More than a million Texas kids in low-income families have lost their health insurance since last spring, according to state-reported data. Three out of four Medicaid recipients in Texas are children, and nearly two out of three Texans disenrolled during the post-pandemic “unwinding” process have been kids.

During the pandemic, a provision in a federal COVID relief package blocked states from kicking people off of Medicaid, even if they were no longer eligible. When that federal legislation expired in April 2023, states began reassessing people’s eligibility in a process called unwinding. It’s been chaotic in Texas with large backlogs and extremely long delays for families applying for health care or food assistance.

“Texans in need have been forced to wait several months for their SNAP and/or Medicaid applications to be processed. As a result, countless Texas families will go hungry,” stated a December letter to the Texas Health and Human Services Commission (HHSC) sent by a pair of legislative caucuses, the Texas Women’s Health Caucus and the Texas House Early Childhood Caucus.

That letter implored the agency to resolve the backlogs by this March, but they have only grown.

HHSC Spokesperson Tiffany Young told the Chronicle that staff has moved aggressively to reduce the number of applications in the queue. The good news is that the maximum wait for an application to be assigned to an eligibility worker has gone down – from 120 days in November to less than 40 days in December.

But even with reduced lead time, backlogs grew from December to January. As of Dec. 8, there were 207,465 SNAP applications and 288,939 Medicaid applications waiting to be processed. As of Jan. 26, there were 18,173 more SNAP applications and 64,604 more Medicaid applications in the backlog, per data provided by HHSC spokesperson Jennifer Ruffcorn.

Though the current eligibility crisis is acute, HHSC has chronically failed to meet federal standards for timely processing of SNAP applications since at least 2021, two years before unwinding began, according to the joint caucus letter. (Young said HHSC found no factual errors in that letter.)

Most Medicaid recipients in Texas are kids, and 65% of people kicked off Medicaid since last April were children.

Prior to unwinding, it would have been difficult to directly compare how efficiently states automatically renew coverage, but as part of the process states have reported their “ex parte” renewal rates, meaning the percentage of applications that are renewed automatically based on data. Now, it’s clear that Texas fails to renew coverage more often than any other U.S. state.

The joint caucus letter demanded an answer from HHSC on that point: Why does our system renew eligibility for so few people?

An HHSC spokesperson told the Chronicle the low renewal rate is a side effect of the state’s approach. During unwinding, Texas has reviewed applications from those most likely to no longer qualify first. “Not all states are distributing renewals in the same manner,” Young said.

But Texas is not the only state taking that approach. The research nonprofit Kaiser Family Foundation (KFF) closely tracks how states are handling unwinding and found 16 states are using a hybrid approach that involves frontloading applicants who are unlikely to qualify. KFF reports “several states will focus first on enrollees who have been flagged as potentially ineligible.”

Whatever the cause of Texas’ worst-in-the-nation ex parte renewal rate, the two caucuses want to understand it better. The December letter asked for an analysis on ex parte renewal, adding that HHSC should “quickly address the shortcomings identified in that analysis.” HHSC did not answer whether such an analysis is planned.

The letter penned by the caucuses made several other demands, some of which HHSC met. (For example, HHSC asked for an emergency waiver from the USDA to extend SNAP for people up for recertification until backlogs are eliminated – though the USDA denied that request.) One demand HHSC has so far refused sticks out: The letter called for HHSC to request a waiver from the federal Medicaid agency – Centers for Medicare & Medicaid Services (CMS) – to temporarily extend children’s Medicaid for kids in limbo during unwinding. When asked if HHSC had requested that waiver, Young said “no,” adding that HHSC “has implemented dozens of strategies to make the unwinding as smooth as possible for clients and eligibility staff.”

Where does that leave us? Lawmakers in the two caucuses want to know “the full range of investments and policy changes needed to maintain a high-performing eligibility system,” per the letter. We asked HHSC what some of those investments and policy changes might be. Young answered that the 88th Legislature approved 25% salary increases for eligibility staff, plus more than 600 temporary staff to help with unwinding. “Hiring, training and retaining staff are long-term solutions to managing workload and reducing reliance on mandatory overtime,” Young said. “However, it takes a new eligibility adviser a year to be proficient with application processing and overtime is the most readily available tool to address workload quickly.”