In many ways, Texas is an unhealthy state, and that was true before the pandemic.
It ranks dead last in health insurance coverage, for children as well as adults. Residents are much more likely to skip care because of the costs and to not have a primary doctor. A whopping 75% of adults don’t get appropriate flu and pneumonia vaccines — tying Louisiana for the worst uptake in the country.
The mortality rate is higher for conditions that could be treated, and for Black Texans, it’s much higher still.
Health care is no bargain here, either. The cost of employee insurance, measured as a share of median income, is almost 21% higher in Texas than the U.S. average.
These are among the findings of the Commonwealth Fund’s 2020 Scorecard on State Health System Performance, released on Friday. Most of the data is from 2018-19, so it predates the pandemic.
But once again, Texas ranks near the bottom, and those vulnerabilities become even riskier during the COVID-19 era.
“What really stands out is how little progress Texas has made in the last five years,” said David Radley, senior scientist for the fund’s program on tracking health system performance.
The Commonwealth report tracks 49 health care indicators, such as the uninsured, breast cancer deaths, vaccinations and state-based funding of public health. Nine metrics improved in Texas in the past five years, including more children getting a medical home and more young kids getting vaccines.
But Texas lost ground on nine measures, including potentially avoidable trips to the emergency room and adults who are obese.
In Florida, another large Southern state with Republican leadership, 17 indicators got stronger. They include significant gains in insurance coverage.
"Texas seems to be standing still,“ Radley said.
It’s actually backsliding. Data released Tuesday by the U.S. Census Bureau, which was not in the Commonwealth report, showed that Texas' uninsured rate rose by over half a percentage point in 2019. It’s the third consecutive year of Texas having more uninsured residents, and the number is likely to surge in 2020 because of soaring unemployment.
Last year, Texas had over 5.3 million uninsured — more than twice as many as Florida. Texas lawmakers have railed against the Affordable Care Act since it was passed in 2010, and the state filed suit to overturn it.
Like Texas, Florida has not expanded Medicaid to cover the working poor, rejecting a key plank of the health care law. They’re among a dozen states to not expand Medicaid despite the federal government absorbing most of the costs.
The lack of insurance coverage is one of the biggest barriers to care in Texas, and the shortcoming reverberates through the Commonwealth’s scorecard. More adults skipped care in the past year because of the costs, putting Texas 49th among the states on that measure. More adults went without appropriate cancer screenings, and more went without mental health treatment.
When Texans got sick, a higher share — almost 32% higher than the U.S. average — went to the emergency room even though care could have been provided in a less expensive setting.
Texas has lagged on health care for years, and the response of state leadership is reminiscent of the federal response to climate change, said Vivian Ho, a health economist at Rice University.
“The people in Austin who have the power to do something don’t think this is a problem,” Ho said. “But those who can’t afford health care are like the ice in the North Pole. They’re melting, and eventually, when that ice melts, we’ll all start flooding.”
This poses additional challenges during a pandemic. Residents who don’t have a regular doctor, much less health insurance, are more reluctant to get tested or treated. Even if the federal government says it will cover the costs, many may feel financially exposed.
Their reluctance could easily transfer to the COVID-19 vaccine after it becomes available, which would make it harder to contain the spread of the infection.
“The pandemic is revealing weaknesses in all kinds of public systems,” said Anne Dunkelberg, who oversees health care policy at Every Texan, an Austin advocacy group formerly known as the Center for Public Policy Priorities.
She cited a rash of COVID-19 cases in rural parts of the state that fell through the cracks because no health departments had responsibility.
“We’re learning what happens when you constantly reduce the spending on public health and public infrastructure,” Dunkelberg said. “In an emergency, you find out just how threadbare some of your systems are.”
The Commonwealth report also highlighted major racial and income disparities in health care. The most striking example may be the mortality rate for conditions that could be treated, such as dying prematurely from diabetes, hypertension, Hodgkins disease and respiratory ailments. For Blacks in Texas, the mortality rate was 74% higher than for whites.
In 2018, 14% of whites in Texas didn’t have health insurance compared with 21% of Blacks and 37% of Hispanics. Similar disparities occurred in adults who skipped care because of the costs and who didn’t have a primary doctor. Even flu and pneumonia vaccines were less likely to be taken by Blacks and Hispanics in Texas.
Taken together, Dunkelberg said, this is an example of structural or institutional racism in the practice of public policy.
“We have not prioritized having affordable health care for the working poor in Texas,” she said, and that harms more people of color.
“As a result, they’re more likely to die prematurely,” Dunkelberg said. “This is what racism looks like.”