Backsliding on Texas Children’s Health: More Uninsured, Fewer Enrolled in Medicaid and CHIP

/, Health care, Medicaid & CHIP/Backsliding on Texas Children’s Health: More Uninsured, Fewer Enrolled in Medicaid and CHIP

All Texans should have access to affordable, high-quality health care. This is especially true for children, who represent the future of our state and rely on today’s leaders to enact policies to keep them healthy and safe.  Ensuring that children can access health care without gaps in coverage is a modest and practical investment that will pay dividends for our state.

But Texas now has the worst rate of uninsured children in the country, according to the latest Census data available. An alarming 10 percent of Texas kids lack health insurance coverage.

Additionally, state Medicaid data from the Texas Health and Human Services Commission (HHSC) shows a decline in children enrolled in the Texas Medicaid program and the Children’s Health Insurance Program (CHIP) during 2018. These numbers suggest that our child health insurance coverage rate will likely continue this troubling downward trend when 2018 data becomes available.

Figure 1: Medicaid and CHIP Monthly Enrollment by Risk Group: CPPP analysis of Texas HHSC data accessed August 5, 2019.

Beginning in December 2017, child enrollment in both Medicaid and CHIP began to decline and has been declining ever since. As Figure 1 shows, approximately 154,500 fewer children were enrolled in Medicaid in April 2019 compared to December 2017. During this period, CHIP enrollment also declined by 47,200 children. Combined, Texas children enrolled in Medicaid or CHIP dropped by more than 201,700 children (about six percent) between December 2017 and April 2019.

Recent reports from the Georgetown University Center for Children and Families (CCF) and Families USA indicate that CHIP and Medicaid enrollment declines in 2018 were seen in a majority of states. Since December 2017, child Medicaid and CHIP rolls have decreased by 2.5 percent nationwide, with 870,000 fewer children enrolled by April 2019. According to CCF’s analysis, Texas had the largest number of children lose coverage, with Texas children losing coverage accounting for more than one-fifth of the nationwide decline.

Why Is Enrollment Declining?

Some Texas Health and Human Service Commission representatives suggest that the child Medicaid-CHIP enrollment decline may be due to improvements in the economy overall. However, there is little evidence that the large enrollment declines in 2018 in Texas and other states can be fully explained by improvements in wages and job growth. According to CCF, “historically, enrollment accelerates during economic downturns and slows, rather than declines, during periods of economic growth.”

The experience of Texas organizations engaged in helping families enroll in health coverage, combined with national research, suggest that children are dropping off Medicaid and CHIP coverage for a combination of reasons:

  • First, in recent years the state of Texas has done very little outreach to market the availability of Medicaid and CHIP. Federal outreach and enrollment support worsened after the Trump Administration cut funding for ACA marketing by 90 percent and decimated the grants for ACA Navigators.[i]
  • Second, anti-immigrant rhetoric and proposed policies of the current federal administration have created a chilling effect among mixed-status families (i.e. families that include both U.S. citizens and non-citizens). Reports of immigrants dropping their coverage and the coverage of their children (who are often U.S. citizens) for fear that participation in government programs will lead to deportation or have negative consequences on their ability to change their immigration status have surged in Texas and across the country. Among the most concerning of these policies is the proposed rule changing the definition of “public charge.”
  • Finally, Texas HHSC adopted particularly unforgiving policies for children enrolled in Medicaid that result in thousands of children being disenrolled from Medicaid every month due to red tape—without ever determining whether they remain eligible. While there are multiple and newer factors that are also discouraging enrollment, Texas’ eligibility policies create a compounding effect on the enrollment declines.

Experts have identified additional reasons why children’s enrollment in these programs is declining, but an overall theme emerges. Our Texan and national commitment to ensuring children’s access to health insurance has faded. Texas has taken this a step further and adopted policies that not only decrease the number of children who enroll but also increase the number of children churning off the program mid-year.

The data on the enrollment decline in children’s Medicaid and CHIP in Texas should be a cause for great concern. But there is good news: we know how to fix it (See full report). Texas lawmakers have, in the past, banded together and identified children’s coverage as a top priority. We can do that again. We know how to get health coverage to more kids, and it’s our responsibility to the next generation that we take these steps.


[i]While this funding was identified as support for ACA Marketplace enrollment, children of Marketplace-eligible adults often end up enrolling in Medicaid or CHIP. Plus, organizations receiving Navigator grants provide enrollment assistance for all programs.

Melissa joined the Center in 2015 and works remotely from Houston. She focuses on policy and practice related to outreach and enrollment for the Affordable Care Act (ACA) health insurance Marketplace, Medicaid, and the Children's Health Insurance Program (CHIP), including access to coverage for immigrants. Melissa has provided policy analysis, training, and troubleshooting guidance to health care enrollment assisters across Texas. Prior to joining the Center she worked as a Senior Policy Analyst for the Texas Health and Human Services Commission on the team that implemented eligibility changes to the Medicaid and CHIP programs required by the ACA. Melissa earned a Master of Science in Social Work from the University of Texas at Austin and a Bachelor of Science in Sociology from the University of Central Arkansas.