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Texas health insurance

More than a million people have coverage through the exchange in Texas, but the state still has the nation's highest uninsured rate, largely due to refusal to expand Medicaid

Texas enrollment update

Texas insurance overview

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.

For 2018 coverage, 1,126,838 people enrolled in coverage in the Texas exchange by December 23, 2017. As of February 2018, effectuated enrollment in private plans through the Texas exchange stood at just over a million people.

But the uninsured rate in Texas is higher than any other state. According to US Census data, 16.6 percent of Texas residents were uninsured in 2016 — more than double the national average of 8.6 percent. The state’s refusal to accept federal funding to expand Medicaid is a big part of the reason so many people remain uninsured. An estimated 638,000 people in Texas are in the coverage gap due to the state’s refusal to expand Medicaid. They aren’t eligible for premium subsidies in the exchange, but they also aren’t eligible for Medicaid, leaving them with no realistic access to coverage.

Lawmakers approve a temporary high-risk pool, pending new federal funding and ACA repeal

In May 2017, lawmakers in Texas overwhelmingly approved S.B.2087, and Governor Greg Abbott signed it into law the following month. The bill allows Texas to create a temporary high-risk pool if and when federal funds become available, although the legislation expires in August 2019. The text of the legislation specifically prevents the state from using the pool to expand Medicaid. But the pool could be used to either directly insure people with pre-existing conditions in coverage separate from the private individual market, or to offset costs for private insurers so that people with pre-existing conditions could still obtain affordable private health insurance.

Republicans in Congress spent much of 2017 trying unsuccessfully to repeal and replace the ACA. The American Health Care Act (AHCA) — which passed the  House but failed in the Senate — included $138 billion in new federal funding for various programs that could be used to stabilize health insurance markets and/or reduce premiums and increase benefits.

Some of this money could have been used to fund high-risk pools, but nothing will happen under S.B.2087 if federal funding doesn’t become available. So for the time being, the legislation is dormant. Texas has no need for a high risk pool at this point, as the ACA itself remains intact and private health insurance plans must continue to comply with the law’s requirement that coverage be guaranteed issue, regardless of applicants’ medical histories.

It’s noteworthy that health policy experts have generally said that the money provided by the AHCA would not have been sufficient to create functional high-risk pools or otherwise adequately ensure that people with pre-existing conditions could obtain high-quality, affordable health insurance in the individual market if the AHCA had been enacted. But Texas is prepared for the eventuality of creating a new high-risk pool, if federal funding were to become available and portions of the ACA requiring coverage to be guaranteed issue were to be repealed.

High-risk pools used to be the default last resort coverage option in most states when people couldn’t get private insurance as a result of their medical history. Texas had a high-risk pool (the Texas Health Insurance Pool), but coverage through the pool terminated in March 2014, as medical history was no longer an obstacle to obtaining health insurance in the private market under the ACA.

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 2017, the state dropped slightly, to 41st place, and dropped again, to 44th place, in 2018. 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. 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, according to US 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 2016, at 16.6 percent.

According to Kaiser Family Foundation data, 10 percent of Texas children are uninsured. Only Utah, Arizona, and Alaska have a higher percentage of their children without health insurance. There are a variety of organizations in Texas working to reach more families who may be eligible to apply for the state’s Medicaid and Children’s Health Insurance Program, but the state’s uninsured rate for children remains double the national average.

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. Of the 2.2 million people who are in the coverage gap in states that have refused Medicaid expansion, Texas has by far the largest share, with 638,000 people unable to realistically access any health coverage at all.

Rates and carriers for 2019 Obamacare plans

All eight insurers that offer plans in the Texas exchange in 2018 plan to do so in 2019 as well. Their average rate changes are as follows:

  • Celtic/Ambetter: 4.7 percent increase
  • Blue Cross Blue Shield of Texas: 6.5 percent decrease
  • CHRISTUS: 9.6 percent increase (23,000 members)
  • Molina: 7 percent increase (236,564 members) [Note that there is an additional note in the Molina filing that indicates the average proposed rate increase is 9.4 percent]
  • Oscar: 17 percent increase. Oscar is expanding its coverage area in Texas in 2019. They currently offer plans in San Antonio and Austin, plus off-exchange plans in Dallas. But they’ve filed plans to expand into El Paso and the Dallas/Forth Worth area for 2019.
  • Sendero: 33.8 percent increase (25,000 members in eight counties in Central Texas)
  • SHA/FirstCare: 19.9 percent (17,000 members)
  • Community Health Choice: 8.46 percent

In addition, Scott & White, Insurance Company of Scott & White, and Vista Health Plan all offer off-exchange-only plans, and will continue to do so in 2019.

At ACA Signups, Charles Gaba has calculated an average proposed rate increase of 3.7 percent for 2019, but notes that overall average rates would be decreasing in the state if the individual mandate penalty wasn’t being eliminated, and if the Trump Administration hadn’t finalized rules that expand access to short-term health insurance plans and association health plans — both of which will serve to draw healthy people away from the ACA-compliant market, leaving a sicker risk pool and increasing premiums.


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.

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.

Enrollment declined slightly in 2017, but there were still 1,227,290 enrollees in private plans through the Texas exchange by January 31, 2017.

For 2018 coverage, 1,126,838 people enrolled in plans offered in the Texas exchange. That tally was as of December 23, 2017; open enrollment ended eight days before that, but enrollment continues until the end of December in 53 counties that were hit by Hurricane Harvey. By February 2018, effectuated enrollment in private individual market plans in the Texas exchange stood at 1,014,529, and 90 percent of those enrollees were receiving premium subsidies.

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 11 Democrats and 25 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 the Obama Administration opposed that possibility with other governors. It’s much more likely that the Trump Administration would approve, although a lot is up in the air in terms of the future of the ACA under the Trump Administration and a Republican Congress. Various GOP repeal efforts failed in 2017, but the GOP tax bill, enacted in December 2017, does include repeal of the ACA’s individual mandate, starting in 2019 (people who are uninsured in 2018 will have to pay a penalty when they file their taxes in early 2019, but the penalty will not apply to people who are uninsured starting in 2019).

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).

Because the state refused to expand Medicaid, Texas has 684,000 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 467,000 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 March 2017, Texas’ existing Medicaid/CHIP program saw an increase of about 7 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.

Medicare in the state of Texas

Texas Medicare beneficiaries make up 13 percent of the Lone Star State’s total population, compared with 17 percent of the U.S. population enrolled in Medicare.

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

Additionally, 44 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 care reform that were enacted in Texas in 2017.

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.