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Texas leads nation in number of uninsured
Costly Care

Every major city in Texas exceeds the national average for uninsured residents.

That sobering news comes from an April 2005 report by the Texas Comptroller of Public Accounts. The Uninsured: A Hidden Burden on Texas Employers and Communities found that from 2001 to 2003, Laredo had the state's highest rate of uninsured residents--36 percent.

More Texans go without health care insurance than residents of any other state in the nation. One in four Texans lacks health insurance, compared with one in six in the United States, according to the U.S. Census Bureau.

"The sheer number of uninsured Texans ultimately makes health care less affordable for Texas employers and individuals alike," said Texas Comptroller Carole Keeton Strayhorn. "Much of the costs involved in providing health care to the uninsured ultimately are shifted to those who have health insurance--and to Texas taxpayers."

Who they are
There is no "typical" uninsured person in Texas. Some Texans can't afford private health insurance and some work for small businesses that don't offer health insurance. Others can afford insurance but choose not to buy it. Still others are eligible for, but not enrolled in, government programs like Medicaid or the Children's Health Insurance Program (CHIP). CHIP insures children of working families who can't afford private health insurance but earn too much to qualify for Medicaid.

Between 2001 and 2003, 21 percent of Texas children were uninsured, nearly twice the national average of 11 percent, according to the report.

The Texas Health and Human Services Commission implemented a number of cuts to CHIP in September 2003. By May 2005, 180,450 children, or 35.6 percent of the CHIP caseload, lost health insurance.

"We ought to at least take kids out of this horrible cycle," said Dr. Guy Clifton, chairman of Save Our Emergency Rooms, a Houston-based coalition of medical, business and community leaders. "It makes no sense to have 21 percent [of children] uninsured in Texas."

Urban challenge
Nearly 50 percent of the state's uninsured--more than 2.6 million Texans--live in Houston, Dallas and Fort Worth-Arlington. From 2001 to 2003, Houston had the worst rate of the state's largest metropolitan areas, with 27.5 percent of residents going without insurance. Dallas was next with 25.3 percent Fort Worth-Arlington had 23.6 percent.

To address Houston's health care issues, in January 2005 the Harris County Commissioners Court created the Harris County Public Healthcare System Council, which includes area health care and business leaders. The council is looking at community clinics, technology, insurance and financial support to cut the rate of uninsured, said Rob Mosbacher, chairman of the council.

"We're looking at what can be done to address the severe overcrowding of our emergency rooms, the lack of sufficient primary, preventative, specialty and critical-care clinics and the growing numbers of uninsured," Mosbacher said.

Houston has two hospitals that can treat the most critical trauma patients, Mosbacher said. Yet they are often crowded with under- or uninsured patients seeking treatment for non-emergencies, he said.

The uninsured tend to go to emergency rooms for free, federally mandated care, which increases costs for hospitals that pass them on to insured patients, according to the report. Insurance companies then pay higher claims and pass the costs to the insured through higher premiums. As a result, businesses or employers may transfer the higher costs to employees through higher co-pays and deductibles or may drop coverage of employees or dependents.

"It creates a vicious cycle," said Mosbacher.

Border issues
Three Texas metropolitan statistical areas along the border--Laredo, El Paso and Brownsville-Harlingen-San Benito--had the highest rates of uninsured in the state, according to the report. Laredo led the state with 36 percent.

"It's difficult to find someone who is insured here," said Dr. Sue Fisher-Hoch, a professor at the University of Texas School of Public Health in Brownsville. "If you go to Brownsville to one of the big federally funded clinics here, more than 75 percent of the patients are uninsured."

El Paso, with 33.2 percent of its residents uninsured, faces similar issues, said Rosemary Castillo, chairwoman of the El Paso County Hospital District board.

"The percentage of uninsured that are coming to the Thomason Emergency Unit is just overwhelming," said Castillo. "From my perspective, it's people who are now unemployed for the first time in huge numbers."

The border area also has the lowest wages in the state.

"The cost of health care is about the same on the border as it is in other parts of the state," said Fisher-Hoch. "But residents just don't have the money to pay for it."

The Comptroller's report recommends several solutions, such as restoring the cuts made in 2003 and increasing the number of insured Texas children.

While the 2005 Legislature restored some CHIP services, it left eligibility restrictions imposed in 2003 that result in fewer children with health insurance. Fully restoring CHIP would allow the state to capture federal funds now left on the table to help pay for children's insurance. In fiscal 2005, Texas can insure a child under CHIP for about $98 a month--or $1,175 a year.

The report also calls for the state to restore 2003 cuts to the Medicaid Medically Needy Program, which paid hospitals to care for some patients with excessive medical bills.

The 2005 Legislature identified several ways it could restore some of the Medically Needy Program. Fully restoring the program would allow the state to reimburse hospitals for some patients.

Clifton said that opening more federally funded clinics could cut the number of uninsured seeking non-urgent care at emergency rooms, which could cut insurance costs.

"Unless things change, I think we're going to see the face of the uninsured change to more educated, temporarily unemployed or even employed individuals who are priced out of the market," said Clifton.

The Comptroller's report is available at or call 1-800-531-5441 for a copy.

Karen Hudgins