New report: Texas has highest rate of uninsured people in the nation

A new report issued by Washington D.C.-based think tank the Urban Institute estimates 19 percent of Texans under age 65 are uninsured, the highest uninsurance rate of any U.S. state. Nationally, the report — created using the Urban Institute’s “Health Insurance Policy Simulation Model,” which integrates data from the U.S. Bureau of Census’ American Community Survey, age projections, and enrollment and cost information from Texas state programs — estimates the average rate of uninsurance for the same age group is 11 percent.

“The number of insured people in the US has increased significantly since implementation of the Affordable Care Act’s (ACA’s) coverage reforms in 2014. Since that time, the number of people insured nationally has increased by approximately 19 million (Skopec, Holahan, and Elmendorf 2018). However, the increase in coverage has occurred unevenly across the states, with states that have chosen to expand Medicaid eligibility under the law experiencing the largest increases in coverage.”

The report details characteristics of the uninsured population statewide, as well as by areas based on population and by county (sometimes “groups of less populous counties”).

Among several statewide findings, the report writers found that:

• 56 percent of uninsured Texans are part of families that include at least one full-time worker.
• “8 percent of children are uninsured compared with 25 percent of all adults” under age 65.
• 60 percent of uninsured Texans live in families earning less than $35,000 a year (for a family of four). On the same token, 29 percent of the total number of people in that demographic are uninsured — only 4 percent of Texans in the survey earning roughly $100,000 or more are uninsured.
• 61 percent of uninsured Texans are Hispanic; and 27 percent of Hispanic people are uninsured. By contrast, 12 percent of people who identify as “non-Hispanic white” and 16 percent of people who identify as “non-Hispanic black” were uninsured.
• 48 percent of Texans without a high school diploma aren’t insured, compared with 10 percent of college grads.
• Two-thirds of uninsured Texans are U.S. Citizens; however, 54 percent of people who have at least one non-citizen in their family are uninsured.

“Although citizenship is strongly correlated with insurance coverage, as is Hispanic ethnicity …” according to the report, “many of the uninsured Hispanic residents of the state are citizens … Over 40 percent of uninsured Hispanic Texans are US citizens (1.2 million people).”

The report’s locality-based analysis gives more nuanced findings. Areas with the highest rates of uninsured people were within major cities and the state’s southern tip.

Images: the Urban Institute

The localities with the lowest uninsured rate (10 percent) were majority-white and higher-income. Localities with the highest rate of uninsured people were large majority-Hispanic and very low-income (28 percent) and majority-Hispanic, low-income (21 percent).

An example of differentiation across localities highlighted in the report concerns the race and ethnicity of uninsured people in different counties.  

“61 percent of the uninsured across the state are Hispanic and 24 percent are white, non-Hispanic,” according to the report. “In Hidalgo county, however, 97 percent of the uninsured are Hispanic, and in North Texas (Wichita Falls), 62 percent of the uninsured are white, non-Hispanic.”

The variety across Texas is central to the report’s discussion around policy strategies to address the state’s notably high rates of uninsurance. The report writers posit several points for policy discussion, including Medicaid expansion. If Texas were to expand Medicaid eligibility to adults with incomes 138 percent of the Federal Poverty Level (about $35,000 for a family of four),  the report says “1.2 million uninsured people currently ineligible for assistance would gain Medicaid eligibility,” with majority-white, low-income localities gaining the most from such an expansion (given current law that legal immigrant noncitizens wouldn’t be eligible).

Other points include: advice to cater outreach for an audience with limited education and a warning that, if the recently proposed federal public charge rule were put into effect, it could “exacerbate the uninsurance rate among both citizens and noncitizens in mixed-citizenship families.”

“Without policy changes … the number and share of uninsured Texans will likely increase with time as rising health care costs continue to increase, making coverage less affordable for low- and middle-income residents, in turn putting more financial pressure on state government and health care providers,” the report concludes.

An interactive map and fact sheets that detail the characteristics of uninsured people in the state by county can be accessed here.