Analysis Health Systems

One Million Low-Income Texans Fall Into ACA ‘Coverage Gap,’ With No Help in Sight

Andrea Grimes

Texas Gov. Rick Perry continues to refuse a federal Medicaid expansion, leaving an estimated one million working Texans without access either to Medicaid or federal insurance subsidies.

Click here for all our coverage of the health insurance exchange rollout as part of the Affordable Care Act.

“Sorry. I’m sorry. Sorry.”

This is Ruben Garza’s refrain when it comes to the Affordable Care Act (ACA) rollout in South Texas, where he works as a community organizer with the Texas Organizing Project (TOP), educating Texans in the Rio Grande Valley about the benefits of the new federal health-care law.

The trouble is, he says, those benefits don’t apply to two-thirds of the residents in Hidalgo County, where most people are not poor enough to enroll in Texas’ Medicaid program but also do not make enough to qualify for subsidized insurance through the ACA. Because Texas continues to refuse funds for a federal Medicaid expansion that would have paid to cover those Texans who make up to 100 percent of the federal poverty level, the point at which federal subsidies are available for health insurance coverage, an estimated one million Texans are ineligible both for Medicaid and a federal insurance subsidy.

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This is the so-called coverage gap. Think of the ACA as a free federal car that states have to drive, but they can opt out of getting one with seat belts. The seat belts are paid for, just as the Medicaid expansion is paid for. But the State of Texas wants the car without seat belts, because state leaders believe seat belts would limit their freedom.

The Medicaid expansion, which would have covered Texans who make up to 138 percent of the federal poverty level, is an integral part of Obamacare’s design, says Anne Dunkelberg, associate director at the Center for Public Policy Priorities.

“The ACA is written with the assumption that the poorest uninsured really need to have a different kind of system,” Dunkelberg told Rewire, “because they can’t afford the kind of cost sharing that a traditional insurance model requires.”

Back in 2012, when Gov. Rick Perry first started making noises about refusing the expansion, public health experts had a hard time believing Perry wouldn’t ultimately take the federal funds, saying it was just too good a deal to pass up.

“If you smooth it out over time, it’s a 90 percent federal match for services for a huge amount of low-income residents, but it’s also for city and state governments, nonprofits, health-care agencies, hospitals,” the University of Chicago’s Dr. Harold Pollack told Rewire in the summer of 2012.

But now the health insurance marketplace is live, and Texas has adamantly refused not only the Medicaid expansion, but a modified so-called Texas Solution to the Medicaid problem that was proposed during the last legislative session by one of its most conservative state lawmakers.

In a state that already has some of the most stringent Medicaid eligibility requirements, and where nearly a quarter of residents are uninsured (Texas has the highest rate of uninsured adults in the entire country), Texans are swiftly falling into the coverage gap.

In numbers, this means families of three who make more than about $3,700 per year but less than about $20,000 per year will see no change in their ability to afford health insurance under Obamacare. And Texas won’t enroll any childless adults under 65 in Medicaid, period. That means any individual making less than about $11,500 per year qualifies neither for Medicaid nor for an ACA insurance subsidy. In fact, the only people who qualify for Medicaid in Texas are poor children, pregnant people, some disabled adults, and the state’s very, very poorest parents—parents who make no more than 15 percent of the federal poverty level.

That’s why Garza can only say, “Sorry.”

“People are confused,” said Garza. “When you explain why they don’t qualify, they say, ‘Wait a minute, I’m too poor to get help? That doesn’t make sense.'”

And indeed, financially it doesn’t make sense. From a public health policy perspective, it also doesn’t make sense. But politically, it makes plenty of sense to Gov. Perry, who has railed against what he calls the “Orweillian” ACA in an effort to cast himself as a right-wing hero fighting against the evils of federal government. If that means one million Texans continue to live without health insurance so Perry can tell his most conservative supporters he did all he could to keep the tide of Obamacare at bay, that is a price Perry and his fellow Republicans are willing to pay.

Who are the Texans who fall into the coverage gap? They’re folks who Anne Dunkelberg describes as “a lot of the people you think of as the real backbone of working Texas.”

Broadly, they are the people who take care of our grandparents in nursing homes. They are the restaurant cooks, servers, and dishwashers who make date nights possible. They are the construction workers who frame and roof our new homes. They are the housekeepers who pick up after us in hotel rooms. They are the people trying to make sense of our 2 a.m. burger orders at the drive-thru window. They drive us to work every morning on public buses, and they are the folks who ring up our new jeans at the mall. And an estimated 66,000 are veterans who have served in the United States armed forces.

They work the longest, hardest hours at some of the most physically demanding, and economically unrewarding, jobs in the state. They are people like 22-year-old Rio Grande Valley resident Ash Estevan, who lives in Pharr, a small town close to Reynosa, Mexico, where she says she’s been going for health care since she became uninsured at age 19.

Unable to get health insurance through her retail job, working overnights stocking merchandise, but too poor to qualify for an Obamacare insurance subsidy, Estevan told Rewire that “every day is pretty much just a gamble” when it comes to health care. She lives at home with her parents, who she says cannot afford to include their entire family on the “ridiculously expensive” health insurance offered through their employers.

Texas families, especially single-parent households, are the ones who will be hardest hit by the coverage gap.

Imagine a 22-year-old single person with no dependents, working full-time, 52 weeks each year, for minimum wage in Texas. That person earns $15,080 before taxes, putting her at 131 percent of the federal poverty level. According to the Kaiser Family Foundation’s subsidy calculator, that person is eligible for bronze-level ACA coverage at no cost. Their health insurance, after a subsidy, would be free.

But again, Texas Medicaid will only cover certain adults, specifically some disabled people, pregnant women, and, only if they make no more than 15 percent of the federal poverty level, parents. To put that into perspective: A single adult raising one child in Texas who makes more than about $2,400 per year makes too much money to qualify for Medicaid in the state. That person’s child is covered through the Medicaid Children’s Health Insurance Program, but the parent is not.

So if a single-parent Texan making $2,500 per year seeks health insurance in the new marketplace, her yearly insurance premium is estimated to be $1,250, because she is not eligible for a government subsidy to purchase insurance. That’s almost exactly half of that person’s entire yearly income. And if that same single parent works full-time for minimum wage, she’ll make $15,080, but her premium will still be $1,250, for which she would receive no federal subsidy to purchase the same insurance that her single counterpart gets for free.

When coupled with the fact that conservative Texas lawmakers have spent the last two legislative sessions dramatically reducing access to affordable contraception and reproductive health care, the inequality that is manifest in the coverage gap becomes even more stark. Not only have Texas legislators put some of the state’s poorest parents in a terrible position—asking them to decide whether they’d like to spend $1,250 on health insurance or, say, diapers, day care, groceries, or rent—they have also explicitly and intentionally removed the best, most cost-saving, and efficient ways for Texans to be able to decide when and whether to have children by slashing family planning funds and cutting Planned Parenthood out of the hugely successful, and now effectively defunct, Medicaid Women’s Health Program.

“The single best way for us to ensure access to family planning for Texas women at all income levels is to make sure that they have comprehensive health care,” said Anne Dunkleberg at CPPP. “And the current Texas system doesn’t do enough to help women safely space their children.”

Down in the Rio Grande Valley, Ash Estevan says it’s the “disappointment, above all, that just eats at [her],” when she thinks about how simple it would be for Texas to take the Medicaid expansion. But she says state lawmakers don’t listen to people like her.

“It doesn’t matter how many emails you write, how many rallies you go to,” she said. “At the end of the day, when you see you’re not being helped by your government, it’s a big letdown.”

If Rick Perry continues to dig his boot heels in against Obamacare, refusing the $7 billion or so in federal funds that are on the table for his state, the poorest uninsured Texans will continue to do whatever they can do to get health care, whenever they can afford it. For Ash Estevan, that’ll mean crossing the border to see her doctor in Reynosa. For others, that will mean going to the emergency room, whether or not they can pay the bills, and costs will be passed on to Texas taxpayers.

Ruben Garza says many people in his community already feel forgotten by the rest of their sprawling state, especially by lawmakers in Austin, the state capital. The coverage gap is just the latest, most tangible manifestation of the ways in which Texas’ poorest citizens are pushed aside. Garza saw them frequently at workshops led by the Texas Organizing Project about the ACA.

“It’s something that is challenging for me as an organizer, knowing that most of the people I come into contact with aren’t going to qualify for these subsidies,” said Garza.

They ask themselves, says Garza, “Why did I show up to that workshop?” But because he says “there’s no logic” in Texas’ refusal of the Medicaid expansion, only politics at play, there’s little he can tell them.

“It’s just such an emotional toll that people go through, it’s really overwhelming,” he said. “In the state with the most demonstrated need, it really puts in perspective how massive this problem is. There’s nothing coming their way.”

But part of what the TOP does is voter education, and a change in top-level state leadership may be the only way to get the Medicaid expansion, or some similar “Texas Solution,” happening on the ground in the state. Ash Estevan says she’s counting on it and intends to volunteer with TOP in the future.

“It’s like a real ugly punch to your gut,” says Estevan, when state leaders “shrug their shoulders and be like, ‘Well, we don’t want [the Medicaid expansion].’ It’s not a matter of if they want it or not. It’s what the people need.”

Analysis Law and Policy

The 36-Year-Old Abortion Rights Case Emerging Again in ‘Whole Woman’s Health’

Jessica Mason Pieklo

When the Supreme Court considers the constitutionality of Texas anti-abortion regulations it will look as much to the case that upheld the Hyde Amendment as it will the undue burden standard of Casey.

Read more of our coverage of Whole Woman’s Health v. Hellerstedt here.

As the Supreme Court considers Whole Woman’s Health v. Hellerstedt, the case challenging provisions of a Texas law that has decimated abortion access in the state, much of the media attention has turned to the legacy of Planned Parenthood v. Casey. The 1992 Casey decision, while reaffirming the constitutional right to an abortion, also brought us the famously nebulous “undue burden” standard that the Roberts Court is revisiting in Whole Woman’s Health. But focusing so much attention on Casey is leaving out a crucial piece of the equation: The Texas abortion rights case is much more about the Hyde Amendment and Harris v. McRae, the Supreme Court case that held Hyde constitutional, than it ever was about Casey, no matter what legal standard is before the Roberts Court. 

In 1965, Congress established the Medicaid program via Title XIX of the Social Security Act, in order for the federal government to offset the costs to states of medical treatment for low-income individuals. In 1976, just three years after Roe, Congress first passed the Hyde Amendment, a budget amendment that severely limited the use of federal funds to reimburse the cost of abortions under the Medicaid program. Put more simply, most people on Medicaid cannot use their insurance coverage for abortions, except in the rare cases of rape, incest, or their own life endangerment.

Cora McRae, a pregnant Medicaid recipient, challenged the amendment and took action against Patricia R. Harris, secretary of Health and Human Services. Her lawsuit made it all the way to the Supreme Court, which ruled in a 5-4 decision that the right to an abortion may be fundamental, but that doesn’t mean the government has to make that right affordable.

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“Regardless of whether the freedom of a woman to choose to terminate her pregnancy for health reasons lies at the core or the periphery of the due process liberty recognized in [Roe v.] Wade, it does not follow that a woman’s freedom of choice carries with it a constitutional entitlement to the financial resources to avail herself of the full range of protected choices,” the majority in Harris held. “Although government may not place obstacles in the path of a woman’s exercise of her freedom of choice, it need not remove those not of its own creation, and indigency falls within the latter category.”

“The Hyde Amendment … places no governmental obstacle in the path of a woman who chooses to terminate her pregnancy, but rather, by means of unequal subsidization of abortion and other medical services, encourages alternative activity deemed in the public interest,” the Court continued.

In effect, what the Court held in Harris is that the Hyde Amendment is constitutional because the obstacle for poor women accessing abortion is their poverty, not the fact that their government-funded health insurance refuses to cover the procedure. It continued:

The financial constraints that restrict an indigent woman’s ability to enjoy the full range of constitutionally protected freedom of choice are the product not of governmental restrictions on access to abortions, but rather of her indigency. Although Congress has opted to subsidize medically necessary services generally, but not certain medically necessary abortions, the fact remains that the Hyde Amendment leaves an indigent woman with at least the same range of choice in deciding whether to obtain a medically necessary abortion as she would have had if Congress had chosen to subsidize no health care costs at all.

It takes a great deal of mental gymnastics to distinguish between abortion being inaccessible because a woman is poor, and abortion being inaccessible due to restrictions on government assistance for health care to the poor. But the conservative majority in Harris did just that: It refused a serious examination of the systemic barriers low-income women face to accessing reproductive health care and insisted that poverty, not government obstruction, was the hurdle to low-income women having their right to an abortion respected by the courts.

Fast forward more than 30 years, and the Supreme Court is once again looking at roadblocks to abortion access. ​As in Harris v. McRae, the roadblocks in question disproportionately affect low-income women, especially women of color. But instead of government-created financial barriers to having an abortion, the Court will address certain government-created physical barriers to having an abortion, in the form of targeted regulation of abortion providers (TRAP) laws. The question is whether the Court will again allow the government to refuse to take responsibility for those barriers.

In addition to Texas, 23 other states have TRAP laws that single out abortion doctors and clinics for heightened regulation. Before the Supreme Court in Whole Woman’s Health are two provisions of Texas’ HB 2, the monster anti-abortion omnibus bill that also includes restrictions on medication abortions and a 20-week ban. One provision before the Court requires an abortion clinic to be outfitted with the same physical and professional requirements as stand-alone surgical centers, even if the clinic performs medical, rather than surgical abortions. That provision is currently blocked from being enforced in Texas, thanks to a temporary Supreme Court order.

The second provision before the Court requires any doctor performing abortions in clinics in the state to have admitting privileges at a hospital within 30 miles of the clinic. That part of the law is in effect in most of the state, after extensive previous litigation.

Depending on how the Court rules later this year, the impact of Whole Woman’s Health could have national reach, but will fall hardest on the poorest and most vulnerable in this country.

“The clinic shutdown laws in Texas don’t just impact women in Texas,” Marcela Howell, founder and executive director of In Our Own Voice: National Black Women’s Reproductive Justice Agenda, said in an interview with Rewire. “And specifically for Black women, so many of those laws exist in other southern states. So we are looking at the impact on Black women in Texas, but also on Black women in the entire South, and across the entire country in places like Wisconsin.”

“We are looking at more than 12 million Black women [potentially affected] if you look at the other states where these laws also exist,” Howell said.

“These laws are designed to impede women. And for Black women in particular these laws are just piling on to the history of Black women being disproportionately impacted by laws that supposedly help us, but don’t,” Howell continued, referring to conservatives’ frequent claims that TRAP laws are instated for patient safety.

Howell connected HB 2’s provisions—which, if allowed to stand, would close all but ten clinics in the entire state, according to advocates—to the specific legacy of the Hyde Amendment and the Court decision upholding it.

“The restrictions [in Hyde] were really targeted at Black women because [Rep. Henry Hyde (R-IL)] was looking at low-income women and stopping them from getting abortions, and those were disproportionately Black women at the time,” said Howell.

Once those public funding restrictions were embraced by the Court, conservatives jumped to pronounce them the “law of the land,” despite the fact that the Hyde Amendment is subject to renewal with each budget cycle. So the Hyde Amendment is not, in fact, the law of the land. It is simply a budget preference that has resulted in decades of systemic discrimination.

Howell tied across-the-board challenges for Black women in accessing comprehensive reproductive health with this latest round of attacks on abortion rights.

“You have Black women who are already systemically denied resources and services around health care … And so when you look at those kinds of things and then you look at Texas and you say, well, Black women already have difficulty accessing health care for a number of different reasons,” said Howell. “A large portion of them are in jobs that don’t provide employer-sponsored health care, therefore they have to rely on Medicaid or other sources to get their health care. Or they end up going to the emergency room when they need care.”

In Texas specifically, it is hard not to draw the conclusion that HB 2’s TRAP provisions were designed to target low-income patients. The omnibus law came on the heels of Texas conservatives dismantling the very successful Women’s Health Program, the state’s previous family planning program for low-income Texans.

“HB 2 has been a disaster, quite frankly,” said Jessica González-Rojas, National Latina Institute for Reproductive Health executive director, in an interview with Rewire.

“Latinas make up a majority of women of reproductive age in Texas. We make up 2.5 million women of reproductive age. Many in our community are low-income or live in rural communities or are undocumented or are legal permanent residents or don’t speak English fluently,” González-Rojas said. “So there are many roadblocks we encounter already in terms of accessing basic reproductive health care. When you layer in what’s happening with HB 2, especially in areas like the Rio Grande Valley, it serves as a total de facto ban on abortion.”

As González-Rojas explained, the Rio Grande Valley is full of border towns and communities that are unincorporated. These communities lack a lot of basic infrastructure. Many don’t have running water. Very few, if any, have access to public transportation.

“If the law stands and the Whole Woman’s Health in the Rio Grande has to close, what that means is that women in the Rio Grande Valley would have to drive up [to] and over 200 miles to get to the next nearest clinic, which is in San Antonio,” said González-Rojas. “That means taking time off work, and again, many of them are in jobs that don’t have paid time off or other worker protections. They would have to scrape up the money for the procedure, scrape up money for gas. They would have to stay somewhere. Some would have to sleep in their car.”

“And they would have to cross a border checkpoint,” González-Rojas said.

Federal courts might not look at crossing a border checkpoint as a big deal, but for many women of the Rio Grande Valley, it is a frightening prospect, at the least.

“The first thing you see at that border checkpoint is how many ‘aliens’ have been accosted and how many drugs have been seized. And then you have this very intimidating immigration officer asking for your papers, and where you are going,” said González-Rojas.

“For women in the Rio Grande Valley, even for those who have citizenship or permanent resident status there is such a climate of fear when we are also facing a really harsh and hostile immigration environment to take that risk and to go north, even if they could scrape all the resources to do so,” González-Rojas said.

Texas’ omnibus anti-abortion law, if it stands, will effectively shut down access to the constitutional right to reproductive health care for women all over the state. But similar to the reasoning used by the conservative justices in Harris v. McRae to determine that it was poverty, not insurance restrictions on abortion, that created roadblocks to care for low-income women, the conservative Fifth Circuit recently ruled that it was patient safety concerns, not the overall anti-choice sentiment expressed by conservative politicians, that prompted TRAP laws like HB 2.

In upholding both the Texas regulations and similar Louisiana ones more recently, the Fifth Circuit expressly stated that it was not the job of the courts to second-guess anti-choice lawmakers when they say their abortion restrictions advance patient health—even if the evidence clearly demonstrates that those laws harm patients. As far as the Fifth Circuit is concerned, those promises by conservative lawmakers are enough.

The fact that clinics have been closing left and right as a result of “patient safety” regulations routinely rejected by mainstream medical organizations as bad for patient safety is not because of a government-created roadblock, HB 2 supporters claim. It’s because there’s an overall drop in demand in the “abortion marketplace.” It doesn’t matter that forcing patients to travel hundreds of miles to access reproductive health care demonstrably drives down patient care, supporters of HB 2 state. These regulations are for the benefit of women. Trust us, the anti-choice politicians say.

It’s impossible to know right now whether the Supreme Court will, once again, bite on this kind of circular logic the way it did in Harris and hold that laws passed by the state to close clinics are not, in fact, government-created obstacles to getting an abortion. And given that the current makeup of the Roberts Court is incomplete until a replacement for the recently deceased Justice Antonin Scalia is named and confirmed, an outcome in Whole Woman’s Health is nearly impossible to predict.

But if history is to be any guide, then the fact that the impact of these TRAP laws falls heaviest on poor women of color should give us pause. Because rarely, if ever, have women of color found a sympathetic majority of Supreme Court justices.

Let’s hope this time, and this case, it’s different.

News Abortion

Obamacare Still Falls Short for Abortion Coverage

Jenn Stanley

Though Obamacare was supposed to expand reproductive health coverage, state and federal policies have continued to make it difficult for women in many states to secure abortion coverage.

The Affordable Care Act (ACA) was supposed to make reproductive health care more accessible, but long-standing federal and state policies and a wave of anti-choice state laws have made comprehensive abortion coverage a pipe dream for many women in the United States.

The ACA mandates certain reproductive health services, like contraception, in every state’s marketplace plans. But the landmark federal law left the availability of abortion coverage up to the states. Twenty-five states opted to partially or completely ban abortion coverage, either prohibiting it or limiting it to cases of rape, incest, or when the woman’s life is endangered, according to a newly released analysis by the Kaiser Family Foundation.

California is the only state that requires all private insurance plans, including individual and employer plans, to treat abortion coverage the same as it treats other maternity coverage. Washington state has tried and failed to pass similar legislation each year since the ACA, also known as Obamacare, took effect.

Every ACA marketplace is required to have at least one multi-state plan that excludes abortion coverage by 2017. A multi-state plan is a private health insurance plan sold through the ACA marketplace under a contract between the U.S. Office of Personnel Management (OPM) and an insurance company, according to In Hawaii and Vermont, every ACA marketplace plan includes abortion coverage because there are no multi-state plans yet available.

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The analysis found no recent data on the number of private plans that include abortion coverage. Some believe that the intense political scrutiny of the ACA has made it even harder for women to find plans covering abortion, as Republican state legislators and governors have fought fiercely against full implementation of the program.

“Going into the focus on abortion coverage and debate on the Affordable Care Act brought to light that [private] plans were covering abortion,” said Kelly Garcia, senior counsel for the National Women’s Law Center. The result, she told U.S. News and World Report, is that fewer private plans are now covering abortion.

Since the Hyde Amendment went into effect in 1977, federal law has prohibited the use of federal funds for abortion except in cases of rape, incest, or when the life of the woman is in danger. The law has been attached annually to congressional appropriations bills, and Congress has approved it each year.

When Democratic presidential hopeful Hillary Clinton accepted Planned Parenthood’s endorsement this month, she condemned anti-choice legislation, including the Hyde Amendment, for the burden it places on people seeking abortion care.

Any right that requires you to take extraordinary measures to access it is no right at all. Not when patients and providers have to endure harassment and intimidation just to walk into a health center. … Not when providers are required by state law to recite misleading information to women to shame and scare them. And not as long as we have laws on the book like the Hyde Amendment making it harder for low-income women to exercise their full rights.

Medicaid programs in 33 states and Washington, D.C., do not pay for abortions beyond the Hyde Amendment, according to the analysis. Seventeen states use state-only funds to pay for abortion care that falls outside of Hyde Amendment regulations for women on Medicaid.

No plan is required to cover abortion under federal law, and at least one multi-state plan in a state’s marketplace must exclude abortion. Though most states include exceptions for rape, incest, and when a woman’s like is in danger, Louisiana and Tennessee do not.

The ACA has insured many formerly uninsured Americans. One way it’s done that is through its Medicaid expansion. Under the ACA, states can opt to expand Medicaid to low-income adults with no children living at home.

But 20 states have not implemented that expansion, according to the analysis, so people in these states who don’t meet traditional Medicaid eligibility and whose incomes are below 100 percent of the federal poverty level are not eligible for Medicaid and do not qualify for marketplace subsidies. That has created a coverage gap, according to the analysis.

Some GOP governors have expanded Medicaid access after fighting against health-care accessibility for several years. Alaska Gov. Bill Walker, a Republican turned Independent, moved ahead with Medicaid expansion last summer despite protests from his state’s GOP-majority legislature.