A middle-aged woman with severe rheumatoid arthritis. A young landscaper with bipolar disorder. An older woman with liver failure.
These are just some of the many uninsured patients I cared for over the years who needed specialists and couldn’t see them. As a family doctor working in community clinics, I pushed the limits of my training and experience as I tried to help them, calling physician friends for advice and reading up on affordable treatments. Sometimes I sent them to the emergency room as the only option for care, knowing they would be saddled with bills they could never pay.
I felt like a failure when I couldn’t meet the needs of my patients. Yet the constraints of our system made it impossible.
Despite spending far more on health care than any other country, the United States is the only developed nation that does not provide universal health coverage. As reported earlier this year by The Commonwealth Fund, compared to other high-income countries we have the poorest health outcomes: lower life expectancy, higher infant and maternal mortality, higher rates of avoidable death. We have miracle cures for cancer. We can do surgeries on babies still in utero. Gene therapies are under development, with treatments already approved for conditions like spinal muscular atrophy and some types of leukemia. But millions of people don’t have access to any of this – or even more common tests and medications – because they don’t have insurance.
Our priorities are skewed, and nowhere is that more apparent than in my home state of Texas.
The Texas Legislature, which only meets for about five months every other year, is wrapping up another session without any serious effort to address the fact that nearly one in five Texans is uninsured – the highest rate in the nation.
Instead, the Legislature has been preoccupied with banning books, prohibiting trans-youth from receiving gender-affirming care and ensuring that 18- to 20-year-olds can continue to purchase assault rifles.
Lack of health insurance translates into higher risk of delayed care, medical debt and early death. Regina Rogoff, CEO of People’s Community Clinic, a full-service primary care clinic for underserved and uninsured Central Texas residents, said that some people without insurance “only seek care when they are very ill, when their conditions are more costly to treat.” They sometimes wait until their diabetic foot ulcer is infected or their high blood pressure causes a stroke.
Those decisions impact everyone. “These costs are eventually passed on to the government or are recouped through higher insurance premiums,” Rogoff said.
Medicaid, a public insurance program for those who meet certain income and other eligibility requirements, offers a safety net to many families who would otherwise be uninsured. But in Texas, the net is full of holes: Childless adults under 65 who aren’t disabled or pregnant are always ineligible. Adults with dependent children will only qualify for coverage if they have very low incomes: less than $332 per month for a family of three. Eligibility in the Lone Star State is more restricted than anywhere else in the country.
The Legislature had a recent opportunity to expand Medicaid to cover adults with incomes at or below 138 percent of the federal poverty limit but voted it down without a hearing.
Diana Forester, director of health policy for Texans Care for Children, a statewide, non-partisan policy organization, said that Medicaid expansion would be “the single biggest step state policymakers could take to connect more Texans with health coverage.”
Forty other states and the District of Columbia have adopted expansion, a key provision of the Affordable Care Act. In refusing to join them, the Texas Legislature effectively deprived over 1.4 million Texans of health coverage and rejected an estimated $5 billion to $10 billion in federal money annually.
Potential Loss of Coverage
The Legislature’s failure to expand Medicaid comes at a particularly bad time for low-income Texans. After three years of continuous coverage during the COVID-19 Public Health Emergency, Medicaid recipients in Texas and around the country are facing a “redetermination” period that began April 1. An estimated 5.9 million Texans must offer proof of continued Medicaid eligibility or have their coverage terminated.
The Kaiser Family Foundation estimates between 8 and 24 million current enrollees will lose coverage across the U.S. Some will be able to re-enroll after a lapse in benefits; others will gain insurance through employment or a plan offered by HealthCare.gov. But some will remain uninsured, especially in states like Texas, where Medicaid is restricted to low-income children, pregnant women and adults with disabilities.
Texas is prioritizing redetermination for Medicaid recipients who are most likely to have lost eligibility. But the paperwork, which includes verification of income and identity, is time-consuming; those who miss the return due date (30 days, in some cases) or fail to complete the forms correctly could lose coverage.
Dr. Louis Appel, director of pediatrics at People’s Community Clinic, worries about the impact on patients who will no longer have access to critical medications, specialists, radiology services, and financial support for a hospitalization. “We are concerned that many of our patients may not receive information on re-enrolling because they have moved or their contact information has otherwise changed,” he said.
Forester agreed. “We’re concerned that kids are going to get knocked off their health coverage — even though they are still eligible for it,” she said.
A Rare Act of Bipartisanship
Not all the news is bad.
In a rare act of bipartisanship, the Texas Legislature is expected to extend Medicaid coverage for people who give birth from two to 12 months after delivery. These benefits will ensure that many new moms can access support for chronic conditions, preventive care and behavioral-health needs. The timing is important, since many of these people will otherwise lose coverage during the redetermination process.
“Extending health coverage for moms is a critical part of the strategy to prevent maternal deaths and to address a number of health challenges that moms can face during that first year, including postpartum depression, cardiac arrest, infection, and extreme blood loss or hemorrhage,” Forester said.
Advocates are optimistic that the bill will pass, but efforts to amend it could, at a minimum, delay its implementation. Time is running out; the legislative session ends May 29.
I learned about the importance of health insurance when I became a patient myself. In 2009, I was diagnosed with multiple sclerosis, a chronic, progressive disease of the central nervous system known to cause a variety of symptoms including mobility problems, pain, fatigue, and sensory changes. I was running a clinic for people without private insurance at the time, and I struggled every day to help my patients find discounted medicines and address unreasonable hospital bills.
Meanwhile, because I had insurance, I got appointments with top specialists and started medicine that was priced about the same as a mid-range used car for a three-month’s supply. Health insurance has been a lifeline for me, allowing me to receive the best care, work full-time and avoid disability.
The Texas Legislature’s failure to prioritize quality, affordable healthcare for everyone, by expanding Medicaid and developing other solutions to increase access – at a time when over a million people may lose Medicaid during the redetermination process – is callous and irresponsible.
Lisa Doggett, senior medical director of Sagility, is a physician in Austin and a columnist for Public Health Watch. Her memoir, “Up the Down Escalator”, will be published in August 2023 by Health Communications, Inc. The views expressed in her columns do not necessarily reflect the official policies or positions of Public Health Watch or Sagility.