Texas has been criticized recently in both the Houston Chronicle and the Texas Tribune for having the highest uninsured rate in the nation, 17 percent. While this is true, it is unfair. Texas is getting a bad rap.
No one creates a health care system in order to insure people. Health care systems exist to deliver timely health care to the most people at an affordable price. Most people believe that having insurance is the key to getting care, and then conclude that people without insurance don’t get care.
Based on this rationale, Texans must be getting the least care, since they are the most uninsured group in the U.S. But is this true?
Compare care in Texas, with its 17 percent uninsured rate, to care in New York, which has the lowest uninsured rate in the country, at 5.4 percent. New York also has the highest enrollment in Medicaid or Children’s Health Insurance Program (CHIP) at 32 percent. The Lone Star State has the lowest Medicaid/CHIP enrollment of just 16 percent, half of New York’s rate.
Two helpful indicators of access to care are wait times and primary care needs met. Wait times refer to how long it takes a patient with a new problem to see his or her physician. Primary care needs are considered routine, preventative and screening care as well as minor and non-acute problems. In January 2017, Merritt Hawkins performed a national survey of these measures. New York and Texas figured prominently.
New York City, representing the state with the lowest uninsured rate, had wait times of 22 days to 28 days, while Dallas, Texas, had the shortest wait time in the entire nation, 16.5 days.
New York, with its low uninsured rate and high Medicaid enrollment, satisfied the primary care needs of its population 45 percent of the time. The state with the highest uninsured rate and the lowest Medicaid enrollment, Texas, did the best: Lone Star doctors met primary care needs of Texans 71 percent of the time.
Clearly, being uninsured does not mean failing to get care. Furthermore, having government-supported insurance does not guarantee timely care, or care at all. In fact, an internal VA audit of our veterans, who have TRICARE coverage, suggested that more than 300,000 may have died while waiting for care.
Some have suggested that Texas should solve its so-called problem of the high uninsured rate by expanding Medicaid. For a demonstration of the effect of expansion, Texas need look no farther than its northwest neighbor, New Mexico.
New Mexico expanded its Medicaid program in 2013, and now 42 percent of the state population is covered with Medicaid insurance. (Texas’ Medicaid enrollment is 16 percent.) As a result of the higher cost of expansion, New Mexico Medicaid had a 2017 shortfall of $417 million. The state had to slash reimbursement schedules to providers. This decreased access to care as doctors stopped accepting new Medicaid patients. In other words, when Medicaid is expanded, fewer people have access to care.
Most media outlets praise the Affordable Care Act for lowering the uninsured rate, mostly by giving no-charge Medicaid insurance to more than 16 million Americans. The pundits ignore the more important factor in healthcare–access to timely care. Instead of getting the credit Texas deserves for providing good care to the most people, it gets a bad rap for its high uninsured rate.
No good deed goes unpunished.
Dr. Deane Waldman, MD, MBA, is a retired pediatric cardiologist and director of the Center for Health Care Policy at the Texas Public Policy Foundation.