Supporters of sweeping tax and spending legislation sent to President Donald Trump say changes to Medicaid, food aid, and other programs will encourage personal responsibility and stop system abuse.
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In Texas, Medicaid covers a third of all children, half of all pregnant women, the elderly in long-term care, and the disabled. Critics say new requirements in the bill will disrupt lives, while supporters argue it will prevent people from scamming the system.
The bill introduces work requirements for many adults ages 19 through 64 to enroll and remain on Medicaid. Beneficiaries would need to work, attend school, or perform at least 80 hours of community service a month. This change will heavily impact the 40 states that expanded Medicaid. Since Texas did not expand Medicaid in 2014, it is in a unique position.
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Ann Barnes, president and CEO of the Episcopal Health Foundation, said there’s a possibility Texas may not be as hard hit as other states but is already behind in insurance coverage.
“I don’t think that we will be as hard hit, but we are already behind many other cities and states in the country. Fewer people in Texas have insurance. In fact, we rank number one in the uninsured rate. So we’re already behind the ball,” Barnes said.
She added that if Medicaid funding is reduced, Texas will face tough decisions. The state may have to choose which populations remain eligible—children, elderly, pregnant women, or the disabled—or reduce services and reimbursements to the point that care is minimal.
“These are things that are really concerning to me. I do think that the effect on Texas is maybe less dramatic than it will be on some other states, especially those that expanded Medicaid,” Barnes said.
Most people covered by Medicaid already meet the work requirements or qualify for an exception. However, advocates worry that even those who meet the requirements could lose coverage because eligibility will be reassessed regularly by 2027. They fear paperwork could get in the way.
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Community clinics, which rely on Medicaid for up to 70 percent of their revenue, expect to feel the impact.
Dr. Charlene Flash, president and CEO of Avenue 360 Health and Wellness, said about a third of their patients rely on Medicaid.
Flash noted the challenge Texas faces with its high uninsured rate.
“Texas happens to have the dubious honor of the highest rate of uninsured in the country with about 20% of the people in Texas not having access to insurance,” Dr. Flash said. “Anything that we do in our state that dismantles coverage for people is a real challenge because we already are at the bottom of the pile in terms of access to coverage for the nation.”
According to the Episcopal Health Foundation, Medicaid covers a third of Texas children and half of all pregnancies, plus the elderly and disabled.
Flash explained the importance of Medicaid for elders who rely on it to cover gaps left by Medicare.
“Even those who have access to Medicare, there’s a fair bit of our elders that are impoverished and so those things that Medicare doesn’t cover, Medicaid closes the gap,” Flash said. “Are we going to send grandma and grandpa to go and work so that they can actually be able to cover the co-pays that Medicare doesn’t cover?”
When asked how community health centers would function amid Medicaid cuts, Flash said, “We already are one of the most restrictive states in the nation in terms of access to Medicaid. So, any additional cuts are just asking for our hospitals to be overrun, our people, especially the people that are front line folks out there not have access to care. Moms, babies, elders, disabled people, to make their lives just a little bit more challenging.”
Barnes warned that staffing shortages will force clinics to reduce services. With existing nursing and physician shortages causing longer emergency room wait times, Barnes said conditions will worsen.
“They’re going to continue to get worse and they’re going to affect everybody in the community. So, as individuals don’t have access to regular care, they will end up in emergency rooms and those are the same emergency rooms that we all need when we have something emergent happen,” Barnes said. “If all the beds in the emergency room and all the beds in the hospital and the intensive care units are filled with individuals who couldn’t take care of things early, we will all have to wait for the care that we need.”
Barnes also warned that cuts could lead to job losses, with an estimated 100,000 health-related jobs at risk in Texas. Fewer staff and services could overwhelm emergency rooms, affecting everyone, including those with private insurance.
There is a victory for rural hospitals buried in the new bill. The final approval includes a $50 billion boost for rural hospitals.
