The Uninsured Population in Texas: Understanding Coverage Needs and the Potential Impact of the Affordable Care Act

Policy Implications

The survey findings have implications for early implementation of the ACA in Texas and for ongoing policy development in the state. Uninsured adults in Texas are generally in low-income, working families and have lacked insurance coverage for quite some time. Most do not have access to coverage through their jobs, and many have unsuccessfully tried to enroll in coverage in the past. Many uninsured adults in Texas have substantial health care needs but have only loose ties to the health system, facing considerable barriers in trying to access care when they need it.

Removing Some Barriers to Health Insurance and Care

Many ACA provisions may facilitate moderate-income adults’ access to health insurance in Texas. Large employers will face penalties if they do not provide coverage to their workers, and insurers may not deny coverage based on health status and history. In addition, private premiums can only vary based upon age, location, and tobacco use, and health plans may not use annual or lifetime spending caps.  Texans who purchase health plans through the Marketplace, and have incomes between 100% and 400% of the federal poverty level, may receive tax credits to help them pay for premiums, with those who have incomes between 100% and 250% of the federal poverty level also eligible for subsidies to aid with the cost sharing. The survey results indicate that these provisions may address many of the barriers that Texans have faced in accessing coverage, such as not having coverage through a job, not being able to afford coverage, or having a health condition that might price them out of the market. While open enrollment has ended for Marketplace coverage in 2014, as of November people can sign up for Marketplace plans to begin in 2015.

Not expanding Medicaid limits the coverage options for poor Texans.  Because Texas is not expanding Medicaid, over a million uninsured Texans who would have been eligible for Medicaid fall into the coverage gap. They are not eligible for the Marketplace subsidies and tax credits, most do not have access to coverage through a job, and they likely are unable to afford coverage on their own. These remaining uninsured adults are likely to continue to face the access to care issues that they currently face by being unlinked to the health care system. The survey shows that currently less than half of the uninsured have a usual source of care, and even uninsured Texans with an ongoing health condition face barriers to receiving care compared to their insured counterparts.

Although Texas is not expanding Medicaid, the ACA does include other provisions that affect low-income Texas residents who were already eligible for Medicaid. The survey shows that 35% of adults who attempted to sign up for Medicaid found assembling the paperwork difficult. The ACA included provisions to simplify the Medicaid application, enrollment, and renewal processes. These requirements included implementing a single application that is available online, by phone, and on paper; electronic transfers of accounts between health coverage programs; and reliance on electronic data to verify eligibility, rather than requiring paper documents. These provisions may lead to smoother enrollment and renewal in the Medicaid program.

Reaching Eligible Uninsured Adults

There are many challenges to reaching uninsured adults who are eligible for coverage under the ACA. Some uninsured adults in Texas may be hard to reach as part of outreach efforts: many do not speak English, and the eligible population is very diverse. Over half (56%) of the uninsured identify as Hispanic and 40% are under age 35. Additionally, many families have mixed citizenship status, and effectively reaching these families and building enough trust to enroll the eligible in health insurance is a challenge. Many uninsured Texan adults have been outside the insurance and health care system for quite some time and may not be easily reached through traditional avenues.

Outreach and enrollment is an ongoing process. While there was much focus on the initial push to enroll people in coverage under the ACA, enrollment is not a “one shot” effort that will be completed in the first few months of implementation. The survey findings reveal that nearly one in five (19%) of Texans lose and gain coverage throughout the year because of job changes, income fluctuations, or problems at renewal. Thus, implementing the ACA is an ongoing effort to enroll and keep people in coverage.

The Continuing Role of Safety Net Providers in Texas

Many people will remain without coverage in Texas. Uninsured residents access health care less frequently than insured individuals, often forgoing preventive care measures. The survey shows that nearly half (47%) of the uninsured postponed needed care in the previous year, and three quarters of those uninsured who postponed care did so because of the cost. The low-income uninsured are particularly vulnerable, as they face even more financial strain when they do get sick than their insured counterparts. Many uninsured adults rely on federally qualified health centers and public hospitals when they do access care. However, many health centers are already operating at capacity, and these facilities are generally not equipped to provide specialty care. Additionally, DSH funding will be reduced in next several years.  It will be important to monitor how well the safety net in Texas is able to meet the continuing and growing demand for services in this context.