Health Care Access

Too few Houston-area residents are able to access affordable, high-quality health care consistently, contributing to poor health outcomes for a significant portion of our neighbors

Uninsured rates in the three-county Houston region have steadily increased since 2016, while physician availability and preventable hospital stays have improved.

The data

After six years of decline, uninsured rates in Houston’s three-county region have ticked up since 2016

When the Affordable Care Act was passed in 2010, its goal was to expand health insurance coverage by making it more affordable to more people. Many aspects of the program were implemented in 2014, including the establishment of health insurance marketplaces and the optional expansion of Medicaid eligibility.

Nationwide there were immediate gains in health insurance coverage, as the percentage of people without health insurance fell to 11.7% in 2014 from 14.5% in 2013. By 2019, the uninsured rate had declined to 9.2%, according to estimates from the U.S. Census Bureau.

Texas has had the highest percentage of residents without health insurance among all states in the U.S. each year for the last decade. In 2019, 18.4% of Texans didn’t have health insurance, double the U.S rate for that year. Not only is the uninsured rate in Texas nine points above the national rate, it is also four points above Oklahoma, the state with the second highest uninsured rate in the U.S.

Texas is one of 12 states that has not expanded Medicaid to cover additional low-income residents. Currently, legal residents of Texas can qualify for Medicaid if they are pregnant, responsible for a minor, have some kind of disability or a household member with a disability, or are older than 65 with low incomes. The income threshold for a household size of four is $59,400 before taxes. If Texas expanded access to low-income Medicaid beneficiaries, then residents with incomes up to 133% of poverty level could benefit. In 2019, an estimated 759,000 adult Texans were in what is known as “the coverage gap.” The coverage gap is experienced by people with incomes below the poverty level who are not eligible for financial assistance in the ACA marketplace.

The percentage of residents without health insurance in Houston’s three-county region has declined since the implementation of the Affordable Care Act in 2014. However, it remains well above the national average, and in recent years, has begun to increase again. Residents in Fort Bend County have historically had the lowest uninsured rates in the region, though figures have ticked up since 2016 and in 2019 matched Montgomery County at nearly 14%. In 2019, 22% of the Harris County population was uninsured, the highest uninsured rate in the region. 

Uninsured rates in 2019 in both Fort Bend and Harris counties were slightly above their 2014 level, when the ACA was implemented. These coverage losses likely stemmed from policy changes in 2017 that contributed to reduced access to and enrollment in coverage. Among these changes were decreased funds for outreach and enrollment assistance, and changes to immigration policy that made some immigrant families more reluctant to participate in Medicaid and the Children’s Health Insurance Program (CHIP), according to research by the Kaiser Family Foundation.³

COVID-19 Impact

How did health insurance coverage change during COVID in Houston? In an attempt to capture real-time effects of the COVID-19 pandemic, the Census Bureau began its Household Pulse Survey in April 2020. One of the questions asked about health insurance coverage. People in the Houston Metropolitan Statistical Area and in Texas were more likely to report lacking health insurance than that for the nation overall, by about 10 percentage points each survey period.

The majority of the area’s residents are enrolled in private health insurance (60%), mostly through employer-based health insurance. Slightly more than one in four have public health coverage such as Medicare and Medicaid. This has remained virtually unchanged since 2013, when Texas first had the option to expand Medicaid. As of 2019, 35% of the U.S. population had public health insurance, an increase of almost four percentage points from 2013.

Uninsured Rate for Nonelderly Residents

Another important measure of health care coverage is the uninsured rate for the nonelderly population — residents who are younger than 65 years old and not eligible for Medicare.

Over the last decade, the number of uninsured residents under 65 years old in Houston’s three-county region declined to a decade-low of 1 million in 2016 from a decade-high of 1.3 million in 2010. However, that number has steadily crept up to nearly 1.2 million uninsured in 2019. Harris County alone was home to nearly 1 million uninsured residents under the age of 65 in 2019.

Similarly, the uninsured rate dropped in each county during the last decade — peaking in 2010 and reaching the lowest levels in 2015 and 2016. However, despite this progress, uninsured rates in the region remain consistently higher than the U.S. average. More recently, between 2018 and 2019, the uninsured rate among the non-elderly population ticked up 1.8 percentage points in Fort Bend, 1.6 points in Harris, and nearly one point in Texas. In 2019, one out five people under 65 in Texas is uninsured (21%); one in four in Harris County (24%); 17% in Montgomery County; and 15% in Fort Bend County.

To learn about uninsured rates specifically for children, visit our Maternal and Child Health page.

Uninsured Rate for Nonelderly Adult Residents by Race/Ethnicity

Most people who remain uninsured are nonelderly adults age 19-64. In 2019, the uninsured rate among nonelderly adults was 28.4% across the three-county area.

Uninsured rates vary among racial/ethnic groups within Greater Houston’s diverse population. The uninsured rate among Hispanics in the three-county area (44%) is nearly four times that of whites (12%). Black adults also have a fairly high uninsured rate at 22%, which is higher than their rate for Texas and the U.S. Overall, nonelderly adults in Harris County have lower health insurance coverage rates, compared to Fort Bend and Montgomery counties.

The Kaiser Family Foundation identified several reasons why insurance coverage gaps differ and persist across race/ethnicity. For instance, people of color are more likely to live in low-income families that do not have coverage offered by an employer or to have difficulty affording private coverage when it is available. Additionally, uninsured nonelderly Hispanic and Asian people are more likely to be ineligible for coverage because of immigration status, reflecting higher shares of noncitizens among these groups.⁴

Primary care physician availability in the Houston region has improved slightly over the last decade

What factors affect access to health care? Sufficient availability of primary care physicians is crucial for preventative and primary care. Primary care physicians serve as the first point of contact with the health care system for many patients, thus they are more likely to be the first to screen major health-related conditions, detect early signs of disease and address health concerns at an early stage. Adults in the U.S. who have a primary care provider are more likely to report significantly better health care access and experience.⁵ They also have 19% lower odds of premature death than those who only see specialists for care.

Additionally, primary care also reduces overall costs. People with access to primary care providers are less likely to use an emergency room for care. It is estimated that the U.S. could potentially save $67 billion a year if everyone saw a primary care provider first rather than a specialist.⁶ Access to providers can be measured by the ratio of the total population to the number of primary care physicians. It represents the number of residents potentially served by a registered primary care physician in a county.

Although availability to primary care providers has improved slightly in Texas, the gap between the state average (1,642:1) and the national average (1,319:1) persists. In the three-county area, there were 3,779 registered primary care physicians in 2018. On average, for every 1,622 residents, there was one physician. The ratio of population to primary care physicians ranges from 1,709:1 in Harris County to 1,164:1 in Fort Bend County, indicating residents in Fort Bend County have more access to primary care providers than the other two counties. In the past seven years, access to primary care physicians has been improved steadily in Fort Bend County, passing both the state and national average. Montgomery County’s ratio, however, increased  to 1,674:1 in 2019 from 1,640:1 in 2010.

Read about challenges and availability of mental health care in the Houston area.

Preventable hospital stays in the Houston region have declined in recent years

Reducing preventable hospitalizations is critical for increasing quality of care and controlling costs. Medical conditions such as asthma and diabetes are considered ambulatory care sensitive conditions (ACSC). Generally, these conditions can be treated in outpatient settings by primary or preventative health care providers, which reduces the need for emergency room visits or inpatient hospitalization. Nationally, about 12.9% of inpatient hospital stays in 2017 were potentially preventable.

Data show that the majority of preventable hospital stays occur in patients aged 65 and older. Preventable hospital stays are measured by the number of hospital stays for ACSC per 100,000 Medicare enrollees in a given time period. High hospitalization rates for ACSC suggest a tendency of overusing emergency rooms and urgent care as a main source of care. It also places financial burdens on patients, insurance providers and hospitals as well.

In 2020, there were about 38,000 ACSC hospital stays and 756,000 Medicare enrollees in the three-county area, making its preventable hospitalization rate around 5,000 per 100,000 enrollees, higher than the national average. The rate for Montgomery County is the highest among the three counties and also higher than the state rate. However, the incidence rate of these stays has declined in each county in the region, in Texas overall and nationally between 2016 and 2018 — 12% in Fort Bend, 7% in Harris, 6% in Montgomery, 3% in Texas and 6% in the U.S. overall.

Preventable hospitalization rates also vary by racial/ethnic groups. Black residents have a much higher rate compared to Hispanic and white residents. The number of hospital stays for ACSC among Black adults in Montgomery County was 8,333 per 100,000 Medicare enrollees in 2018, almost double Texas’s average rate for all racial and ethnic groups (4,793).

This is not a new trend. Since 1998, racial and ethnic disparities in hospitalizations from chronic ACSCs have increased, resulting in over 430,000 excess hospitalizations among non-Hispanic Blacks compared to non-Hispanic whites.⁷ According to one study, Black adults had significantly higher rates of ACSC hospitalizations than white adults, even after controlling for demographic, socioeconomic, and geographic factors.⁸ There is no biological reason for race or ethnicity to predict preventable hospitalizations. Reasons for these persistent disparities include, but are not limited to, health care providers’ attitudes and implicit biases, disease stereotyping and clinical nomenclature, and clinical algorithms, tools, and treatment guidelines.

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