Prior to the pandemic, the Rural & Community Health Institute at Texas A&M University established a national blueprint to improve health accessibility in rural areas. It recommended establishing engaged community health centers structured to meet rural needs through expanded service lines like telemedicine, mobile outpatient care, and home care.
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While the current budget allocates spending to expand community health centers in rural areas, the high cost and low supply of primary care outside of the Texas Triangle have led to some of the poorest community engagement levels for clinical care in the country. Texas ranks dead last in health access, registering both the largest number (5.4 million) and percentage (18.4%) of uninsured people in the country. The percentage of Texans without health insurance is higher in rural counties, between 20-25%.
Rural hospitals disproportionately serve older and lower-income individuals, which makes them dependent on Medicare and Medicaid reimbursement to remain viable. Low engagement contributed to Texas having the nation’s highest rate of rural hospital closures from 2010-2020, with more than half of the remaining facilities “vulnerable” to shutdown.
Health experts contend that the pandemic has exacerbated that viability because high-profit services, such as elective surgery, were unavailable for most rural care providers throughout peak periods. Cuts to public health spending left the state ill-prepared to respond to a public health crisis, exacerbating already severe shortages in labor, equipment, and emergency response especially in rural counties that have higher concentrations of elderly residents.
Texas is also one of a dozen states that has refused to expand Medicaid to ineligible adults under the Affordable Care Act because their incomes are too low. Republican leaders have excluded Medicaid expansion from the state budget since the ACA passed in 2010.
In November of 2020, a panel of medical and economic experts recommended joining the national Medicaid program because the 10% matching requirement to access federal funds would create potential savings and revenues that would “more than offset the cost and result in a net positive fiscal impact.”
Expanding Medicaid would have potentially enrolled an estimated 950,000 eligible adults and accessed $5.4 billion in federal dollars while contributing an additional $75 million to $125 million to the state budget each biennium.
The Texas Hospital Association contends that bolstering Medicare and Medicaid reimbursement and expanding health coverage to the more than 5 million uninsured Texans are keys to protecting the viability of rural care providers. This would include preserving the federal support through supplemental payments and special financing arrangements that rural hospitals receive.
Due to easing of income eligibility under federal COVID-19 emergency measures, Texas saw its Medicaid enrollment grow during the pandemic by more than 1.2 million people, mostly children and low-income women. Now that emergency relief is set to end, eligibility redeterminations could drop Medicaid coverage for thousands in Texas and prevent thousands more from joining.