The Uninsured in Texas

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 5.04 million Texans - including 784,000 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. 

Health Insurance Coverage of Adults 18-64, 2014, U.S. and four largest states  

United States 
Population: 195,537,213 
Uninsured: 31,850,086
% Uninsured 16.3%  

Population: 24,264,509
Uninsured: 4,193,432
% Uninsured: 17.3%
Rank: 3 

Population: 16,366,994 
Uninsured: 4,204,601 
% Uninsured: 25.7% 
Rank: 1  

Population: 11,813,708
Uninsured: 2,812,892
% Uninsured: 23.8%
Rank: 2 

New York: 
Population: 12,485,670
Uninsured: 1,531,914
% Uninsured: 12.3%
Rank: 4 

 Health Insurance Coverage of Children 0-18, 2014, U.S. and Four Largest States   

United States
Population: 73,440,273
Uninsured: 4,396,536
% Uninsured: 6% 

Population: 7,106,727
Uninsured: 783,938
% Uninsured: 11%
Rank: 1 

Population: 9,153,133    
Uninsured: 497,090
% Uninsured: 5.4% 
Rank: 3

Population: 4,046,150
Uninsured: 377,987
% Uninsured: 9.3%
Rank: 2

New York
Population: 4, 217,078
Uninsured: 137,525
% Uninsured: 3.3%
Rank: 4 

Health Insurance Coverage of Total Population, 2014, U.S. and Four Largest States  

United States
Population: 313,890,422
Uninsured: 36,370,223
% Uninsured: 11.7% 

Population:  38,297,457
Uninsured: 4,766,711
% Uninsured: 12.4%
Rank: 3 

Population: 26,485,838
Uninsured: 5,047,477
% Uninsured: 19.1% 
Rank: 1

Population: 19,583,357
Uninsured: 3,245,161
% Uninsured: 16.6%
Rank: 2

New York
Population: 19,499,548
Uninsured: 1,696,596
% Uninsured: 8.7%
Rank: 4

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. 50 percent of all companies in the US offer health coverage for their employees.  In 2012, Texas ranked 42nd in the nation, with only 45 percent of Texans having employment-based health insurance coverage. The Kaiser Family Foundation reports 63 percent of the uninsured have at least one family member who works either full-time or part-time in 2011 to 2012.

The average annual premiums for employer-sponsored health insurance in 2012 was $5,384 for single coverage and $15,473 for family coverage.  The average annual worker contribution in 2012 was $1,118 for single coverage and $4,236 for family coverage.  For family coverage, the worker contribution increased 136%  ($1,787 to $4,236) from 2001 to 2012. Workers in small firms (3–199 workers) have lower average contributions for family coverage than workers in larger firms ($15,581 vs. $16,715) The average single premium did not differ significantly based on firm size.

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 43 percent of the uninsured population had incomes below 139 percent of the federal poverty line from 2011 to 2012, and 19 percent had incomes at or above 139 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 129 million emergency room visits in 2010. The U.S. Centers for Disease Control and Prevention says that about 7 percent (9.1 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 2008 to be more than $116 billion. Of that:

  • The patients and their families pay about one-third (37%);
  • Third party sources such as government health programs and charities pay 26%; and
  • Those with private health insurance subsidize the remaining 42.7 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 2008, typical premiums for family health insurance coverage provided by private employers in the U.S. include an extra $1,017 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 2011 and 2012, 16 percent of Texas children were uninsured, compared to 9 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, 30 percent of Hispanics/Latinos, 16 percent of African Americans were uninsured, compared to 10.8 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, 40 percent have a high school diploma as their highest level of education; 16.9 percent have not completed high school and 42.4 percent have a post high school education.
  • Among uninsured adults born outside the US, 28.1 percent have at most a high school diploma; 48.1 percent have not completed high school and 23.8 percent have a post high school education. (ERIU, 2005)

In 2010-2012 estimates from the America Community Survey, Texas had a lower percentage of high school (81.4 percent vs. 86.4 percent) and college graduates (26.7 percent vs. 29.1 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 Counties in Texas, 2014

# Uninsured: 132,241
% Uninsured: 31.7%


# Uninsured: 82,242
% Uninsured: 31.1%

# Uninsured: 264,634
% Uninsured: 32.2%

# Uninsured: 572,664
% Uninsured: 22.9%

El Paso
# Uninsured: 184,232
% Uninsured: 22.8% 

# Uninsured: 971,441
% Uninsured: 22%

# Uninsured: 9,557
% Uninsured: 25.3%

# Uninsured: 64,457
% Uninsured: 18.3%

# Uninsured: 342,752
% Uninsured: 17.8% 

# Uninsured: 14,914
% Uninsured: 16.6%

# Uninsured: 47,076
% Uninsured: 16.2%

# Uninsured: 30,961
% Uninsured: 20%

# Uninsured: 26,204
% Uninsured: 22.83%

# Uninsured: 16,839
% Uninsured: 13.2%

# Uninsured: 43,023
% Uninsured: 19.9% 

# Uninsured: 20,984
% Uninsured: 16.1%

# Uninsured: 15,285
% Uninsured: 17.4%

# Uninsured: 189,247
% Uninsured: 16.5%

# Uninsured: 23,172
% Uninsured: 19.1%

# Uninsured: 15,174
% Uninsured: 12.9%

# Uninsured: 41.187
% Uninsured: 17.2%

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.