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Slow Crawl to Insuring Kids in Texas

By Marissa Evans, CQ Roll Call

November 9, 2015 -- Like the U.S. overall, Texas saw a decline in the number of children without health insurance in 2014. But supporters of the federal health care law say hostility to the Affordable Care Act is preventing the state—which still has the nation's biggest population of uninsured kids—from making faster progress.

The number of uninsured children in Texas fell by 11.7 percent to about 784,000 in 2014, down from around 888,000 in 2013, according to a Georgetown University Center for Children and Families report released in October.

Nationwide, the number of uninsured children fell more than 15 percent, from 5.2 million in 2013 to 4.4 million in 2014, the study found, using data from the Census Bureau's American Community Survey.

In measuring that population in 2014, the study captured the impact of key provisions of the 2010 health care law during their initial year, including the expansion of Medicaid in many states and the creation of state and federal health insurance exchanges that allow Americans to compare coverage options and sign up for federal subsidies to make premiums more affordable.

The Georgetown study found that states that expanded Medicaid under the health care law added twice as many children to insurance rolls. In those states, the rate of uninsured children fell by 21.7 percent in 2014 while states that did not expand Medicaid only saw an 11.6 percent decrease.

In Texas, two successive Republican governors and the GOP-controlled legislature declined to expand Medicaid or establish a state insurance exchange. And there's no sign of  movement toward either option.

"Governor Abbott believes that expanding a program that is bad for patients, doctors, and taxpayers is no way to solve our health care issues," said John Wittman, Gov. Greg Abbott's deputy press secretary. "Texas should be able to address our unique health care situation without federal interference, putting patients and doctors in charge of health care decisions."

Even if Texas doesn't expand Medicaid, it should at least improve efforts to help more citizens obtain coverage in the federal marketplace or through Medicaid or the Children's Health Insurance Program (CHIP), says Anne Dunkelberg, an associate director at the Center for Public Policy Priorities, a nonpartisan research organization based in the state capital, Austin.

"We're missing this opportunity in Texas and I think the data clearly shows that getting parents enrolled in insurance is very important," Dunkelberg says. "The legislature and elected officials have been a really big gatekeeper of these efforts."

Dunkelberg says state legislators don't understand how their resistance to the federal health law is preventing Texas children from getting coverage.

"The fact that it's so caught up in political struggles is a source of frustration," she says. "It doesn't make sense necessarily that this would be an ideologically fraught issue."

But even with the third year of open enrollment underway, educating consumers in Texas about health insurance is especially difficult, Dunkelberg says.

In 2013, Abbott signed into law a bill requiring navigators who assist people with the online insurance marketplaces to register with the state, submit to background checks and complete 40 hours of state training on top of the 20 to 30 hours required by the federal government.

In response to public comments in 2014, the Texas Department of Insurance issued revised rules that reduced state training to 20 hours, but set fees ranging from $100 to $400. According to Texas' registry list, there are 501 navigators throughout the state. 

Such rules are a hurdle to expanding access to insurance to disadvantaged Texans, says Jill Ramirez, executive director for the Latino HealthCare Forum, a Texas-based nonprofit.

"My day is spent getting people to be able to trust us enough to get them enrolled and letting other people know they can do the same," Ramirez says.

Hispanic adults are at the highest risk of being uninsured in the U.S., with more than one in four lacking coverage, according to a Kaiser Family Foundation report. The Latino HealthCare Forum has been keen on dispatching volunteers to schools, malls, recreation centers, parks, churches and anywhere else in the Eastern Crescent community of Austin to connect with potential enrollees. Ramirez says a lot of the residents may not speak English or understand that they qualify for help.

Mixed-status immigrant families also may assume no one in their family is qualified for health insurance, even though children can qualify for Medicaid and CHIP, she says.

"There's still a lot of fear in terms of believing that if you're mixed immigration you can still apply for your children," Ramirez says. "We have to do a lot of education about that issue letting people know that if you have a mixed immigration household that the government isn't going to come after you for signing up."

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