Dallas County has the highest rate of uninsured people in North Texas. Why?

Dallas County has the highest uninsured rate among large counties in Texas, as well as major counties in the DFW region. More than 1 in 5 people in the county lack insurance to help cover medical costs.

And insurance coverage throughout the state may get even worse as Medicaid recipients are required to re-enroll for the first time in years.

Federal changes to public health insurance programs during the COVID-19 pandemic increased the percentage of people with health insurance coverage. Now, a massive effort to reassess who qualifies for the Medicaid program is moving hundreds of thousands off of the rolls, although private insurance sold through the Affordable Care Act may be low cost or free for many people due to expanded subsidies.

Texas is notorious for having the highest uninsured rate in the nation – 18% – and refusing to expand Medicaid under the Affordable Care Act. That choice leaves millions uncovered, or wondering what’s next.

Why having insurance matters

LaShundra Randall would like to be able to afford health insurance and see doctors of her own choosing. Randall has sickle cell anemia, which requires regular blood transfusions.

“If I don’t get a blood transfusion, that can be bad for me,” she said.

Randall waits several hours at Parkland Hospital, the public hospital in Dallas, to get transfusions at very low cost to her. Having insurance, she said, would shorten her wait time and also allow her to pick her own doctor.

Randall is one of the approximately 550,000 residents of Dallas County who are uninsured. Her two kids are both enrolled in Medicaid, a health insurance program funded by the federal and state governments. But as a working adult, she is one of the millions of low-income Texans who have very little chance of qualifying for public health insurance.

Randall, an employee with the American Airlines subcontractor Prospect Airport Services, is an escort for unaccompanied minors at DFW Airport. She is trying to form a union with her coworkers. Randall’s job caring for child travelers during their layovers pays $14 an hour.

“They offer insurance. The only thing is, it’s expensive,” she told KERA. “You can’t get that insurance – especially with how much we make an hour.”

Anne Dunkelberg, a senior fellow at the left-leaning policy group Every Texan, said that while insurance alone doesn’t make an individual person healthier, the insured are “substantially healthier and substantially more likely to get preventative care,” like immunizations, as well as care when they’re sick or injured.

The most uninsured

Among Texas’ 254 counties, there’s a wide range of uninsured rates, from low single digits to over 30%. So why does Dallas stand out among its peer counties and neighbors?

Dallas County’s uninsured rate, 21.4%, is slightly above Harris County’s 21.1% and well above Tarrant County’s 16.8%. North Texas counties Collin (10.6%) and Denton (10.9%) have much lower uninsured rates.

Comparisons with Tarrant County — also one of Texas’ largest, and home to one of the biggest cities in the country – are helpful but doesn’t completely answer the question.

“There’s not going to be a slam dunk answer to that,” said Dunkelberg.

Income and poverty

One potential explanation is Dallas County’s lower median income compared to Tarrant County ($65,011 versus $73,545), as well as its higher rate of poverty compared to Tarrant County.

“Income is the single most potent predictor of whether somebody’s going to be insured in the United States,” said Dunkelberg.

Another strong predictor is poverty, she said.

Collin and Denton Counties, as more affluent communities with a significant number of commuters, are more likely to have residents obtain insurance through their jobs.

A common misconception, Dunkelberg said, is that Medicaid is an option for poor, working adults.

“We have much more generous Medicaid for children than we do for parents,” Dunkelberg said. “And then if you don’t have any dependent children, then there is no way for you to get Medicaid in Texas unless you are fully disabled or over 65 and in poverty.”

Immigrant populations

Both Dallas County and Harris County have much higher percentages of foreign-born residents, at 24.5% and 26.2%, than Bexar at 13.1% or Tarrant at 16.3%. Many foreign-born residents are U.S. citizens but may have family who is not.

The think tank Texas 2036 is studying the uninsured population in the state to learn why people go without insurance. They found that immigration status was one reason people chose not to enroll.

“There are concerns among many Hispanic families that, if they sign up for one of these plans, if there’s anyone in their family who is here undocumented, that that might subject them to scrutiny,” said Charles Miller, a senior policy advisor at the group.

Dunkelberg said the fear factor ramped up during the Trump Administration, which proposed rules restricting immigration or public benefits for the undocumented.

“It can take years to overcome that in the community,” she said.

Public hospitals in Dallas and Tarrant Counties treat undocumented patients differently. Parkland Health in Dallas provides charity care for undocumented people, while Tarrant County commissioners block the JPS Health Network from doing the same.

Age

Dallas County is relatively younger than peer counties Tarrant and Bexar, which also may affect its uninsured rate.

“You’ve got a younger population that’s not eligible for Medicare,” said Stephen Love of the Dallas Fort Worth Hospital Council.

Generally, less than 5% of people over 65 years old are uninsured.

American Community Survey data that excludes the over-65 population shows a narrowing of the gap between Dallas and Tarrant Counties when it comes to the percent uninsured. Dallas County’s population under 65 was 22.5% uninsured. In Tarrant County, 19.7% were uninsured.

Outreach and information

Experts said the visibility and effectiveness of groups who enroll people in insurance can also make a difference in the uninsured rate, although it’s difficult to quantify and compare across counties.

Miller said people often do not know they are eligible for very low-cost insurance, even though they believe they have all of the information.

“If there are local groups who have been going out and really working to sign people up, that can make a difference,” he said.

Dunkelberg said that while Dallas and Harris County have strong community partnerships, in Bexar County the groups are particularly visible.

“I think if you’re in Bexar County, as long as you’re not undocumented, you’re going to be presented with lots of opportunities to sign up,” she said.

Dallas County’s Health and Human Services Department did not make anyone available for an interview.

Health care facilities like hospitals are sparser in the southern sector of Dallas County than in the northern half, a fact detailed in the latest version of the county’s Community Health Needs Assessment.

The hospital council’s Love acknowledged the disparity and said, “we’re doing everything we can to see what we can do to drive health equity throughout North Texas.”

How will the insurance rate change?

As the pandemic-era public health emergency expires – and people are forced to reapply for Medicaid for the first time in years – hundreds of thousands of Texans could lose their health insurance.

An analysis by two professors at Texas A&M University estimated more than 55,000 people in Dallas County would lose insurance. More than 50,000 Tarrant County residents would lose insurance, followed by about 18,000 in Collin and 15,000 in Denton County.

Miller said it’s unclear how this change will affect the state’s uninsured rate, because many of the people leaving the Medicaid rolls may obtain coverage elsewhere.

What’s clearer, he said, is that many of the roughly 5 million uninsured people in Texas currently qualify for free or low-cost insurance on the healthcare.gov marketplace. That’s due to more generous subsidies passed by Congress and President Joe Biden.

“If you’re making below 150% and above 100%” of the federal poverty level for your family size, insurance is “basically free to you,” Miller said. “If you look at our overall enrollment numbers of the ACA marketplace, about half of the enrolled population is in that [income] bucket.”

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