SCOTT WOMACK

Public Health

Dallas Is the Second Least-Insured Large City in the Country

Only Houston has a worse rate, and Dallas is joined by Fort Worth and Arlington in the bottom ten.

Dallas ranks in the bottom 3 percent of cities in the country for health insurance rates, making it the second least insured large city in the country. About 27 percent of its adults lack insurance coverage, according to a study by WalletHub compiled from U.S. Census Bureau data. 

Of the 548 cities in WalletHub’s latest ranking of uninsured cities, Dallas ranks 538th. It is joined at the bottom by Garland, Irving, and Mesquite in the overall ranking, while Fort Worth and Arlington are in the bottom ten of large cities. Six of the worst 10 cities in the country are in South Texas near the border with Mexico, and Texas has nine of 10 cities with the country’s worst health insurance rates. Last year, Dallas was ranked last among large cities, but this year was passed by Houston. 

Texas is one of 12 states around the country that has yet to expand Medicaid, which would shrink the gap between those working adults who make too much to qualify for Medicaid in its current iteration but not enough to afford subsidies on insurance purchased through the Affordable Care Act. Many of the cities with low health insurance rates have large Hispanic populations, who often fear interacting with the government or entering the insurance market because of immigration worries. Expanding Medicaid in Texans would provide health insurance to millions of working Texans. 

Statewide, Texas has the largest uninsured rate by a wide margin. It ranks dead last, with an uninsured rate of 18.36 percent. The next lowest state is our northern neighbor Oklahoma, which has a rate of 14.28 percent. (Expect that gulf to continue; Oklahoma voters approved Medicaid expansion in June.) Across the state, over 12 percent of children and over 20 percent of adults are uninsured. 

Here is why we should all care, even we have health insurance: there are 5.3 million Texans without health insurance, but that doesn’t mean they are not receiving medical care. They are just not receiving regular care that would reduce the number of catastrophic illnesses that result in people in the hospital.

Many of these working Texans get no medical care because they lack insurance until they can no longer work, meaning the problem is probably serious enough to require a hospital visit or other expensive treatment. So rather than regular check-ups and medication that maintain low healthcare costs, missed work, and overall discomfort, many uninsured individuals don’t receive care until things are expensive and catastrophic. 

When someone shows up at the hospital because they are in diabetic shock or their tumor causes severe pain, the hospitals can’t turn them away. They must be treated or stabilized until they can be transferred to a safety net public hospital.

According to the state of Texas, hospitals administered over $26 billion in uncompensated care in 2016, meaning treatment they performed without receiving payment. The federal government will subsidize some of those costs, but the domino effects impact us all. These costs could increase local tax rates from the hospital district (though Dallas’ property value increases have allowed the rates to remain constant). Still, more often, it results in higher charges from hospitals for their services, as the costs need to be recouped somewhere. When hospitals increase their charges for procedures and treatments, insurance premiums go up as well. 

Between 1998 and 2018, hospital services have increased more than 200 percent, outpacing overall inflation (56 percent) by a wide margin. While there are several factors for the increase, uncompensated care increases every year. These increases can be manipulated by setting higher prices for their services, resulting in larger amounts of uncompensated care.

Still, they translate to higher premiums for everyone, employers included. According to the National Council of State Legislatures, an individual’s yearly insurance premium had gone from around $2,000 in 1999 to more than $6,000 in 2018. For a family, premiums had gone from approximately $6,000 in 1999 to nearly $20,000 in 2018. 

In Texas, there are doubts that Medicaid expansion would improve the fiscal situation in the state. Still, data from the Commonwealth Fund show that expanding Medicaid saves the state money because of the savings it generates.

“During 2014–17, Medicaid expansion was associated with a 4.4 percent to 4.7 percent reduction in state spending on traditional Medicaid,” the report reads. Expanding Medicaid reduces uncompensated care, shifts costs for correctional facilities, and allows the federal government to pick up the tab for mental health and substance abuse treatment, which is often now covered by states for those without insurance. 

In Michigan, Medicaid was expanded under a provision that ends the expansion if savings do not offset growing care costs. So far, savings have averaged around $160 million per year, and the program appears to be solvent until at least 2028. 

As long as Texas remains one of the few states not to expand Medicaid, it will continue to retain ignominious records like leading the nation by a wide margin in uninsured rates, and we all pay for it in the meantime. 

Explore more of the data here.

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