Charles Miller: Uninsured remains high despite available free marketplace plans

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In late September, the U.S. Census released its report on health insurance coverage by state, and while Texas saw a small improvement, the state still holds the unfortunate distinction of having the highest uninsured population in the country. Nearly five million Texans — or about 16.4% of the population — remain without health coverage. Although this is down slightly from last year, the numbers remain stubbornly high.

Within this state data, there was another trend that will need to be watched over the coming years. Private insurance in Texas is rising, increasing from 61.8% in 2019 to 63.3% today. This uptick may reflect the state's booming economy, with more employers offering health benefits, but there may be another factor at play — the expanding reach of the Affordable Care Act (ACA) Marketplace, which could help many within the uninsured population.

Based on our research in 2022, around two million uninsured Texans — nearly 40% of the state's uninsured population — are likely eligible for free coverage through the ACA Marketplace or children's programs like Medicaid or CHIP. Last year, almost 3.5 million Texans purchased health insurance through the ACA Marketplace — an increase of more than one million from the previous year and representing about 18% of the estimated 19 million Texans with private insurance today. And this year, as open enrollment begins on November 1, the opportunity for millions more Texans to gain low-cost or even free coverage remains available.

Too often, the debate about reducing Texas' uninsured rate focuses solely on Medicaid expansion, but that conversation overlooks the low-hanging fruit: Texans who are already eligible for free or heavily subsidized plans. The number of uninsured Texans eligible for free coverage is more than two-and-a-half times larger than those in the so-called "Medicaid coverage gap"—people who earn too much to qualify for Medicaid but not enough to qualify for ACA subsidies.

This means that millions of Texans have the opportunity to gain health insurance without paying a dime in premiums. Yet, many of these eligible Texans remain uninsured, not because of barriers like cost, but simply because they don't know affordable options are available. Our research and focus groups across the state revealed that many Texans were unaware they could find affordable coverage if their employer didn't offer it — or that the ACA Marketplace even provided free plans, even for those who might think that they would not qualify because of their annual income.

So why isn't the needle moving faster? Part of the answer lies in the disconnect between perception and reality when it comes to health coverage in Texas. Policy changes at the state and federal levels have made ACA plans available in our state significantly more affordable than in years past, but these improvements aren't well known to the people who need them most.

In 2021, a bipartisan effort led by state Sen. Nathan Johnson (D-Dallas) and state Rep. Tom Oliverson (R-Cypress) resulted in the passage of Senate Bill 1296. This law made premiums better align with federal subsidies, effectively lowering net premiums for many Texans. In its first year, this legislative reform helped an additional 350,000 Texans gain ACA coverage, and millions more stand to benefit this year.

As we approach the Nov. 1 open enrollment period, Texas needs to be focused on getting the word out about what Texans can find on the ACA Marketplace.

The truth is, Texas doesn't have to lead the nation in its uninsured rate. With free or affordable ACA plans available to millions, the state could reverse its current trend and lead the nation in newly insured residents. But the key is awareness. Now is the time to ensure that Texans know where to look and how to sign up starting in November.

Charles Miller is the director of health and economic mobility at Texas 2036, a nonpartisan nonprofit think tank.

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