They say everything’s bigger in Texas, and that commentary extends to the state’s uninsured population—even in the age of Obamacare. Health disparities in Texas are significant, and the state has maintained a firm stance against the Affordable Care Act, including Medicaid expansion. Despite having a long ways to go, the state continues to have the third highest exchange enrollment in the country, following California and Florida.
As of December 19, 2016, the deadline to enroll in plans effective January 1, 2017, a total of 775,659 Texans had purchased health insurance through the state’s federally facilitated exchange. Of all states using the HealthCare.gov platform, Texas had the second-highest enrollment after Florida.
The future of healthcare reform under the Trump Administration is uncertain, and nation is watching as the process of repealing the Affordable Care Act begins. An estimated 2.6 million Texas residents could lose their health coverage by 2019 if the ACA is repealed, according to projections from the Center on Budget and Policy Priorities. Currently, 4,377,000 Texans are uninsured. Under a repeal, the total could reach 6,927,000.
While there are few concrete answers right now, our Repeal and Replace section includes a number of articles about what has been proposed and the potential impact.
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. The Lone Star state came in last for access, performing at 51st and 48th for uninsured adults and children, respectively. Texas adults placed 46th for the percentage of adults who went without care in the past year due to cost (18 percent). Texas children ranked 27th in the nation for having a medical and dental preventive care visit in the past year (68 percent).
If Texas were to improve to the level of the best-performing state, more than 3 million adults would be insured and more than 2 million fewer adults would go without needed healthcare because of cost. Review the Texas scorecard for more details on where the state’s health system succeeds and where it could use the most improvement.
In the 2016 version of America’s Health Rankings, Texas placed 33rd overall. 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. Since the 2009 report, Texas has ranked No. 1 for the number of uninsured adults. However, in that time, the percentage of uninsured adults has dropped from 24.5 to 19.1. The state ranks second for the number of children under age 18 who are uninsured (11 percent).
The Robert Wood Johnson Foundation has also compiled health factors and outcomes data in Texas on a county level. The state’s uninsured population is as low as 16 percent in its best-performing county for this health factor and as high as 39 percent in its worst-performing county. You can use this interactive map to see how the counties in Texas compare with one another.
Has the ACA helped Texans?
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: 22.3 percent of Texas residents were still without health insurance as of the end of 2015. This is still by far the highest rate in the nation. Texas is the only state with more than 20 percent of its population uninsured. Georgia has the next-highest rate with 18.2 percent of its population uninsured.
According to Census data, 1 in 5 uninsured U.S. children live in Texas; only Alaska fared worse. However, Texas officials have stated that they are pushing to reach more families who may be eligible to apply for the state’s Medicaid and Children’s Health Insurance Program.
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.
Rates and carriers for 2017 Obamacare plans
Entering 2017 open enrollment, Texans saw higher health insurance rates and fewer options, as was the case for consumers nationwide. UnitedHealthcare, Aetna, Scott & White, Cigna and Allegian all ceased to offer individual health plans through the Texas exchange, leaving 10 exchange carriers remaining for 2017. The remaining carriers offering plans through Texas’ federally facilitated exchange and their approved average rate increases are as follows:
- AmBetter (Celtic) – 15.38 percent
- Blue Cross Blue Shield of Texas – 44 to 48 percent, depending on the plan
- CHRISTUS Health – 17 to 30 percent, depending on the plan
- Community Health Choice – 21 percent
- FirstCare (SHA) – 48.45 percent
- Humana – 45.35 percent
- IdealCare (Sendero) – 28.9 percent
- Molina – 10.3 percent
- Oscar – 17 to 25 percent, depending on the plan; coverage area is being reduced, and plans will not be available in the Dallas area in 2017
- Prominence Health First – 31.2 percent
While these rate increases are substantial, premium subsidies will be adjusted to offset these increases for eligible enrollees. As of March 2016, nearly 84 percent of Texas exchange enrollees received advanced premium tax credits, and nearly 60 percent received cost-sharing reductions.
Texas enrollment in qualified health plans
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 2014, when the first open enrollment period ended, 733,757 Texans had finalized their enrollment in qualified health plans through the exchange, and HHS reported that 84 percent of them had their premiums reduced with subsidies.
Despite maintaining the nation’s highest uninsured rate, Texas has seen significant improvements. In 2015, the uninsured rate fell to 16.8 percent—the national average was 9.1 percent.
At the end of 2016 open enrollment, more than 1.3 million Texans had selected a qualified health insurance plan through HealthCare.gov. At the end of the first quarter of 2016, effectuated enrollment was 13 percent higher than it was in 2015. Marketing efforts by the Texas Hospital Association have been given credit for this improvement.
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. In the House, representatives from Texas currently include 12 Democrats and 24 Republicans.
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 has 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, but HHS has opposed that possibility with other governors.
Texas Medicaid/CHIP enrollment
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. As stated above, Texas remains among the states who declined to expand Medicaid under the healthcare reform law.
Texas is currently one of 19 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.
Because the state refused to expand Medicaid, Texas has 766,000 people 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 is Florida, with about 567,000 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.
Between 2013 and May 2016, Texas’ existing Medicaid/CHIP program saw an increase of about 6 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 $3,000 annually for a family of three). Medicaid and CHIP enrollment is open year-round.
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.
Medicare in the state of Texas
Of these enrollees, 84 percent qualify based on age and 16 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 as a way to gain more health benefits. In 2015, about 31 percent of Texas Medicare recipients selected a Medicare Advantage plan instead of traditional Medicare, consistent with the national average
State-based health reform legislation
Here’s a summary of recent Texas bills related to healthcare reform: