The final weeks of 2014 were a stressful time for Jasmine Johnson, then a 20-year-old expectant mother who was moving to Conroe after attending business management school in Brenham. Unbeknownst to Johnson, they were also the final weeks of her Medicaid health coverage.

Johnson spent most of her childhood in the state’s foster care system, so she’s entitled to public health insurance until she turns 26 under the Affordable Care Act. But when many former foster youth turn 21, the Texas Health and Human Services Commission cuts off their insurance through Medicaid, the federal-state insurer for the poor and disabled, and makes them re-apply. When doing so, those youth find that coverage can be difficult to hold onto.

A few weeks into the new year, Johnson gave birth to a baby daughter, Rain — and, after learning she had recently become uninsured, brought home a $1,500 hospital bill she said she could not afford.

Though Johnson remained eligible for Medicaid coverage, state records obtained by The Texas Tribune show her application to re-enroll was denied three times, in January, March and April. Meanwhile, the hospital kept asking her to pay up.

“I felt scared,” Johnson recalled in a telephone interview. “I mean, I’d just had my baby.”

With the help of a social worker at the transitional community for aged-out foster youth where Johnson lives and an attorney at Texas RioGrande Legal Aid, Johnson’s Medicaid coverage was restored retroactively in June, and medical bills that were then nearly six months old were finally paid.

But the whole experience was “a big headache,” she said — and one she could not navigate alone. “It was really, really horrible.” 

Advocates for former foster youth say Johnson’s experience is hardly an outlier in Texas. Mary Christine Reed, director of the Texas Foster Youth Justice Project, says she has evidence that state officials are routinely denying health coverage to young adults who should be entitled to it. Often, Reed says, state employees wrongfully tell former foster care youth they are ineligible.

“We have seen youth after youth struggle” to get their health insurance renewed once they realize it expired, Reed wrote in a letter this week to Texas Health and Human Services Executive Commissioner Chris Traylor. “They are not isolated incidents.”

A spokesman for the Health and Human Services Commission says it is reviewing the allegations and will meet with representatives of the Texas Foster Youth Justice Project “to ensure their concerns are heard.”

“The Health and Human Services Commission is committed to serving everyone who is eligible for the programs we administer,” agency spokesman Bryan Black said in a prepared statement. “HHSC’s top priority is to make sure Texans are connected to the resources they deserve.”

Reed said state health officials have been “very good” about addressing individual cases where former foster care youth were wrongfully denied Medicaid coverage but that she had gotten a “noncommittal response” about fixing a problem she believes is systemic.

In Texas, roughly 1,200 foster care youth age out of the state’s system each year.

Last year, the health commission predicted that the Affordable Care Act’s expanded coverage of former foster youth would lead thousands more people to enroll in Medicaid, bumping enrollment in that group up from about 1,500 people in 2014 to 5,000 in 2015.

State officials on Friday said they could not immediately determine how many foster care youth are now enrolled in the program.

Before the Affordable Care Act expanded coverage to age 26, Texas provided “transitional Medicaid” to some foster youth until they turned 21. But under President Barack Obama’s signature health care law, the state split Medicaid coverage for former foster youth into two plans based on age. Most former foster youth in the first coverage plan must request to be switched to a second plan when they turn 21.

Advocates have long argued that aged-out foster care youth should be automatically enrolled in Medicaid to help them avoid a gap in health coverage.

Ashley Harris, a policy associate at Texans Care for Children, said in an email that Texas policymakers should devote more attention to making sure children in foster care “have the support they need to grow into healthy, successful adults.”

“Right now, the state is falling short of that obligation,” she said.

Automatic enrollment would have helped Angelica Gutierrez, a former foster care youth who re-applied for Medicaid coverage in December 2014. A month later, she was interviewed by a state employee who told her she was not eligible for health insurance, according to the Texas Foster Youth Justice Project.

Reed said those bureaucratic obstacles can be insurmountable for youth transitioning out of the foster care system, who move frequently and experience disproportionate rates of homelessness.

“When they are told they do not qualify for Medicaid, even if it is contrary to what they learned about after foster care benefits, most don’t see the point in pursuing what seems to be a futile process,” she wrote.