W
ith over 4.6 million uninsured Texans in
2015, substantial gaps in access to health
care will remain a problem for many Texans
in the near term, despite the important gains and
new options provided by the ACA. Listed below is a
partial inventory of notable holes in the Texas health
care safety net for non-U.S. citizen residents.
Undocumented. The greatest access gaps for non-
citizens aect Texans without legal immigration
status. Barred from Medicaid, CHIP, and the
Marketplace and its subsidies, private health
coverage is available only to undocumented
individuals who have adequate income to
purchase a policy at full price, without a subsidy.
Undocumented residents can look to Federally
Qualied Health Centers, some (but not all) urban
hospital/health districts, and independent charity
clinics for care, meaning that access to aordable
care is highly variable depending on where an
immigrant lives in Texas.
Lawfully present: Immigrants who are lawfully
present in the U.S. face certain barriers that are
specic to their non-citizen status, as well as some of
the same barriers aecting U.S. citizens.
● The Coverage Gap traps some lawfully present,
including refugees and asylum seekers. Most
lawfully present individuals with incomes below
100 percent of the FPL can qualify for subsidies in
the ACA Marketplace. However, certain lawfully
present immigrants are caught in the Coverage
Gap in states like Texas that have not accepted
federal ACA funds to extend Medicaid to adults
who earn less than 138 percent of the FPL. So
the categories of legal immigrants that Congress
intended in 1996 to have access to Medicaid
and CHIP, actually are the very ones who are left
without coverage options in Texas and other
states that have not expanded Medicaid.
● Texas law excludes most lawfully present
immigrant adults from Medicaid. The state
legislature would have to authorize a change to
this state policy (adopted in 1999) in order for a
Texas solution to insure low-income Texans in
the Coverage Gap to also benet lawfully present
adults below the poverty line.
● Technical Marketplace application processing
issues for individuals with immigration
documents, as well as for mixed-status families
have delayed coverage and discouraged eligible
Texans from completing enrollment. Improved
Marketplace performance during the second
and third open enrollment period appears
to be improving enrollment rates but further
improvement is still needed.
● The “family glitch” aects both lawfully present
immigrants and U.S. citizens. These families
may not qualify for premium subsidies in the
Marketplace , and face either paying full price and
an unlimited, unaordable percentage of their
incomes for job-based or Marketplace insurance
premiums, or remaining uninsured.
● Aordability issues occur even for families that
have access to premium subsidies and out-of-
pocket help in the Marketplace. Those below
poverty may have a hard time aording 2
percent of income in premiums with additional
copayments and deductibles. Families at any
income level who experience high health care
needs may face spending up to 20 percent of
income before deductibles and out-of-pocket
caps kick in.
● Separated, but not divorced, parents may not
have access to Marketplace subsidies because
of tax ling status or lack of access to income
information on the absent spouse.
● Hard-to-verify incomes. The income verication
systems that the Marketplace and state Medicaid-
CHIP programs rely on can work well for those
with steady employment and predictable hours
and wages. They are less helpful for those working
irregular hours, multiple jobs, or being paid cash
or by hand-written check. Advocates will need to
monitor the systems to identify and try to reduce
any barriers to enrollment, renewal, or qualifying
for premium subsidies that may result from
the additional documentation families in these
situations may have to produce on an ongoing
basis.
Executive Summary
Key Findings and Recommendations for Texas