ACA marketplace enrollment in Texas reached record high in 2021


Boram Kim


The number of ACA marketplace enrollees grew by 550,000, or 42%, to 1.8 million people in 2021. According to recent CMS open enrollment data, Texas has witnessed the fastest growth since 2019 and the largest percentage increase last year in the country.


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Overall, 94% of enrollees received financial assistance to lower premiums, paying on average $86 per month. About 1 in 4 people who signed up were new customers. Counties that saw enrollment growth exceed 60% include Bell, Cameron, and Hidalgo.

Enrollemnt in the Texas Insurance Marketplace (2014-2022)
Image Source: Every Texan


Texas remains 1 of 12 states that has yet to expand Medicaid under the ACA. The Kaiser Family Foundation estimates 1.4 million uninsured low-wage Texans would become eligible for Medicaid health insurance under federal expansion.

Reducing the uninsured rate has been shown critical for improving health outcomes. According to the National Bureau of Economic Research, people with insurance coverage are healthier and less likely to die prematurely.

With current inflationary pressures weighing on household budgets in a state with the highest rate of uninsured people in the country, quality of health in Texas could suffer.  

Health policy leaders argue that managing health issues for the uninsured to prevent them from becoming chronic or terminal conditions would help to lower costs for the entire system. 


“In Texas, one third of our premium costs [are] basically going to subsidize the uninsured, to subsidize uncompensated care,” said Representative Chris Turner (D – Grand Prairie), Chair of the House Democratic Caucus, speaking at the 2022 Texas State of Reform Health Policy Conference in April.

“One of the biggest challenges we face in Texas health care with so many people not having access to see a primary care provider and letting these chronic conditions become real health care emergencies. … Then they end up in the hospital emergency department, which is the most expensive form of health care in the world. So, I think Medicaid expansion for lowering costs for those or creating access for those 1 million or so Texans is going to help lower costs overall and more importantly, improve the quality of life and extend lives.”


Nationwide, health coverage during the 2022 Open Enrollment Period (OEP) also grew more broadly with over 14.5 million consumers being either selected or automatically re-enrolled in health insurance coverage through and State-Based Marketplaces (SBMs).  

Some 2.5 million of those customers were new, growth that was attributed to more favorable eligibility requirements and affordable plans outlined under the American Rescue Plan Act of 2021