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


In January 2014, the major coverage provisions of the 2010 Affordable Care Act (ACA) went into full effect. While millions have gained coverage under the law, many remain outside its reach. In Texas, which had the highest uninsured rate in the nation prior to the ACA and has opted not to expand its Medicaid program, many uninsured residents remain. Much attention has recently focused on the population that is newly-enrolled in coverage, but a focus on the uninsured population, their needs, and the consequences they face because they lack coverage can also inform ongoing policy development in the state. This report uses findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA to explore who the uninsured in Texas are and to understand their ongoing health care and health coverage needs.

Key Findings

Characteristics of Uninsured Adults in Texas

While the population without health insurance coverage in Texas includes people from a range of backgrounds, most uninsured Texan adults are low-income workers: nearly 70% of uninsured adults are in a working family, and 40% live below the poverty level. Uninsured adults in the state are also, on average, younger and more likely to be people of color than those who have insurance. In addition, 20% of uninsured adults in Texas are undocumented immigrants, who remain outside the reach of many provisions of the ACA.

Patterns of Coverage Among Adults in Texas

While some people lack health insurance coverage during short periods of unemployment or job transitions, for most uninsured adults in Texas, lack of coverage is a chronic problem. Over half of uninsured adults in the state (53%) reported being uninsured for five years or more, including 31% of the uninsured who reported that they have never had coverage in their lifetime. In addition, many Texans experience spells of uninsurance throughout the year, and coverage among those with insurance may not be stable. Among Texan adults who were insured at the time of the survey, 8% reported being uninsured at some point in the past year, and 11% had coverage for the full year but had a change in their coverage source.

Access to Coverage Among Uninsured Adults in Texas

Many uninsured adults in Texas report trying to obtain insurance coverage in the past, but most did not have access to affordable coverage. Most (84%) uninsured adults in Texas report that they do not have access to employer-sponsored coverage through either their job or a spouse’s job. Of the 16% who do have access to coverage through an employer, the majority report that the coverage offered to them is not affordable. In addition, uninsured adults report problems accessing Medicaid, which is not surprising given the limited eligibility for this group in Texas. More than one fifth (21%) of uninsured adults said they tried to sign up for Medicaid in the past 5 years, but the vast majority were told they were ineligible. Some who applied for Medicaid also reported challenges with the application process, with 57% who applied to Medicaid (including those who enrolled) indicating that some part of the process—was somewhat or very difficult. Last, uninsured Texans report problems in finding affordable coverage on their own: prior to the ACA, 15% tried to purchase a plan directly from an insurer, but most said that the policy offered to them was too expensive.

Access to Health Care Services Among Uninsured Adults in Texas

A large segment of uninsured adults in Texas have little or no connection to the health care system.Only 48% of uninsured adults report that they have a usual source of care, or a place to go when they are sick or need advice about their health, and only 28% of uninsured adults say they have a regular doctor at a usual source of care, less than half of the rate of insured adults in Texas. This lack of a connection to the health care system leads many uninsured adults to go without care. Fifty-six percent of uninsured adults in Texas reported at least one health care visits in the past year, compared to 89% of Medicaid beneficiaries and 85% of adults with employer coverage.  Still, many uninsured Texans have health needs.Uninsured adults are less likely than those with employer coverage to report receiving care for an ongoing health condition. About half (47%) of the uninsured and half (50%) of Medicaid beneficiaries in Texas report needing but postponing care, compared to 31% of adults with employer coverage. The most common reason for postponing care among the uninsured is cost.

Financial Security Among Uninsured Adults in Texas

Health care costs pose a challenge for poor and moderate-income families in Texas, particularly if they are uninsured. Health care costs translate to medical debt for many poor adults. Over a third (36%) of uninsured adults in Texas have outstanding medical bills. These medical bills can cause serious financial strain. In addition, the vast majority of uninsured Texas adults across all income groups reported that they lack confidence in their ability to afford health care, given their current finances and health insurance situation. Difficulty or worry about paying for health care translates to expenses in other areas as well, and almost six in ten uninsured adults below poverty (59%) reported that they feel generally financially insecure. This general financial insecurity translates to concrete financial difficulties in making ends meet. Patterns across coverage groups indicate that this issue is common among people in poverty, regardless of insurance.

Policy Implications

The survey shows that affordability and access are major challenges to obtaining coverage for adults in Texas. Though most uninsured adults or their spouses work, most still live on very limited means and are unlikely to be able to afford coverage on their own.

For those who are eligible for coverage, the ACA can help facilitate access to affordable coverage by requiring employers to offer coverage, making available tax credits for Marketplace coverage, and prohibiting denials of coverage. These provisions could address barriers that Texans have faced in accessing private 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. Further, provisions to simplify Medicaid application and enrollment may lead to smoother enrollment and renewal in the Medicaid program.

Open enrollment has ended for Marketplace coverage in 2014, but as of November, people can sign up for Marketplace plans to begin in 2015. In addition, the survey findings reveal that many Texans lose and gain coverage throughout the year because of job changes, income fluctuations, or problems at renewal. Thus, enrollment is an ongoing process, and ongoing efforts to enroll and keep people in coverage will influence the number of people who gain coverage. A substantial share of the uninsured population has been outside the insurance system for quite some time and may require targeted outreach and education efforts to link them to the health care system and help them navigate health insurance should they gain coverage.

However, because Texas is not expanding Medicaid, over a million uninsured Texans who would have been eligible for Medicaid under the ACA instead 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 access barriers and financial hardship due to health care costs.  These individuals will continue to have health care needs and may continue to lack a usual source of care, forego preventive care, and face cost barriers to using services. As attention shifts to the newly-insured population, the uninsured in the state will still need care, and clinics and health centers will continue to help serve the poor and moderate-income population.


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