Written by Emily A. Cheslock

Not just a public health crisis, the COVID-19 pandemic has caused global economic distress. Pandemic-induced economic downturn has led to record-breaking unemployment rates. In just the first four months of the pandemic, nearly 660,000 Texans lost their health care coverage with their jobs, according to Families USA, a nonpartisan consumer advocacy group. Texas has long led the nation in the rate and percentage of uninsured residents. Unemployment caused by the pandemic only exacerbated this.

Currently, 29% of the state’s population, or 4.9 million Texans, do not have health care coverage—still the highest uninsured rate in the nation. But Texas is not alone. Families USA estimates that 5.4 million Americans lost their health insurance due to COVID-19-related layoffs from February through May. Uninsured rates have not been this high since the economic crisis of 2008 when 3.9 million Americans lost coverage.

More Americans than ever are uninsured, and at a time when access to health care coverage is more important than ever.

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While sobering, this fact also is a timely opportunity. For better or worse, COVID-19 has changed many things, including the way we think about health and its relationship to our economy. With these issues at the forefront, lawmakers and other elected leaders are attuned to the health of our nation and they are leaning on health care policy experts to inform decisions and solutions to improve it. As the COVID-19 response continues, Texas hospitals and other providers and advocacy groups remain committed to increasing needed access to health care coverage in Texas.

Access to Care & Health Outcomes

Hospitals and other health care providers have seen significant decreases in patient volumes as the pandemic has progressed. Concerns about risk of COVID-19 transmission in health care settings impact patient behavior. But financial constraints and loss of health care coverage also deter people from seeking needed care.

A Gallup poll from April found that one in seven Americans said they would avoid seeking health care for a fever or dry cough for themselves or someone they live with because of concerns about their ability to pay. Nearly 10% still reported they would avoid seeking care even if they believed they were infected with COVID-19.

Increasing awareness of free and affordable health care services encourages people to seek care and helps protect their baseline health. Texas hospitals, counties and health authorities that provide testing services are working hard to inform the public about free COVID-19 testing opportunities. Hospitals are using social media and other methods to guide their communities to free testing facilities. While free testing helps, Texans still need access to more comprehensive health care services to address broader health conditions.

Jennifer Bartnesky-Smith

Providers now know that underlying health conditions can prolong and even complicate recovery from COVID-19. “Those with untreated health care needs are the patients that seem to be more susceptible to not only getting COVID-19 but also having a hard time recovering,” said Jennifer Bartnesky-Smith, chief strategy officer at Valley Baptist Medical Center in Harlingen.

The decrease in people seeking non-COVID-19-related care for chronic conditions such as heart disease is alarming. For instance, admissions for a serious type of heart attack known as STEMI dropped 38% after the pandemic hit, according to an April study in the Journal of the American College of Cardiology.

Meghan Weller

“We’ve seen many people delaying care during this time. Two often parallel reasons are a lack of insurance coverage and increased financial strain, preventing people from pursuing the care they need,” said Meghan Weller, director of government relations at HCA Healthcare’s Texas division. “Delayed care doesn’t only result in poor patient outcomes at that moment; it can lead to chronic and long-term debilitating conditions,” said Weller.

Expanding Medicaid Coverage in the Future

Texas is one of 12 states that has not yet expanded Medicaid coverage. The Urban Institute, a Washington-based think tank, estimates that only one-third of Texans who lost jobs due to COVID-19 will qualify for Medicaid. Some will qualify for COBRA or health care coverage through the federal marketplace. Even so, they estimate that 40% will become uninsured.

In 2012, the U.S. Supreme Court ruled that states could not be forced to opt into the Affordable Care Act’s Medicaid expansion programs. Since then, the Texas Legislature has chosen not to expand Medicaid. Instead, Texas has some of the strictest eligibility requirements. For adults with children, the income cap to quality for Texas Medicaid is 14% of the federal poverty level, according to the Texas Health and Human Services Commission. For a family of three, that’s $230 a month.

The COVID-19 crisis has changed the calculus for some states that were hesitant to expand Medicaid. COVID-19 has highlighted the need to increase health care coverage options and even expand Medicaid. Missouri residents voted in July to expand Medicaid. State lawmakers in Texas have proposed legislation that would put a constitutional amendment on the ballot for voters to decide whether the state should expand Medicaid coverage. But those bills have never passed.

John Hawkins

“COVID-19 is going to have a huge impact on the state budget in Texas. With less tax revenue this fiscal year, budget cuts are going to happen. Hospitals and health care are often a target for cuts,” said John Hawkins, senior vice president, advocacy and public policy at the Texas Hospital Association. “This makes a case for the state legislature to look for additional federal funds.”

Medicaid expansion is financed at a 90/10 federal-state match. This is much more favorable than the traditional 60/40 Medicaid match. “This is a big opportunity to expand Medicaid without having a huge impact on the state’s bottom line,” said Hawkins.

Whether state lawmakers will propose Medicaid expansion during the 2021 session, which begins in January, remains to be seen. While the 90/10 match is better, some worry that even a 10% state match is a significant amount in a state the size of Texas, according to Hawkins.

Still, there are ways to increase health care coverage for certain populations that do not require full Medicaid expansion. These opportunities, however, are funded at the traditional Medicaid match rate. For example, “in the 2019 legislative session, we discussed extending Medicaid coverage for postpartum mothers from two months to six- or 12-months. This could help combat maternal mortality rates. We likely will look into that once again as well as a targeted coverage package for severe mental illness or other chronic conditions,” said Hawkins.

Hospitals Helping Texans Find Coverage

Without Medicaid expansion, there are still things that can be done to help Texans find access to health coverage.

Valley Baptist has a team of financial counselors that help patients determine their eligibility for insurance programs or state assistance. “Once we determine eligibility, our counselors help with the application process to make sure everything gets submitted correctly,” said Bartnesky-Smith.

Before the pandemic, this work was done in person. Hospitals now have to isolate patients with COVID-19, creating a challenge for financial counselors to verify coverage or determine eligibility. Valley Baptist is working on ways to use technology to overcome this challenge. “We’re working on parameters where we can have our staff remote into patient rooms to get the information they need to get them enrolled,” said Bartnesky-Smith.

As the pandemic progressed across the U.S., hospitals saw a rise in the number of people losing health coverage —especially employer-sponsored coverage. This summer, HCA Healthcare opened its health insurance hotline, a free tool that is open for any Texan to use to help find coverage.

graphic of building blocks with an upward-pointing arrow

“We know the negative impacts of people delaying health care. We saw a need to offer solutions and guidance to individuals who lost coverage,” said Weller. The hotline walks callers through their specific situations to outline possible coverage options. This personal guidance will help Texans determine their eligibility for various insurance options—whether it be COBRA, Marketplace, government options or other resources that can offset the cost of insurance premiums.

HCA has been using social media and community partners to get the word out about the hotline. HCA doesn't have their own insurance plan; the program is solely there to help connect Texans with health care coverage. “It’s not exclusively for our patients, it’s for any Texan that has found themselves without insurance during this time,” said Weller.

The COVID-19 pandemic has brought many issues with our health care system and gaps in access to care to the surface. Texas hospitals and public health officials are banding together to solve problems and turn challenges into opportunities. It’s uncertain what the future holds, but one thing is certain – it’s time to expand access to health care in Texas.