By Nicole Rodriguez-Robbins

The state of Texas has among the highest rates of uninsurance in the country, with 24% of the state’s residents uninsured in 2011-2012[1]. The ACA was intended to expand coverage both by offering market plans and closing the coverage gap via Medicaid expansion, with the federal government financing the full cost of the Medicaid expansion for the first three years (2014-2016); after that, the federal government’s share of costs will phase down, reaching 90% in 2020[2]. While an estimated 1.85 million uninsured adult Texans would have been eligible for Medicaid under the ACA, the state has opted not to expand Medicaid, leaving an estimated 1.7 million without coverage[3].

An October, 2013 policy brief from the Geiger Gibson / RCHN CHF Research Collaborative “Assessing the Potential Impact of the Affordable Care Act on Uninsured Community Health Center Patients: A Nationwide and State-By-State Analysis” outlines the impact in those 26 states that were not planning to go forward with Medicaid expansion. The authors found that 501,327 Texas CHC patients were uninsured in 2011[4], and estimated that only 170,451 of those would be eligible for coverage with no Medicaid expansion. The cost to health centers is staggering; with expansion, Texas CHCs stood to gain about $180,192,888 in revenue, but with expansion blocked, the centers will receive about half that amount[5]. This creates a huge challenge for health centers as they seek to expand access to quality services in their communities.

I got one insider’s perspective from Lupe Vela, the Community Services Coordinator at Community Health Development, Inc., (CHDI) a community health center in Uvalde, Texas. Prior to joining CHDI in April 2013, Mr. Vela served as coordinator of the ACA outreach and enrollment efforts for the State’s regional Medicaid office in San Antonio. These two roles have provided him a unique perspective on how the first enrollment period played out in the state, which he graciously shared with me.

CHDI’s outreach and education efforts occurred in the midst of a difficult state backdrop. First, glitches and confusion with the Health.Gov website, resulted in significant delays. According to Mr. Vela, the San Antonio regional Medicaid office had to process over 65,000 applications within a two-week period. The CHDI Outreach and Enrollment team, made up of three Certified Application Counselors (CACs), made over 2,400 direct contacts and enrolled approximately 825 individuals in Medicaid or marketplace exchange insurance plans. Just over 1,000 contacts didn’t qualify for Medicaid or CHIP and did not reach the income level to qualify for a tax rebate if they signed up for one of the exchange plans, landing them in a “coverage gap.”

A big role of the CACs was related to general education about the healthcare system and insurance coverage. In the local community, health insurance is a new concept for many residents, who are gaining coverage for the first time. They are unfamiliar with the system and some of the terminology and, for example, do not know what copay or a deductible is, or how that figures into their overall cost. Many community members who tried to enroll were ineligible for Medicaid since they made too little money and were unable to afford the premiums for the health exchange insurance plans. According to CHDI staff, many more may not have tried to apply for coverage, because of misconceptions about the ACA and the insurance application process. Staff reported that many health center patients were complacent about enrolling in marketplace insurance coverage. Because they were used to accessing services at the center at a sliding scale fee, they didn’t see the value in also paying the cost for insurance. Enrollment staff at the center had to explain to patients that insurance covers patients for services that are not available at the health center such as emergency care, inpatient care, lab fees and medications that aren’t dispensed at the CHDI pharmacy.

Looking ahead to the next enrollment season, the CHDI enrollment team plans to create a seminar to educate the community about the new healthcare law and how the health insurance exchanges work. Still, with many local residents not able to secure coverage, the challenge of bringing people into care remains. Another looming issue is the lack of health care providers and the paucity of providers who accept Medicaid or offer comprehensive services. Many existing providers do not accept Medicaid or the new insurance exchange plans, and CHCs that serve a large portion of the uninsured and low-income population are already stretched in terms of resources. The Uvalde area is in the midst of a 5 year drought which has wreaked havoc on the local economy. The price of produce has sky rocketed and put additional financial strain on many low-wage seasonal farmworkers in the area. Even sliding scale rates at the health center are too high for many families, for whom the cost of an $18 dollar copay for a doctor’s visit must we weighed against the cost of food and other basic necessities. And without new funding and more coverage, CHDI, like other health centers, can’t add programs or services.

This year, an estimated $2.39 billion federal dollars will not reach Texas [6]because state elected officials refused to close the coverage gap. The loss of this potential revenue for the state is significant. Texas is shouldering these costs and not receiving any federal funds to alleviate this financial burden. Recognizing the strain this loss has on the community and on health centers, the Texas Association of Community Health Centers (TACHC), the statewide organization representing safety-net providers, has orchestrated a comprehensive, multi-faceted approach to addressing the coverage gap in Texas. This past summer, TACHC launched a Civic Engagement Campaign which seeks to mobilize health center patients, staff, board members and allies across the state to advocate for closing the coverage gap, retaining existing health center funding, and improving access to care. The campaign has three phases: Awareness, Action and Sustain. Working closely with its member health centers, TACHC is building an advocacy network of health center patients, CHC staff and board members, transforming them from patients to patient advocates. Participants complete a training that teaches them how to convey their own personal healthcare stories, to vocalize why closing the coverage gap and health center funding matter in their lives, and to share these messages with friends and family. These trainings teach participants how to frame their personal stories within the larger context of the need for Medicaid expansion and to advocate for continued health center funding. Through trainings and community meetings, TACHC hopes to identify leaders who will help inspire and mobilize others to participate, creating a groundswell of support among coworkers, neighbors, family and friends. The current phase is to make these voices heard across the state through targeted media events and a coordinated and strategic plan to impact public opinion. TACHC’s ultimate goal is nothing short of expanding access to high quality, comprehensive and affordable care, throughout the state. They recognize that it takes a village to change policy and impact legislation. TACHC is helping health centers and communities gear up for the challenge.

For more information, to share your story, or to sign up to become a Texas health center advocate, see



[1] Kaiser Family Foundation, State Health Facts, Health Insurance Coverage of the Total Population.

[2] Kaiser Family Foundation,  (April 2014) The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid

[3] Kaiser Family Foundation (April 2014.) A Closer Look at the Impact of State Decisions Not to Expand Medicaid on Coverage for Uninsured Adult. s

[4] Shin, Peter, Sharac, Jessica and Rosenbaum, Sara. (October 2013)Assessing the Potential Impact of the Affordable Care Act on Uninsured Community Health Center Patients: A Nationwide and State-by-State Analysis.

[5] Ibid.

[6] Texas Primary Care Association, Closing the Coverage Gap, Estimates based on State Fiscal Year 2014 federal funds. Source:  HHSC  “Impact to Texas Medicaid of ACA Implementation by Levels of Implementation,” (spreadsheet), August, 2012.