Why Texas is the worst state for health insurance in the country

A new analysis of data from the US Census Bureau has revealed two major reasons why Texas has the highest rate of residents without health insurance in America: The state's two largest cities, Dallas and Houston, are the least insured major metropolitan areas in the US.

The Census Bureau ranked the largest American cities based on the rates of uninsured residents. Houston and Dallas are first and second on the list, and San Antonio — the third-largest city in Texas — comes in fourth, behind Miami.

The Texas health system was put under the microscope in August after multiple reports showed that its maternal mortality rate has doubled in recent years. The current rate of 30 deaths per 100,000 live births is higher than the national average of 23 per 100,000, and worse than most industrialized countries.

The high rates of uninsured residents are linked to Texas' failure to expand Medicaid coverage as part of the Affordable Care Act, according to Census data. Since the bulk of the "Obamacare" law took effect in 2014, the rates of insured people are now higher in states that chose adopt the Medicaid expansion provision. Texas is one of 19 states that decided not to adopt that part of the bill, and it's hitting residents hard — especially in urban areas.

With a population of nearly 30 million people, expanding Medicaid in Texas would significantly impact insurance rates in the US. Failing to take on the policy, however, keeps millions of people in the Lone Star state living without insurance, creating a continued strain on the medical system and affecting public health. People without health insurance are more likely to resort to emergency rooms for basic care, and chronic conditions like diabetes often go untreated.

"The system is unsustainable," said Kristie Loescher, a healthcare policy expert at the University of Texas. "You're cutting off a vital aspect of productivity in your communities by having people who are having to deal with illness and things like that without care."

The low insurance rates in Texas reflect a nationwide trend. Across the country, uninsured rates are higher among lower income groups. In the case of Texas, the state's cities have the largest populations of people in poverty. Lack of health insurance is also an issue in the state's rural areas, where a shortage of healthcare providers is already a problem.

The insurance figures reported by individual cities tend to reflect state policies as a whole, according to Jennifer Cheeseman Day, the assistant chief of the Census Bureau's income, poverty, and health insurance division. In Texas, the main factor is medicaid.

In 2013, a total of 27 percent of Texans were not covered by health insurance, compared to 17 percent in 2015. Just across the border, uninsured rates in Arkansas have dropped by more than any state in the country after it expanded medicaid, from 22.5 percent in 2013 to less than 10 percent in 2015.

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