V3I7P23

Bridging the Coverage Gap: Healthcare Access, Uninsured, and the Case for Medicaid Expansion in Texas    -A Comprehensive Research Study

Akinola Adio^1*

Abstract

Background: Texas records the highest uninsured rate in the United States at 16.7% of the total population (ACS 2024), more than double the national average of 8.2%. Over 5.1 million Texans, including 1.1 million children, lack health insurance coverage. This structural failure is compounded by the state’s persistent refusal to expand Medicaid eligibility under the Affordable Care Act (ACA), leaving an estimated 617,000 to 1,435,000 adults in a coverage gap with no viable insurance pathway. This research provides a comprehensive, evidence-based analysis of the multidimensional healthcare access crisis in Texas, examining uninsurance trends, rural hospital infrastructure collapse, racial and ethnic health disparities, and the economic consequences of sustained policy inaction.

Objectives:  This study pursues six interconnected objectives: (1) quantify the scope of uninsurance in Texas across demographic and geographic dimensions; (2) examine the systemic consequences of Medicaid non-expansion; (3) analyze the economic burden of uncompensated care and foregone federal revenue; (4) assess racial and ethnic health disparities; (5) document rural hospital closure patterns and their community impacts; and (6) formulate evidence-based, politically grounded policy recommendations for a more equitable and financially sustainable Texas health system.

Data and Methods:  This research employs a mixed-methods secondary analysis design, integrating data from ten authoritative sources: the U.S. Census Bureau American Community Survey (ACS 2024 and 2019 to 2023 trend series); the Kaiser Family Foundation (KFF) Medicaid and Coverage Gap databases; the Commonwealth Fund State Health System Performance Scorecards (2020 to 2024); the Texas Department of State Health Services (DSHS) Behavioural Risk Factor Surveillance System (BRFSS 2018 to 2024); the Texas Health and Human Services Commission (HHSC) Medicaid enrolment and uncompensated care records; the Centre for Healthcare Quality and Payment Reform (CHQPR) rural hospital closure risk models; the Episcopal Health Foundation economic impact analysis; the Texas Hospital Association (THA) rural financial performance reports; the State Health Access Data Assistance Centre (SHADAC) ACS analysis; and a systematic review of peer-reviewed literature from JAMA, Health Affairs, the New England Journal of Medicine, and PubMed, spanning 2012 to 2025.

Key Findings:  Texas has foregone approximately $5 to $6 billion annually in federal Medicaid funding while its emergency departments absorb $5.5 billion per year in uncompensated care. Since 2005, twenty-five rural Texas hospitals have closed permanently, more than any other state, with 87 of the state’s 156 remaining rural hospitals currently at risk of closure. Black Texans face infant mortality rates more than twice those of White Texans (10.0 vs. 4.5 per 1,000 live births), and Hispanic adults are uninsured at a rate of 35.1%, nearly three times the White adult rate of 11.2%. Evidence from the 40 states that have adopted Medicaid expansion consistently demonstrates 40 to 50% reductions in adult uninsured rates, stabilized rural hospital finances, improved preventable mortality, and net positive fiscal impacts for state budgets.

Conclusions:  The evidence establishes that Texas’s non-expansion of Medicaid constitutes a compounded policy failure: it is simultaneously a public health crisis, a fiscal mismanagement problem, and a structural health equity failure. This paper recommends full Medicaid expansion, rural hospital stabilization investment, a statewide Community Health Worker program, health information technology modernization, and governance accountability mechanisms. A better Texas health system is achievable. It requires political will, evidence-guided decision-making, and a commitment to the principle that healthcare access is a foundation of economic and social well-being.

Keywords:

Texas Uninsurance, Medicaid Expansion, Healthcare Access, Health Disparities, Rural Hospital Closures, Coverage Gap, Social Determinants of Health