Abstract

Background: In March 2021, Healthy Texas Women (HTW), a Texas Medicaid program, expanded its application form from 2 to 13 pages. This study aimed to assess how the expanded application form affected HTW enrollment rates. Additionally, the study assessed staff and patients’ experiences with the new HTW form.

Methods: This study involved an eight-clinic system that provides primary preventive and reproductive health care to adolescents and young adults (AYA) (13 – 24 year olds) in a metropolitan city in Southeast Texas. The study utilized a mixed methodology, including a quantitative analysis of randomly selected patient charts (n = 597) and, through convenience sampling, one-on-one semi-structured interviews with patients (n = 5) and clinic staff (n = 4). The quantitative analysis included adult clinic patients (18 years old or older) who utilized clinic services from 2020 – 2022 who were eligible to apply for HTW. The qualitative analysis included participants who utilized or worked at the clinic in 2023. The quantitative analysis of the study assessed enrollment outcomes, applicant characteristics, and survey interactions that led to program denial. The qualitative analysis included semi-structured one-on-one interviews to evaluate how the expanded application affected staff and patient experiences.

Results: The quantitative analysis included 521 HTW applications during the study timeframe and showed the expanded application led to a 20 percentage point decrease from 56% (175 of 312 2-page applicants) to 36% (75 of 209 13-page applicants) HTW approval for eligible patients. Few applicant characteristics and response behaviors such as being employed (50%), incomplete and/or incorrectly filled out fields (average number of errors per application = 0.8) were significantly associated with HTW approval or denial. Through the qualitative analysis, patients and staff noted experiencing increased administrative and user burden. Based on study findings, expanding the application was correlated with decreased HTW enrollment and increased administrative burden. Clinics and providers were unable to help patients successfully enroll in HTW due to the lack of transparency surrounding application denials and no clear patterns regarding program enrollment.

Conclusions: HTW should reassess enrollment procedures to improve healthcare access and user experience.