The coordination and implementation of the Affordable Care Act in Texas : Medicaid eligibility and the environmental context

The Affordable Care Act (ACA) seeks to increase the low-income population’s access to health care coverage by expanding Medicaid eligibility and providing subsidies to individuals meeting certain income thresholds. The citizens of Texas would benefit greatly from the ACA provisions, as the state offers limited opportunities for individuals to access insurance, evidenced by the 6.3 million residents without health care coverage. But political leaders in Texas have a long-standing commitment to limited government, low taxes, and states’ rights in a federal system of government. In the 1990s, Texas legislators, with bipartisan support, laid the groundwork over the last decade for the minimal, yet significant preparations that administration used to coordinate ACA implementation. Yet legislators’ commitment to limited government and states’ rights placed additional constraints on the ability of the Texas Health and Human Services Commission (HHSC) to implement ACA provisions by refusing to utilize the 82nd legislative session to prepare the state for impending deadlines. Instead, administrators developed an interagency effort, the Eligibility Modernization Project (EMP), to streamline eligibility determinations and increase clients’ access to information and services. EMP’s initiatives mirror ACA provisions, but also seeks to achieve policy goals that both Republican and Democratic legislators support, such as providing effective and efficient eligibility determinations. Nevertheless, legislators and administrators must go beyond EMP’s efforts to adequately prepare the eligibility system for impending ACA deadlines. Policy recommendations include further streamlining and integrating the health subsidy system with a state-based health insurance exchange, increasing access to coverage by expanding Medicaid eligibility, adequately preparing the workforce for changes, and promoting long-term planning. These solutions will provide a sounder infrastructure for HHSC to prepare for ACA coordination and implementation, while increasing access to health care coverage for the low-income population.