Health insurance, accessibility and the business of medicine in the Lone Star State

Physicians, health system leaders, elected legislators, policy makers, and patients all have been inundated with recent news about federal policies involving the Affordable Care Act, the Great Healthcare Plan, health insurance, health care access and the medical best treatments.

Apart from Congress and the White House, there are state governments, medical societies and advocacy groups all examining their own best ways to maintain health care access and affordability among the 50 states.

That includes Texas, the second-most populous state of the union — and one where health insurance has been a struggle for years.

Texas 2036 is a nonprofit, nonpartisan public policy group examining the best ways to make Texas the best state over the next decade, in time for the bicentennial of the founding of Texas as a nation. While not exclusively a health care organization, health is a key priority.

Charles Miller, JD, is director of health and economic mobility policy for Texas 2036. He spoke with Medical Economics about what the policy analysts found when they drilled down on health insurance and medical care needs of more than 31 million people spread out over an area larger than France.

The following transcript has been edited for clarity and length.

Medical Economics: Why did Texas 2036 make health care policy a priority in recent years?

Charles Miller, JD: Texas has struggled. Many states have struggled with this, but Texas has uniquely struggled with health insurance in particular. For years and years, Texas has had the unfortunate designation of having the highest uninsured rate as well as the highest number of individuals without insurance, and that has been a sore spot for a lot of folks in Texas. So we saw this as one area that we could work to take on. As we got into that work, we also realized that it's not just simply limited to the issue of coverage and getting people covered, but that there is a broader ecosphere of making sure that the overall systemic nature of our health care system is affordable, and that goes beyond simply looking purely at insurance, but making sure that the entire system has affordable prices that remain accessible, both to individuals but also to the state as a whole.

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

Charles Miller, JD: 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.

Going back to that group of people, when the Affordable Care Act first rolled out and it was available back in 2014, 2015, and people went on, prices that they saw were much higher than they are now. Affordability has just increased for a number of reasons, due to state and federal actions, and the prices that are available now, and especially at the time that our survey and focus groups were being conducted, had changed dramatically. And so for those folks, our message was, go take another look. This group, I would say, was probably the smallest group that had actually gone on previously and had a very data informed opinion. The larger group, we think, seemed to be getting their perceptions of affordability largely from media coverage talking about premium increases and gross premium increases, as well as maybe just political perceptions of the program based on their political news. And to those folks, our message was, go take a look at this and go in with an open mind and just check it out. When people found out that they were eligible for plans that were, again, under $25, under $50, and in many cases, free plans that really changed their views of what was available for them. Now there were other there were other groups of people and other reasons that compounded on these but those were the big factors, the biggest factors we found as to why the existing population that was eligible for these plans had not signed up. And the numbers are wild, right? So we had 5 million uninsured folks in Texas, and our calculations at the time was roughly 40% of them were eligible for a free plan. Now that was in the world where we had the enhanced subsidies still in place that have since expired. Those numbers are a little bit lower now than they were, but we would still estimate that of the uninsured, a little over a million of those folks are still eligible for a free plan and had not signed up at that time.

Medical Economics: There has been discussion about possibly extending those tax credits that function like insurance subsidies. Do you have an estimate about how many people that would affect in Texas?

Charles Miller, JD: It depends, it'll affect in different ways, right? And so different people, depending on their income status, are affected differentially. The group that is impacted the most, that will have the most extreme swing in what they would be expected to pay for their premiums is that group of people that makes more than 400% of the federal poverty level. And just for context and real numbers, that's about $60,000 for an individual, about $85,000 for a couple, and about $120,000 a year for a family of four. If you make more than that amount of money, you have now basically lost eligibility for any subsidy. And so the premiums that you would be expected to pay for a plan on the individual marketplace could jump dramatically, and we're talking $10,000 or even more for that family. So they are going to be affected dramatically. In Texas, of our roughly 4 million enrollees last year, that was about 125,000 people. So that's about 3.5% of our marketplace. It's a relatively small percent of our marketplace, but it is a very big impact that those people will be feeling with the expiration of those enhanced subsidies. Now for the remaining folks, about 95% of our marketplace is receiving subsidies, and so outside of that 3½% last year that may have been receiving subsidies, the rest of the people on there who are subsidy eligible are going to see the amount that they would be expected to pay for any given plan go up slightly. We're not talking tens of thousands of dollars a year for these folks. We are talking increases more in the tens to hundreds of dollars a month, depending on what kind of plan that you get. So while the expiration or not of those subsidies can impact a wide number of people, the extent to which the impact is felt is going to vary dramatically based on your income level. One of the things that we have noted is that even with the expiration of those enhanced subsidies, is everybody in Texas who makes less than 200% of the federal poverty level is still going to have access to at least one free plan, and a good chunk of the folks who make up to 250% or even slightly higher than that of the federal poverty level, are also going to have access to at least one free plan that tends to vary most significantly by age. It can also vary by region, but perhaps paradoxically or counterintuitively, if you are eligible for subsidies, the older you are, the more likely you are to find a free plan. Plans tend to be more affordable for those who are older because of the complex subsidy dynamics that exist.