Texas Has 19 of the 20 U.S. Counties With the Most Uninsured | Insurify

The state of Texas continues to fall behind in health insurance enrollment, according to new research from SmartAsset. The investment advisory firm ranked 810 U.S. counties based on the percentage of their under-65 population who didn't have health insurance in 2024.

Of the 810 counties SmartAsset reviewed, 19 of the 20 with the lowest health insurance enrollment are in Texas.

Those counties are:

Hidalgo County (32% uninsured)Cameron County (30.1%)Webb County (29.7%)Starr County (29%)Ector County (25.3%)Potter County (24.4%)Dallas County (24.2%)Harris County (23.8%)El Paso County (23.5%)Liberty County (23.24%)Bastrop County (22.81%)Jefferson County (22.68%)Angelina County (22.52%)Gregg County (22.01%)Nacogdoches County (21.99%)Henderson County (21.69%)Smith County (21.18%)Nueces County (21.16%)Wise County (20.88%)

Whitefield County, Georgia, was the only non-Texas county to make the list, placing 10th between El Paso and Liberty counties, with an uninsured rate of 23.43%.

Another Texas county, Orange County, ranked last in the study's physicians-to-citizens ratio, averaging one primary care physician for every 6,053 residents.

Why are so many uninsured in Texas?

Multiple factors contribute to the number of uninsured Texans. SmartAssets' research points to people consciously choosing not to secure health insurance in an effort to save money.

"In 2024, the average annual premium for a single individual was nearly $9,000 — and an estimated $25,500 for a family of four," SmartAsset wrote in its findings.

Research from the Congressional Budget Office shows some common factors increase the likelihood a person will be uninsured, including:

Falling below 200% of the federal poverty levelBeing young, specifically ages 19 to 34Being HispanicBeing in a family where adults only work part-time or part of the yearHaving poor or fair health status

Texas workers are also less likely to have health insurance through their employer than workers in other states, according to the Texas Medical Association. And those making low or moderate wages are less likely to have access to health insurance than higher-wage workers.

What's next? Reversing a continuing trend

The U.S. Census Bureau's American Community Survey revealed that 21.7% of Texas adults ages 19 to 64 went without health insurance in 2023, the worst rate in the nation.

Texas' rate of uninsured adults is nearly double the national rate of 11%, according to the research.

Texas children are also far more likely to go without health insurance than children nationwide. The rate of uninsured children in Texas is 11.9% compared with the national average of 5.4%.

These findings have prompted advocates to demand legislators make health insurance a focus of the state's 2025 legislative session.

They're calling for Texas legislators to improve access to health insurance for children, reduce the backlog of Medicaid applications, improve language access, and pass Medicaid expansions, which would provide insurance to an additional 1.4 million low-income earners.

"We're deeply concerned that so many Texas kids are missing out on the health insurance they need for reliable access to healthcare," Diana Forester, director of health policy at Texans Care for Children, a member of the Cover Texas Now coalition, said in a statement.

"If state leaders want to make sure that kids can go to checkups, head back to school quickly when they're out sick, and get other critical healthcare, then they need to make children's health insurance a priority during the next legislative session."

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