Whether you’re leading a public hospital, a nonprofit health system or a Federally Qualified Health Center, your payer mix drives everything, from service lines and workforce planning to growth strategy and risk tolerance. It’s the bedrock of sustainable healthcare delivery.
But what happens when that mix shifts suddenly—when thousands of patients lose coverage almost overnight?
That’s the scenario now unfolding across expansion states. With Medicaid redeterminations underway and new federal constraints on the horizon, executives are confronting coverage volatility at a scale they’ve never had to plan for.
In Texas, we’ve been living that reality for decades.
Texas as a Stress-Tested Model
Texas is one of just 10 states that never expanded Medicaid under the Affordable Care Act. Nearly 1 in 5 Texans remains uninsured. For systems like CommUnityCare Health Centers, a large FQHC system in Central Texas, and Central Health, the county’s hospital district, that reality has shaped every operational decision—from financing to care model design.
As expansion states face similar pressures, Texas offers more than a cautionary tale. It’s a stress-tested model for delivering care in underfunded environments. Here are five strategies that have helped us sustain access and why they matter more than ever.
- Diversify Revenue and Support Infrastructure
CommUnityCare delivers more than 500,000 patient visits annually. While prospective payment system reimbursement and $340 billion in savings help, what sets us apart is the support from Central Health, the county hospital district that funds care for the uninsured. This partnership allows us to serve more adult patients than most FQHCs. Even after a nine-point drop in Medicaid coverage during the redetermination period, we treated a record number of patients last year.
Other diversification tactics: braided grant funding, philanthropic partnerships and sliding scale revenue.
Takeaway: Don’t wait for coverage losses to hit. Build flexible, local, multi-stream support now.
- Design Care Models That Assume Coverage Gaps
In Texas, Medicaid primarily covers children and pregnant women. Adults without disabilities often fall through the cracks, cycling between ACA plans, short-term coverage or nothing at all. That instability forces health systems to prioritize access over eligibility.
CommUnityCare’s model centers integrated behavioral health, community health workers and care navigation. Preventive care isn’t just about outcomes—it’s a financial strategy to reduce ER use and hospital readmissions.
Takeaway: Uninsured care isn’t the exception. It’s the foundation.
- Build Local Partnerships as Force Multipliers
Texas providers understand they can’t go at it alone. CommUnityCare has partnered with school districts, housing authorities, academic medical centers and municipal libraries to extend reach and impact. These relationships support pop-up clinics, co-located services and shared staff across systems.
Central Health plays a pivotal role—coordinating specialty referrals, funding infrastructure in care deserts and investing in services for high-need communities. These place-based partnerships are especially critical for patients with chronic conditions and unstable coverage.
Takeaway: If coverage is fragile, your local network must be strong.
- Build Workforce Resilience from Within
Workforce challenges persist across the country, and Texas is no exception. But when funding is tight, building from within becomes essential.
CommUnityCare and Central Health have invested in “grow-your-own” pipelines: a Medical Assistant Academy developed with local colleges, robust primary care residency programs (including pharmacy), and a wide range of clinical and nonclinical training opportunities that connect early career professionals to mission-driven care.
We’ve also prioritized culture. Our wellness director leads efforts to support the well-being of all staff—not just providers—through proactive burnout prevention and employee engagement.
Is it enough? Not always. We still face turnover and workforce fatigue. But we’ve stopped waiting for stability. We’re building it ourselves.
Takeaway: Coverage doesn’t guarantee workforce. Internal pipelines and culture do.
- Treat Policy Engagement as Operational Strategy
In a non-expansion state, policy isn’t a side conversation—it’s survival.
CommUnityCare and Central Health work closely with local officials, state agencies and advocacy coalitions to shape the safety-net environment. That includes budget priorities, clinically integrated networks and policy adaptations in real time.
Being at the table has allowed us to stay ahead of threats and to help drive smarter investments in underserved communities.
Takeaway: Policy isn’t just for your government relations team. It belongs on your operational dashboard.
From Warning Sign to Playbook
Texas isn’t perfect. The system is under strain, and the coverage gap remains wide. But for healthcare executives facing Medicaid contraction, Texas offers more than a warning—it offers a playbook for resilience.
These strategies weren’t built in crisis. They were built over time, out of necessity and purpose.
If coverage erosion is coming, your organization can adapt—but only if you plan for it now.
Tara Trower is interim COO/chief strategy officer for Austin-based CommUnityCare Health Centers, the second largest FQHC system in Texas, serving more than 143,000 individual patients in 2024 over more than a half million visits. She is also an ACHE member.