Ashley Mann:

Title: The Medicaid Troops are Coming (for Child Autism Services)

The Texas House Committee on Human Services gaveled in on May 5, 2026 to discuss Medicaid in Texas. The focus shifted from Medicaid related legislation to the state's increasing focus on "preventing fraud, waste, and abuse" around the delivery of Medicaid services to Texas' most vulnerable populations. The first time the phrase, "long been vigilant in efforts to protect" was not in regards to protecting the highest number and rate of uninsured children in Texas, but instead, "efforts to protect taxpayer dollars." The committee hearing revealed something many who follow policy-making in Texas already know- that protecting the dollar has long been the priority over protecting sick children.

After a thick review of state fraud prevention, detection, and monitoring work, sometimes referred to as "chasing the dollar" by top Medicaid Managed Care Organization (MCO) lobbyists, the focus shifted to recent probes coming from both the Office of the Governor and the federal government via Dr. Oz. Keep in mind, Texas Health and Human Services (HHSC) serves more than 7.5 million people across 200 programs, Medicaid and SNAP being two of the largest for which taxpayers invest more than $60 billion in state and federal funding total.

After detailing their successful efforts to combat fraud, waste, and abuse in Medicaid, HHSC was very clear when they stated that they received a letter from Dr. Oz to re-evaluate Medicaid providers, specifically their "highest risk" (for fraud) providers to look at what they can do over the next two years.

Provider enrollment in Medicaid is piecemeal, HHSC witnesses testified. Providers must first enroll in Medicaid, and this has several pieces between HHSC; their contractor, Texas Medicaid and Healthcare Partnership (TMHP); and the HHSC Office of the Inspector General. We later learn in committee that health providers who wish to enroll in Medicaid are thoroughly background checked and validated once by HHSC before they are allowed to enroll in the program to serve our vulnerable and uninsured populations, which is then followed by a second round of credentialing checks by the MCOs (Managed Care Organizations).

No where during the hearing is this revealed- the cost or cost-benefit to taxpayers for the creation of this public investigative state complete with "thousands and thousands of automated systems that are monitoring"; as well as "third party data sources" which are used not only to verify a provider status, but also recipients of Medicaid, of course, but also used again, potentially months later to re-scan sources including social media posts, bank data, and other sources to determine income levels and the number of people living in a household. They call these scans of personal information, "quality sampling" for "case reads." The second round of background checks performed by the MCOs are described as "the same background checks" that were completed during the first round by the state- "FBI background checks" and "checking medical board records, the National Medical Board records." We also learn that, for some reason, MCOs do not contract with every single provider, but the witnesses do not explain why this is the case.

What is not explained to legislators or taxpayers listening is the cost for this propped up police state created to chase down every dollar. Does this entire enterprise to combat "fraud, waste, and abuse" actually cost taxpayers more money than, say, the actual benefits going out to people and children who need to see a doctor? What are the effects of this for uncompensated care costs? Keep in mind that for payments going to Medicaid providers, the state sets the premium amount and pays the companies a set amount per member, per month. So if the providers are not making profits from providing healthcare to vulnerable patients via Medicaid, are they making profits from the algorithms, computer software, software contracts, monitoring programs, and Artificial Intelligence programs used to look through everyone's data? HHSC admits to giving their workers an Artificial Intelligence tool, as information for workers is spread across too many sources. However, I do not recall the legislature authorizing the state Medicaid investigators to use Artificial Intelligence to scan personal and healthcare records.

When the chairwoman asks the HHSC Office of the Inspector General whether there are any diagnostic codes that exist for child abuse within a hospital, she is told this does not exist. However, she is told that this is a "work-in-progress" in coordination with her office. The committee is also informed that a lot of HHSC data is moving onto the Cloud.

Which services has the state been directed to perform targeted reviews over next? HHSC states they will be targeting Community First Choice, Non-emergency medical transportation, peer support services, durable medical equipment, and mental health rehabilitation services. Further, they will be performing a targeted utilization review of the ABA- the Applied Behavioral Analysis benefit, which in Texas requires an autism diagnosis in order to receive services. Texas may not be providing health to all children, but they may be driving an increase in autism diagnoses within our families striving to find healthcare for sick children.

A theme followed from the House Select Committee on Health Care Affordability hearings on April 30 and May 1, but at least the testimony was transparent. There are barriers put into place by the industry that make it more difficult for people to get the care they need. The Select Committee heard testimony over the cross-ownership of the largest insurance companies whereby they own the largest Pharmacy Benefit Managers. For example, CCS owns Aetna and it has a PBM, CVS Caremark. Their financials show that Caremark PBM contributes more revenue every quarter than every one of the 9,000 CVS stores or their Aetna health plan. The committee learned how cross-ownership effectively increases hospital consolidations or mergers which has led to both higher premiums and the virtual disappearance of the independent physician and independently owned physician practice. The select committee learned that the three major barriers the industry (mostly cross-owned) has erected to make it more difficult for people to get the care they need are: 1. inadequate networks, which they state is intentional 2. high out-of-pocket costs, as they know people will forego care, and 3. prior-authorizations- simply saying no. This theme was mirrored in the Committee on Human Services' Medicaid hearing, as the committee learned that controls used by HHSC or the industry to restrict services are 1. diagnostic restrictions on the service, such as requiring an autism diagnosis; requiring that only a certain type of practitioner may make said diagnosis; and prior-authorizations and re-authorizations at set intervals- policies, or barriers to service, that HHSC admits "set Texas apart from other states." They also tout benefit limitations, such as the example to only allow a certain number of visits to a therapist before you have to get another authorization. And don't forget the HHSC special investigative team of 150 members holding special access to third party data sources.

We hear endless testimony on "thousands and thousands of automated systems," the "very sophisticated systems that are monitoring millions of claims that are going back and forth"; but we hear nothing of the healthcare being delivered to our sick and vulnerable children, nor do we hear how these sophisticated methods could potentially be better used to provide health to all children in Texas. We've been too busy chasing the dollar.