In 2007, more than 19 percent of Texans reported they were unable to see a doctor when needed due to cost. Between 2003 and 2009, health insurance costs for Texan families rose 38 percent to an average annual premium of $13,221. Single policyholders saw their premiums increase by 32 percent over the same period.  Of the Texans who do have health insurance, 45 percent are covered through employment. Public programs such as Medicaid and Medicare insure 27 percent of the population, and four percent of Texans purchase individual private policies. This leaves more than six million Texans, 24 percent of the population, uninsured. 
Who are the uninsured in Texas?
Texas children, at all income levels, are uninsured at a rate of 17 percent. This figure rises to 22 percent for children living in households with incomes less than 139 percent of the Federal Poverty Level (FPL). Non-elderly adults living in these lower-income households, those younger than 65, are uninsured at a rate of 58 percent.  The majority of the state’s six million uninsured are employed with more than four million living in homes with at least one full-time worker, and nearly 774,000 have part-time workers in the household. 
More than one-third, 38 percent, of the non-elderly Hispanic population in Texas lacks health insurance. Non-elderly Black Texans have an uninsured rate of 23 percent, and 16 percent of non-elderly White Texans have no health insurance. 
How does the Affordable Care Act affect Texans?
The Affordable Care Act (ACA) requires states provide access to an online marketplace, also called an exchange, where individuals and small businesses may compare, select and purchase private health insurance policies that offer a minimum level of coverage. States have the option of establishing their own exchange, operating an exchange in cooperation with the federal government, or turning all administration of the health care marketplace over to the federal government.
In a July 2012 letter to U.S. Health and Human Services Secretary Kathleen Sebelius, Texas Governor Rick Perry announced that the state would not establish its own exchange, nor would Texas expand its Medicaid program to include a larger group of unissued Texans. Provisions of the ACA allow states to expand their Medicaid programs to include households with incomes up to 138 percent of the FPL.  Perry asserted that establishing a state-based exchange under the ACA provisions would strip Texas of its authority to regulate its own insurance industry. Therefore, by default, the Texas health insurance exchange is run by the federal government.
Under the ACA, all new policies, and in-force policies upon renewal, must cover a package of essential health benefits, including hospitalization, emergency services and mental health treatments. Annual wellness checkups and other preventative screenings must be covered with no co-payments or deductibles. Residents may not be denied health insurance for pre-existing health conditions, and insurers may not place a lifetime cap on benefits. Households with incomes at or below 400 percent of the FPL may be eligible for tax credits to offset premium costs. An April 2013 report released by Families USA estimates 2.6 million Texans will be eligible for these tax credits in 2014.
The Texas health insurance exchange
Texas residents are able to shop for and enroll in health insurance plans at the federal health insurance marketplace portal HealthCare.gov. All plans offered in the Texas exchange cover essential health benefits based on Blue Cross/Blue Shield of Texas’s Best Choice PPO plan.
Plans are offered in four categories of coverage levels, with the least expensive plan, the bronze tier, covering 60 percent of medical costs. Plans in the silver tier cover 70 percent of costs. Gold plans cover 80 percent. The most expensive tier, platinum, covers 90 percent of medical costs. HealthCare.gov offers information about available tax credits, subsidies and eligibility for free health insurance through Medicaid.
Small Business Health Options Program (SHOP)
Under the ACA, small business employers with fewer than 50 full-time workers, or full-time equivalent workers, will not be required to offer health insurance to their employees. (Check here for a definition and calculator to determine who qualifies as a full-time worker.) However, the ACA encourages many small business employers to provide health insurance by offering small business health care tax credits.
Many small businesses were already offering health insurance packages to their employees before the ACA was passed and signed into law. These plans are accepted, or grandfathered in, under the ACA.
For small business owners who wish to change their coverage plans, or for those who did not offer health insurance before the new law, the ACA establishes the Small Business Health Options Program or SHOP. SHOP allows employers to compare and shop for quality insurance plans side by side for their employees. Texas small business owners may access SHOP through HealthCare.gov. For more information about the ACA and small businesses, visit the U.S. Small Business Administration.
Certified in-person enrollment organizations
The U.S. Department of Health and Human Services has approved the health centers below in Texas for assistance in outreach and enrollment.
- Amistad Community Health Center
- Asian American Health Coalition Of The Greater Houston Area, Inc.
- Barrio Comprehensive Family Health Care Center, Inc.
- Brazos Valley Community Action Agency
- Brownsville Community Health Clinic Corporation
- Centro De Salud Familiar La Fe, Inc
- El Centro Del Barrio
- Gateway Community Health Center Inc
- Health Center Of Southeast Texas
- Heart Of Texas Community Health Center, Inc.
- Legacy Community Health Services, Inc.
- Lone Star Circle Of Care
- Los Barrios Unidos Community Clinic, Inc.
- North Central Texas Community Health Care Center
- North Texas Area Community Health Centers Inc
- Nuestra Clinica Del Valle
- Regence Health Network, Inc.
- South Texas Rural Health Services, Inc.
- Su Clinica Familiar
- Travis County Healthcare District
For the full list, visit the U.S. Department of Health and Human Services.
External resources for Texas residents
- Centers for Medicare & Medicaid Services
- Cover USA.org
- The Kaiser Family Foundation
- State Refor(u)m
- Texas Department of Insurance
 http://bit.ly/18iQknG (The ACA calls for a Medicaid expansion to include households with incomes up to 133 percent of the FPL, but under Modified Adjusted Gross Income tax rules, five percent of income will be disregarded. This creates an effective rate of 138 percent of FPL as the income threshold for Medicaid eligibility.)
Gillian Burdett is a freelance writer covering all things home and living. Her work can be found on Examiner.com.