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Big drop in Texans without health insurance, but poor lag

Texas' lack of success in reducing the uninsured rate among its poor has left the state as the nation's leader for percentage of residents who lack insurance.

Everything's really big in Texas — except when it comes to how much Obamacare has helped poor people.

Texas has seen a nearly 30 percent drop in the number of adult residents who lack health insurance since the Affordable Care Act began taking full effect, according to a report released Tuesday.

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But among poor Texans, the percentage drop among the uninsured was a lot less impressive — just 15 percent.

And even after that decline, a whopping 46 percent of Texans whose household income is below $16,395 still remain uninsured, according to the report by Rice University's Baker Institute for Public Policy and the Episcopal Health Foundation.

Poor adults had the least-dramatic reduction in uninsured rates of any group broken out by age, gender, ethnicity or income group in the report. And the poor have the highest uninsured rate overall of any group in Texas.

The big disparity, the report notes, is due to the state's refusal to expand its Medicaid program to cover more poor adults.

"The ACA as implemented in Texas offers little hope for Texans with the lowest incomes," said Elena Marks, Episcopal Health Foundation's president and a nonresident health policy fellow at the Baker Institute.

The report looked at the rate of uninsured Texans as of September 2013 — the month before private Obamacare health plans became available for sale on government-run exchanges — and compared it with the rate of this past March.

In the fall of 2013, the uninsured rate among nonelderly adults in Texas was 25.5 percent. By this March, the rate was down to 17.9 percent — a 7.6-point decline.

"For more than a decade prior to the ACA, the uninsured rate remained above 20 percent and was rising," said Marks. "It's now clear that it's moving in the opposite direction, and the ACA deserves the credit."

Adults ages 50 to 64 saw the biggest drop, with their uninsured rate being cut by more than half, to 10.3 percent, according to the report.

Among ethnic groups, Hispanics had the biggest drop — an 11.9-point decrease, down to 30.7 percent. Their uninsured rate, however, was still more than twice the rate of blacks and three times that of whites.

Despite such drops, Texas' lack of success in reducing the uninsured rate among its poor people has left the state remaining as the nation's leader for percentage of residents who lack insurance. Texas' overall uninsured rate is about 8 percentage points higher than the overall U.S. uninsured rate.

The big disparity between the success of the poor in getting insured under Obamacare and that of every other group in the Lone Star State stems from the refusal of Texas to expand Medicaid, the joint federal-state health program that covers poor people, pregnant women and children.

Texas and Florida are the two biggest holdouts on Medicaid expansion, which has been embraced by 31 states and the District of Columbia. Louisiana's expansion program began Wednesday.

Obamacare allows states to expand their Medicaid programs to cover adults whose household incomes are as high as 138 percent of the federal poverty level — just below $16,395. Under the ACA's expansion provision, the federal government promises to ultimately pay no less than 90 percent of the costs of insuring the newly eligible for Medicaid, in contrast to traditional Medicaid, where it splits the costs of covered people roughly equally with the states.

In non-expansion states, such as Texas, it's common for adults without children to be ineligible for Medicaid. And such states often have very low cutoffs for Medicaid eligibility for adults with children. In Texas, a couple with children who earn more than $3,628 annually are ineligible for Medicaid.

The low income cutoffs in non-expansion states have led to a phenomenon among many poor Americans known as the Obamacare "coverage gap."

People who fall in the gap are those who earn too much to qualify for Medicaid, but too little — below 100 percent of the poverty level — to qualify for federal subsidies to help pay for private health insurance purchased through Obamacare marketplaces.

The Kaiser Family Foundation, in a recent report, said that 766,000 poor Texans fall into the coverage gap. Kaiser noted that Texas accounts for about 1 in 4 Americans in the coverage gap.

"Unless Texas expands Medicaid or comes up with another system of coverage, they will remain uninsured," Marks said.

However, expansion in Texas isn't likely to happen anytime soon, despite a poll by the Texas Medical Center Health Policy Institute that showed 63 percent of residents favoring expansion, and despite calls by hospitals and business groups for such a move as a way to reduce uncollectable medical debt that's incurred for the treating of the poor.

Texas' Republican governor, Greg Abbott, has been dead set against expansion, calling it "wrong for Texas." Abbott also has said the ACA underwrites a "massive expansion of an already broken and bloated Medicaid program."

Abbott's spokesman, John Wittman, when asked about the new report about the uninsured, said, "I can confirm that the governor's position has not changed."

Rachel Garfield, a senior researcher at the Kaiser Family Foundation, said that while much of the opposition to Medicaid expansion "is politically driven, there are other arguments that have been put forward" for not expanding coverage to more of the poor.

Among those arguments is concern about the cost to state budgets, even with the higher federal level of support, and worry that the federal guarantee of at least 90 percent costs will not be there in the future. Medicaid expansion critics have also objected to the idea of providing coverage to able-bodied adults who can work.