Texas has the Highest Uninsured Rate in the Country—Why is that?

Texas is built on independence, hard work, and neighborly spirit. Health is part of that foundation. When Texans are healthy, families thrive and communities grow stronger. Yet many Texans remain uninsured, putting those values—and lives—at risk. The question isn’t who’s at fault, but how do we fix it, together?

The Reality

Texas has the highest uninsured rate in the nation. Among working-age adults, more than one in five Texans lacks health coverage. Texas children are uninsured at roughly twice the national average. And in rural areas, hospitals are shutting their doors faster than anywhere else—Texas leads the nation in rural hospital closures.

When people lack insurance, the ripple effects hit everyone. Uninsured Texans are more likely to skip medications, delay check-ups, and face medical debt. And when people without insurance can’t pay their hospital bills, those costs get passed on to everyone else through higher taxes, medical fees, and insurance premiums. When your community has weak health access, that’s not just a personal burden—it affects everyone. 

Why So Many Texans Are Uninsured

Let’s pull back the curtain. There’s no single villain here. It’s more like a clutter of small obstacles blocking the door to coverage.

Premiums and deductibles have gone up faster than wages, especially for small business and gig-economy workers. Many low-income adults fall into what’s called the “coverage gap”—too poor for marketplace subsidies, but ineligible for Medicaid. Eligibility rules for adults are also among the strictest in the nation, meaning most non-disabled Texans without children can’t qualify at all.

Workplace coverage adds another layer of difficulty. Many Texans work in small firms, part-time jobs, or industries less likely to offer affordable employer health plans. So coverage isn’t just about income—it’s also about job structure and access to employer benefits.

Even for those who could get help, the system is notoriously complex. Some eligible Texans don’t realize they qualify for low-cost or no-cost coverage. Others face language barriers, digital divides, or get lost in a maze of overlapping programs, deadlines, and confusing rules. It’s like climbing a ladder that keeps moving while you’re on it.

Sometimes, the system simply fails. When the federal pandemic rule protecting Medicaid coverage ended in 2023, Texas began rechecking eligibility for millions of residents—a process known as “Medicaid unwinding.” The goal was to remove people who no longer qualified, but confusing paperwork, long wait times, and system errors caused many eligible Texans, including children and people with disabilities, to lose coverage by mistake. As a result, hundreds of thousands were left uninsured, often with no warning or clear way to fix it.

And then there’s the rural challenge. People are more likely to get insured when they have a nearby clinic or hospital that helps with enrollment and preventive care. But with many rural hospitals in Texas closing or on the brink, coverage and care become harder for everyone.

The Impact on Real Texans

Behind every number is a neighbor. 

Take Royce Reed, a former Houston postal worker living with diabetes. When he lost his job-based health insurance, he also lost access to the care that kept his condition under control. He was only permitted a hospital bed after a small foot ulcer had spiraled into a severe infection requiring repeated surgeries and months-long hospital stays.

Or take Amelia Whites, who has six heart defects, cerebral palsy, and autism. She was only three years old when she suddenly lost the coverage that kept her alive—all because of a bureaucratic error during Texas’s “unwinding” process. This forced her family to rely on donations just to keep her stable.

These horrific stories show how easily a gap in coverage can turn a manageable condition into a medical crisis.

An Invitation to Build

Here’s the hopeful part: this isn’t a force of nature—it’s the product of policy choices, and that means it’s fixable. Lowering the uninsured rate doesn’t have to be partisan. It’s about protecting the people and places that make Texas work, from the mail carrier with diabetes to the child with heart defects. 

The fix starts not in Washington, but by asking curious questions right here in Texas: What would a uniquely Texan approach to healthcare look like? How can we make care affordable without sacrificing independence? Where can business, government, and local leaders partner rather than compete? 

This isn’t about left or right. It’s about working side by side to build a state where no one’s health depends on their luck, their zip code, or the fine print of their coverage.

—Alex Buscemi (abuscemi@buildersmovement.org)