Public health and realistic, affordable access to healthcare 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, and Texas is among the states that frequently makes headlines for its disparities.
Here’s a summary of how Texas compares with other states in terms of overall health, access to affordable health insurance, and the state’s approach to healthcare reform:
Texas health ratings
In 2014, The Commonwealth Fund’s Scorecard on State Health System Performance ranked Texas 44th (up a few spots from 47th in 2009) out of the 50 states and the District of Columbia. It earned especially low marks in the categories of access and prevention and treatment. For the scorecard’s data year of 2011 to 2012, 32 percent of adults ages 19 to 64 were uninsured and 16 percent of children ages 0 to 18 were uninsured. The percentage of adults with a usual source of care was 68 percent – the all-state median was 78 percent. More details about how the state was rated are available in the Texas Scorecard.
In the 2014 America’s Health Rankings, Texas climbed to 31st after holding 36th in the nation in terms of overall health. This may have been helped by a 13 percent decrease in smoking from one year to the next. The state’s strengths include a low prevalence of smoking, low rate of drug deaths and high immunization coverage among teens. However, it faces challenges that include a high prevalence of physical inactivity, a high percentage of children in poverty and limited availability of primary care physicians. Poor mental health days were a key challenge for Texas based on previous rankings, but from 2013 to 2014 the state saw a decrease of 11 percent in this realm, too.
Trust for America’s Health provides another look at overall public health in Texas in their 2015 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. 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.
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 Obamacare 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 2014, six months after full Obamacare implementation. After the first half of 2015, a Gallup poll showed Texas’ uninsured population had fallen to 20.8 percent.
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. Wyoming has the next-highest rate with 18.2 percent of its population uninsured.
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. Despite having a long ways to go, the state continues to have the third highest exchange enrollment in the country, following California and Florida.
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.
As of March, HHS reported that 1,205,174 had enrolled in private plans through Texas’ exchange during the 2015 open enrollment period. However, that number dropped to 943,218 by June 2015 due to people dropping coverage or failing to make their premium payments. Of the remaining enrollees, 85.3 percent were receiving advanced premium tax credits and 59.1 percent were receiving cost-sharing reductions.
For the 2016 coverage period, eight Texas exchange 15 carriers requested double-digit rate increases for some of their plans. Among them was Time Insurance, which belongs to Assurant Health and exited the individual market for the upcoming year. Time Insurance had proposed rate hikes up to 65 percent in Texas. HHS reviews proposed premiums for exchange plans in Texas and four other states.
One Texas carrier, Blue Cross Blue Shield of Texas, announced it will stop offering individual PPO plans in 2016 and will only offer HMO options in the individual market.
Texas Medicaid/CHIP enrollment
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.
Texas is currently one of 20 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 July 2015, 192,441 people enrolled in Texas’ existing Medicaid/CHIP program, an increase of about 4 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.
State-based health reform legislation
Here’s a summary of recent Texas bills related to healthcare reform:
On Nov. 18, 2014, Republican Sen. Donna Campbell introduced SJR16, which would create an amendment to the state’s constitution prohibiting the state of Texas from imposing, collecting or enforcing Obamacare’s individual mandate and its penalty. There have been no updates since the bill was introduced in the 2015 legislative session.
Medicare in the state of Texas
Texas Medicare beneficiaries make up 12.4 percent of the Lone Star State’s total population, compared with 16 percent of the U.S. population enrolled in Medicare. Of these enrollees, 82 percent qualify based on age and 18 percent qualify based on disability.
The state spends about $11,479 annually per recipient – there are about 20 states that spend $10,000 or more per recipient. When it comes to overall Medicare spending, Texas ranks 4th with $33 billion per year.
Texans who qualify for Medicare can select Medicare Advantage plans instead of Original Medicare as a way to gain more health benefits. In 2014, 29 percent of Texas Medicare recipients selected a Medicare Advantage plan instead of traditional Medicare. Additionally, 44 percent of Texas Medicare enrollees selected a Medicare Part D stand-alone prescription drug plan.