Texas health insurance
With worst rate of uninsured in the nation, the Lone Star State has plenty to gain from ACA provisions
By Louise Norris
August 7, 2014
Public health and realistic, affordable access to health care are significant factors that play a role in quality of life, productivity, and long-term health outcomes. They vary quite a bit from one state to another however. Here’s a summary of how Texas compares with other states in terms of overall health, access to health insurance, and the state’s approach to healthcare reform:
Texas health ratings
In 2014, Texas was ranked 44th (up a few spots from 47th in 2009) out of the 50 states and the District of Columbia by The Commonwealth Fund’s Scorecard on State Health System Performance. Details about how the state was rated are available in the Texas Scorecard.
America’s Health Rankings rated Texas 36th of the 50 states in 2013 in terms of overall health. The state’s rating is helped by low incidence of drug deaths and cancer deaths, and relatively good mental health. But it’s lowered by factors that include high rates of physical inactivity and obesity, a very high uninsured rate (the highest in the country), and a significant disparity in health outcomes based on education level.
Trust for America’s Health provides another look at overall public health in Texas in their 2014 listing of Key Health Data About Texas, which includes information on specific diseases and health outcome predictors. The Robert Wood Johnson Foundation has also compiled health factors and outcomes data in Texas on a county level; you can use this interactive map to see how the counties in Texas compare with one another.
Texas and the Affordable Care Act
In 2010, Texas’s U.S. Senators, Republicans John Cornyn and Kay Hutchison, both voted no on the ACA. In the U.S. House, 20 Republican Representatives from Texas voted no, while 12 Democrats voted yes. Ted Cruz has since replaced Hutchison in the Senate, and is one of the country’s most outspoken opponents of the ACA. In the House, Representatives from Texas currently include 12 Democrats and 24 Republicans.
Gov. Rick Perry is also staunchly opposed to the ACA, and has a state legislature with a strong Republican majority. The state opted to let HHS run the exchange, has refused to expand Medicaid, and has even worked to make it more difficult for navigators to do their job in Texas.
How did the ACA help Texas residents?
Before the ACA was implemented, the uninsured rate in Texas was 27 percent, giving Texas the dubious honor of having the highest uninsured rate in the country. Unfortunately, that rate is still hovering at nearly a quarter of the state’s population: 24 percent of Texas residents were still without health insurance as of the end of June, six months after full Obamacare implementation.
This is still by far the highest rate in the nation, and Texas is now one of only three states with more than 20 percent of their population uninsured. (The other two – Georgia and Mississippi – have uninsured rates that are just slightly above 20 percent.)
Texas leaders have been vocally opposed to the ACA, and the state has thus far refused to expand Medicaid, so a cornerstone of the law’s ability to reduce the uninsured rate is unavailable in Texas. The ACA has benefitted the nearly 900,000 people who enrolled in coverage through the exchange (in both existing Medicaid/CHIP and private plans) during the first open enrollment, but the state has a long way to go.
Texas enrollment in QHPs
Texas went into the 2014 open enrollment with a much larger uninsured population and pool of potential exchange enrollees than most states. In November 2013, the Kaiser Family Foundation estimated that 3,143,000 Texas residents were potential exchange customers, and that 2,049,000 of them would qualify for premium subsidies.
By mid-April, when the 2014 open enrollment period ended, 733,757 people had finalized their enrollment in the Texas exchange, and HHS reported that 84 percent of them had their premiums reduced with subsidies.
State-wide, a total of 11 carriers are offering plans in the Texas exchange, but in nearly three quarters of the counties in Texas, only one or two carriers are offering plans. In the metropolitan areas of east Texas (mainly the triangle from Dallas to San Antonio to Houston), most counties have at least three carriers available, but in the rest of the state, the choices are more limited.
Texas Medicaid/CHIP enrollment
Texas is currently one of 22 states that has not yet expanded Medicaid and has no pending plans to do so. Researchers at New York University estimate that if the state has still not expanded Medicaid by 2022, Texas will be forfeiting $9.6 billion in federal funds that year (the state’s portion of Medicaid expansion in 2022 would be just $1.2 billion – federal funding for Medicaid expansion will always cover at least 90 percent of the cost of covering people newly eligible based on Medicaid expansion).
The general consensus is that states like Texas will eventually expand Medicaid simply because it makes sense economically. The question becomes when, rather than if – but in states where political leadership is staunchly opposed to the ACA, it could still be several years out.
The Texas exchange still enrolled 141,494 people in existing Medicaid by mid-April, despite the very strict eligibility guidelines that the state uses: Non-disabled adults without dependent children are ineligible regardless of income, and parents with dependent children are only eligible if their household income doesn’t exceed 15 percent of poverty (less than about $3,000 annually for a family of three).
Because the state refused to expand Medicaid, Texas has 1,046,430 people – about 27 percent of its uninsured population – in the coverage gap, with no access to financial assistance with their health insurance. This is far more than any other state (the next highest is Florida, with about 764,000 people).
These residents would be eligible for Medicaid if the state were to accept federal funds to expand coverage. But for now, there is no financial assistance available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing stringent guidelines
The ACA would have expanded Medicaid to cover all legal residents in Texas with incomes up to 138 percent of poverty, but a Supreme Court ruling in 2012 allowed states to opt out of Medicaid expansion, and Texas has so far chosen that path.
Does Texas have a high-risk pool?
Prior to 2014, individual health insurance was underwritten in nearly every state, including Texas. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions. The Texas Health Insurance Pool was created to give people an alternative if they were unable to obtain individual health insurance because of their medical history.
Implementation of the ACA and the advent of a guaranteed issue individual market has made high risk pools largely obsolete, and the Texas Health Insurance Pool terminated coverage on March 31, 2014. Members were able to transition to new policies available through the exchange instead, with full coverage for pre-existing conditions.
State-based health reform legislation
Here’s a summary of recent Texas bills related to healthcare reform: