Time for Texas to Start the Health Coverage Conversation

Although Texas has the highest uninsured rate in the nation, with a particularly high uninsured rate in rural communities, in recent years most of our state policymakers have shown little interest in discussing Medicaid expansion or any other strategies for expanding health coverage.


As a result, it has been more difficult for Texas to address numerous challenges linked to the state’s high uninsured rate, including maternal and infant health, mental health, substance use disorders and subsequent child removals by CPS, property taxes, rural hospital closures, families’ financial security, and more.

But there are four reasons why this is now the time for Texas leaders to start discussing solutions to the state’s high uninsured rate:

  1. Health care politics are changing. As political analysts have noted, Obamacare cost the Democrats the U.S. House in 2010, but it won them the House in 2018. Not only did voters support pro-health care candidates this November, but they also voted directly for Medicaid expansion in the red states of Idaho, Nebraska, and Utah. Exit polls showed that health care was the most important issue for voters this year.

  2. Texas politics are changing. For years in Texas, Republicans elected to the Legislature or statewide offices have focused on winning their primary elections without giving much thought to beating the Democrats in November elections. After Democrats picked up 12 seats in the Texas House and two in the Texas Senate, and ran competitive campaigns up and down the ballot in Texas, Republican officeholders are likely to pay closer attention to those issues that are important to a broader electorate. (And multiple polls show that nearly two-thirds of Texans believe state leaders should accept Medicaid expansion funding from the federal government to expand health coverage.)

  3. Texas faces a federal health care funding cliff. Because Texas has a high uninsured rate and has turned down Medicaid expansion funding, Texas hospitals get stuck with lots of medical bills that patients can’t pay. Last year the federal government agreed to a five-year extension of the “uncompensated care” funding that it provides to Texas to cover these bills through a “1115 Medicaid Waiver,” but that funding runs out in 2022. Expiration of the Waiver without a new Texas health care plan in place also threatens funding for innovative local health projects financed through the Delivery System Reform Incentive Payment Program (DSRIP) program. Texas needs a plan to replace those funding streams, get those hospital patients insured, and build DSRIP innovations into new coverage.

  4. Medicaid expansion is working in states that accepted the funding. Now that we have several years of data from states around the country, the health and economic benefits of expanded health coverage have become clear. In fact, Medicaid expansion has created budget savings for many of the participating states.

As a reminder, Texas is one of only a handful of states to turn down the Medicaid expansion funding offered by the federal government to cover adults with incomes too low to qualify for assistance on healthcare.gov. As a result, the current Texas Medicaid insurance program essentially just covers people with severe disabilities and low-income kids, pregnant women, and seniors. That leaves many adults with serious and chronic illnesses uninsured, and hundreds of thousands of child care workers, cooks, sales clerks, and other low-wage Texas workers — including many mothers — without a viable health insurance option.

It’s time for Texas leaders to start the conversation about how they will ensure that low-wage Texans have an affordable way to get health insurance — whether it’s through the traditional Medicaid expansion that could cover one million Texans or through an alternative Texas strategy.