TMA’s Top Legislative Priorities: Enhance Medicaid Payments and Coverage
By Jessica Ridge Texas Medicine January 2025

Background: Cynthia Peacock, MD, has experienced firsthand the short shrift of Medicaid payments and the implications of their inadequacy on access to care. 

“I take care of people who have intellectual and developmental disabilities,” complex needs that take more time to care for, the chair of Texas Medical Association’s Committee on Medicaid, CHIP, and the Uninsured said. “For primary care, and even subspecialty care, in order for my population to be seen, we need to enhance reimbursement.”  

Despite piecemeal progress in achieving enhanced payments and coverage for women and children, Medicaid expansion remains a nonstarter in Texas. But the perennial inertia on that front – due in part to the program’s status as one of the state budget’s largest line items – is arguably less pressing than the practical, immediate concern of insufficient payment rates.  

Some payment rates were increased during the 2023 Texas legislative session for the first time in more than a decade, setting the stage to bolster access to care in the future simply by enabling doctors who participate in Medicaid to stay afloat. Not all specialties, however – including those like Dr. Peacock’s – were included; for those that were, the Texas Health and Human Services Commission (HHSC), as of this writing, was expected to release an impact report by the end of 2024. 

Also looming is a gradual wind-down of the public health emergency’s Medicaid eligibility extensions, a state Medicaid managed care organization recontracting process, and potential loss of the state’s Healthy Texas Women waiver – administrative issues that could leave patients falling through the cracks and cause participating physician practices to experience significant financial difficulties. 

“Expansion is well and good, but if you’re not paying for the cost of care, it’s really not going to matter anyway,” said Clayton Stewart, chief lobbyist for TMA. 

Valerie Smith, MD, a member of TMA’s Committee on Medicaid, CHIP, and the Uninsured who sees many patients who are covered by those programs, has felt the sting of inadequate payment rates. 

“Our current payment model for Medicaid is that we receive roughly 70-75% of what [Medicare pays], and often far less than that for what we receive for caring for children who are on commercial insurance,” the Tyler pediatrician said. 

Last session, TMA was instrumental in passing legislation that secured a hard-won waiver extending postpartum coverage for women from two months to one year. But some of the funding required to support the Healthy Texas Women program hangs in the balance this session as it is tied to renewal of the state’s Medicaid 1115 waiver, which is still pending before the Centers for Medicare & Medicaid Services (CMS). HHSC applied for a five-year extension in March 2024. Without the waiver, Texas would have to make up for $200 million to support the program’s current services.  

Healthy Texas Women provides preventive health care services, including mobile units that screen for breast and cervical cancer for qualified women who are uninsured or underinsured.  

“Texas already has the highest uninsured rate for women of reproductive age,” TMA public health policy analyst Erin Thompson said. “If we don’t get that funding, those women wouldn’t have access to those services.” 

Solutions: TMA plans to pursue a tiered advocacy strategy this session to protect and build on last session’s wins.  

On top of maintaining the 6% increase secured in 2023 for an array of pediatric, maternal, and labor and delivery services – and fighting for the inclusion of related specialty care left behind, such as anesthesia – TMA will seek an additional 10% payment increase in Medicaid codes across the board. Within that goal, the association will work to prioritize improving rates and coverage for primary, preventive, and women’s health care as well as needed specialty services, so practices providing care to the Medicaid population stay viable. 

While the fate of the Medicaid 1115 waiver for Texas is a federal matter that will be decided by CMS, the funding it enables is achieved through a state budget item to pull down federal funding in the absence of traditional Medicaid expansion in Texas, Mr. Stewart says. 

Texas physicians are eager for those types of creative approaches to the ongoing challenges they face. 

“We are so fortunate to live in a state where families are thriving and we are seeing a growth in our population,” Dr. Smith said. “But in order for us to be able to care for [patients] and still pay our employees and keep the lights on and do the important work that we need to do, we need equitable payment rates.”