One day, Alexandria Robertson's carefully crafted life suddenly started falling apart.
Watch which benefits will disappear when Biden ends COVID-19 national and public health emergencies in May in the video player above.
She returned from vacation in January 2020 to learn she'd been laid off from her corporate job in the Austin area. Her car was totaled in an accident. At the same time, she found out she was pregnant with her first child.
"I was pregnant. I had no job. I had no car. And I had no health insurance," Robertson said. "I, at the time, just did not have money for the expenses of having a baby."
Robertson qualified for Medicaid, but since Texas is one of just 11 states that haven't expanded the program, she would be covered only up to two months after childbirth.
But then, just a few weeks later, COVID-19 descended on the United States. For the length of the public health emergency - which turns three next month - no one would be moved off of Medicaid.
Robertson accessed crucial health care during and after pregnancy - and straight through her next pregnancy.
"As mothers, we know we need health care, we know we should be taking care of ourselves, but it's so expensive," she said. "It just put me at ease to have that covered, and my second pregnancy was the best one I've had."
The public health emergency allowed almost three million Texans - mostly children, young adults and new moms - to access consistent health insurance. But now, Congress is bringing this experiment in Medicaid expansion to an end. In April, the state will start moving people off of Medicaid for the first time since March 2020.
For many patients and providers, though, it's hard to imagine going back.
"If you are afforded a window, however long that window is, where you know you can get care anytime you need it, it completely changes your perspective on health," said Dr. Vian Nguyen, chief medical officer at Legacy Community Health, Texas' largest federally qualified health center. "We're seeing our patients want to come back. We're seeing that mindset shift."
Three years of coverage
While navigating a layoff, pregnancy, and a global pandemic, Robertson connected with Any Baby Can, an Austin-area nonprofit, and nurse Wiltse Crompton.
Crompton helps first-time moms like Robertson navigate the first two years of their child's life, through the nurse-family partnership. For many low-income moms Crompton works with, pregnancy is the first time they get on health insurance as adults.
It's then that many of her clients learn about other diagnoses, like diabetes and high blood pressure, which require long-term care. The pregnancy itself may introduce or exacerbate health concerns, like gestational diabetes or postpartum depression.
But typically, two months after childbirth, right when they started to get consistent with treatment, these moms would lose Medicaid. Crompton helped where she could, but the state's patchwork of free and low-cost services was a weak facsimile of full health care coverage.
"It's just so hard to be a new mom and take care of a baby, and then on top of that, you don't feel well or you're worried about other things," Crompton said. "To me, if mom's health is good and she feels good, then that's going to make a big difference in that baby's health."
The last three years, though, have been a sea change, Crompton said. One client had been in and out of the hospital for untreated Type 1 diabetes.
"Obviously, once the baby's born, she still has Type 1 diabetes, and she still needs insulin," Crompton said. "So for her, it was literally lifesaving that she got pregnant and then because of COVID was able to stay with the continued Medicaid coverage."
Crompton's also seen more moms take control of their fertility and family planning. Before, if these women missed their six-week postpartum checkup due to transportation or childcare issues and couldn't reschedule before their coverage expired, they'd often miss their chance to access long-acting reversible contraception, like an IUD.
If they did get on birth control, Crompton said, "you better like the one you get, because you can't switch without having to pay out of pocket and it can be really expensive."
The continuous coverage has also allowed many women, like Robertson, to maintain health insurance in between pregnancies. At Parkland Health and Hospital System in Dallas, they've noticed moms and babies are coming into pregnancy and childbirth healthier than ever, said Marjorie Quint-Bouzid, the senior vice president for women's and infants specialty health.
"Typically, people will just fall off because they don't want to engage if they're not sure how they're going to pay for their medical care," Quint-Bouzid said.
If they can't manage chronic conditions or access early prenatal care, she said, "that (next) pregnancy is now significantly high-risk, at significant cost to the system and even potentially their life or the life of the child that they're carrying."
Quint-Bouzid said continuous coverage incentivized the entire healthcare system to engage with pregnant and postpartum women more fully.
"When a woman typically could not afford to make (follow-up) visits, there was the barrier to care," she said. "As clinicians, we've been able to see some of the benefits and the value of really designing programming that looks beyond that one postpartum visit."
At Legacy Community Health, Nguyen said about 60% of their patients typically had returned for a six-week postpartum checkup. Now, it's more than 75%, and many of these patients continue to access a wide array of physical and mental health services long after the typical two-month coverage period.
The great unwinding begins
Almost since the public health emergency went into effect in March 2020, healthcare providers, advocates, and the state braced for the day it would expire.
Three years later, that day has arrived. While the full public health emergency expires in May, continuous Medicaid coverage ends even sooner, at the end of March.
States have 12 months to determine who still qualifies for Medicaid. But the Texas Health and Human Services Commission created an ambitious plan to complete the process in just six to eight months.
Health advocates have raised concerns about this timeline, especially with agency staffing shortages. HHSC is short more than 300 "eligibility advisors," who help process benefits applications and renewals, a vacancy rate of 6.35%. This is down from more than 20% in April 2022, the agency said.
The short-handed agency is also dealing with a 68% increase in Medicaid applications during open enrollment in 2022 compared to the same period in 2019. In January 2023, about 70% of Medicaid applications were processed "timely," within 45 days, up from only about 50% in September.
The agency is making a significant hiring push by raising salaries, offering merit bonuses, allowing flexible work schedules and pushing overtime to keep up with the increased demand.
The state is urging people on Medicaid to ensure their information is up to date at YourTexasBenefits.com and to respond to renewal notices from the state.
"After nearly three years, families are rusty at completing the renewal process, and many families have moved to a new home," Stacey Pogue, senior policy analyst at Every Texan, a health care advocacy group, said in a press release. "We need all hands on deck to make sure Texans know how to update their addresses with the state and renew their health coverage."
In addition to existing programs that allow community organizations to help Texans access benefits, HHSC created the Case Assistance Affiliate program, which allows Medicaid managed care plans to directly assist with redetermination. Jamie Dudensing, the CEO of the Texas Association of Health Plans, said she hopes this cuts through some red tape.
"If you have a problem with your insurance, who do you call? Your insurance company," she said. "We already have always been the first people they call, even though we've never really been responsible for eligibility. Now, we can actually log in ourselves and we can set up a (virtual) visit with them and go through this entire application together."
The state intends to start with people who most likely no longer qualify for Medicaid, including young people who aged out and postpartum women. Many will instead qualify for state programs, like Healthy Texas Women and the Children's Health Insurance Program, or low-cost plans at HealthCare.gov.
A lot of Texans will have to navigate new paperwork, figure out whether they qualify for new programs and potentially find new healthcare homes as they roll off of Medicaid. Even as they work to make the process as smooth as possible, healthcare providers - especially those who treat low-income Texans - are prepared for the impact this will have on the whole healthcare system.
"It's not that the mom doesn't get the care," Nguyen said. "The domino effect is on all of us trying to scramble to make sure she gets the care regardless."
And after three years of saying "yes" a lot more, Nguyen said it's hard to return to the old reality.
"It's a very heavy burden for health care providers to carry when they see someone in front of them who needs something, and they feel like they can't help them," she said. "When we talk about physician burnout and nurse burnout, it is, of course, around the hours, but it really is more of the mental component of feeling like you just cannot help when that's what you signed up to do."
During the last legislative session, in the throes of the public health emergency, the federal government offered states a way to easily expand Medicaid for pregnant women from two months to 12 months postpartum.
It passed the Texas House with bipartisan support, but the Senate cut the proposal down to six months. That required Texas to apply for a waiver, which the feds said is "not approvable" in its current form.
This session, as continuous coverage and other pandemic-era provisions expire, there's broad bipartisan support for the 12-month extension. House Speaker Dade Phelan has said it is a top priority for his chamber; Lt. Gov. Dan Patrick did not respond to a request for comment.
Beyond that, though, it seems unlikely as ever that Texas will expand Medicaid more fully. Texas is in the small - and dwindling - minority of states that has resisted the expansion, turning down billions in federal funding in the process.
More than a million additional Texans would qualify for health insurance if the state fully expanded Medicaid. But conservatives have challenged the Affordable Care Act since its inception, arguing that it's poorly managed, financially unsustainable, and encourages government dependence.
In 2021, a proposal called "Live Well Texas," which proposed expanding Medicaid, increasing reimbursement rates and incentivizing participants to work, died despite broad bipartisan support.
For Robertson, having access to Medicaid after childbirth made all the difference in the world. She was able to stay home and breastfeed without worrying about immediately getting a new job with affordable health benefits.
"As a mom, as a woman, I got to take some time to get myself back together and to then put my heels on and get back to work," she said. "That time really allows a mother to get back on track, get herself back into the workforce, and get herself out of poverty."
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