Health care lessons from Texas: Who are the uninsured? Part 1

Texas 2036 began examining the state of health care access and affordability by asking: Who are the uninsured? They were people saying they could not afford health insurance, although their general perceptions in some instances were misperceptions. Charles Miller, JD, director of health and economic mobility policy for Texas 2036, explains the organization’s deep dive into health insurance coverage for Texans.

Medical Economics: Texas 2036 conducted a deep dive in the state population to ask, who are the uninsured? What were those findings? And how do you answer that question, who are the uninsured in Texas?

Charles Miller, JD: So we were really prompted by what seemed to be some incongruities with the data that we were looking at, one of the big questions, and the biggest source of data that we had for this question is, well, why are you uninsured if you are uninsured, and the existing source of data came from the American Community Survey, and the overwhelmingly top answer was it's unaffordable or it's too expensive. And we started looking at this, and started doing some demographic breakdowns and looking at cross tabs, and our back-of-the-envelope calculations were that a huge chunk of the folks who were saying that affordability was the reason why they were uninsured were actually eligible for free or very inexpensive plans. And so we wanted to go deeper than the survey and really start to find out, what are these answers getting at? What can this tell us? And so we did something radical. We asked the people themselves. Who are you? Would tell us about your life experiences? Why are you uninsured? What are your perceptions or awareness of various programs. And the results we got were pretty interesting. I think one of the findings we found is that a lot of people who are uninsured were uninsured because they thought they could only get insurance through their employer, and so if they were unemployed or if their employer was not offering insurance, they simply didn't know that there were other options available.

The other big barrier that we found is that people had a very different perception of what insurance would cost to them than the reality. And so this is getting at that disconnect that we saw earlier in that survey response to the American Community Survey. When we talked to people, we would get enough demographic information that we felt pretty good about being able to estimate what their out of pocket premium or enrollment cost would be. And then we asked them what they thought that it would cost, and the disconnect was extreme. A lot of folks who were eligible for free, or say, under $25 a month plans, had a perception that they were going to have to pay $300 to $500 a month. Some of those perceptions were based in reality, they had done past work and conditions had changed. Some of them were based on almost vibe-casting, they just had a sense of this. And some of it was a different perception of their place in society. And this last group, what we would hear is, insurance isn't for someone like me, and that's a direct quote. We heard people say things like, insurance is like a luxury handbag, it's just something that I'm never going to have.