In early June, Jennifer Barrios took her 4-year-old daughter to the dentist for a routine check-up. She was stunned when office staff told her that she would have to pay for the exam herself — her youngest child was no longer covered by Medicaid.
That was the first time Barrios learned her family, which lives in Donna, Texas, was among the estimated 6.4 million people disenrolled from Medicaid nationwide since April, including more than 1.2 million children. This wave of coverage loss was triggered when the country’s pandemic-era pause on Medicaid redeterminations ended last spring, overwhelming state agencies and cutting people off from their health care.
So far, federal data suggest seven in 10 people have lost their Medicaid coverage for procedural reasons, such as missed deadlines, paperwork getting lost in the mail, or state agencies processing applications too slowly. In those cases, state agencies claim they cannot verify whether a person still qualifies for Medicaid or if their income exceeds set limits, and drops their coverage. But according to research, most people disenrolled from Medicaid for procedural reasons were still eligible, said Joan Alker, executive director for the Georgetown University Center for Children and Families.
Before Medicaid’s unwinding began, Texas already had the nation’s highest rate of uninsured people at 16.6 percent of its population, according to newly released 2022 data from the Census Bureau. During that same period, more than 6 million Texans received Medicaid.
Chart by Megan McGrew/PBS NewsHour
Since April, Texas has shed roughly 900,000 people from its Medicaid rolls – more than any other state and at the highest rate nationwide. By August, roughly 95,000 of the state’s Medicaid recipients were found to have been erroneously disenrolled, including pregnant people and newborns. Children make up about 80 percent of Texans who have lost Medicaid coverage – more than anywhere else among states that have broken down disenrollment data by age. According to the state, Texas has to process millions more renewals by June.
About half of all U.S. children are covered by Medicaid or the Children’s Health Insurance Program (CHIP), and advocates say Medicaid’s unwinding has put many families in a precarious situation.
“Medicaid is the backbone of our pediatric health care system,” Alker said. “When we see large numbers of children losing Medicaid, we have to worry.”
The problem of children losing their Medicaid coverage has gotten so bad nationwide that on Aug. 30, the Centers for Medicare and Medicaid Services issued a letter to all states and territories, saying they had until Sept. 13 to fix whatever systemic bugs are causing so many children and families to lose their Medicaid coverage, present preliminary findings and offer a timeline for when the state will finish assessing what’s wrong, or face consequences for being out of compliance. The agency did not say exactly how many children have been affected, but said that states must “immediately act to correct the problem and reinstate coverage.”
“CMS has learned of additional systems and operational issues affecting multiple states, which may be resulting in eligible individuals being improperly disenrolled,” the agency said in its letter. “These actions violate federal renewal requirements and must be addressed immediately.”
In reports and statements by the Texas Health and Human Services Commission (HHSC), the state did not appear to acknowledge anything wrong with its process.
In an August dashboard report, the agency said that “procedural denials occur when HHSC does not have enough information to determine if the recipient is eligible for Medicaid coverage. In most cases, the recipient failed to return a renewal packet or provide requested information.”
In response to an inquiry by the PBS NewsHour after the CMS deadline for states had passed, Texas HHSC said that they “confirmed to CMS that HHSC completes a redetermination of Medicaid or CHIP eligibility based on available information for each individual in the household, regardless of the eligibility of others in the household unit.”
Schools struggle to fill gaps in care
The end of summer is typically a time for students to get annual physicals, dental exams, vaccinations and doctor’s notes to ensure they’re ready to return to classrooms or participate in after-school activities. But advocates and health care providers say instability in Medicaid enrollment means families may avoid getting kids the care they need, even if they qualify for Medicaid or CHIP, because they don’t know if the coverage exists.
Many families in Texas and elsewhere aren’t finding out they have lost their Medicaid coverage until they visit a provider for an appointment, like Barrios and her daughter did, or until they try to fill a prescription or experience a medical emergency, said Sasha Pudelski with the American Association of School Administrators.
Chart by Megan McGrew/PBS NewsHour
These disruptions also hurt schools, she said. Medicaid serves as the fourth-largest funding stream for schools nationwide, Pudelski said, paying for many health care services that schools deliver. Even before Medicaid’s unwinding began, Pudelski said, lines of parents and students often formed in parking lots on Monday mornings to see a school nurse for basic health care, such as checking for a fever (a needed service for households without thermometers) or determining if a rash is contagious.
“This is what schools have to pick up,” she said, and in many cases, “the consistency in that child’s life may be the school.”
This is uncharted territory, and schools are trying their best to fill in gaps. School nurses do what they can, but more families are turning to community health centers, emergency rooms or simply forgoing care. Taken together, children’s health advocates and educators are concerned that children with unstable Medicaid status may miss more school and endure worsening health outcomes.
Along with being a crucial access point of health care, schools can play a big role in keeping kids connected to Medicaid, Alker said. That has been happening in many districts across Texas.
In the San Antonio Independent School District, where 46,000 students are enrolled, social worker Claudia Cisneros-Tabares helps students and families connect with Medicaid, particularly behavioral health services, something she has done for two decades. But over the last year, especially during Medicaid’s unwinding in Texas, she said, “I’ve filed more appeals than at any point in my career.”
Most families that Cisneros-Tabares assists live in low-income households where caregivers work in hourly jobs. “Being on the phone is really difficult” for those families, she said, because it could result in less pay. “If we can do any of that legwork for the families, we do.”
The “biggest obstacle” the families face are delayed responses from Medicaid, Cisneros-Tabares said. One student’s mother had covered the family with private insurance until she lost her job earlier this year. With “extremely limited income,” the mother applied for Medicaid in April but “still doesn’t have a response,” Cisneros-Tabares said. “It’s not for lack of trying.”
“You need to be healthy enough to learn,” Pudelski said. “You need to be in school to learn, and access to insurance is key.”
Not fast enough
Barrios said she learned her daughter’s coverage had lapsed after state workers failed to see her youngest child’s name on the application alongside her two older children, who were successfully re-enrolled. State officials twice told Barrios that her case would be escalated, but had no estimate for when there would be a change in status.
In July, she called a Medicaid office, desperate for answers.
“What’s the time frame? I’ve been waiting for 30 days already,” Barrios said she told a state agency official. She recalled being told there is no time frame and that “it could take another day or two, or maybe another 30 days.”
Before redetermination started up again, Texas officials took an average of 45 days to process an application, because Texas Health and Human Services was already short-staffed and applications were backlogged, said Stacey Pogue, a senior policy analyst with Every Texan, a social justice advocacy group.
Layer that dysfunction onto Medicaid’s historic unwinding, and hundreds of thousands of Texans losing their health care coverage is “not an unpredictable outcome,” Pogue said.
In Texas, the backlog in re-enrollments has grown so large that state whistleblowers said in August it would take Medicaid officials 75 days to begin processing an application.
“We have a lot of barriers in the system that are making it harder for people to renew,” Pogue said. “Unless the governor of Texas from the top says ‘No more eligible kids will be booted off Medicaid on my watch,’ that will continue.”
Texas Gov. Greg Abbott has long criticized Medicaid, calling it “broken and bloated” in 2015. When he was the state’s attorney general, he sued the Obama administration to prevent the implementation of the Affordable Care Act.
States have shortcuts to make the process of sifting through Medicaid applications less painful for patients, health care providers and agency workers. While shedding millions of people from Medicaid, most states can and do check if a person receives help through other programs, such as food stamps. If done correctly, these ex parte renewals require less time, fewer applications and reduce the likelihood that a person could lose their health care. But in Texas, only one in 10 renewals are achieved through this method, among the lowest rates of ex parte renewals in the country, according to KFF analysis.
Graciela Camarena, child health outreach coordinator at the Children’s Defense Fund in Texas, works with families like Barrios’ in the southernmost tip of Texas, serving as an ad hoc caseworker to help Medicaid recipients keep or restore their coverage. Many families are of mixed-immigration status, Camarena said, with children who were born in the U.S. and qualify for Medicaid. She gets as much information as she can when she meets each family.
“Did you receive a renewal packet or notice?” she often asks. Many families tell her that they received nothing from the state, she said. Highly mobile households are most likely to miss those critical pieces of mail because the state doesn’t have a current address on file. Advocates say Texas also failed to conduct enough outreach beyond English or Spanish, missing people who may speak or read neither. On virtually every level, Camarena said, “This system is in crisis.”
“Every child is important,” she said. “We have to make sure the state and the agencies humanize these children. It’s not just numbers and percentages and data. These are children who need access to their health care, especially for back to school.”
’Everything is overstretched right now’
Since Texas began disenrolling people from Medicaid in April, “it has not gone well at all,” said Jana Eubank, executive director for Texas Association of Community Health Centers. She added that the vast majority of people losing coverage in the state have been children.
Nationwide, more than 30 million people rely on community health centers for primary care, regardless of their insurance status, according to the Health Resources and Services Administration. In Texas, about 1.8 million people turn to these centers, including the 675,000 children that were covered by Medicaid prior to this year’s disenrollments, according to Eubank. She said the redetermination process has been “incredibly disruptive,” bloating wait times and complicating efforts to connect patients with specialists willing to treat patients with Medicaid or no insurance – physicians who were already hard to find in Texas, she said.
Eubank said she is “incredibly concerned about all the children being impacted” and that centers are already seeing “changes in patient behavior in terms of their willingness to seek preventative care.”
“It’s a scary thing when you have to choose between accessing health care and feeding your family,” she said. “This pause is going to be critical.”
In August, still uninsured, Barrios’ daughter became sick with strep throat shortly after going back to school. Barrios knew a doctor’s visit was as unavoidable as the bill that would soon follow.
“I need the Medicaid to get here,” said Barrios, who paid for the visit out of pocket.
More families are turning to emergency room services for basic care “because they know they cannot be turned away,” Cisneros-Tabares said. Those same families are told to “rely on local resources,” she said, but many agencies providing those resources, like those that offer financial assistance to cover prescription drug costs, limit assistance to one time per year for an individual or household or run out of funds altogether.
“Everything is overstretched right now,” she said.
While lawmakers and agencies at all levels of government figure out how to navigate this historic moment of health care coverage, Cisneros-Tabares said she is watching students struggle as they are forced to go without daily medication, psychiatric care or therapy: “There’s no way our kids can learn if they’re not stable, and that comes with providing them the care that they need.”
Alker said she wants to see more states release data about how many children have lost their Medicaid coverage so far. She called for the Biden administration to hold them accountable and “very rigorously investigate these data that we’re seeing where children are having large coverage losses, particularly in non-expansion states.” And in places where large numbers of kids are losing their health care coverage for procedural reasons, Alker said, “The governor needs to step in and pause the process.”
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That was also the recommendation of several experts following whistleblower complaints from employees of Texas Health and Human Services, which in multiple complaints this summer detailed internal errors and systems issues that led to erroneous denials of coverage. The state told the Austin-American Statesman in August that it increased development resources, including additional support contractors.
Officials from Texas Health and Human Services stand by how the process has played out so far.
“Since April 1, 2023, no eligible individuals have been disenrolled from Medicaid or CHIP in Texas due to a failure to account for the individual’s eligibility status, independent of that of others in the household,” according to a statement from the state agency to the PBS NewsHour.
Back in South Texas, two months after Barrios learned that her youngest child was uninsured, her Medicaid application moved forward with the assistance of a caseworker. On Aug. 29, Barrios’ daughter’s coverage was restored – not because the process was fixed, but because she had help from an army of advocates. Hundreds of thousands of others are still waiting.
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