|  Who are the Uninsured  |  Medical Impact  |  Financial Impact  |  Children  |  Special Populations  |  Geographic Breakdown  |  Sources  |

Texas is the uninsured capital of the United States. More than 6.3 million Texans - including 1.2 million children - lack health insurance. Texas' uninsurance rates, 1.5 to 2 times the national average, create significant problems in the financing and delivery of health care to all Texans. Those who lack insurance coverage typically enjoy far-worse health status than their insured counterparts. 

• Quick Statistics on the Uninsured in Texas and in the U.S.  
• Download table of Uninsured Rates for All 254 Texas Counties   

Health Insurance Coverage of Adults 19-64, 2009-2010, U.S. and four largest states  

 Health Insurance Coverage of Children 0-18, 2009-2010, U.S. and four largest states   

 Health Insurance Coverage of Total Population, 2009-2010, U.S. and four largest states   

Who Are the Uninsured in Texas? 

The uninsured are a diverse group that includes people who cannot afford private health insurance; who work in small businesses that do not offer insurance; who simply choose not to purchase health insurance, even though they can afford it; who are eligible-but not enrolled-in government sponsored programs such as Medicaid or the Children's Health Insurance Plan (CHIP); and recent immigrants.

According to a summary of national data by the Congressional Budget Office (CBO), groups with a high likelihood of lacking health insurance include:

• People in families with income below 200 percent of the poverty level;
• Hispanics;
• Young adults, age 19 to 34;
• People in families in which the adults worked either part-time or only part of the year; or
• Individuals in fair or poor health status who are significantly more likely than others to be uninsured for longer periods.

Texas workers are less likely to have employment-based health insurance coverage than those in other states. 60 percent of all companies in the US offer health coverage for their employees.  In 2009, Texas ranked 49th in the nation, with only 50 percent of Texans having employment-based health insurance coverage. The Kaiser Family Foundation reports 78 percent of the uninsured have at least one family member who works either full-time or part-time in 2009 to 2010.

The average annual premiums for employer-sponsored health insurance in 2011 was $5,429 for single coverage and $15,073 for family coverage.  The average annual worker contribution in 2011 was $921 for single coverage and $4,129 for family coverage.  For family coverage, the worker contribution increased 131%  ($1,787 to $4,129) from 2001 to 2011. Workers in small firms (3–199 workers) have lower average contributions for single coverage than workers in larger firms ($762 vs. $996), and higher average contributions for family coverage ($4,946 vs. $3,755).

People making moderate and low wages are much less likely to have job-based health insurance coverage than those earning more. In Texas, an average of 66 percent of the uninsured population had incomes below 200 percent of the federal poverty line from 2007 to 2008, and 30 percent had incomes at or above 200 percent. 

Medical Impact of Lacking Health Insurance 

The uninsured are up to four times less likely to have a regular source of health care and are more likely to die from health-related problems. They are much less likely to receive needed medical care, even for symptoms that can have serious health consequences if not treated. About one in four Texans lives at or below the poverty level; for children, it's nearly one in three. Extending health coverage to the uninsured could improve their overall health by 7 to 8 percent. Lack of insurance increases their dependence on Medicaid. 

Financial Impact of Texas' Uninsured Crisis 

Lacking a medical home, uninsured people tend to look for health care in the emergency room, the most expensive setting they could possibly choose. Nationally, patients made over 123 million emergency room visits in 2008. The U.S. Centers for Disease Control and Prevention says that about 8 percent (9.9 million) of ER visits are for non-urgent issues that could be treated in a doctor's office or clinic. 

Using Medicaid payment rates and data on Medicaid patients' unnecessary emergency room visits, the Legislative Budget Board estimates that a condition that could be treated in a doctor's office for $56.21 (including lab and x-ray) costs $193.92 in the emergency room. National studies back up that data, finding, for example, that the charge for treating an ear infection in the emergency room is $170 versus $55 in a family physician's office.

Taxpayers, Texans with insurance, and employers who offer health benefits also pay extra for caring for the uninsured. Families USA estimated the total cost for Texas in 2005 to be more than $9.2 billion. Of that:

• The patients and their families pay about half ($4.6 billion);
• Government health programs pay one-sixth ($1.6 billion); and
• Those with private health insurance subsidize the remaining third ($3 billion).

Texas hospitals spent about $208 million treating uninsured trauma patients in 2003. To cover these costs, hospitals charge insured patients higher prices, which in turn drives up insurance premiums. In what Families USA calls a "vicious cycle," those increased costs are added to already-rising health insurance premiums, leading more employers to drop coverage, and leaving even more people without insurance. That further adds to premiums for the insured and further boosts the roles of the uninsured.

In 2005, typical premiums for family health insurance coverage provided by private employers in the U.S. include an extra $922 in premiums due to the cost of care for the uninsured. In Texas, because of the very large percentage of uninsured, that figure is $1,551. By 2010, the national average will catch up to Texas' current figure; by then, the annual cost per Texas family will soar to $2,786.

Health Insurance Coverage Among Children and Young Adults in Texas

Texas' share of uninsured children is higher than the U.S. average. Between 2006 and 2007, 22 percent of Texas children were uninsured, compared to 11 percent nationally.

CHIP Re-enrollment Requirement in Texas 

More than half of the uninsured children are eligible for public programs, but are not enrolled. In Texas, this could be a result of the SCHIP program requirement to re-enroll every six months or the lack of parent coverage in the program.

Health Insurance Coverage Among Special Populations in Texas

Health Insurance Coverage in Relation to Race and Ethnicity  

Disparities based on race and ethnicity also exist. People of racial and ethnic minorities are more likely to go without health insurance than whites. In Texas, 37 percent of Hispanics/Latinos, 21.4 percent of African Americans, and 21.1 percent of Asians were uninsured, compared to 13.5 percent of whites

Uninsured Among Non-Citizens in Texas  

In Texas, non-citizens are almost three times as likely to be uninsured as native U.S. citizens. Immigrants, many of whom are Hispanics, often work in economic sectors less likely to offer health insurance than others, such as construction.

Foreign Born Residents and Non Citizens in Relation to Uninsured Population 

Non-citizens are almost three times as likely to be uninsured as are native US citizens. Over 62 percent of non-citizens went without insurance in 2010, compared to 18.3 percent of US native citizens and 26.2 percent of naturalized citizens. In Texas, 29.3 percent of the uninsured are non-citizens.

Health Insurance Coverage in Relation to Level of Educational Attainment

Another factor that increases the likelihood of being uninsured is the level of educational attainment. Texas has lower rates of high school and college graduates than the national average (Murdoch, 2003). There is a strong correlation between education and income as well as between income and insurance.

Those who have more education on average earn more money and have insurance coverage.

• Among uninsured adults born in the US, 56.3 percent have a high school diploma as their highest level of education; 16.5 percent have not completed high school and 39.8 percent have a high school diploma.
• Among uninsured adults born outside the US, 73.7 percent have at most a high school diploma; 46.8 percent have not completed high school and 26.9 percent have a high school diploma. (ERIU, 2005)

In 2000, Texas had a lower percentage of high school (75.7 percent vs. 80.4 percent) and college graduates (23.2 percent vs. 24.4 percent) in the 25-and-older-population compared to the national average. In addition, over half of all Hispanics in Texas over the age of 25 did not have a high school diploma (Murdock et al., 2003). This is significantly higher than other ethnic populations in the state.

Health Insurance Coverage By Geographic Areas in Texas

Estimates of the Uninsured for Texas Cities in Texas, 2010 

Counties in Texas with Highest Uninsured Rates 

In Texas, 35 of the state's 254 counties account for 80 percent of the uninsured. A common misconception is that the uninsured are concentrated in the counties along the Texas - Mexico border. Texas’ 28 largest cities, including Houston, Dallas, San Antonio, Austin, Ft. Worth and El Paso, had a greater percentage of their population without insurance than the collective United States. 

 Sources 

• Code Red: The Critical Condition of Health Care in Texas , Chapter 2, The Uninsured, Chapter 7 Trauma Care in Texas
• Texas Comptroller of Public Accounts: The Uninsured: A Hidden Burden on Texas Employers and Communities  
• Kaiser Family Foundation State Health Facts  
•  A Steep Price for the Uninsured Texas' Uninsured Residents Outpace the National Average. Fiscal Notes: A Monthly Review of the Texas Economy from the office of Susan Combs, Texas Comptroller of Public Accounts. May 2007. 
• Income, Poverty, and Health Insurance Coverage in the United States: 2007 . U.S. Census Bureau., August 2008. DeNavas-Walt, C.B. Proctor, and J. Smith. 
• Overview of the Uninsured in the United States: An analysis of the 2005 Current Population Survey  
• Working Together for A Healthy Texas . Texas Department of Insurance State Planning Grant Project. September 2005.
• The Uninsured: Race/Ethnicity, Immigrant Status and Education Level . Economic Research Initiative of the Uninsured. 

This report was prepared by TMA staff for the TMA Council on Health Promotions.