Lawmakers overlook high rates of uninsured, foster care fixes

Occupied with reining in rising property taxes and overhauling the school finance system, state lawmakers left Austin last month without substantively addressing other long-standing issues: the high number of uninsured Texas residents and problems that still plague the child foster care system.

Advocates were encouraged that bills addressing shortcomings in state social services, including those that would have expanded Medicaid, received public committee hearings at the beginning of the legislative session -- something previous Legislatures had been loath to do. But dozens of bills -- including those that would have extended Medicaid coverage for new mothers, prepared older teenagers to make the transition out of foster care, and instituted trauma-informed care across the child welfare system -- died in large part because they carried hefty price tags.

Instead, the Legislature spent $16 billion on Hurricane Harvey recovery and flood-control projects, cutting property tax rates, improving school safety, shoring up the pension system for retired teachers and boosting funding for classrooms and teacher salaries.

"The first step is for state leaders to acknowledge that we have a health coverage problem in Texas. So far, we just haven't seen them do that. It hasn't been their priority. The Legislature passed bills on lemonade stands and other small efforts, but a bill to ensure that kids don't lose health insurance languished," said Adriana Kohler, senior health policy associate for Austin-based child welfare advocacy group Texans Care for Children.

Combined federal and state spending on Medicaid in Texas will top $66.5 billion over the next two years. Although this reflects an $800 million increase from the current two-year budget, the state will end up spending $1.9 billion less.

About $3.8 billion will be spent on child welfare services over the next two years, a 6% increase from this biennium. Last session, the Legislature provided a 16% increase in spending for child welfare services.

Medicaid coverage

Texas has the highest uninsured rates for children, adults and women of childbearing age, according to most recent data available from the Georgetown University Center for Children and Families and the Census Bureau. After years of declining uninsured rates, the rate of Texas residents without coverage grew in 2017 to 17.3 percent -- an estimated 4.8 million people, 835,000 of them children.

Texas is among just 14 states that have not expanded Medicaid, contributing to the high uninsured rate.

Expansion of the federal and state-subsidized health insurance program could cover 686,000 Texans who make too much to qualify for Medicaid yet earn too little to qualify for tax credits to purchase Obamacare through healthcare.gov, according to the Kaiser Family Foundation, a policy research organization.

Expanding Medicaid coverage also could make an additional 439,000 Texans eligible for Medicaid, those eligible for Obamacare but who are just above the federal poverty level.

"The citizens of Texas are taking their tax dollars and giving them to the federal government, who then pays for Medicaid expansion in other states," said David Fleeger, an Austin surgeon who serves as president of the Texas Medical Association. "I understand Medicaid expansion is not a political reality, but ... we're losing out and we're last on the list when it comes to a lot of health care issues."

Republican state leaders reject Medicaid expansion because they say they don't trust the federal government to fulfill its promise to reimburse 90 percent of the cost. They also say the program is riddled with problems, including providing inferior quality of care.

In Texas, Medicaid eligibility is largely limited to people with severe disabilities or near-death illnesses, as well as for children from low-income families, seniors and pregnant women.

House Bill 565, which called for expanding Medicaid coverage for adults and children, received a hearing in the House, a first for any Texas Medicaid expansion legislation, but it never received a vote in the committee. Other bills would have asked voters whether to approve Medicaid expansion, something three other Republican-voting states have done -- Nebraska, Utah and Idaho.

Another bill would have allowed women to maintain Medicaid coverage for a year after delivering a baby or miscarrying, instead of the current 60 days. The bill, which passed the House but not the Senate, would have cost the state $75 million over the next two years.

The state's Maternal Mortality and Morbidity Task Force, created by the Legislature to address increasing maternal deaths, had recommended extending health insurance coverage for postpartum women, but it didn't specifically say through Medicaid.

State officials would prefer postpartum women obtain coverage through the state's Healthy Texas Women program, which isn't funded with Medicaid dollars and will be expanded to offer more postpartum benefits. It's just not clear yet if those services will be on par with those offered through Medicaid, Fleeger said.

"Because it's state run and doesn't have federal dollars, it has a much smaller benefit package as it exists now because that wasn't its intent. Its intent was to deal with some level of healthy women care, reproductive care, contraception," Fleeger said. "Now it will be expanded. We're hopeful it will be sufficient."

Legislative efforts that would have prevented children -- about 50,000 a year -- from being kicked off Medicaid due to paperwork problems also did not advance.

Foster care

In 2017, lawmakers overhauled the state's foster care system and Child Protective Services, which had been troubled by child abuse and neglect deaths and high employee turnover.

Sweeping bills addressed, among other things, pay increases for family members who serve as foster parents, pay increases for caseworkers and handing over foster care services from the state to nonprofits and local governmental entities.

Problems persist, however, including insufficient foster care placements and 18-year-olds unprepared to leave foster care.

"Because this was such a big issue last session, many of the legislators figured the problem was solved and that it did not need focus nor attention," said Will Francis with the Texas chapter of the National Association of Social Workers. "I think the Legislature pretty much just punted."

HB 3379 would have helped prepare foster teenagers to live more independently, from ensuring they find stable housing to helping them better understand any medication they're taking. HB 4138 would have ensured youths aging out of foster care didn't lose Medicaid coverage if they still qualified. Neither bill received hearings.

The Legislature approved $1.5 million over the next two years to hire more state employees to help youth transitioning out of foster care. Lawmakers also approved a measure to train such youth on civic engagement and financial literacy.

The Legislature also approved $12 million to increase payment rates to foster care providers so they can better attract and retain foster families and specialized homes for high-needs children, like residential treatment centers. Advocates had requested $45 million.

Some areas are reporting a severe space shortage in residential treatment centers, emergency shelters and foster homes, according to the latest review by the Texas Department of Family and Protective Services.

"You have to grow capacity across the whole continuum," said Katie Olse, chief executive officer of Texas Alliance of Child and Family Services, which represents child welfare service providers.

The state also will contract with an independent entity to update how foster care rates are calculated.

"It is so much more than having a bed for a kid. A lot of it is based on making sure the right services are available for the right child at the right time," Olse said.

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