More Texans than ever before enrolled in ACA health plans in 2024, feds say

Medical assistant Alesia Bolden checks Nereyda Penaloza's vital signs during a visit to Women's Services at CommUnityCare, a federally qualified health center, Feb. 25, 2013, in Austin. (Tamir Kalifa/The Texas Tribune, Tamir Kalifa/The Texas Tribune)

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More Texans than ever have signed up for cheap or free health care coverage through the Affordable Care Act, with more than 1 in 9 residents covered under government-subsidized health plans for 2024, according to federal health data released on Wednesday.

In a state that has the highest number of uninsured residents in the nation, public health advocates say it’s an encouraging trend that the number of Texas enrollees in ACA programs climbed by 37% to nearly 3.5 million over last year’s figures.

Texas enrollment in ACA plans has more than doubled since 2020 and is among the states with the highest rate of enrollment growth for the last three years. The plans were first made available in 2014 and designed to offer more health insurance options for those individuals whose income was not low enough for Medicaid insurance but who could not access insurance through their workplaces.

“This is a huge success,” Karla Martinez, a senior policy analyst at Every Texan, a left-leaning policy group, said in a prepared statement.

National enrollment hit record highs as well, with more than 16.3 million people signed up for the plans, according to the federal Centers for Medicare and Medicaid Services, also known as CMS. Nationally, the number of Americans signing up for ACA plans has doubled since it was launched in 2014.

“We’ve made record-breaking progress in expanding coverage and lowering health care costs for American families, saving them money and giving more Americans the peace of mind that comes with affordable health insurance,” President Joe Biden said in a statement on Wednesday.

State health care policy watchers attribute part of the large rise in Texas ACA signups to the release of some close to 2 million Texans from the Medicaid rolls — part of a nationwide effort to return the bloated program to normal levels in the wake of pandemic-era restrictions.

Nationally, about 2.4 million ACA enrollees were in Medicaid or Children’s Health Insurance Programs previously, according to CMS.

Advocates say the increase is also likely due to efforts by state and federal lawmakers to increase affordability, outreach and enrollment through a well-functioning federal marketplace administered through the website.

According to Biden’s statement, about 4 out of 5 people searching for an ACA health insurance plan found it for $10 a month or less.

“The clear takeaway is that Texans want coverage that is affordable, and comprehensive, and when you make sure they have that — and it's easy to know about, and it's easy to get signed up — they sign up in droves,” said Stacey Pogue, a health care policy analyst at Every Texan, a progressive think tank in Austin.

According to the federal government, Texans have saved an average of $560 on the annual health care premiums they pay for ACA marketplace insurance coverage. That savings came to them, according to the White House, because of federal tax dollars spent on health care subsidies and premium tax credits via the 2021 American Rescue Plan Act and the 2022 Inflation Reduction Act.

“We’re thrilled to see the federal government’s investment is paying off, with millions of people across Texas and the nation now getting the insurance they need to stay healthy,” Martinez, of Every Texan, said. “Clearly our elected officials can improve access to affordable health care when they make it a priority.”

In 2021, state lawmakers from both political parties unanimously supported efforts to boost the impact of federal subsidies and make some insurance plans in the marketplace more affordable.

“Importantly, it showed that the Texas Legislature is interested in and can work together on innovative solutions to our persistently high uninsured rate,” said Charles Miller, a senior policy advisor for the advocacy group, Texas 2036.

Currently, Texas leads the nation in the number of uninsured residents with nearly 5 million people living here without health insurance coverage, nearly double the national average.

And although public health advocates and policy watchers can often agree that there is no single solution for the problem of the high uninsured rate, they differ on how to attack it.

For more than a decade, progressive public health advocates, as well as lawmakers from both sides of the political aisle, have pushed for Texas to expand access to Medicaid beyond adults with disabilities and children. They believe the move could cover about 800,000 more Texans whose income is too low to qualify for the ACA marketplace but too high to receive Medicaid.

Opponents argue that the current Medicaid system is already broken and shouldn’t be expanded. They insist that federal entitlement programs don’t deliver the best care and that solutions should be expanded beyond Medicaid.

The emphasis, they say, should be on creating jobs with workplace plans, finding innovative ways to cover Texans, creating a state marketplace health exchange to replace the state’s reliance on, incentivizing prevention to reduce the need for serious care, and overhauling the current system to bring health care costs down.

Many uninsured Texans have middle-class incomes and don’t qualify for Medicaid, while for others who are qualified but not enrolled, advocates say, one problem may simply be access and awareness.

Streamlining the process of enrolling in Medicaid for those who do qualify, so it’s not as complicated as it is today, would help boost enrollment numbers tremendously, Pogue said.

A 2022 study by Texas 2036 showed that between 2.7 and 3.5 million uninsured Texans were eligible for free or subsidized health coverage through existing ACA subsidies, Medicaid or the Children’s Health Insurance Program (CHIP) but were not enrolled.

The theories on why that is vary, but include a lack of awareness, an inability to afford even the ACA plans, lack of access to resources that can help with the complicated enrollment process — or few opportunities to go through the cumbersome, time-consuming process — and mistrust in government health care.

A state-run health care marketplace exchange could help Texas streamline the enrollment process, attracting people who may be mistrustful of the Affordable Care Act (also known as Obamacare), supporters say.

As of 2024, 18 states — including Kentucky, California, and Idaho — and the District of Columbia are operating their own exchanges, covering about 4.9 million people for the next year.

Operating a state-based marketplace could allow Texas to streamline the enrollment process and rebrand it for those who may not trust a system run by the federal government.

“Some approaches to reducing Texas’ uninsured rate only become possible if Texas builds and operates a state exchange,” said Miller. “Creating a state exchange would not only provide administrative flexibility for Texas to implement tailored solutions, but it would also provide a revenue stream to pay for such policies and efforts.” The key to its success, he said, would be in the details.

“While we think a state exchange has a lot of potential, in fairness, there are risks if it isn't set up properly,” he said. “It's important not just to do it, but to do it right.”

An effort to do this during the last legislative session never made it past a committee hearing, where opponents argued, among other things, that the idea was unnecessary.

The federal marketplace is clearly working well — given the enrollment successes — and so the time and energy it would take to build an entirely new system should be put toward other solutions that complement the impact of ACA and improve overall coverage rates, Pogue told The Texas Tribune.

That would include not just expanding Medicaid but other creative approaches large and small, such as better communicating to immigrants that applying for health coverage for their children doesn't endanger their legal status, she said.

“The question isn’t, ‘Which level of government should run it?’” Pogue said. “It’s, ‘What do you want to do? What’s the goal?’ ”

Disclosure: Every Texan and Texas 2036 have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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