Texas faces a healthcare crisis characterized by three significant challenges: a large uninsured population, adversities in women’s healthcare, and a growing physician shortage. With federal pandemic-era health protections expiring and over half of Texas counties lacking access to primary care services, robust programmatic frameworks must be established to support our most vulnerable Texans.
Everything is Bigger in Texas, Including the Uninsured Population
The rising cost of medical services underscores the value of health insurance. Yet, Texas continues to rank number one for the highest number and highest percentage of uninsured residents – more than twice the national rate. The most updated Census Bureau report estimated that 5 million Texans do not have health insurance coverage. Texas’ uninsured rate is nearly twice as high as similarly populated states, including Florida and California. When people are concerned about medical costs, they may avoid seeking care, leading to worse health outcomes, including the progression of preventable diseases and higher mortality rates. Additionally, the lack of insurance often results in greater reliance on emergency rooms for both preventable and non-preventable care, driving up overall healthcare costs for taxpayers and straining the state’s medical infrastructure.
The federal government’s COVID-19 Public Health Emergency, which allowed continuous Medicaid coverage and lowered the state’s coverage gap, expired in May 2023. In the month following the expiration, more than 500,000 Texans lost their Medicaid coverage due to both eligibility and procedural reasons. This was referred to as “Medicaid Unwinding.” Nearly 2.5 million Texans were disenrolled from Medicaid and CHIP health coverage in the year following the emergency expiration, with 1.4 million of these Texans being disenrolled for procedural reasons.
Who is Uninsured in Texas?
Texas is one of 10 states that has yet to adopt the Affordable Care Act’s (ACA) Medicaid expansion, contributing to its high uninsured rate. Attempts to expand Medicaid in Texas have been unsuccessful due to opposition in the Legislature.
- 16% of Texans are uninsured. 81% of Texas’ uninsured population are working-aged (19-64).
- 11% of Texas’ uninsured population are children (under 19). Texas children are twice as likely to be uninsured as the average U.S. child (5.1%).
The coverage gap depicts racial disparities in access to healthcare. Minority children and working-aged adults are far less likely to be insured than White, non-Hispanic children and working-aged adults. People of color, specifically African Americans, Hispanics, and American Indians are at a significantly heightened risk of dying from preventable and treatable health issues than any other racial group.
According to 2022 Census data, Texas Hispanic children face a significantly higher risk of being uninsured, with 15% lacking health coverage – more than double the rate of White, non-Hispanic children (7%). Hispanic children make up two out of three uninsured children in Texas. American Indian/Alaskan Native/Native Hawaiian, and Pacific Islander children have the highest uninsured rate at 19%. The disparities extend to adults as well, with 31% of Hispanic and 17% of Black working-aged adults uninsured, compared to 10% of White non-Hispanic adults.
Challenges in the Texas Healthcare Workforce
Texas is facing a growing physician shortage, with rural and underserved areas experiencing the most severe gaps in healthcare access. 88% of counties are considered Health Professional Shortage Areas (HPSAs), and 71 do not have a hospital. A 2020 report by the Department of State Health Services estimates that the provider shortage will increase through at least 2032.
The Texas Medical Association highlights several factors driving the physician shortage, with the COVID-19 pandemic exacerbating existing challenges. Healthcare worker burnout surged, and patient volumes plummeted for private practices, leaving many struggling to stay afloat. Physicians were forced to reduce hours, lay off staff, or close their doors entirely. Economic pressures, including reduced wages due to declining patient numbers, only deepened the crisis.
These challenges have been particularly severe in obstetrics and gynecology, where the shortage of providers continues to worsen. Almost half of Texas counties are “maternity care deserts”– areas where there is no doctor for women to see during pregnancy and nowhere to give birth. Additionally, 44% of Texas OBGYNs surveyed said they have considered leaving the state, plan to retire early, or have already relocated due to the abortion ban.
How the Abortion Ban Affects Women’s Healthcare
The impact of Texas’ abortion ban extends far beyond those seeking abortion services—it affects women’s healthcare as a whole. State leadership is pushing physicians to prioritize a political agenda over medically proven best practices, leading many physicians to leave the state or the profession entirely.
A survey by the American College of Obstetricians and Gynecologists found that nearly two-thirds of physicians worry about legal consequences when practicing evidence-based medicine, and 44% have either considered or made changes to how and where they practice due to Texas’ abortion restrictions.
To add insult to injury, Texas is already facing a maternal health crisis. The Texas Maternal Mortality and Morbidity Review Committee’s 2024 Report found that 80% of pregnancy-related deaths were preventable, with disproportionately higher rates among Black, Hispanic, and non-White women.
Without legislative changes clarifying abortion ban restrictions, Texas must work to improve maternal health outcomes with supplementary programs, or the quality of healthcare for women and families across the state may worsen.
Improving Health Care Access
The following proposed solutions were chosen based on their feasibility, potential impact, and ability to address the gaps in access in Texas’ healthcare system. While not an exhaustive list, these strategies focus on improving access to care, reducing disparities, and strengthening the healthcare workforce. Many other policy changes could further support Texans, but these recommendations provide a strong starting point for meaningful progress.
Expand Medicaid
Expanding Medicaid coverage in Texas could provide coverage to an estimated 1.4 million low-income Texans, improving access to preventative care, reducing uncompensated hospital costs, and lowering maternal and infant mortality rates. States that have expanded Medicaid have seen economic benefits, including job growth and reduced financial strain on state funds.
Improve the Medicaid Eligibility System
In 2021, over 495,000 Texas children who qualified for Medicaid or CHIP were not enrolled. One method to increase enrollment involves using verified information from other state programs to enroll eligible children in Medicaid and CHIP automatically. Although a bill to do this (HB 1599 by Rep. Bucy) passed the House during the 88th Legislature, it was never heard in the Senate.
Clarify Abortion Laws
Physicians remain unclear on how to practice women’s health under the abortion ban, leading to higher maternal mortality and a decreasing OB-GYN workforce in Texas. Although the LSG does not support the abortion ban, if it remains in place, additional legislation to clarify the life-of-the-mother exemptions and provide exceptions for fatal fetal abnormalities may be the next best course of action to protect women’s health.
Allow Reimbursement for Doula Services
Case Management for Children and Pregnant Women (CPW) is an integral piece of service coordination for pregnant women and children receiving care from Medicaid. HB 1575 by Rep. Hull, which passed during the 88th Legislative Session, allowed doulas and community health workers to be reimbursed for the coordination of non-medical drivers related to mental and physical wellbeing (social, housing, educational, etc.). Advocates are now urging for new legislation, like HB 2573 by Rep. Walle, to make doula services eligible for Medicaid reimbursement.
Doulas provide supplemental support for medical and mental health needs during pregnancy, birth, and the postpartum period, and are highly effective in promoting positive maternal health outcomes. The Texas Maternal Mortality and Morbidity Report recommended that legislators allow doulas to be reimbursed for medical care services. According to Medicaid claims from California and Florida evaluated by the National Institute of Health, women who received doula care had 52.9% lower odds of cesarean delivery and 57.5% lower odds of postpartum depression/postpartum anxiety.
Doulas could be Texan’s largest maternal health asset by mitigating health disparities with at-risk mothers by working as liaisons between pregnant women and healthcare staff. This would be highly beneficial in Texas, where vulnerable pregnant patients in rural communities face multiple physical and logistical barriers to care.
Implement Integrated Care Models
Additionally, many solutions point to utilizing integrated care models. Integrated care brings different healthcare providers together to address all of a patient’s needs – physical, mental, and social. This holistic healthcare approach has led to:
- Enhanced patient health outcomes
- Lower overall healthcare costs
- Expanded access to behavioral health services
- Increased patient satisfaction
- Improved workforce productivity and satisfaction
- Reduced healthcare disparities and stigma
Integrated care models can benefit rural communities by enabling primary care providers to connect patients with mental health specialists and other providers, often through telephone or telehealth appointments. They can also reduce doctors’ burnout by improving efficiency through better communication and collaboration. The Medicaid and CHIP Payment and Access Commission has recommended that all states develop an integrated care strategy for individuals eligible for both Medicare and Medicaid. This recommendation is especially important given the prevalence of serious mental illness among dually eligible individuals. Incorporating policies targeting non-medical drivers of health into MCO contracts is also essential to increasing healthcare quality.
Texas can enhance its healthcare services by incorporating key elements of an integrated care model within Managed Care Organizations (MCOs), which are the primary providers for Texans enrolled in Medicaid and CHIP. This includes provisions enforceable via state purchasing contracts that focus on aligning financial incentives between physical and behavioral health and promoting collaborative care teams charged with the integration of medical, behavioral, and long-term support services as necessary. States like Tennessee, Washington, and Minnesota have rolled out similar integrated care models through their MCO contracts.
Conclusion
Texas stands at a critical juncture in its healthcare landscape. The convergence of a high uninsured rate, a growing physician shortage, and increasing challenges to women’s healthcare necessitates immediate and comprehensive action. While the extent of these problems–from millions of uninsured Texans to the expanding “maternity care deserts” is daunting, viable solutions are within reach. By prioritizing streamlined Medicaid enrollment, clarifying abortion laws to protect both patients and physicians, expanding access to doula services, and implementing integrated care models, Texas can start addressing these urgent issues. These targeted interventions and a commitment to data-driven decision-making and investment in the healthcare workforce present a path toward a healthier and more equitable future for all Texans.
Writing Credits: Alirma Davis, Sydney Medina, Kwi Myers