Texas can cut its own coverage solution path

A collective sigh of relief was heard around the state in late January, when the federal government approved a 10-year extension of the state’s Medicaid 1115 waiver to continue uncompensated care funding for hospitals and other healthcare providers. Since 2011, when the waiver was first approved, it has been a critical piece of healthcare financing. Many Texas hospitals would be on the brink of closure without the more than $3 billion in annual funds the waiver allocates to offset some of the costs associated with providing care to low-income and uninsured Texans.

However, it would be a mistake to assume that the federal money minimizes the urgency of solving our uninsured problem.

As many as 29% of Texans have no viable source of health insurance, as of September 2020, according to a study from the Episcopal Health Foundation. For Harris County, Memorial Hermann’s home, the figure is even higher — 37%. Before the pandemic, Texas had more uninsured residents than any other state. The pandemic only exacerbated the problem, with one in 10 residents losing their health insurance since the pandemic began.

Part of the reason for our high uninsured numbers is the state’s low Medicaid income-eligibility thresholds. For able-bodied parents or caretakers, the maximum annual income to remain eligible is just $3,500 for a family of four. Able-bodied adults without dependents are not eligible at all.

Yet the Medicaid 1115 waiver does not provide health insurance or a means of reducing the number of uninsured. A Texas-sized problem still exists. Coverage is still lacking. The waiver approval letter itself clarifies that waiver funding is not medical assistance, does not provide benefits to individuals and does not create Medicaid beneficiaries. Rather, the funding “promotes the objectives of Medicaid by helping stabilize safety-net providers.”

This matters, because health insurance, while no guarantee of access to care, is an important determinant in access to timely and appropriate care. Numerous studies have demonstrated that people without health insurance are far more likely than those with insurance to delay health care or forgo it altogether. The health consequences can be severe, particularly when preventable conditions, such as coronary heart disease, or chronic diseases, such as diabetes or high blood pressure, go undetected.

Every day, in our emergency rooms across the Houston metropolitan area, our clinicians see patients in advanced stages of disease and complications from untreated injuries and conditions. These patients come to us only when their pain is unbearable and their symptoms intolerable. Often, hospitalization or surgery or both are necessary, although they could have been avoided with earlier detection and initiation of appropriate treatment.

With the 87th Texas Legislature in session, lawmakers again have the opportunity to work with the federal government to develop a coverage program for low-income uninsured Texans that is best suited to the needs of our state. Expanding coverage could give up to 1.3 million uninsured Texans, including 223,700 Harris County residents, access to affordable health insurance.

As one of only 12 states that has not expanded coverage, Texas still can identify a coverage solution — one that works financially, logistically and politically. Other states such as Indiana, Arkansas, Utah and Montana have successfully challenged the notion that traditional Medicaid expansion is the only option. Texas can, too. A Texas solution could require personal responsibility. It could subsidize the purchase of private health insurance coverage. Or it could start with a focus on select populations, such as veterans or Texans with serious mental illness.

Health insurance isn’t a panacea. There are many genetic, behavioral, environmental and societal factors that determine a person’s health status and ability to improve it. But comprehensive, affordable health insurance that encourages the use of primary and preventive care and incentivizes healthy behaviors is, without question, a necessary piece of the equation.

The extension of the Medicaid 1115 waiver is welcome news, and represents a robust commitment to a strong health system. Let’s build on that commitment by working together to figure out how we get more of our fellow Texans the health insurance coverage they need.