Austin (KXAN) — Several different attempts to expand Medicaid coverage did not materialize into law in Texas during the recently completed legislative session. Among those disappointed include groups that have been calling to expand health care coverage for women who could become pregnant, are pregnant or have given birth in the past year.  

Postpartum care legislation 

Despite a recommendation from a state task force to increase coverage for mothers during their first year after pregnancy, a bill that would have expanded Medicaid to women after pregnancy didn’t make it through the Texas legislature. 

HB 744 passed in the House but didn’t advance to a vote in the Senate. The bill would have extended Medicaid eligibility for mothers for a year after delivery. Currently, Texas mothers are only eligible for Medicaid for two months after delivery. 

In 2013, the state legislature formed the Texas Maternal Mortality and Morbidity Taskforce to review cases of maternal deaths. Their first recommendation was to extend access to health care coverage to mothers for twelve months after delivery. They found that the most common associated or contributing factor to maternal mortality was having an underlying medical condition, like diabetes, hypertension, or heart disease. Additionally, they found that preventative health visits are a “key opportunity” to decrease risk of morbidity or mortality for mothers. 

A significant increase in Texas’ maternal mortality ratio was reported from 2010 to 2012, but a corrected study found that ratio to be inaccurate and more than three times the actual rate. A second study also found maternal deaths that weren’t captured in the original count, observing a total of 56 maternal deaths in Texas in 2012. 

“Still, it’s very important for us to emphasize making sure we provide these women with excellent health after their deliveries and even before their deliveries,” said David Fleeger, a colorectal surgeon in Austin and President of the Texas Medical Association.

Fleeger explained that TMA was hoping the Texas legislature would extend Medicaid coverage for women twelve months after birth. 

“Because there are a significant number of women who die from 60 to 365 days, typically because of postpartum depression and suicide, substance abuse, the stress of having a new family can ultimately lead to their death,” Fleeger explained. 

But without that postpartum Medicaid expansion, Fleeger said the Texas Health and Health and Human Services Commission will instead use the Healthy Texas Women Program funded by the state to increase care for women in the year after they’ve given birth.

“We’ll need to work with HHSC to see what the benefit package will be because that still needs to be essentially put together,” Fleeger explained. 

He explained that the current Healthy Texas Women program would need to be expanded to include the kind of specialty care these women may be seeking, such as help from psychologists or behavioral help. 

“It’s a major concern that the women of Texas and the children of Texas don’t have an adequate health care safety net for us to be able to adequately take care fo them, we need to bring down the dollars from the federal government to be able to take care of them,” Fleeger said.

New research from the Georgetown University Health Policy Institute, Center for Families and Children shows that the percent of “childbearing age women” (18-44) who are uninsured is higher in Texas than in all other states.

Their findings show that in 2017, 25.5% of Texas women ages 18-44 were uninsured. While that rate is 6.7 percent lower than it was in 2013, it’s a smaller percent change than the nationwide total which decreased by 8.7% over the same period of time. 

The report also found that states which expanded Medicaid have seen larger reductions in maternal deaths and infant mortality.  The findings have leaders at both the March of Dimes and the American College of Obstetricians and Gynecologists calling for Medicaid expansion to protect the lives of mothers and babies. 

“We’re deeply disappointed that our state leaders have once again failed to support the health of Texas moms in low-wage jobs and the health of their babies,” said Laura Guerra-Cardus, Deputy Director of Children’s Defense Fund – Texas in a release.  “As this research shows, denying health coverage to so many Texas women has serious – and sometimes deadly – consequences for them
and their babies.”

But the Texas Public Policy Foundation, a right-leaning Austin-based think tank, believes Medicaid expansion — to support postpartum health or generally — is not the solution. 

“The intended purpose of Medicaid is to provide medical coverage to the most vulnerable of our population who are unable to obtain medical care otherwise,” Jennifer Minjarez, TPPF’s health care policy analyst explained in a statement. “While expanding Medicaid may incentivize some women to seek pre-natal healthcare, it will not expand the number of providers accepting Medicaid to treat these women.”

Minjarez said that more studies are needed to find out “whether expanding  Medicaid would have a significant impact on maternal health.”

David Balat, director of Right on Healthcare for Texas Public Policy with TPPF believes that people confuse coverage with health care. 

“Insurance is not health care and we need to start getting away from that thinking,” Balat said. 

He spoke from his previous experience as a hospital administrator, “I’ve seen the negative impact that Medicaid beneficiaries have.”  

“They have difficulty finding specialists that their primary care doctor wants to refer them to,” Balat said. “They have trouble getting the medications that their doctor feels that they need because the doctor has to go through a lengthy prior authorization requirement.”

“We need to reform Medicaid, we don’t need to expand it, it is a broken system,” he added

“There are a lot of things we’re going to try to do over the interim,” he noted, “Especially we’ll try to improve that especially in our Medicaid population,  getting direct primary care more prevalent, introducing even more telemedicine options.”

During the interim, the Texas Medical Association plans to continue pushing state leaders to curb maternal mortality rates, Dr. Fleeger said. They have a policy that says they would like more patients to have access to Medicaid, but they know the odds are against that happening. 

“We realize that Medicaid expansion through Obamacare is not a political reality within Texas,” Fleeger said. “At the same time [we] all pay taxes that go to the federal government and then the federal government gives them to California and New York  and allows them to use those monies to take care of their Medicaid patients.”

Fleeger said in the process Texas winds up not drawing down between eight and ten billion federal dollars each year.

“Our goal is that we don’t ever have to have one of our doctors walk out to a family and tell that family on what should be the happiest day of their lives that their mother had a complication and has died,” Fleeger said. “That’s our goal is to try and get rid of postpartum mortality, postpartum death postpartum injuries and ultimately, were going to keep working that until we’re successful and we want the state to help us every way they can.”

Medicaid related legislation 

Throughout the session, lawmakers in support of Medicaid expansion continually cited Texas as one of the 14 states that have not expanded Medicaid under the Affordable Care Act. Other states like Maine, Idaho and Utah have approved Medicaid expansions through voter initiatives. 

State Senator Nathan Johnson  (D- Dallas) filed a bill that would have expanded Medicaid eligibility through a voter referendum, but that bill it didn’t make it out of a House committee. Representative Celia Israel (D- Austin) also proposed a Joint Resolution that would have let voters decide whether to expand Medicaid, but that resolution didn’t make it out of House Appropriations Committee either. 

During state budget talks, Representative John Bucy (D-Cedar Park) laid out an amendment in the budget which would allow Texas to expand Medicaid coverage, but that failed too. 

“It didn’t pass, but it got more support than it’s ever gotten,” Bucy told KXAN. “I think it’s going to bring awareness back to that issue and the importance of bringing Medicaid expansion to this state for how it helps our economy and the people of Texas.”

The Children’s Health Coverage Bill which tried to prevent low-income children from losing Medicaid coverage did not make it to a vote in the house.