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Nearly 1.7 million Texans have lost their health insurance — the largest number of people any state has removed — in the months since Texas began peeling people from Medicaid as part of the post-pandemic “unwinding.” Around 65% of these removals occurred because of procedural reasons, according to the state.

Texas’ Health and Human Services Commission has neared the end of a chaotic and overburdened process to remove people from state Medicaid insurance who became ineligible during the coronavirus pandemic. The state had not unenrolled people before this year because of federal pandemic rules, which forbid states from cutting coverage.

As a result, more than 5 million Texans had continuous access to health care throughout the pandemic through Medicaid, the joint federal-and-state-funded insurance program for low-income individuals. In Texas, the program’s eligibility criteria is so restrictive, it mainly covers poor children, their mothers, and disabled and senior adults.

But the effects of speedrunning this process have reverberated: still-eligible Texans were kicked off both in error and for procedural reasons, adding to backlogs of hundreds of thousands of Medicaid applications and pushing wait times back several months. Backlogs for SNAP food benefits applications, which the same state agency also manages, also skyrocketed because of the burden.

“The state handled this with an incredible amount of incompetence and indifference to poor people,” U.S. Rep. Lloyd Doggett, D-Austin, told the Texas Tribune. “It's really appalling.”

Doggett has repeatedly demanded for changes in the process, most recently sending a letter to the U.S. Centers for Medicare and Medicaid Services calling their scrutiny of the state “woefully inadequate.”

He said he also contacted the agency overseeing the nation’s Supplemental Nutrition Assistance Program program, the U.S. Department of Agriculture, about improving the state’s food benefit access during this time. He suggested pausing upcoming SNAP renewals so Texas staffers could focus on working through backlogs first.

Neither federal agency had responded to him as of Thursday morning, he said.

As of Dec. 8, there were 207,465 SNAP applications and 288,939 Medicaid applications waiting to be processed, according to HHSC spokesperson Tiffany Young.

“Nobody who watched this is surprised about the backlog. We had delays before the unwinding, and then we put a gigantic amount of work on the system that wasn't spaced in any sort of even, realistic way, that was totally front-loaded,” said Stacey Pogue, a senior policy analyst at Every Texan.

“The way the state's choosing to do this is one gigantic, long backlog. That's a choice, and it hurts people in need,” she added. “But they had other choices to take workload off the system that don't ask people to wait and wait and wait and wait.”

The wait time for Texans who now apply for both SNAP and Medicaid has decreased to a little over a month, as they have to wait for their Medicaid application to go through first. This is a reduction from a five-month waiting period in place at the beginning of December, Young said.

As of October 2023, some previously submitted applications in the queue had been sitting there for as long as four months, HHSC spokesperson Jennifer Ruffcorn said.

“HHSC is moving 250 eligibility staff from other priority projects to focus on processing applications that request SNAP and another benefit,” Ruffcorn said in a statement. “Additionally, within the next five months, HHSC will be sending 600 of our newer staff to Medicaid training. This will also increase our capacity to process more SNAP and Medicaid combined applications.”

For those without food, even a month is a long time. Food banks had already felt a strain before the holidays approached.

“It's just a difficult time, it’s sort of a perfect storm,” said Celia Cole, CEO of the nonprofit Feeding Texas, earlier this fall. “Food banks are seeing higher demand. They're struggling to get food in and out the door, and it's costing more to do that.”

And for those without health insurance coverage, options remain limited, often to either stomach thousands of dollars in medical debt or turning to federally qualified health centers, which are required to provide medical care regardless of insurance.

“It’s tragic to think that children are missing their check ups or medications because their Medicaid application is collecting dust in a state office,” said Diana Forester, Director of Health Policy at Texans Care for Children, in a Thursday news release.

Some of the solutions the state has offered have been bleak. In a cheerfully-toned email from HHSC to its staffers obtained by Doggett’s office, leaders suggested employees participate in a "6 Days of Merry Service Challenge" where they would work overtime every day through either extending hours or coming in on a Saturday.

The email included a prize raffle for employees who worked more than 15 hours of overtime that week.

“There's other pathways besides asking an overworked staff to work more,” Pogue said of the email. “Of all the solutions to pick, that's just the last one on the list.”

Texas also has made limited use of an automated eligibility checking system, which uses previously submitted data like pay stubs as well as federally provided data about people’s work. Only 6% of Medicaid renewals came through the automated system, according to state numbers.

Throughout the process, advocates like Pogue made unheeded calls for a pause so HHSC staffers could catch up on backlogs before sending more eligible people to the back of the line.

Now that the state has gotten through most of its “cohorts” of trying to renew people — one million people’s coverage has renewed — advocates say the state has an opportunity to fix the system.

“Texas lawmakers can look forward to like, ‘What kind of system do we want? How hard should it be to get through the Medicaid renewal process? How do we staff our system to process paperwork?’ ” Pogue said. “It's no longer about how we're going to do unwinding. It's: ‘How are we going to run the Medicaid program?’ ”

Karen Brooks Harper contributed to this report.

Neelam Bohra is a 2023-24 New York Times disability reporting fellow, based at The Texas Tribune through a partnership with The New York Times and the National Center on Disability and Journalism, which is based at the Walter Cronkite School of Journalism and Mass Communication at Arizona State University.

Disclosure: Every Texan, Feeding Texas, Texans Care for Children and New York Times have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2023/12/14/texas-medicaid-unwinding/.

The Texas Tribune is a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy. Learn more at texastribune.org.