Expansion in care for new moms may cut aid elsewhere

Doctors and health care advocates have been trying for years to expand Medicaid in Texas, especially for new mothers who can experience severe depression and physical complications in the months after birth.

So when Republicans this spring agreed to a modest boost in the coverage period for postpartum benefits, from two months to six, many were elated. Even Gov. Greg Abbott, a critic of the health program, was celebratory, hosting a ceremonial signing of House Bill 133 with fellow conservatives.

But in South Texas, Martha Zuniga was panicking.

To push the legislation over the finish line, Democrats and members of the Texas House acquiesced in major changes made in the Senate, including a last-minute provision to move the state’s family planning and women’s health program, Healthy Texas Women, entirely into managed care.

Under the new system, the state will outsource its day-to-day management of patients on the presumption that companies doing the work can cut costs while improving health outcomes. Critics of managed care say some companies abusively deny services and pocket the savings.

Zuniga, who runs a half-dozen health clinics in and around Corpus Christi, worries the decision will further squeeze her already overworked network and could end up reducing access to birth control, cancer screenings and other essential health services.

It is part of a larger concern among family planning providers that as lawmakers focus on postpartum care, they are weakening equally critical efforts that prevent unplanned pregnancies in

the first place. Birth control is much cheaper for the state than an uninsured birth and follow-up treatment.

“The components of the program that were key elements to its success have already been removed,” Zuniga said. “Now they’re just trying to cut the whole legs off.”

The move is complicated by the state’s long-standing refusal to fully embrace Medicaid. Family planning providers could have been spared the move to managed care if top Republicans had expanded postpartum Medicaid coverage to a full year, as recommended by maternal health specialists. Both Democrats and Republicans in the House supported 12 months of coverage, but the more conservative Senate would agree only to six.

With a year of coverage, managed care would have likely overseen only postpartum services.

Key services not covered

Nearly all of the state’s Medicaid programs are now in managed care, and proponents say this will provide continuity for women after their postpartum Medicaid coverage ends. Those who transition into Healthy Texas Women will be able to work with the same health plan that managed their visits under Medicaid, or they could request a different one if they’re dissatisfied.

“When you talk about what really matters to patients, removing the bureaucracy is more important,’’ said Jamie Dudensing, a lobbyist for managed care companies. “Having consistency is more important, having more access to contraception and cancer screenings is more important.”

Last year, at the behest of Republican state Sen. Lois Kolkhorst, the Texas health agency added some postpartum services to Healthy Texas Women, though they have yet to start because of the coronavirus pandemic. The move was viewed as a response to criticism directed at the state for not having expanded Medicaid coverage for new mothers before this year.

Many of the services that new mothers may need, however, are not covered. The excluded services include surgery, cancer treatment, physical therapy and prescription drugs for most medical conditions.

‘Approaching it with caution’

Women’s health advocates say the managed care model may be especially helpful for women in their first months of parenting, providing familiarity as they navigate the state’s fragmented system. Health plans also have clinical networks for any postpartum services that traditional family planning clinics don’t provide.

Advocates are less certain, however, about the benefits of simply allowing women access to contraceptives and other preventive health services.

“It’s an opportunity to make improvements, and we’re hopeful that’s what it is,” said Erika Ramirez, a policy director for the Texas Women’s Healthcare Coalition. “But we’re also approaching it with caution to ensure that we don’t see changes that are just too monumental, that will negatively impact getting women in the door.”

Lawmakers asked the Health and Human Services Commission in 2019 to study the move into managed care, including the “potential impact of that delivery model on women receiving services.” A spokeswoman said the agency conducted the review but was not required to release its findings. Neither Ramirez nor Democratic lawmakers have been able to review them.

Kolkhorst, who steered the legislation, did not respond to requests for an interview. The transition is slated for 2024.

In April, Kolkhorst laid out an earlier version of the managed care transition, saying the purpose was to “help women be more healthy during these childbearing years.”

“The coordination of these efforts is extremely important,” she said. “And we are starting to see better health outcomes through bills that we pass and the efforts of our agencies, and of course our providers.”

Dudensing contends that state health data shows patients in managed care have better outcomes than those in a traditional fee-for-service model — the model under which Healthy Texas Women currently operates.

But family planning providers say they have had difficulty dealing with managed care companies and become trapped in convoluted appeals processes over relatively minor charges.

“Then it becomes a matter of, ‘Is it worth the staff time and the expense of appealing a $30 or $40 charge in order to get paid, if my costs are so high in order to actually end up getting paid?’ ” said Amanda Stukenberg, chief executive of Women’s and Men’s Health Services of the Coastal Bend.

She added that some health plans have been easy to work with.

Speed and certainty over reimbursement is especially important with birth control, because women who don’t receive their preferred method when they visit a clinic might not return in time for it to matter.

“I’m not going to have a patient come in today, fill out her application and have her come back in three weeks to get her birth control, because by the time three weeks comes around, she could likely be pregnant,” said Mandi Edwards, a billing specialist for Zuniga’s clinics.

Enrollment hurdles

Managed care is the latest change in a program that has been in near constant flux over the past decade. The state created what would become Healthy Texas Women in 2013 after it lost federal funding over Republican leaders’ refusal to contract with Planned Parenthood, which had been providing a bulk of its preventive, nonabortion medical care to low-income women.

After a rocky start, participation in the program steadily increased. Average monthly enrollment in the last fiscal year was 310,000.

But earlier this year, the health agency rolled out new procedures that it said had been ordered by the federal government, including a much longer application process and an end to automatically enrolling low-income women who were recently on Medicaid or who already qualify for other assistance programs.

Patricio Gonzales, who heads Access Esperanza Clinics in the Rio Grande Valley, said the clinics have lost about 20 percent of their Healthy Texas Women population since then.

Many women either don’t have the time or all the information to fill out the application, which can run as long as 20 pages. It used to be one page, Gonzales said.

Things had been going so well before this spring that Gonzales was thinking about opening two new clinics. Between the new enrollment hurdles and the added administrative staff needed to work on managed care claims, he’s reconsidering.

“When you think you’ve got it down and all these great systems are finally in place,” he said, “suddenly it gets taken away.”