Texas has the highest rate of uninsured children, and it’s getting worse

From Public Health Watch:

HOUSTON, Texas — Almost 1 million Texas children and teens went without health insurance at some point over the most recent year recorded. Many of them live in Houston, which has a higher rate of uninsured children than any other major metropolitan area in the nation.

Overall, Texas has the worst coverage rate for kids in the country, with nearly 12% going uninsured in 2023 — up from nearly 11% in 2022.

A number of issues are driving the numbers. But the fact that many uninsured Texas children are actually eligible for public insurance exposes what experts say are alarming gaps in the state’s enrollment and outreach system — gaps that can limit health-care access for low-income kids and endanger their health.

Among the issues is a backlog of thousands of families who applied for Medicaid or the Children’s Health Insurance Program, known as CHIP. For most of 2024, the average waiting time for a decision by the state was well over two months, which triggered a federal probe under the Biden administration. The application process remains tedious and confusing, requiring families to sometimes round up dozens of documents to prove they’re eligible. Some give up.

The state has booted more than 1 million children from Medicaid since it began reviewing recipients’ eligibility again in 2023 after a pause during the COVID-19 pandemic. Many were dropped not because they were ineligible, but for procedural reasons, such as their parents’ failure to submit a renewal packet.

Texas lawmakers also have rejected or stalled proposals that typically help more children access CHIP or Medicaid. A 2023 state House bill would have streamlined Medicaid and CHIP enrollment for kids by relying on information already verified via other state benefit programs, such as food assistance. Despite bipartisan support, the bill failed to advance. It’s been introduced again in this year’s session.

Texas has shunned broad proposals enacted by other states, such as expanding Medicaid for low-income adults. Research shows Medicaid expansion has a “welcome-mat” effect for children, with parents on Medicaid more likely to sign up their eligible kids as well.

The range of barriers mean many Texas children go without vital medical care or health screenings, health experts and advocates say.

“When kids are enrolled in Medicaid, they do have better access and better health care outcomes,” said Alec Mendoza, senior policy associate for health at Texans Care for Children.

Until recently, Houston native Maria Reyes was terrified that her 7-year-old daughter, Maya, might join the ranks of Texas’ uninsured. No child should miss out on regular medical checkups, but Maya really can’t.

She was born with a rare genetic condition that prevents her pancreas from properly absorbing nutrients and her bone marrow from producing enough blood cells. As a baby, she couldn’t put on weight and her breathing was erratic, a symptom of rib-cage abnormalities caused by the condition, known as Shwachman-Diamond syndrome. After multiple hospitalizations, she was diagnosed at 8 months old.

Maya needs frequent care to stay healthy, including visits with a blood specialist every two months and a bone marrow biopsy every year, Reyes said.

Without Texas Medicaid coverage, which Maya has had since she was a baby, the family would be swimming in medical debt, Reyes said. Just one of her prescriptions costs about $1,500 a month.

Reyes was braced for that reality last fall when the state conducted its yearly assessment of Medicaid eligibility for Maya and her two younger siblings. She was worried that her new job as a medical assistant, making less than $20 an hour, might bump her income enough to disqualify her kids. While the family could visit a local community health center that serves the uninsured, finding affordable specialty care would be very difficult.

She spent weeks trying to prove their eligibility. “It’s like they don’t believe you need it,” she said.

Maya has more complex medical needs than most kids. But research shows that going without health insurance has serious risks for all children, particularly in their early years, when their bodies are still developing and they’re vulnerable to infections.

In interviews with Public Health Watch, health providers and advocates in Houston said their experiences mirror what the research already reports: Uninsured children are more likely to have unmet health-care needs. As a result, their families, who typically have low incomes, face more financial stress.

The number of Texas kids who are eligible for public insurance but not signed up is especially frustrating, advocates said. A 2023 report from Texas 2036, a public-policy nonprofit, estimated that 400,000 uninsured Texas children were eligible for Texas Medicaid or CHIP but weren’t enrolled.

For Reyes, her hunch about her kids’ Medicaid coverage wasn’t totally off. Maya was still eligible, but to keep all three of her children covered and healthy, Reyes had to cut her work hours.

Risks for uninsured kids

In April 2023, states began dropping people from Medicaid rolls when federal pandemic protections came to an end. Texas disenrolled 2.5 million people by September 2024 — the most of any state, according to a Kaiser Family Foundation tracker of the Medicaid “unwinding.” A year after it began, more than 1.3 million  Texas kids had lost their Medicaid coverage, most of them for procedural reasons, Texas Human Health and Services reported.

While community health centers can still serve as medical homes for the uninsured, parents of uninsured kids are often less likely to bring them in for care, said Jana Eubank, executive director of the Texas Association of Community Health Centers. They are often worried about incurring unexpected bills they can’t pay.

“If they need specialty care or inpatient care, they often just go without or wait until it’s very serious and present at the emergency room,” she said.

Regular checkups for kids are vital. They give doctors a chance to catch developmental delays early, such as low weight gain or trouble walking and talking.

In the first two years of life, the American Academy of Pediatrics recommends that children visit with their physicians nearly a dozen times.

Years of research show that people with health insurance, including kids, are more likely to access preventive care and receive medical treatments they need. One study, published in 2017, followed a group of 237 children in Dallas County, Texas, who were eligible for Medicaid or CHIP. Researchers found that uninsured children were almost four times more likely than insured ones to have no primary care provider and three times more likely to delay or skip needed health or dental care.

With Medicaid or CHIP, families rarely have out-of-pocket costs, said pediatrician D. Maneesh Kumar, who runs a small practice in southwest Houston. About 70% of his patients rely on public insurance. “It’s actually really good coverage,” he said.

But for uninsured kids in households with few resources, even minor medical needs — like treatment for an ear infection or head lice — can be a financial strain, said Dr. Kavon Young, chief clinical officer at El Centro de Corazón, a community health center with three clinics in East Houston. About 40% of its 5,500 pediatric patients are uninsured.

“Something very simple for a child who’s insured can pose a lot of difficulty for a child who is not,” Young said.

The health center can offer families low-cost primary care for their uninsured kids, but parents have far fewer, if any, affordable options if their child needs more complex medical care.

Keren, who asked that only her first name be used, has been bringing her three young children to El Centro de Corazón for the last year. All three are uninsured, she said last fall through an interpreter, but the clinic offers a sliding-scale rate she can afford.

She said at times it can be stressful to cover the costs, especially for her children’s dental work. But she said she is nervous about filling out the paperwork to apply for Medicaid or CHIP.

Providers and advocates say parents’ hesitancy is one reason so many Texas children remain uninsured despite being eligible for state coverage. Some parents are confused by the application process; still others have tried and been rejected for procedural reasons.

Then there are the huge backlogs at the state level in reviewing Medicaid and CHIP applications.

One of the biggest impediments to enrolling eligible kids is the current “political environment around immigration,” said Marcie Mir, CEO of El Centro de Corazón, referring to state and federal policies, such as Gov. Greg Abbott’s 2024 order  requiring public hospitals to collect information about undocumented immigrants who seek treatment.

Even if their children do qualify, many immigrant parents don’t want to draw any attention from government officials, Mir said. Nearly half of Houston children are in a household with at least one immigrant parent, according to a 2023 report.

Months of waiting

The checklist that Maricela Delcid gives parents wanting Texas Medicaid for their kids is long and tedious: Social Security cards, birth certificates, lease contracts, child support records, utility bills, bank statements and two months of detailed income verification. The paper application is 33 pages.

Delcid is team leader for benefits assistance at Epiphany Community Health Outreach Services, or ECHOS, a Houston nonprofit that helps residents apply for public programs like Medicaid. Last year, the nonprofit assisted with about 1,400 applications for Medicaid or food assistance. Many of them families with mixed eligibility status, meaning parents might not be eligible for assistance but their children are.

Delcid is well acquainted with the Texas online benefits portal. She whips around the site with her mouse and keyboard, peppering clients with questions as she helps them apply. The system is confusing to most, she said, especially those who aren’t proficient in English or computer use.

The Medicaid application process confuses even medical students who visit the nonprofit to learn about challenges their clients face, said Cathy Moore, ECHOS’s executive director.

“We can all hear about it, but until you see how difficult it is, you don’t know,” she said.

On top of the application process, the waiting period for a decisioncan take many weeks longer than it should.

The bottleneck became so bad at one point that some families stopped trying, even though their kids were eligible, Delcid said.

In mid-September, the median statewide wait time for an eligibility determination for Medicaid was 83 days, state officials reported — longer than the 45-day federal limit. Delcid said that at one point last summer, the wait time reached more than 90 days. “I’d never seen anything like that,” Moore said.

As of Jan. 31, more than 244,000 applications for Texas Medicaid or CHIP were waiting to be processed, up from nearly 132,000 in late November, said Jennifer Ruffcorn, a spokesperson for the Texas Health and Human Services Commission. Applicants were waiting an average of 54 days for an answer.

The backlog has grown even after Texas HHSC dealt with major staffing shortages. By April last year, the agency had reduced its vacancy rate for eligibility advisors to 2.5%[21] , down from over 21% in March 2022. As of November, Ruffcorn said the vacancy rate was about 3.5%.

The long waits prompted the U.S. Centers for Medicare and Medicaid Services, or CMS, to open an investigation into the backlog last May.

At ECHOS, Delcid said wait times are back to normal — no more than 45 days. But the delays have hada lastingimpact, asit’s hard to convince families who got caught up in the backlog to try again, she said.

When wait times were much longer, some kids were rejected and their families told to re-apply — not because they were ineligible, but because the information they had submitted was too old to process by the time they reached the front of the line.

At that point, some families give up, believing the system doesn’t work, Delcid said. “It gets to the point that they’re hopeless. It’s a story we kept seeing.”

Delcid and Moore said they suspect the children who remain uninsured see a doctor only when they’re sick and don’t get all the preventive care experts recommend. Their families also risk being saddled with medical bills they can’t afford and that Medicaid would have covered.

In a statement to Public Health Watch in November about its investigation, CMS said it “continues to be actively engaged to bring [Texas] into alignment with federal requirements.”

Emails to CMS earlier this month about the probe’s status went unanswered. Ruffcorn at Texas HHSC confirmed the review was still ongoing.

A fast track to coverage

When Congress reauthorized CHIP in 2009, it included a new option for states — “express lane eligibility” — that made it easier for eligible kids to get covered. But first state lawmakers had to adopt it.

In Texas, State Rep. John Bucy III, an Austin Democrat, sponsored a bill to create an express lane in the 2023 legislative session.

The bill passed the House with bipartisan support. It was even endorsed by leading conservative groups such as the Texas Public Policy Foundation, an opponent of Medicaid expansion. But it died in the state Senate, where it never got a hearing.

“Increasing access [to health coverage] is such an uphill fight here,” said Bucy, who has introduced the bill again in the current session.

As of 2021, seven states had an express lane for children’s Medicaid; two had it for Medicaid and CHIP. The idea is that states use the information that families submit for other safety-net programs, such as the Supplemental Nutrition Assistance Program, to determine kids’ eligibility for Medicaid or CHIP.

Bucy’s bill requires parents’ permission before an eligible child is enrolled in Medicaid. But families wouldn’t have to endure another application process. Bucy said an express lane could reach hundreds of thousands of uninsured Texas kids who are eligible but unenrolled.

Research shows express lane laws for children have yielded significant coverage gains and administrative cost savings for states.

Alabama started express-lane eligibility in 2010 and has experienced such results, said pediatrician Marsha Raulerson, who is on the state’s medical advisory committee for Medicaid. “It’s rare a child doesn’t have access to health insurance here,” she said.

While Alabama has one of the country’s worst child poverty rates, just under 4% of children there are uninsured — about a third of the Texas rate.

In Texas, newer technology and more eligibility workers would help fix the state’s enrollment problems, the Texas HHSC said. In its 2026-2027 appropriations request, the agency wrote that without more funding, wait times for Medicaid applicants will “continue to fluctuate” and Texas will be unable to fully comply with the 45-day federal standard.

State lawmakers have responded with budget bills in the Texas House and Senate that include the $300 million that HHSC requested to meet federal waiting-time rules, said Mendoza at Texans Care for Children. If approved, he said the funding would help Texas Medicaid streamline its enrollment process.

But in Congress, Republican proposals to cut federal Medicaid funding could dampen efforts to insure more low-income kids.

Children face the brunt of such cuts, said Edwin Park, a Medicaid researcher at Georgetown University’s Center for Children and Families. As of October 2024, about 75% of Texas Medicaid’s 3.8 million enrollees were kids.

“In Texas, it’s mostly kids, seniors and people with disabilities on Medicaid,” Park said. “That’s where the cuts would hit. There isn’t anywhere else.”

Will uninsured rates keep rising?

Most of the people who rely on Hope Clinic, a community health center with five clinics in Houston, are immigrants and refugees. Its patients speak more than 30 languages.

Dr. Andrea Caracostis, the clinic’s CEO, said its staff is well versed in helping parents overcome application obstacles to Medicaid and CHIP enrollment for their kids. In Texas, children who are lawfully in the country are eligible for the programs.

But misinformed fears that applying will hurt a family’s immigration status persist and are a major reason children remain uninsured, Caracostis said.

“I have patients that I beg — I say ‘Please get on Medicaid. You have a complicated pregnancy, anything can happen, you’re going to rack up debt,’” Caracostis said. “And they won’t … They’re afraid of being perceived as a public charge.”

Under federal law, people deemed likely to become dependent on public assistance can be denied lawful permanent residence.

The policy doesn’t include Medicaid, but that changed under the first Trump administration. Biden rescinded the change, but policy experts expect it to return during Trump’s second term.

While Trump’s public charge change never applied to children, Caracostis said many parents remain confused and afraid to enroll anyone in the family.

According to Every Texan, fears about accessing public services in immigrant communities was likely the main reason for a 237,000 decline in children in Texas Medicaid and CHIP from December 2017 to February 2020.

Caracostis expects those fears to roar back. “There are lives at stake,” she said.

This story is part of “Uninsured in America,” a project led by Public Health Watch that focuses on life in America’s health coverage gap and the 10 states that haven’t expanded Medicaid under the Affordable Care Act.