Texas has more uninsured residents than any state. But we shouldn’t

Policy solutions and an effective outreach program can narrow this gap.

Nearly 5 million Texans lack health insurance — more than 16% of the total population. While this is lower than in recent years, it remains the largest of any state.

Too often the debate about how to address this challenge gets stuck in a political deadlock over Medicaid expansion. While Medicaid expansion would provide coverage to hundreds of thousands of Texans, it would only solve 15% of our challenge.

Even if Texas expanded Medicaid — and 100% of the newly eligible individuals enrolled — we would still be 50th among states in our uninsured rate. Additional solutions will also be needed to provide health coverage to the vast majority of uninsured Texans.

Here’s the good news: A large majority of Texas’ uninsured population is currently eligible for existing coverage.

As part of a long-term effort to solve this problem, Texas 2036 conducted a first-of-its-kind multiyear study to find out why so many Texans are uninsured. What we learned challenges the conventional wisdom that has been driving debates about how to effectively provide millions of Texans with health coverage. It turns out that many of the barriers Texans face are not what we thought they were.

Roughly 70% of uninsured Texans age 16 and above are in the labor force, including 64.2% who are employed; and about half of uninsured Texans have incomes over 200% of the federal poverty level (about $55,500 annually for a family of four). While affordability may be an issue for many Texans, the out-of-pocket cost of coverage for much of our uninsured population is often an issue of perception, not financial reality.

Of the approximately 5 million uninsured Texans, nearly 2 million are either eligible for a free Affordable Care Act plan or are children eligible for a free Medicaid or Children’s Health Insurance Program plan. The number of uninsured Texans currently eligible for a free plan is over 2½ times as many Texans in the coverage gap. Just by getting every Texan currently eligible for a free plan enrolled in coverage, our uninsured rate would drop, raising us out of last place.

So why aren’t people taking advantage of these programs? Our multiyear study took a radical approach: We asked them. By talking with them, we learned that most were unaware of the existence or affordability of existing coverage options.

The Texas Legislature has been expanding access to affordable plans in the ACA marketplace. In 2021, Texas lawmakers unanimously passed bipartisan legislation that instituted a “focused rate review” aimed at better aligning health insurance premiums across the different tiers of coverage in the ACA marketplace.

For many Texans, this effectively reduced their net premiums — sometimes to zero. And word is starting to get out. The number of Texas enrollees in plans on the ACA marketplace last year jumped 37% to nearly 3.5 million.

This is a great start, but there’s still more work to be done. Texas should build on this success by continuing to support innovative solutions to optimize awareness of the availability and affordability of these coverage options. All solutions should remain on the table as we work together to solve this challenge.

Texas may have the largest population of residents without health coverage, but we shouldn’t. That’s because affordable — often free — health coverage is available to millions of uninsured Texans today through existing programs.

By combining some commonsense policy improvements and an effective outreach program, Texas could go from having the largest number of uninsured residents to the state with the largest number of newly insured residents. For a healthier and more prosperous Texas, we must.

Charles Miller is a senior policy adviser at Texas 2036, a nonpartisan nonprofit think tank.