This document discusses health care policy issues in Texas, including: 1) Over 6 million Texans are uninsured, most of whom are working-age adults below 400% of the federal poverty level. Hispanics in Texas have particularly high uninsured rates. 2) If Texas expands Medicaid, over 1 million residents could gain coverage, bringing in an estimated $6 billion in new annual federal funds. This would significantly benefit large urban and South Texas counties. 3) Without expansion, about 1 million low-income Texans will remain in a "coverage gap" below the poverty line and ineligible for subsidies. Stakeholders will continue advocating for inclusion of these working poor.

1. Texas Health Care:
Current Action & Policy Issues
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Latino Policy Summit
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Anne Dunkelberg, Associate Director – dunkelberg@cppp.org
Center for Public Policy Priorities
Saturday, October 19, 2013
CPPP.org
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2. Most Uninsured Texans are WorkingAge Adults, 2011
81,000
3% of Texas Seniors
uninsured
65+
<2/3 are
below 200%
FPL
63% are below
200% FPL
6.1 million uninsured
Texans (23.8% of all ages)
0-18
1.2 million
Rate: 16.3% of 0-18
are uninsured
19-64
Compare to
Massachusetts:
219,000, just 3.4% of
all ages
4.8 million
Rate: 30.9% of 19-64
are Uninsured
Source: U.S. Census,
March 2012 CPS
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3. Texas Uninsured by Income 2011…
89% of the 6.1 million uninsured have incomes <400% FPL
>400% FPL
>$89,400
656K
300-400% FPL
$67,050-$89,400
501K
250-300% FPL
$55,875-$67,050
<100% FPL
<$22,350/yr for
family of four
1.912 Million
6.1 million includes 1.7
million non-US
citizens; ~2/3 of these
(about 1.1 million)
likely undocumented
421K
626K
614K
200-250% FPL
$44,700-$55,875
921K
100-125% FPL
$22,350-$27,938
525K
150-200% FPL
$33,525-$44,700
125-150% FPL
$27,938-$33,525
Annual income limits given for a family of four, 2011 federal poverty level
CPS
U.S. Census, 2012
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4. Figure 4
Hispanics have particularly high uninsured rates.
Insurance Coverage of Hispanics in the United States and Texas, 2011:
Employer/Other Private
Medicaid /Other Public
32%
30%
38%
25%
39%
37%
United States
Texas
Data may not total 100% due to rounding.
SOURCE: KCMU/ Urban Institute analysis of 2012 ASEC Supplement to the CPS.

5. Figure 5
Hispanics in Texas have particularly high stakes in the
Medicaid expansion decision.
Nonelderly Uninsured <138% FPL by Race/Ethnicity
United States
Texas
Black
17%
Hispanic
Hispanic
63%
35%
Black
11%
White
40%
Asian/
Pacific
Other
Islander
2%
5%
Total = 25.4 Million
NOTE: Totals may not sum to 100% due to rounding.
SOURCE: KCMU/Urban Institute analysis of 2011 American Community Survey
White
21%
Asian/
Other Pacific
1% Islander
3%
Total = 3.1 Million

6. ACA Coverage and Coverage Gap
>$94,200 for a
family of four;
>400% of FPL
Job-based coverage, or
Full-cost coverage in the exchange
Family Income
$70,650-$94,200;
300-400% of FPL
Job-based coverage, or
Subsidized exchange coverage: premiums capped at
9.5% of income
$47,100-$70,650;
200-300% of FPL
Job-based coverage, or
Subsidized exchange coverage: premiums capped at
6.3 – 9.5% of income
$31,322-$47,100;
133-200% of FPL
CHIP
<$31,322 for a
family of four;
< 133% FPL
• Job-based coverage, or
• Subsidized exchange
coverage: premiums capped
at 2% - 6.3% of income
Medicaid
Coverage Gap below
poverty line
($23,550 for family of four)
Children
Adults
(not eligible for Medicare or Medicaid today)
Family income based on 2013 federal poverty income levels for a family of four

7. The Texas Coverage Gap
• About 1 million U.S. citizen
adults < 100% FPL are
uninsured in Texas and will
have no coverage options.
• The average “coverage
gap” Texan works in frontline entry-level positions
such as:
– Retail trade
– Accommodation and food
services
– Healthcare and social
assistance, and
– Construction
6.1 million uninsured
Michael E. Cline, Ph.D., and Steve H. Murdock, Ph.D. , Rice University, Estimates
of the Impact of the Affordable Care Act on Counties in Texas, April 2012.

8. Texas Medicaid/CHIP: Who is Helped Today
CHIP,
591,756
January 2013, HHSC data
Disabled,
422,467
Elderly,
326,501
Poor Parents,
144,040
Medicaid
Children,
2,547,199
Total enrolled 1/1/2013:
3.6 million Medicaid;
TANF Parent,
83,772
Maternity
86,975
592,000 CHIP
1 in 7 Texans,
but 42% of Texas kids
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9. Status of State Action on the Medicaid Expansion
Decision, as of September 30, 2013
Source: KFF.org
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10. Large Urban Counties & Medicaid Expansion
2014-2017: Share of $6 billion new statewide annual federal
health care spending
El Paso
Dallas
Harris
Lubbock
Travis
$222
million
$580.1
million
$935.3 million
$77.7
million
$224.1
million
Uninsured
NOW
208,379
601,492
1,025,922
66,405
233,067
Estimated #
Gaining
Medicaid
51,462
131,042
223,165
19,693
55,676
Yearly Avg.
NEW Fed $
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC
historical Medicaid spending by county, 2010. Cline & Murdock estimates of
ACA insurance gains by county.
10

11. Largest South Texas Metro Counties & Medicaid
Expansion: 2014-2017 Share of $6 billion new statewide annual
federal health care spending
Bexar
Cameron
Hidalgo
Nueces
Webb
NEW Fed $
$ 503.5
million
$ 198.4
million
$ 404.7
million
$ 127.1
million
$92.0
million
Estimated
# Gaining
Medicaid
179,654
27,987
50,509
22,403
16,031
One-year
Avg.
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC
historical Medicaid spending by county, 2010. Cline & Murdock estimates of ACA
insurance gains by county.
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12. Who Is Eligible?
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13. Subsidies in the Marketplace
• Advanced Premium Tax Credits
– Individuals and families b/w 100 and 400% of
poverty (FPL)
– Sliding scale relative to income
– Must be used to purchase inside the
Marketplace
– Can be paid directly to insurer, so you only owe
the balance as a monthly premium
• Cost-Sharing Reductions
– Individuals and families b/w 100 and 250% FPL
– Lower deductibles and copays
– Must select a silver-level plan to qualify
Family
Size
Annual income range –
premium credits
1
$11,490-$45,960
2
$15,510-$62,040
3
$19,530-$78,120
4
$23,550-$94,200
Family
Size
Annual income range –
cost sharing reductions
1
$11,490-$28,725
2
$15,510-$38,775
3
$19,530-$48,825
4
$23,550-$58,875
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14. Coverage Level Options in the
Marketplace
Essential Health Benefits
ambulatory services;
2. emergency services;
3. hospitalization;
4. maternity and newborn
care;
5. mental health and
substance use disorder
services;
6. prescription drugs;
7. rehabilitative and
habilitative services and
devices;
8. laboratory services;
9. preventive and wellness
services and chronic
disease management
10. pediatric services dental
and vision care
1.
% paid by
enrollee
% covered by plan
Platinum
Gold
90%
80%
Silver
70%
Bronze 60%
0%
20%
40%
60%
10%
20%
30%
40%
80%
100%
Catastrophic plan for people under 30; or if no other
coverage is affordable
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15. In-person Assistance to Enroll in
Marketplace
In-person assistance:
• Agents/Brokers
• Navigators
• Certified Application
Counselors (CAC)
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16. Get Involved, Stay informed!
Unless our leaders take action , on January 1, 2014:
• an uninsured parent with two children living on $18,000 will have NO
help from ACA for health coverage, but
• another uninsured parent with 2 children earning $20,000 a year will
qualify for full coverage on a sliding scale for $33 a month or less.
A Diverse network of Texans and Texas organizations will keep working
to find health care for the Texans in the “Gap Group,” to tell their
stories, and to seek inclusion of Texas’ working poor in the ACA’s
health reform.
www.cppp.org You can link to all the websites below from our CPPP
website:
www.covertexasnow.org; www.TexasLeftMeOut.org
www.texaswellandhealthy.org
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17. FAMILY BUDGETS
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18. Figure 18
The Texas Medicaid expansion decision has important
impacts for the overall uninsured and Hispanics
nationally.
Distribution of Total Uninsured <138% FPL
Distribution of Uninsured Hispanics ≤138%
FPL
CA
15%
CA
26%
TX
12%
FL
9%
Other
States
49%
GA
5%
NY
IL4%
NC
4%
4%
Total : 25.4 Million
NOTE: Totals may not sum to 100% due to rounding.
SOURCE: KCMU/Urban Institute analysis of 2011 American Community Survey
TX
22%
Other
States
43%
FL
9%
Total: 8.9 Million