*Corresponding Author:

Dr. Allyssa A. Abacan, PhD, Assistant Professor, Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA, Tel: +1 346-286-3253; E-mail: abacan@bcm.edu;

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.

Key words: Medicaid; administrative burden; access; usability.

INTRODUCTION

Texans have the lowest levels of health care coverage in the United States [1]. In 2017, roughly one in four women in Texas between the ages of 18 and 44 years old did not have health insurance [2]. There is a large gap in reproductive and sexual health care access. More Texans are in need of family planning services compared to women in any other state besides California [3]. These issues disproportionately impact low-income women who rely on public funding to access reproductive health services, where almost 15 percent of women in Texas live below the federal poverty line [4]. In 2011, Texas cut two-thirds of the state’s family planning budget and terminated state contracts with Planned Parenthood, which had previously serviced a sizeable number of low-income Texans [5].

Since Texas opted out of Medicaid expansion in 2012, the state needed to find an alternative way to provide healthcare to low-income and uninsured women, through programs such as the Medicaid 1115 Waivers [6]. The state attempted to meet the needs of vulnerable women during the 84th Texas Legislative Session in 2016. It combined Texas Women’s Health Program and the Expanded Primary Health Care Program, two state health programs, into the Healthy Texas Women (HTW) program, which provides free preventive care and family planning services to eligible, uninsured women [7]. These services may include preventative care such as screening and treatment for high blood pressure or diabetes, family planning services such as the provision of birth control, and reproductive health services such as STI testing. To be eligible, women must be 15 to 44 years old, U.S. citizens or qualified immigrants, living in Texas, without health insurance, not pregnant, and making less than a specified income based on family size [8].

After the Centers for Medicare & Medicaid Services (CMS) approved the 1115 HTW demonstration waiver in January 2020, HTW began receiving federal funding. Consequently, although HTW eligibility requirements did not change once the program fell under the 1115 Waiver, as a new requirement, HTW had to follow Medicaid regulations, including screening patients for all available Medicaid programs [9]. To meet these new CMS screening requirements (i.e. screening all patients for traditional Medicaid and other state programs in a step-wise fashion), the Texas Health and Human Services Commission (HHSC) lengthened the HTW application form in March 2021 from a 2-page application to a 13-page application. The lengthened form includes additional questions about demographics, family composition, tax returns, family health coverage, and employment – items needed for Medicaid enrollment. For clinics to bill and receive reimbursement through HTW for services rendered, patients must complete an HTW application and have their enrollment approved [7]. This meant that although the patient may not qualify for Medicaid, they are still required to fill out the longer application form to then be denied for Medicaid and enrolled in HTW.

Longer application requirements may place an administrative burden on patients and clinic staff, which can negatively impact HTW program enrollment rates. Herd and colleagues define administrative burden as “an individual's experience of policy implementation as onerous” [10, p.S69]. Providers are concerned that the expanded HTW application is more difficult to navigate [9]. Overall, shifting administrative burdens from the state to the patients and providers is shown to decrease program uptake [11]. Further, physicians and health care professionals worry about the effects of lower HTW enrollment, which may lower access and worsen health outcomes [9, 12].

Previous studies have not explored how the new 13-page HTW application affects health care access, including whether the lengthened application form resulted in its intended outcome of increasing traditional Medicaid enrollment, nor the experiences of patients and clinic staff. Existing research has not investigated how the new 13-page HTW application has affected patient health care access and patient and clinic staff experience. The purpose of this study was to assess how the lengthened application affected HTW enrollment and staff and patient experiences among young adults accessing sexual and reproductive health care in a clinic system located in Southeast Texas.

Data and Methods

Research Site. A mixed-methods study was conducted at an eight-clinic system that provides primary preventive and reproductive health care to adolescents and young adults (AYA). The clinics primarily serve low-income individuals between the ages of 13 and 24 who live in Southeast Texas. Medicaid applications from different regions were not included in the analysis given the studied clinic system does not serve patients outside of Southeast Texas. An Institutional Review Board (IRB) provided approval for the study. The clinic system is predominantly state-funded through state family planning health programs and is an important safety net for low-income, and un- and under-insured AYA individuals, conducting over 20,000 visits a year.

The front desk staff performed an initial Healthy Texas Women (HTW) eligibility screening with every patient. If the patient passed the initial eligibility screening, they filled out an HTW application via paper forms. The clerks were available to patients if they had any questions regarding the application. After patients finished their application, the clerk would review them for completeness. Clerks faxed the completed HTW application to the Texas HHSC for review and approval/denial.

Quantitative Methods. This study accessed clinic records from January 2020 to December 2022 to analyze HTW enrollment rates of adult patients pre- and post-application change in March 2021. In total, 597 unique HTW applications were randomly selected from the eight clinic locations. Data collected from the 13- and 2-page application forms included patient characteristics, patient responses, enrollment status for HTW, and application submission date. To assess indicators of HTW status (approval or denial) for the lengthened 13-page application, researchers coded HTW eligibility, application field completion, and application field errors. Researchers coded an application field as an error if a patient answered a question with recognizably irrelevant information, like providing an email address instead of a mailing address or if the patients’ answers contradicted with one another. The study excluded 13-page applications deemed ineligible based on HTW criteria and applications for which eligibility could not be determined. This approach was not applied to the review of the 2-page application.

The study investigators calculated basic descriptive statistics and ran a simple logistic regression of enrollment status on application length to address whether the application change led to significantly different enrollment rates. They also analyzed whether there were significant differences between approved and denied 13-page applicants using chi-square tests and t-tests. The analysis included two iterations of a multivariate logistic regression using 13-page enrollment status as the dependent variable with various controls that fit into three categories: application completion, application errors, and applicant characteristics. Study investigators ran a Correlation Matrix and Variation Inflation Factor (VIF) Test for each model. Analyses were performed in R [13].

Qualitative Methods. The qualitative arm of the study utilized convenience sampling to conduct semi-structured interviews. The semi-structured interviews sought to assess how the application change affected clinic staff and patient experience between February and March 2023. Interviews provided a contextual understanding of patients’ and staff’s experiences and helped identify specific issues users experienced while completing the lengthened HTW form. Both patient and staff respondents had time to review the consent form and provided written and verbal consent to participate. One-on-one interviews took place in person and lasted around 30 minutes using a semi-structured interview guide [14]. Three co-investigators, under the supervision of A.A, PhD (female) and B.R., PhD (male), conducted the interviews. Both A.A. and B.R. have extensive academic experience in qualitative research including interviewing and analysis, specifically in the social sciences field.

Staff members were identified using purposive sampling. Interviews were conducted via Zoom and no other individuals were present during the interviews. Study investigators asked staff respondents about their experience assisting patients with the lengthened HTW form, clinic flow related to HTW application completion, the features of the form patients found difficult and easy, confidence and assistance with helping the patients fill out the form, and any recommendations on how the application process could be improved. Researchers asked staff who had worked with both the 2- and 13-page applications to compare experiences using both forms. For staff interviews, the coded themes were barriers to application completion, form length, features they perceived as confusing or easy, patient assistance, perceptions of the 2- versus the 13-page application, enrollment outcomes, and policy recommendations. The codes were initially identified prior to the interviews, reflecting the semi-structured interview questions. However, the codes were adjusted after reviewing the interviews.

Patients who completed the 13-page application were identified using convenience sampling at the clinic sites. Patients who were deemed eligible for HTW and were adults were recruited for the study. The patients were given a summary of the research purpose and methods. If the patient agreed to participate, the patient signed the consent forms and participated in the interview the same day. The interviews were conducted in the clinic and no other individuals outside the interviewer and study participant were present during the interview. Study investigators asked patients about their health care access, HTW application experience(s), and thoughts on potential form improvements. For patient interviews, the coded categories included features of the form patients perceived as confusing or easy, form length, self-efficacy in filling out the application, need for staff assistance, patient perceptions of the clinic, and barriers. The codes were initially identified prior to the interviews, reflecting the semi-structured interview questions. However, the codes were adjusted after reviewing the interviews.

A thematic content analysis was conducted using categories established a priori based on the research questions and modified based on patient responses to interview questions [15]. Interviews were audio recorded and then later transcribed by hand. The three interviewers and A.A. reviewed and coded the interview transcripts, dividing transcript data into small meaningful units (i.e. sentences, phrases, paragraphs related to a topic). Study investigators used the coding software, Dedoose, to code and analyze the interviews [16]. Two coders were assigned to each interview transcript. Themes across interviews were compared. Each interview was double-coded to check for internal validity.

Study Results

Enrollment rates between 2- vs. 13-page application

Fifty-six percent of patients who filled out the 2-page application (n = 312) were approved for Healthy Texas Women (HTW), compared to 36% of individuals who filled out the 13-page application (n = 209) (Table 1). Six patients who used the 13-page application were deferred to other Texas Medicaid programs and, therefore, excluded from our regression analyses. Figure 1 depicts a line graph showing the enrollment rates for the 2-page form and the 13-page form from January 2020 through December 2022. A simple logistic regression shows that the chances of becoming enrolled in HTW are significantly lower for women who apply with the 13-page application compared to the 2-page application, b = -0.81, t(513) = -4.5, p <0.001 (Table 2). 

13-Page Application Response Behaviors

The study sought to determine whether application completion behaviors and applicant characteristics were associated with 13-page application HTW enrollment (n = 203). Instances of application incompleteness were far more common than application errors. As demonstrated in Table 1, applicants were most likely to leave fields related to job changes (67%), pretax contributions (44%), and additional income sources (39%) incomplete. Applicants were most likely to incorrectly mark themselves as incarcerated (11%) or erroneously fill out the date and signature field (7%).

As shown in Table 2, the average age in the sample was 22 years old. Twenty-seven percent of these applicants identified as Black, 30% as White Non-Hispanic, and 42% as Hispanic. Fifty percent of applicants were unemployed. Chi-square tests and t-tests revealed statistically significant differences between approved and denied applications. For example, denied applications were found to have more instances of incomplete fields (M = 6.39, SD = 5.48) than approved applications, t(201) = 2.25, p < 0.05; however, denied applications had fewer errors (M = 0.80, SD = 0.98) than approved applications, t(102) = -2.79, p < 0.01. Additionally, the percentage of participants that were denied differed by completion of the Social Security Number (SSN) field, χ^2 (1, N=203) = 13.45, p < 0.001.

In Model 1, study investigators ran a regression of enrollment status on variables related to field errors and completion. In Model 2, investigators added more control variables related to an applicant’s personal characteristics, such as race and age. As shown in Table 3, applying more times to HTW, b = -8.21t (187) = -2.29, p < 0.05, and omitting one’s SSN, b = -2.42, t (187) = -3.03, p < 0.01, were significantly correlated with a lower likelihood of HTW approval. Unemployed applicants, b = 1.48, t (187) = 2.90, p < 0.01, were significantly more likely to become enrolled in HTW. Variation Inflation Factor (VIF) was between 1 and 2, indicating low multi collinearity between variables.

Patient Experience

Five patients were interviewed (Table 4). Their average age was 20 years old, 60% identified as Hispanic, 20% as White Non-Hispanic, and 20% as Black. Most patients found the beginning section of the form, such as date of birth, address, and contact information the easiest to complete. One patient also noted that the information on the first page, which includes instructions, was helpful. All patients mentioned feeling confident after staff introductions to the form.

[The front desk clerk] was very helpful. Like, she walked me through everything. She was like, “oh, you’re gonna fill this out like it’s for this,” etc. So she helped out. (Patient Respondent 5)

[The staff] make it pretty easy. They kind of just explain to like, fill out all the parts that apply to you. And whatever obviously doesn’t apply, don’t fill out. (Patient Respondent 4)

Despite staff assistance, patients expressed confusion while completing the form. In particular, two patients noted that having sections for “Person 1” and “Person 2” were confusing. Three patients did not understand how to correctly fill out the section about their family’s health coverage. Two interviewees also mentioned that the form was repetitive, suggesting the 13-page application length to be unnecessary.

It’s just long. Since this was my first time here, I had other paper work. So, it just kind of felt like a lot of the same. There were lots of the same demographic questions. (Patient Respondent 2)

I did have one spot that I was a little unsure about. I think it was like my family’s health coverage and stuff like that, I don’t know that stuff about my family. (Patient Respondent 3)

Staff Experience

Four staff members were interviewed (Table 5). Staff members had worked an average of 11 years at the clinic system. Staff observed an increased number of patient questions and requests for assistance filling out the 13-page application compared to the 2-page application.

Most of the time [patients] don't want to do it, especially when I show it to them it looks very long … The first reaction when seeing form is not wanting to fill it out. (Staff Respondent 4)

It was easier. Patients filled that one out really fast… Once they started using 13 page forms, the approval rate went way down. (Staff Respondent 4)

They also commonly mentioned seeing an increase in HTW application denials, needing to check forms for completion and correctness more often, and observing patients fill out application sections incorrectly due to the patient not having the correct information or not understanding how to properly fill out the form. Staff emphasized the length of the form and increased denial rates as main concerns. Staff unanimously expressed preference for the 2-page form. They noted that the shorter application length was easier, less time consuming, and resulted in more approvals.

Of all the patients that I've [given the form to], I do see that the two page application was so much easier than the 13-pager, because it's way less questions. And I've noticed that more people will get approved [with the two-page application]. (Staff Respondent 1)

Additionally, for patients whose applications were denied, staffs were unable to see the reason for the denial. Staff 1 and 3 discussed patients receiving denial letters from Texas HHSC but either not reading the denial letter or not understanding what the denial codes meant. Staff asked patients to bring in the letter to add to their chart, and help them reapply, but patients rarely did. Staff 2 noted that when patients are denied, they usually do not want to apply again. Overall, both staff and patient participants expressed frustrations, higher user burden, and decreased enrollment with the 13-page application compared to the 2-page application.

They don't tell me why [patients] got denied. We just know that they did, because we check [enrollment]...[I] asked [patients], “Hey, did you receive a letter?” And they're like, “Yeah, it says, I got denied”, or “It says I need more information.”...So I really think they aren’t putting their income on here. (Staff Respondent 1)

Discussion

The study findings provide the first assessment of the impacts of the March 2021 Healthy Texas Women (HTW) application change. The lengthened application form was significantly correlated with HTW program denial. Eligible patients who completed the 13-page application were less likely to successfully enroll in HTW. The study identified factors correlated with HTW enrollment including the number of times patients applied to HTW, providing a Social Security Number (SSN), and employment status. Staff and patient qualitative respondents provided additional context about the HTW application process, such as perceived self-efficacy and overall user burden with the new application. These findings align with existing administrative burden literature, in which a higher burden placed on individuals applying for benefits is associated with reduced program uptake [10]. The study highlights elements of the HTW application associated with patients’ ability to easily apply to and access a critical health care program, and providers’ ability to draw HTW reimbursements from provider interventions. Additionally, the goal of expanding the application form was to screen and enroll patients in traditional Medicaid; despite this, less than 3 percent of patients who filled out the HTW application were approved for other Medicaid programs.

The number of times a patient completed the HTW application was significantly associated with a decrease in successfully enrolling in HTW. Texas HHSC does not disclose to patients or clinic staff the reason for denial in a digestible and transparent manner. Per correspondences with Texas HHSC, provider groups must have the patient physically with them in order to access reasons for denials. Due to a lack of understanding about why patients were denied, the study investigators suspect individuals may have resubmitted the same information that initially led to program rejection or resubmitted the form with fewer sections completed. Previous research shows that the number of times someone fills out a form or survey is associated with lower-quality answers [17]. However, there were instances when individuals completed an additional application after rejection with the same information and gained HTW coverage. This highlights the study’s findings that showed no discernable patterns between response behaviors and HTW denial, which may suggest programmatic inconsistencies in reviewing HTW applications.

While patients reported finding the beginning section of the application easy, the quantitative analysis showed that coverage denial was highly correlated with missing an SSN. Not providing an SSN was significantly correlated with program denial, even though providing one’s SSN is not listed as a criterion for program acceptance on the HTW website. However, in 2019, Texas HHSC created guidelines requiring that individuals supply their SSNs when applying for Medicaid [18]. Given that HTW falls under an 1115 Medicaid Waiver, the state might automatically screen out individuals who do not provide such information.

In the sample, being unemployed was associated with program acceptance. Given the income threshold to qualify for the program, those who work might make too much money to be eligible for HTW and underreport their income on the application form. While study investigators assessed each applicant’s eligibility before including them in the sample, they relied on the patient’s self-reported income to make this determination. Texas HHSC verifies income information when reviewing HTW applications, and patients may under-report or incorrectly-report their income.

During the study period, individuals had extended state healthcare coverage due to the COVID-19 pandemic [19]. Continuous coverage ended on March 31^st, 2023. The unwinding of continuous coverage meant many current HTW members will be required to reapply to the program over the following months with the longer 13-page application form still in place.

Given the 13-page application’s impact on a patient’s enrollment status and user burden, policymakers, program administrators, and clinic staff should consider implementing policy and practice changes that could help reduce patient and staff burden and improve HTW enrollment.

Reinstate the 2-page application: The data demonstrate that the 2-page application had a higher enrollment success rate before March 2021. Staff expressed preference for the 2-page document. To return to the 2-page document, both Texas HHSC and CMS would need to agree, given that HTW falls under an 1115 Medicaid waiver. If returning to the 2-page form is not feasible, specific alterations could be made to make the 13-page form easier to complete.

If the 2-page application cannot be reinstated, change the 13-page application: Specific changes may include changes to the 13-page application to make it easier to use, such as eliminating the employment section or reducing the number of demographic questions. Additionally, Texas HHSC could provide clarifying instructions that would make the application more straightforward, reformat the application for greater clarity, and address the aspects that appeared most challenging for patients, such as reporting household data and family health coverage.

At the end of 2023, Texas HHSC approved funding for Patient Navigators. The objective of hiring Patient Navigators was to assist patients one-on-one in successfully applying for HTW and other Medicaid programs, depending on patient eligibility. This initiative could make applicants feel more confident, given that patients felt prepared to answer the form questions after staff assistance. Although Patient Navigators can help provide patient assistance, more is needed to solve the upstream issue of user burden with the 13-page application. No data on HTW enrollment rates pre- versus post-Patient Navigators have been released.

 While this research is important and the study’s data is robust, there are limitations. Clinics were expected to adopt the new application in March 2021. However, there was not a clean cut-off as expected. Due to the increased user burden on patients and clinic staff, HTW providers have returned to the 2-page application in an attempt to enroll more patients in HTW. Although the state has provided no guidance on returning to the shorter application, the shorter forms have been processed by Texas HHSC, with some applications getting approved. In this study, we could not capture eligibility for applicants using the 2-page forms. Therefore, the study investigators did not exclude ineligible 2-page applicants, meaning the difference in acceptance rates between the two application forms might be even more drastic than we report. The study chose not to analyze the impact of immigration on enrollment. In an effort to be extremely cautious about patient privacy, the study did not collect information regarding a patient's citizenship or immigration status. Certain qualified immigrants are eligible for HTW. However, the study did not capture whether specific statuses or documents are associated with certain enrollment outcomes. Lastly, the study investigators only collected data from patients between the ages of 18 and 24 from Southeast Texas. Given that individuals between the ages of 18 and 44 are eligible, study findings cannot be generalized to the experiences of younger and older applicants who may have lower medical literacy or past exposure and experience with other health care program application forms. Additionally, individuals living in other parts of Texas may have different experiences completing the HTW application form.

Implications for Policy and Practice

Given the 13-page application’s impact on a patient’s enrollment status and user burden, policymakers, program administrators, and clinic staff should consider implementing policy and practice changes that could help reduce patient and staff burden and improve HTW enrollment. Based on the study findings, there are two main implications for policy and practice: reinstate the 2-page application form, or make changes to the 13-page application form if the 2-page application cannot be reinstated. In 2023, Texas HHSC changed state policy and expanded funding for Patient Navigators to assist patients one-on-one in applying for HTW and other Medicaid programs, which may improve HTW acceptance rates. The researchers have shared this information with policymakers and advocates across Texas via a policy brief and will continue to disseminate the study’s findings.

Conclusion

The lengthening of the HTW application coincided with a decrease in enrollment rates. The HTW application change is a potential example of the administrative burdens placed on individuals, as opposed to the government, who utilize social programs. The longer HTW application has turned program enrollment processes into a black box. Study findings can be used by policymakers and advocates to reduce administrative burden and improve women’s healthcare enrollment and access in Texas.

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PEER REVIEW

Not commissioned. Externally peer reviewed.