Texas has the most uninsured kids in the nation. But state lawmakers have made it especially difficult for kids to stay on Medicaid.

It’s becoming a familiar scene across Texas: a parent brings her child to the doctor for a checkup. She signs in at the front desk. Only then does she learn that her child has been kicked off her health insurance—a casualty of missing paperwork and hoops she didn’t know existed. Next comes the awful decision: Pay out of pocket or delay the appointment, skipping critical care like vaccinations against measles, which is seeing a resurgence in Texas and around the country.

Tamisha Jones, a Harris County pediatrician, estimates that this happens several times a week at Legacy Community Health in Houston, where she sees primarily Medicaid patients. Each time, it’s “heartbreaking” for parents and dangerous for kids. “The sad part is that it typically happens right around that one-year mark, when there’s a need to come in and get screened for things like anemia, lead poisoning, and get a slew of vaccines,” Jones says. “Each day [a child’s] not protected is another day that [that child is] at risk.”

Jones works in the county with the most uninsured kids in the nation—166,000—in the state with the most uninsured kids—873,000. Eleven percent of Texas kids were uninsured in 2018, more than double the national rate. And the numbers are getting worse. A recent report from Georgetown University found that the rate of uninsured kids nationwide increased for a second consecutive year in 2018, after several years of decline that were due at least in part to the Affordable Care Act (ACA).

Texas has made it especially difficult for kids to stay on Medicaid. While many states check children’s eligibility yearly, Texas moved in 2014 to a system of income checks multiple times per year, burdening families with heaps of paperwork. According to Adriana Kohler, policy director at Texans Care for Children, families have just 10 days—starting from when the state puts papers in the mail—to receive the forms, gather necessary documentation, fill them out, and send them back. This has caused thousands of eligible kids to lose Medicaid coverage each month. State lawmakers have repeatedly declined to pass bills to move to 12-month continuous coverage.

There are other causes too: Attacks on the ACA from Trump and GOP lawmakers have reduced enrollment outreach and confused families. Anti-immigrant policies—particularly Trump’s “public charge” rule, which would make it harder to get a green card if applicants might need public assistance—have led families to pull kids out of benefit programs for fear that they could negatively affect the parents’ immigration status. The rule is currently blocked by the courts, but the “horrible” policy is already “having the desired effect,” according to Jason Terk, a Keller pediatrician and the former head of the Texas Pediatric Society.

Missed vaccinations are one tangible effect of these coverage lapses, and they’re riskier than ever. Vaccine exemptions for kids have skyrocketed from about 2,300 in 2003 to 64,176 in 2018, and there were 21 confirmed measles cases in Texas this year.

The consequences of insurance gaps and missed appointments can be long-lasting. “Pediatricians are in the prevention business,” Terk says. “If we don’t do things the right way, especially in the first few years of life, we end up with worse outcomes in the end.”

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