Why 5 million Texans are uninsured: New study

Initial findings put spotlight on the challenges the uninsured face

Most of the roughly five million uninsured Texans already qualify for a government health program or for federal subsidies that would help pay for coverage — but they have not signed up. Texas 2036 has launched a groundbreaking, multi-year study to find out why.

The new Texas 2036 study seeks to create a more holistic understanding of Texas’ uninsured population — the largest in the country — and to better identify barriers and personal decisions that result in Texans not having access to affordable care.

Texas’ future is in our people. For our state to prosper, we must work to ensure they receive a quality education and access to affordable health care.” –Margaret Spellings, president and CEO of Texas 2036

“While Texas’ health coverage challenge is widely known, policymakers need a clear, data-driven view of our uninsured population: who these fellow Texans are, what they know about their coverage options, whether and how they are accessing care, and what barriers they face.

“This multi-year study attempts to answer these questions and offer a path toward strategic, targeted health policies that will benefit our people and state for generations to come.”

Texas has the unfortunate distinction of having the nation’s highest uninsured rate — about 18% in 2021, compared to the national average of 8.6% — and its largest uninsured population of roughly 5 million people.

Rather than start with policy prescriptions, Texas 2036 initiated a comprehensive effort — including months of surveys and focus groups — to learn more about this population, and to surface the most effective ways for Texans to get the affordable care they need. Texas 2036 also hopes to better understand the thought processes and decision-making of uninsured Texans to better inform the development of solutions that meet their needs.

Texas 2036’s multi-year study is being funded in part through the generous support of Texas Mutual Insurance Company, Blue Cross and Blue Shield of Texas (BCBSTX), St. David’s Foundation and the T.L.L. Temple Foundation. To learn more about additional funding opportunities that are available, contact donorrelations@texas2036.org.

“The comprehensive approach Texas 2036 is taking to better understand the reasons why millions of Texans lack health insurance, despite being eligible for affordable government-funded or private health plans, is an important step to helping close the coverage gap,” said Jo Betsy Norton, senior vice president for public affairs at Texas Mutual, which is the lead sponsor of the project.

“A study of this magnitude is long overdue when you consider that most of the roughly five million uninsured Texans already qualify for some type of subsidy, but don’t sign up,” said BCBSTX president Jim Springfield. “Understanding why, can help lead to the necessary solutions that can get uninsured and underinsured Texans covered with access to care that will make for a healthier Texas.”

Texas 2036 launched this multi-year research project partly in response to key facts and trends that run counter to general narratives about the uninsured population in Texas — and the need to further explore the dynamics driving these facts and trends. They include:

  1. While expanding eligibility for Medicaid to 138% of the federal poverty level (about $38,300 annually for a family of four) offers a cost-effective solution to increase coverage eligibility, it would only add coverage eligibility for about 16% of Texas’ uninsured population. Regardless of whether Texas decides to expand eligibility for Medicaid, additional work is required to meet the needs of the remaining 84% of uninsured Texans.
  2. Roughly half of uninsured Texans have incomes over 200% of the federal poverty level (about $55,500 annually for a family of four). This challenges a narrative that uninsured Texans are low-income, and it shows that accessing affordable care is a challenge for working, middle-class Texas families.
  3. A significant majority of uninsured Texans — 70% of respondents in our initial survey research — are unsure of their eligibility for financial assistance through the federal Affordable Care Act (ACA). According to some analyses, more than 40% of all uninsured Texans likely qualify for federal subsidies that would help pay for health insurance through ACA marketplaces, but they are nonetheless unenrolled. This suggests that insufficient awareness and utilization of current programs may be an important barrier facing uninsured Texans — which is also the case for government health programs, such as Medicaid, where an additional 13% of uninsured Texans may qualify.
  4. The most-cited reasons among uninsured Texans for not having health coverage is related to their employment status and the availability (or unavailability) of insurance through their employer. While there are ways to obtain coverage outside of employer-sponsored insurance, the primacy of these responses demonstrates that many uninsured Texans think of coverage as an employment benefit rather than a stand-alone plan.

The health care debate in Texas would be very different if all sides were laser-focused on an objective we all should share: more affordable, accessible health care across Texas.” –Charles Miller, senior policy advisor for Texas 2036

“This multi-year study helps create that focus. As we roll out results over the next three years, we hope and believe this study will help policymakers and elected officials chart paths and devise solutions that all sides can rally around to effectively reduce the number of Texans who face unexpected medical debt or who skip care due to cost. Increasing the number of Texans with health insurance can play an important part in that process.”

As part of the ongoing study, Texas 2036 conducted a survey of more than 2,000 uninsured Texans, and the organization has been conducting dozens of focus groups with uninsured people around the state for the past two months. Focus groups have been held in English and Spanish, reflect regional diversity, and have included a focus on uninsured Texas mothers. Groups were conducted both in-person and virtually, using dozens of local partners to help recruit participants and capture as many points of view and experiences as possible. This process helped ensure a holistic representation of Texas’ uninsured population.

What makes this multi-year research study so unique is its comprehensive approach to answering multiple questions that arise when discussing Texas’ high uninsured rate, including why eligible Texans are not signing up for ACA plans when subsidies are available, or why they are not signing up for government programs like Medicaid.” –Holly Heard, PhD, vice president of data and analytics at Texas 2036

“This study seeks to answer all of these questions so that policymakers and the public can develop comprehensive, data-driven solutions for this diverse population of Texans.”

While careful evaluation and study is needed to better understand the distinctive groups of Texans who do not have health insurance, one early insight has already prompted further study into the enrollment process for government programs: Focus group discussions revealed a stark disconnect between the ACA marketplace enrollment premiums the team had estimated participants would owe, and the enrollment premiums participants reported seeing when they had tried to enroll in the past. As open enrollment approaches in November, Texas 2036 aims to observe individuals as they go through the enrollment process, and to identify where those disconnects arise and ways to reduce friction in the enrollment process.

See attached for a presentation that provides data and charts based on our preliminary findings from the study. For more information, visit texas2036.org/uninsured.