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Texas health insurance

Open enrollment for individual market plans will begin again in November 2020. Until then, people with qualifying events can enroll or make plan changes.

Health insurance in Texas

The Texas health marketplace

State legislative efforts to preserve or strengthen provisions of the Affordable Care Act

Texas is among the states that have done the least to preserve the Affordable Care Act’s gains.

Texas utilizes the federally run marketplace at HealthCare.gov and has one of the highest exchange enrollments in the country. Only Florida and California have higher exchange enrollment.

Open enrollment for 2020 health plans has ended, although residents with qualifying events can still enroll or make changes to their coverage for 2020. The next open enrollment period, for plans effective in 2021, will begin November 1, 2020.

Read our overview of the Texas health insurance marketplace.


Texas enrollment in qualified health plans

During the open enrollment period for 2019 health coverage, 1,087,240 people enrolled in private plans through the Texas exchange — the third year in a row that enrollment had declined. But enrollment grew for 2020, with 1,117,882 people signing up during open enrollment. Texas was one of only a handful of HealthCare.gov states where enrollment grew in 2020.

Read more about yearly enrollment totals in the Texas health insurance marketplace.

Medicaid and CHIP in Texas

The ACA would have expanded Medicaid to cover all legal residents in Texas with incomes up to 138 percent of the federal poverty level, but a Supreme Court ruling in 2012 allowed states to opt out of Medicaid expansion. Texas remains among the dwindling minority of states that have continued to reject the expansion of Medicaid.

Because of the state’s refusal to expand Medicaid, 759,000 Texans are in the coverage gap, with no access to financial assistance with their health insurance. This is far more than any other state that has not expanded Medicaid – the next highest was Florida, with about 445,000 people.

Between 2013 and March 2017, Texas’ existing Medicaid/CHIP program saw an increase of about 13 percent, 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 $3,200 annually for a family of three). Medicaid and CHIP enrollment is open year-round for those who are eligible.

Read more about Medicaid expansion in Texas.

Short-term health insurance in Texas

Texas regulations regarding the definition and duration of short-term health plans align with new federal short-term rules. As a result, plans in Texas can have initial terms of up to 364 days and can be renewed for a total duration of 36 months.

Read more about short-term health insurance in Texas.

Texas health ratings

The Lone Star state continues to founder in national healthcare rankings across the board. Though seeing slight improvements, the state’s large population of uninsured surely impacts its performance in many health dimensions.

In 2015, The Commonwealth Fund’s Scorecard on State Health System Performance ranked Texas 40th out of the 50 states and the District of Columbia, consistent with its 2014 ranking. In 2018, the state dropped to 44th place, and dropped again, to 49th place, in the 2019 analysis.

The Lone Star state came in last for the Access & Affordability metric, at 51st place. The only metric in which Texas scored in the upper half of states was Healthy Lives; within that metric, Texas ranked in the top quartile for three measures: The prevalence of smoking, the prevalence of suicide, alcohol, and drug-related deaths, and the prevalence of adults who had lost six or more teeth.

The 2018 overall scorecard includes details on the specifics of each state’s performance, and the Texas scorecard includes a summary of how the state performed for each metric.

America’s Health Rankings, however, gives Texas better marks. The state is still in the bottom half in the Rankings, but it came in 34th on the 2017 Ranking, down one spot from 33rd overall in 2016. For many years, the state has placed poorly in Policy measures, repeatedly ranking 50th for its high percentage of uninsured.

Trust for America’s Health provides another look at overall public health in Texas in their 2016 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.

Obamacare in the Lone Star State

In 2010, Texas’s U.S. Sens., John Cornyn and Kay Hutchison, Republicans, 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.

Former Texas Gov. Rick Perry was also staunchly opposed to the ACA and had a state legislature with a strong Republican majority. The state opted to let HHS run the exchange, has refused to expand Medicaid, and even worked to make it more difficult for navigators to do their job in Texas.

In January 2015, Greg Abbott took office as Texas’ governor. He has voiced his opposition to expanding the current Medicaid system. However, he would like to see Texas use federal Medicaid funds in the form of block grants.

Has the ACA helped Texans?

Before the ACA was implemented, according to U.S. Census data, Texas had the highest uninsured rate in the country in 2013 (22.1 percent). It’s gone down since then, but Texas still had the highest uninsured rate in 2018, at 17.7 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.

Medicare in the state of Texas

There are 4,172,453 Texas residents enrolled in Medicare as of 2019. That’s about 14 percent of the state’s population, versus nearly 19 percent of the US population enrolled in Medicare.

Of these enrollees, 85 percent qualify based on age and 15 percent qualify based on disability. The state spends about $10,549 annually per recipient – 18 percent more than the national average of $8,970 per recipient.

Texans who qualify for Medicare can select Medicare Advantage plans instead of Original Medicare — there are pros and cons either way. In 2018, about 36 percent of Texas Medicare recipients selected a Medicare Advantage plan instead of traditional Medicare, consistent with the national average

Additionally, 41 percent of Texas Medicare enrollees selected a Medicare Part D stand-alone prescription drug plan.

State-based health reform legislation

Texas only has legislative sessions in odd-numbered years. This resource, published by the Texas Department of Insurance, details bills related to health reform that were enacted in Texas in the 2017 legislative session.

Several important healthcare reform-related bills have been enacted in Texas in 2017 and 2019. They include:

  • SB1742, enacted in 2019, requires health plan provider directories to make it clear whether specialists practicing at in-network facilities are also in-network. In addition, the legislation imposes new rules related to prior authorization, including a readily available list of services that are subject to prior authorization requirements, and information about the insurer’s total volume of prior authorization requirements and denials.
  • SB1264 will end surprise balance billing for Texans enrolled in state-regulated health plans (ie, plans that aren’t self-insured). It applies to medical services received on or after January 1, 2020, and essentially requires the insurer and the out-of-network provider to work out the payment arrangements without involving the patient. Surprise balance billing refers to situations in which emergency care is provided at an out-of-network facility, or when a patient goes to an in-network facility but is treated — often unknowingly — by a medical provider who isn’t part of the patient’s insurance network. Instead of billing the patient for amounts above their normal cost-sharing requirements, the out-of-network provider has to use a state-regulated mediation/arbitration process to work out a payment amount with the patient’s insurer.
  • SB1037, enacted in 2019, ensures that surprise balance bills that are sent to collections won’t show up on the person’s credit report.
  • HB214, enacted in 2017, prohibits coverage for elective abortion on all major medical plans (including plans sold through the exchange) in Texas. Twenty-five states had already enacted similar legislation.
  • SB1406, enacted in 2017, authorized the state to submit a 1332 waiver proposal to the federal government, seeking permission to waive the actuarial value requirements that currently apply in the small group health insurance market. The idea is to allow small group plans to have a wider range of actuarial values, instead of having to conform to the current bronze, silver, gold, or platinum categories. The legislation was signed into law in May 2017, but the state never submitted a 1332 waiver proposal. The Texas Department of Insurance published a brief in early 2018 detailing several other potential 1332 waiver proposals that could be used to stabilize the individual market, but related legislation was not enacted in 2019.

Scroll to the bottom of this page for a summary of other recent Texas bills related to healthcare reform.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.