New numbers show Texas continues to have the highest uninsured rate & the highest number of people without health insurance in the U.S.

After three years of improvement, new Census data released in September shows that the uninsured rate in Texas increased to more than 17% in 2017. For adults ages 19-64, the uninsured rate is now 23.5%. That means 4.8 million Texans don't have health insurance - about 270,000 more than last year.

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Texas compared to other states
In looking at uninsured rates across the country, the percentage of people without health insurance coverage varies significantly state by state. States that opted in to Medicaid expansion have lower uninsured rates and states that opted out have higher uninsured rates. Texas, as a non-Medicaid expansion state, leads uninsured rates in every age category, even compared with other states that opted out of Medicaid expansion.

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Houston had the highest number of uninsured residents among large U.S. cities, with 19.2% of the population (all ages) lacking health insurance in 2017. This may be surprising to some, since Houston is also home to the Texas Medical Center, the largest medical complex in the world.

Improving trend stopped in 2017
Across the country, there had been an overall decline in uninsured rates over the past 10 years. Even without Medicaid expansion, Texas followed that general declining trend largely due to the implementation of the Affordable Care Act (ACA).  There was a noticeable drop in uninsured rates across the state between 2013-2014 when several key aspects of the ACA went into effect: health insurance exchanges opened, restrictions on pre-existing conditions went away, and requirements for large employers to offer health benefits began. This declining trend continued through 2016.  The uptick of the uninsured rate in 2017 could be an ominous sign for more uninsured Texans in future years unless federal and state policymakers make changes to address access to affordable health services.

Changing the conversation
In an Episcopal Health Foundation/Kaiser Family Foundation health policy poll released earlier this summer, 64% of Texans say that the state is not doing enough to help low-income adult residents get needed health care. That's despite the fact that only 31% of Texans correctly knew that Texas had an above-average uninsured rate.


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The same EHF/KFF poll found that the majority (64%) of Texans favor expanding the state’s Medicaid program to cover more low-income adults. While Medicaid expansion is one way to increase the numbers of Texans with health insurance, it's not the only option to help more Texans access needed care, says Elena Marks, EHF's president and CEO.

“Moving the needle on this requires expanding the debate beyond a 'one-way or no-way' solution. Let’s stop talking only about Medicaid expansion and let’s start talking about expanding access to affordable coverage.”

Elena Marks

Marks says she believes a conversation only focusing on Medicaid expansion in Texas is limiting ideas to help people get more health coverage. Instead, she says the state should have a conversation about coming up with its own way to expand access to affordable health services.

"Any successful plan will require a dual approach to both expand coverage and improve enrollment of eligible Texans," Marks said.

The announcement of further cuts to marketing campaigns to promote ACA health insurance plans in Texas, plus the elimination of the individual mandate in 2019 will likely lead to a further decline in ACA health insurance enrollment in 2019.  This may lead to a future increase in the uninsured rate in Texas. 

EHF hopes that the latest uninsured data, combined with constant change and debate over the future of the Affordable Care Act, sparks policy conversations among federal and state lawmakers to explore various options to expand health coverage in Texas. 

September 2018

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