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An ongoing series on the states that refuse to expand Medicaid. Read other project stories.

As a family physician in Austin’s community clinics for 13 years, I saw hundreds of patients without health insurance.

Some of their stories still haunt me: the young mother who struggled to find a surgeon to remove a spinal tumor (cancer, it turned out), and the middle-aged man with serious lung problems who couldn’t afford to pay $4 for his anxiety medicine. My patients often skipped diagnostic tests and rationed medications. Some delayed care until the last minute, such as a patient with advanced breast cancer who finally found her way to my clinic with an enormous tumor that felt like a jagged golf ball. Others had to forgo expensive specialty care even when their complex conditions pushed the bounds of my knowledge and training. 

Lisa Doggett

Despite decades of debate and legislative efforts – most notably the Affordable Care Act (ACA) – nearly one in 10 residents of the United States remains uninsured. Many lack reliable access to a doctor. They often end up in emergency departments, which are required by the federal Emergency Medical Treatment and Active Labor Act to see them, for preventable medical problems or even routine care. They receive bills they can’t pay, perpetuating a cycle of poverty. They’re often one medical crisis away from financial ruin, even homelessness. Studies show that their overall risk of death is higher than for those with insurance.

Lack of insurance has impacts far beyond the individual. Those of us with coverage may face more crowded emergency rooms, higher premiums and higher taxes to pay for uncompensated care than we would if everyone had health insurance. COVID-19 and monkey pox show how interconnected we are – and there will be other infectious-disease outbreaks to deal with. As we look ahead to the mid-term elections next month, we’d do well to prioritize the elusive goal of universal coverage.

Despite its shortcomings, including its failure to address health-care barriers for undocumented immigrants, the ACA put us on the right path. In the years immediately preceding the law’s passage in 2010, the uninsured rate among the nonelderly population in the U.S. hovered a little above 17%. By 2016 it had fallen to 10%. Estimates for 2022 range from 8.9 to 11.6%.

In some parts of the country, however, the situation is much worse.

My home state of Texas isn’t known for humility. Texans brag about being the number one producer of livestock, cotton and oil and gas. We have the biggest rodeo and the tallest capitol building. We also have the highest number of people – both children and adults – without health insurance among all states and Washington, D.C. Nearly a quarter of Texans aged 19-64 and about 11% of Texas children lack health insurance. Rates of uninsured people in Texas – about 18% overall in 2021 – are 4.2 points higher than those in the second-worst state for coverage, Oklahoma.

This shameful distinction is connected to the decision by Gov. Greg Abbott and the Texas legislature to reject federal funds for Medicaid expansion to cover people who earn up to 138% of the federal poverty level – just $3,191 a month for a family of four in 2022. Eleven other states also have failed to implement this cornerstone provision of the ACA.

The Texas decision effectively deprives at least 1.4 million people of Medicaid coverage and, by some estimates, is leading to the loss of $100 billion in federal dollars to the state over 10 years. It also perpetuates a cruel coverage loophole, which bars people with incomes below the federal poverty line from receiving subsidies to help pay for ACA marketplace plans that are available to those with higher incomes. People who most need premium support don’t qualify.

‘Unimaginable Challenges’

Community clinics, like the ones where I worked, fill an important gap in the safety net for those without health insurance. They need to be well-funded, but they have limitations.

At my clinics, for example, we could draw blood for lab work and give immunizations but couldn’t provide radiology services or IV fluids. Also, community clinics often serve distinct areas. Some people, especially in rural areas, don’t have one nearby.

Many of those without insurance are discouraged from seeking care at all. According to a Kaiser Family Foundation report, in 2019, 41.5% of nonelderly uninsured adults did not see a health-care provider in the prior 12 months, compared to 11.9% of those with Medicaid or other public funding. They miss preventive screenings and delay care for chronic conditions or new symptoms, sometimes until it’s too late.  

Short of Congress improbably passing legislation to support universal health coverage, like Medicare for All, Medicaid expansion is the best way to curb uninsured rates. “It is not possible to address the uninsured problem without Medicaid,” said Sara Rosenbaum, a professor of health law and policy at George Washington University.

According to an Urban Institute report published in July, 3.7 million people would gain coverage if the 12 holdout states expanded Medicaid. State economies and hospital and family finances would improve. There would be fewer unwanted pregnancies and more lives saved. All of this would come at “little or no cost to state governments,” the report concludes.

My uninsured patients faced unimaginable challenges. One rented an apartment infested by bats; another cared for a grandchild after her daughter disappeared and was presumed murdered. Some couldn’t read, and many didn’t have home computers. Most of them worked, often more than one job. But the cost of insurance was out of reach.

In Texas, we have a state government that seems hellbent on maintaining the status quo. We also have “serious issues with a meltdown of the eligibility system where our state agency is short many, many workers,” said Anne Dunkelberg, senior analyst for health and food justice at Every Texan, a nonprofit policy institute. Texas is already behind on processing Medicaid applications, she said. The end of the federal Public Health Emergency declaration, expected in January, will add to the bottleneck because it will require Medicaid beneficiaries to re-enroll after years of continuous coverage during the pandemic. Millions in Texas and other states could be kicked off the rolls.

Universal health care in the United States is already a reality. Anyone can see a doctor any time they want – by going to the emergency department.

The ED was often the only option for my patients when we reached the limits of what my clinic could offer. The emergency room provides a critical service. But it’s expensive and inefficient. Big bills from emergency-room visits can be catastrophic. And it’s not suited for prevention or continuity of care. Tackling the high rates of uninsured in Texas and elsewhere through Medicaid expansion and a simplified, well-supported enrollment process would help ensure that our EDs become the care settings of last resort, reserved for true emergencies. Prioritizing policies to cover more people with insurance is humane and ethical, and makes economic sense.

Lisa Doggett, senior medical director of Sagility, is a columnist for Public Health Watch. The views expressed in her column do not necessarily reflect the official policy or position of Sagility or Public Health Watch.