How a grandmother fell into the health insurance divide – and why the Build Back Better plan could help cover Texans like her


Perla Rosalez, an unemployed grandmother in the Rio Grande Valley, stays awake at night, worrying about falling ill and leaving her three grandchildren behind.

The 50-year-old is rationing both her medications and the doctor visits she needs to manage diabetes, high blood pressure, cholesterol and COVID-19 because she does not have health insurance for help pay them. She avoids expensive specialists and prays that she does not have to return to the emergency room.

Becoming the sole babysitter of her three grandchildren allows her husband and daughter to work outside of Mercedes, the small town near the Texas-Mexico border, where they live. But it also means that she can’t afford to get sick.

“I realize that I can’t take care of my grandchildren if I’m about to have a heart attack or stroke,” Rosalez said before acknowledging the added burden of not to be insured. “I’m stressed all the time worrying about paying for doctor’s visits and medication. Where will I find the money to pay the doctor to monitor my health? “

It’s a problem Rosalez and about 770,000 Texans who live in poverty face every day because they can’t claim government help to pay for Medicare.

But a provision of the $ 1.75 trillion Build Back Better legislation, which is being considered by Congress, would correct that loophole until at least 2025. Rosalez and 2.2 million other Americans in her situation would be eligible for free health insurance plans sold by the state. markets for the first time since their creation by the Affordable Care Act over ten years ago.

This provision only applies to Texas and 11 other states that refuse to extend Medicaid health coverage.

The legislation could get final passage in the United States House before Thanksgiving, and then move to the Senate.

But whether it would really improve Rosalez’s life is a hot topic of debate in Texas.

Those who oppose the extended ACA subsidies proposed in the Build Back Better plan say too much focus on Medicare because being insured does not guarantee access to more care or better health. best quality.

Instead, says David Balat, director of the Right on Healthcare initiative at conservative think tank Texas Public Policy Foundation, healthcare costs should be revised from top to bottom.

“Health insurance and health care have been so confused,” Balat said. “Even those with insurance in this country … can’t get the care they need, or it’s so expensive that they won’t get the treatment they need.”

The Build Back Better plan would help the more than 700,000 Texans not covered by insurance or Medicaid pay for their health insurance. The plan would direct the money that currently goes to hospitals to cover patients who cannot pay their medical bills to instead cover those who cannot get health insurance.

This is, according to many, the wrong way to fund the new grants because it uses taxpayers’ money to pay for a system that is expensive and inefficient.

“Withdrawing money from safety net hospitals and specialist care hospitals hurts communities,” Balat said.

Those who advocate for government-subsidized health coverage for the poor say the lack of coverage severely restricts access to health care in a system structured around insurance.

When people are uninsured, they say, hospitals and other providers are burdened with the cost of caring for those who cannot pay their bills. They say that not being insured causes unnecessary problems for poor families and costs the state billions of dollars in health care and lost wages.

It also prevents them from having access to preventive care, the kind Rosalez needs, that would help stop health problems before they turn into serious problems, said Elena Marks, president and CEO of the Episcopal Health Foundation, a Houston-based nonprofit researching the issue.

“We’re talking about the cost of health care, but what about that person’s life? Marks said. “Imagine the difference between [detecting] cancer during a regular mammogram, as opposed to after the cancer has progressed to where it is obvious to you? “

Balat said that health insurance has benefits when it provides reliable and affordable care from quality providers, not when it is so expensive that people cannot afford to use it or when it is expensive. there are so few providers available that they cannot access them.

“Would it be better if everyone had some form of health insurance or health coverage?” Of course, ”Balat said. “But at the moment it’s just not working. “

With roughly 5 million people without medical coverage, Texas has more uninsured people than any other state in the country.

In the gap

Rosalez falls into a divide between those who cannot qualify for either a low cost insurance plan available in the markets or Medicaid, the health insurance plan for the poorest residents of any state.

Anyone can buy a plan from the state-run health insurance markets, but government grants to help pay are only available to those earning at least the federal government’s definition of poverty, which is $ 12,880 per year for an individual or $ 21,960 for a family of three.

To be eligible for this grant or tax credit, a person must be at or above this income threshold and not have access to government programs like Medicaid or affordable coverage through an employer. .

Without these subsidies, insurance plans can cost several hundred dollars per month.

When it comes to qualifying for Medicaid, Texas is one of the stingiest in the country. To be eligible for Medicaid here, a person must have a family income of $ 140 per month or less. For a family of three, this threshold is just over $ 300 per month.

That said, Medicaid in Texas is a program primarily for children, adults with disabilities, or legal guardians and parents of dependent children.

And so it was that Rosalez, as poor as she was, and despite caring for three children, fell into the health insurance coverage gap.

She does not claim that the grandchildren are tax-paying and that she does not have a disability, so she cannot claim Medicaid.

Her husband’s jobs out of state are irregular, temporary, and do not offer workplace coverage plans. The Rosalez’s income does not push them above the monthly minimum of $ 1,450 required for his family of two to qualify for market subsidies.

The two are therefore stuck in the middle, without access to any of the assistance programs.

The Affordable Care Act, when first passed, required states to expand their Medicaid lists to include a higher income level and close the gap between the previously lower income threshold of Medicaid and the higher income levels required for new market grants.

But when the United States Supreme Court overturned that requirement, the gap widened and was never corrected by law.

Since then, 38 states have chosen to expand Medicaid anyway. In these states, a household can earn up to about $ 2,000 per month for a family of two while still meeting Medicaid income requirements.

And while increasing Medicaid’s income level still wouldn’t help Rosalez, it would cover hundreds of thousands of parents working in Texas on near-minimum wages or part-time jobs.

A job of $ 15 an hour to 30 hours a week, for example, would net $ 1,800 a month – too much to qualify in Texas, but more than enough to qualify in states that have broadened their income thresholds for. Medicaid. But Texas is among the states that have resisted.

Earlier this year, lawmakers in Texas and those in other non-expanding states received billions of dollars in federal incentives to make it happen.

A bipartisan bill in the Texas Senate answered that call, but Republican leaders said it exuded coercion from the Biden administration. The bill never got out of committee in the regular session of the legislature this year.

Avoiding the expansion of Medicaid

The Build Back Better Act is a way of trying to force or coerce Texas and the other 11 non-expanding states to open their Medicaid programs to allow more people in.

The legislation provides for more streamlined Medicaid enrollment and longer coverage periods for children and new mothers, but does not require states to change their income requirements for Medicaid.

Instead, the legislation makes it easier to qualify for market grants for people of all income levels, including extensions to parts of the American Rescue Plan Act that have reduced the cost of premiums for the plans. assurance.

The part that likely helps Rosalez, who might never qualify for Medicaid in Texas, is the provision allowing people with incomes below the federal poverty line to purchase plans without any monthly premiums, and in many cases, without franchise.

For Rosalez and her family, that could mean free and comprehensive health care coverage after years of financial hardship and declining health.

For years, Rosalez and her husband worked in factories and construction work in the Rio Grande Valley. They suffered layoffs and bouts of unemployment. High blood pressure and other health issues have been a problem for Rosalez, even sending him to hospital in 2019.

Most of the time, Rosalez is home alone with the grandchildren, the eldest of whom is 10 years old. They are covered by Medicaid, but Rosalez wonders what will become of them if she gets too sick to care for them or if she dies.

These days she cries a lot. She still has trouble breathing after the entire household contracted COVID-19 in late summer.

And she remains hopeful for a lifeline.

“I need affordable, consistent coverage that will cover my visits to my general and specialist physicians and my medications,” Rosalez said. “I don’t want to go to bed every night worrying about these things, and that’s what’s happening now.”

Disclosure: The Episcopal Health Foundation and the Texas Public Policy Foundation have financially supported The Texas Tribune, a nonprofit, non-partisan news organization funded in part by donations from members, foundations, and corporate sponsors. Financial support plays no role in the journalism of the Tribune. Find a full list of them here.

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