Where does Texas rank in the percentage of the population without health insurance?

The Greater Houston region had the highest number of uninsured residents in the country in 2019, with nearly one in five people in the metropolitan area lacking health coverage, according to the Census Bureau.

Houston led Texas — which has both the highest rate and number of uninsured residents among states — with 1.4 million uninsured people, or 19.7 percent of residents, without health coverage. Approximately 5.2 million Texans were uninsured last year, or about 18.4 percent of the state’s population.

That’s double the national average of 9.2 percent.

Both the state and local rates rose last year even as unemployment in Texas fell to a record low 3.4 percent. Doctors and health policy experts worry that the already sky-high numbers have only soared higher as hundreds of thousands of Texans lose both jobs and employer-based coverage during the pandemic-driven recession.

The 2019 levels alone would strain health care systems, doctors and experts said.

“There's not enough money, doctors, hospitals, or room (in Houston) to take care of 1.4 million people,” said Dr. Diana Fite, president of the Texas Medical Association.

Increases in uninsured contributes to higher health care costs, as hospitals treat people who can’t afford to pay and ultimately pass on the financial losses in the form of higher prices for patients with insurance.

Vivian Ho, a health economist at Rice University’s Baker Institute for Public Policy, said the high rate of uninsured patients will affect the health care that everyone, regardless of insurance status, receives.

“This puts tremendous financial pressure on our providers, and the quality of care suffers,” Ho said.

Who is covered

An additional 231,000 Texans, or 0.7 percent, became uninsured between 2018 to 2019. Nationally, Texas was one of seven states with an uninsured rate of 12 percent or more of its population, according to the Census Bureau.

Texas’ uninsured rate is more than 4 percentage points higher than the next highest state, Oklahoma, at 14.3 percent. Massachusetts had the lowest rate of uninsured residents, at 3 percent.

The rate of uninsured Texans under 19 years old increased by 1.5 percentage points, from 11.2 percent to 12.7 percent. The rate of uninsured Texans ages 19 to 64 increased by half a percentage point, from 24 percent to 24.5 percent.

Hospitals are federally mandated to care for every patient regardless of ability to pay. They might send sky-high medical bills to patients, but if there’s no money to collect, they’re left shouldering the costs themselves.

Another problem doctors worry about is how many people will put off care because they don’t have insurance. Uninsured patients are less likely to go in for routine check-ups or minor illnesses, and when they do seek treatment, it’s usually in the emergency room, one of the most expensive places to get care, said Kim Monday, past president of the Harris County Medical Society.

“Instead of spending $25 on preventive care,” Monday said, “we spend $2,500 fixing the eyes, kidneys or another organ system we weren’t able to because of access to good maintenance and prevention.”

At the San Jose Clinic in Midtown, where more than 4,000 patients it treats are uninsured, people are so worried about not being able to afford out-of-pocket costs that they feel discouraged from seeking care, routinely putting it off, said Dr. Diana Grair, the clinic’s medical director.

“You have more fear, more depression, more anxiety,” Grair said.

The pandemic’s impact

The Census Bureau numbers were the last published before COVID-19 hit. Of the 81.6 percent of Texans who were still covered by insurance in 2019, just over half, about 17.6 million Texans, relied on employer-sponsored health insurance for coverage.

Analysts say those numbers will change dramatically in 2020, after the COVID-19 pandemic left millions of Americans unemployed.

Early estimates from Families USA, a consumer health advocacy nonprofit, indicated that up to 659,000 people nationwide lost employer-sponsored health insurance during the pandemic.

Doctors’ groups say that the lack of a Medicaid expansion in Texas is a factor in the rise of uninsured rates. Expanding the federal insurance program for the poor would mean setting higher income caps to allow more Texas residents to qualify. Uninsured rates have gone down in states where legislators extended the safety-net insurance program.

In Texas, uninsured patients are turning to lower cost alternatives, such as direct primary care, which covers doctor’s visits, but not emergencies or hospital stays, and charity clinics, such as San Jose. But they aren’t substitutes for comprehensive health insurance, which encourages preventive medicine that keeps people healthier and lowers systemic costs, analysts said.

“This is going to come back to haunt all of us,” Ho said. “This is going to be a mess for years to come.”

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