UPDATE (March 19, 2021)
We previously analyzed the potential impact of language under consideration by Congress. As that language has been finalized and signed into law, we have learned more details about the potential financial impact to Texas. Accordingly, we are updating our estimates as follows:
We previously had estimated that the impact to state general revenue would be $3 Billion over a two-year period. We are now increasing that to $3.5 Billion over the two-year period. At issue is the 5% increase in the base FMAP – additional clarity surrounding which programs would be eligible for the 5% increase. Our previous estimate only included programs we were sure would be eligible. This updated estimate takes a different approach, only excluding programs we are sure would be excluded. Those programs include all expenditures receiving EFMAP (sometimes referred to as “CHIP FMAP”, including the Medicaid for Breast and Cervical Cancer), all programs receiving 100% FMAP, all programs paid for 100% by the state, administrative costs, and the costs that would be transferred to the new 90% FMAP program as a result of the eligibility changes.
Additionally, we now have greater certainty that the 5% increase would also apply to supplemental funding streams, such as Uncompensated Care and CHIRP. The impact of the increase to these funding streams would accrue to local funding sources, and not to state general revenue. Unfortunately, it is difficult to project what the impact would be, because it is incredibly difficult to project what the baseline amounts of these funding streams will be. These funding streams currently total about $11.0 Billion annually, and may reach as much as $11.5 Billion post-extension of the 1115 Waiver that supports funding. A simple calculation would suggest that a 5% impact would provide about $1.15 Billion over two years. However, this method is not reliable to project the impact in the future. The reasons for this uncertainty are as follows:
- Re-Basing – While these funding streams were extended by the recent 1115 Waiver extension, they are also set to be “re-based” in 2023. Re-basing is a process that occurs in Waiver programs periodically to ensure that federal budget neutrality is met. We do not know what the result of this re-basing will have on the amounts of these funding streams.
- Uncompensated Care – Any state that increases the number of people with insurance will see an impact to the pool of funding to help mitigate effects of uncompensated care (care that hospitals are required to provide to individuals regardless of their ability to pay). Other states that have expanded Medicaid have seen uncompensated care costs drop by an average of 45%. However, the impact to Texas is uncertain because of Texas’ unique demographics.
- Negotiation Process – This is the biggest unknown. If Texas increases eligibility through a unique “Texas Plan” process, this would require an additional 1115 Waiver. These Waivers are enacted through a complex series of negotiations between the state and the federal government. It is possible that the federal government would require, as a condition of any waiver approval, revisiting the amounts of money provided in the 1115 Waiver that was recently extended, particularly for the Uncompensated Care component, especially as that Waiver extension was approved at the last minute by the Trump administration. There is no way to reliably project the results of such a political negotiation process. Further, any shift in the eligibility and coverage dynamics may change the programs funded under a waiver – as some increase in importance/need and others decrease based on the changed healthcare access landscape.