources including state and federal insurance programs and commercial insurance, according to Hernandez.

Because Bexar is surrounded by rural communities, University Health racked up $30.5 million in uncompensated costs during 2021 by caring for patients who came in from contiguous counties and those closer to the border, such as Maverick, Val Verde and Webb.

On top of that, University Health also provided another $5.1 million in uncompensated care to residents from other states.

Medicaid expansion would be as much a boon to rural counties as urban areas, and it also could make the difference in some rural hospitals staying open, said John Henderson, CEO of the Texas Organization of Rural & Community Hospitals (TORCH).

Rural health systems can’t access enough tax dollars to provide a wide variety of services closer to home or to take on a heavy load of uncompensated care, Henderson said. Since 2010, Texas has faced 26 temporary or permanent rural hospital closures, according to TORCH data. Another 76 facilities are considered to be in crisis and at risk of closing.

Elysse Adkins speaks to a Texas Health and Human Services advisor about her health coverage options at a San Antonio Food Bank event organized as Texas began dumping people from its Medicaid rolls. Credit: Travis Poling

Some help available

Those who cannot pay for medical services, including many in the Medicaid gap, are considered indigent under Texas law.

Under the state standard, indigent care is available for people who make too much for Medicaid eligibility. For a family of three that means a household income of more than $3,977 and less than $5,220 a year.

University Health’s Hernandez said rural counties are allowed to bring eligibility up to 50% of the poverty level and not lose state assistance. Urban districts, however, can go up to 200% of poverty to provide health care services, even including access to a regular doctor.

That provides options to Bexar County residents making up to $49,720 in a three-person household.

The primary way of delivering medical services to the uninsured is a University Health program called CareLink. It isn’t insurance, but it makes getting medical services more affordable.

CareLink patients can access University Health providers, pharmacy services, health and wellness programs and discounts. Having a so-called “medical home” helps them manage chronic conditions, and it promotes preventative care.

It also keeps people out of hospital emergency rooms. Even though ERs should be a last resort, they remain the place where many uninsured end up receiving their health care.

Payments for CareLink services are based on income. Hernandez said CareLink members with incomes of less than 75% of the poverty level are asked to make some sort of payment and about half do, even though it isn’t a requirement.

Above that level, patients make payments on a sliding scale and can work out monthly installments. For those with incomes above 150% of the poverty level, CareLink takes payments electronically from their bank accounts.

“CareLink has personal responsibility built into it,” something even some conservative politicians say they like, Hernandez said.

University Health also contracts with community health organizations such as CommuniCare and CentroMed to provide indigent care through clinics they operate around the county.

Paul Nguyen, president and CEO of CommuniCare, said most uninsured patients who come to his organization aren’t looking for a handout. The sliding scale of payments from patients lets CommuniCare stretch $10 million in federal, state and other grants into $13 million in care.

“We see patients who are uninsured and want to pay. It’s a point of pride,” Nguyen said.

Most CommuniCare patients are women between the ages of 25 and 54, he added.

“Men don’t go [if they are uninsured], and if they are truly sick, they end up in the ER,” Nguyen said. “If they do come to us, it’s because their wives or girlfriends made them go.”

About half of CommuniCare’s 114,000 patients are covered by Medicaid, and having access to the insurance benefits means most of them have managed their health care fairly well, he said.

However, obtaining medical care is not so easy for the uninsured. About one in five have challenges that keep them from obtaining care, such as a lack of transportation or not having enough money to afford medications that they’re prescribed.

Those barriers often culminate in worsening conditions and trips to the ER — the most expensive place in a health care system to seek help, according to Nguyen.

“It is 20% of the non-compliant patients that make up 60% of the cost,” he said. “They’re struggling already, then they get sick and have a medical bill. It’s a bad cycle.”

Expanding Medicaid in Texas would go a long way toward solving the problem and ultimately reducing overall health care costs, Nguyen said.

Texas still pays

In addition to state money going to counties for indigent care, Texas taxpayer dollars also fund partnerships with nonprofits find help for those who fall into the Medicaid gap.

One such initiative in partnership with Feeding Texas is the Referral Partner Program, which is doing needs assessments for thousands of Texans through 19 member food banks around the state, including the San Antonio Food Bank.

A referral specialist does a needs assessment with the individual client or family to include food, health care, energy bills, transportation and other basic necessities to get by, said Theresa Pennell, a program manager at Feeding Texas.

The specialist then does quarterly check ins for a year to see if needs have changed with the loss of a job or other life event and to find out if needed assistance was obtained.

The three-year-old program is a still largely unknown resource and navigators are finding more people to send their way.

“It’s been a great collaboration with the state, and we have the capacity for more,” Pennell said.

If Oklahoma can do it…

Like Texas’ state government, Oklahoma’s Republican-controlled legislature and state leadership dodged covering the working poor for years.

However, voters had other plans. In July 2020, a statewide referendum passed with a slim majority and extended health coverage to an additional 200,000 adults in the state.

Before its passage, Oklahoma had about 800,000 children, pregnant women, people with disabilities and elderly residents covered by Medicaid.

The referendum closed the gap and made a single adult eligible for insurance if they made less than about $17,800 a year. For a family of four, eligibility kicks in at less than $36,588 a year.

The measure passed with 50.49% of the vote, with those voting “yes” coming primarily from urban counties, including those where Oklahoma City and Tulsa are located. While the state’s rural hospitals said Medicaid expansion would help save them from going under or slashing services, voters in rural counties largely opposed the change, The Oklahoman reported.

Angered by the defeat, GOP legislators quickly passed two bills to hamstring future progressive ballot initiatives, including one that would force an automatic recount if the majority vote came in at less than half a percent. The recount is also now automatic for a close vote within 1% percent if a constitutional amendment is involved. The second measure required future petitions for certain ballot initiatives to include a fiscal impact statement.

Oklahoma’s share of the expansion is an anticipated $164 million a year and the federal government kicks in the other 90%.

But Texas voters won’t get the chance that citizens of Oklahoma and four other states did to expand Medicaid by bypassing naysayers in Republican-controlled legislatures.

For propositions to make it to the statewide ballot in Texas, including constitutional amendments, they must start in the legislature with a joint resolution in the state House and Senate. If the resolution receives a vote of at least two-thirds in both chambers, then voters will get their say come election day.

There’s no provision in state law that allows initiatives that originate directly from citizens to get on the ballot.

Indeed, Republicans have controlled both Texas houses and the governor’s office for 21 years and aren’t likely to risk voters calling the shots on issues such as health care for the working poor, education funding or legalizing recreational marijuana.

State Sen. Nathan Johnson, D-Dallas, sponsored a bill during this year’s legislative session that would give voters a path to generate ballot initiatives, but it never cleared committee.

Johnson also was behind recent bills that would allow Texas to narrow the Medicaid gap. His bill to create the “Texas Live Well” program would use a waiver from the federal government to expand Medicaid but do so in a way that would be more acceptable to Republican lawmakers.

None of those proposals advanced during the most recent legislative session.

Uninsured people attend a San Antonio Food Bank event aimed at helping them see if they qualify for Medicaid coverage. Credit: Travis Poling

Any way forward?

One incremental step forward in expansion — and a step years in the making — is the state’s recent extension of post-partum Medicaid eligibility for mothers from 60 days after birth to a full year.

House Bill 12, introduced during the most recent legislative session by State Rep. Toni Rose, D-Dallas, had the support of House Speaker Dade Phelan and several other prominent Republicans in that legislative body. Phelan made HB 12 a priority, and “that was a turning point,” said Yanas of Methodist Healthcare Ministries.

A previous version of the bill passed in 2021, but it was a compromise to extend benefits for the mother to six months after birth. The Centers for Medicare and Medicaid Services turned it down because the language of the new law wasn’t in compliance with federal guidelines.

“They were pushing 12 months at the federal level very hard, and it costs the state almost nothing,” Yanas said of the 2021 bill.

A fiscal note attached to the 2023 bill estimated that the extension would cost the state about $117 million in the first year and $80 million in subsequent years.

College student Elysse Adkins isn’t sure what her future holds when it comes to health insurance. At 24 she has two years of coverage left under her parents’ health plan. At 26, she expects she will still be a finance student at St. Mary’s University where she started this fall.

Having left her full-time job at an East Side nonprofit to go to school full time, she attended the Texas Health and Human Services Commission event at the San Antonio Food Bank. Her intent was to apply for SNAP, the Supplemental Nutrition Assistance Program once known as “food stamps.”

“I’m working part time, and everything goes to rent,” Adkins said.

Adkins isn’t sure where the money will come from in two years to add a monthly health insurance premium to her living expenses. Having a part-time job and no dependent children both disqualify her for Medicaid.

“It’s been a major concern just like the economy and the job market,” she said.

Advocates for Medicaid expansion aren’t sure how to get lawmakers to provide Adkins or other Texans facing the gap with the same federally funded benefits enjoyed by residents of 40 other states. At least not without a major shift in conservative talking points.

Advocacy groups are now making their case directly to Texans whose lives and livelihoods are at stake without Medicaid expansion. Those pushing for the expansion hope those voices will make their way to Texas’ statewide elected officials and the House and Senate majorities.

Nothing else appears to have worked.

“We said, ‘Here are the facts.’ That didn’t help. Then it was, ‘Here’s the data.’ That didn’t help.” Yanas said. “Now we’re trying to tell the human stories. It’s about civic engagement. You can’t just play defense like we’ve done for the last 20 years — because we’re losing.”

For Chelsea Martinez, the mother of three at the Food Bank event, the changes can’t come soon enough. She’s struggling to care for her children and herself without any firm hope of getting health insurance or work in a system that punishes the working poor.

“I miss my job as a pharmacy tech,” Martinez said. “I would like to go back to the job I trained for, but too much is keeping that from happening.”

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This article appears in Sep 6-19, 2023.