Texas Didn't Expand Medicaid, but Some Adults Still Find Access

Texas' Republican leadership made sure the state didn't expand its Medicaid program to poor, uninsured adults — an optional provision of the Affordable Care Act. But low-income parents here are increasingly getting covered by the joint state-federal insurer anyway — through the Temporary Assistance for Needy Families program.

The state program, known as TANF, is funded by a federal block grant, and intended to provide cash assistance to Texans who are unemployed and under-employed and their families. But it also makes those who qualify for the financial help eligible for health insurance through Medicaid, which primarily covers children and people with disabilities.

The Texas Health and Human Services Commission estimates that more than 140,000 adults received Medicaid through their TANF eligibility in May — a 21 percent increase over November.

Stephanie Goodman, spokeswoman for the health agency, said the commission is uncertain what’s driving the increase.

Monthly Medicaid enrollment among TANF-eligible adults jumped by almost 5,000 people in January when a new formula to calculate income under the Affordable Care Act kicked in, and it steadily grew through May. But Goodman said several other modifications to the formula under the ACA should’ve offset the surge.

While the state offers little subsidized health coverage for low-income adults who aren’t pregnant, don’t have disabilities and aren’t elderly, parents of TANF-eligible children qualify for Medicaid coverage under TANF guidelines — even if they don’t accept the cash assistance.

“They don’t have to take the TANF, and some families don’t actually want to get the TANF because it has a lot of strings attached and it’s not a lot of money,” Goodman said. “But you can get the Medicaid coverage if you qualify.”

Only families with extremely low incomes are eligible for TANF, and adults who obtain assistance through TANF must agree to take parenting skills classes, look for a job or maintain their current employment, and obtain vaccinations for their children, among other requirements.

While the growing number of TANF-eligible adults enrolling in Medicaid makes virtually no dent in Texas' sky-high rate of the uninsured, advocates for the Affordable Care Act say it is evidence that that the state should comprehensively expand Medicaid to low-income adults.

“More people having the security of coverage through Medicaid is absolutely good news,” said Christine Sinatra, state communications director for Enroll America, a nonprofit group that promotes the federal health reform law. “An uptick like that suggests there’s a demand for the quality health coverage Medicaid provides.”

Opponents of the health reform law, meanwhile, argue that it’s only indicative of the need to reform an already broken program with increasing beneficiaries and out-of-control costs.

“If anything, I would say it’s evidence that the Medicaid program is growing regardless of an expansion,” said John Davidson, a health care policy analyst with the conservative Texas Public Policy Foundation.

Recently, Gov. Rick Perry called the Affordable Care Act's Medicaid expansion provision “federal blackmailing.” If Texas had expanded Medicaid to cover young adults under President Obama's signature health reform law, the federal government would have covered 100 percent of the cost for three years, eventually reducing its coverage to 90 percent.

The federal government currently provides Texas with $60 in matching funds for every $40 the state spends on Medicaid services.

The Texas Public Policy Foundation and Perry have both proposed reforming Medicaid, calling on the federal government to fund the program with block grants that would give states the flexibility to run their programs as they see fit.

Davidson added that increasing demand for subsidized health care among the uninsured, coupled with the growth of state Medicaid rolls despite state leaders' rejection of an expansion, “underscores the need” for long-term structural reform.

“It means that lawmakers need to start taking Medicaid reform seriously and start looking at the bigger picture,” Davidson said.

This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.