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How to Get Half a Million More Texans to Embrace Obamacare? Show Them the Money

October 13, 2022

Here’s something that’s usually not bigger in Texas: growth in Obamacare.

For years, Texas has been a laggard in signing up residents on, despite leading the nation in the number of uninsured. In 2020, just 30% of Texans eligible for subsidized coverage signed up, far less than the share of eligibles who enrolled nationwide.

But for 2022, the state posted a gain of nearly 550,000 enrollees on the health exchange. That was a one-year increase of 42% — the biggest in the country and twice the average gain for all states, according to the Centers for Medicare and Medicaid Services.

Enrollment rose across the board in Texas: in all age groups, among men and women, and in every income bracket.

Enrollment has been climbing since the pandemic, and the momentum got a big push from the Biden administration, which approved billions in expanded subsidies to make coverage more affordable.

For 2019, fewer than 1.1 million Texans enrolled in Obamacare, the lowest total since the second full year of the Affordable Care Act. That number grew to 1.29 million for 2021 and to over 1.84 million for 2022 — easily the largest total for the state.

The peak may be topped soon. Open enrollment for 2023 begins Nov. 1 and runs through Jan. 15. Community leaders are gearing up for another big season.

“Nearly all the people who do not enroll in a plan [say] it’s because they think they can’t afford it,” said Daniel Bouton, senior director of family and community health at United Way of Metropolitan Dallas.

That may have been the case in earlier years of Obamacare, but it’s a lot different now, he said.

After the pandemic, Congress approved billions in health-related relief, including higher tax credits for people buying on the exchange. The expanded subsidies the last two years eliminated or reduced premiums for millions of enrollees, and average annual savings topped $700 a person this year, the government said.

For 2022, 94% of Texans signing up on received subsidies for premiums. Over 60% got help with deductibles and co-pays.

For those getting a subsidy, the average premium was $60 a month, and nearly four in 10 Texas customers paid $10 or less after tax credits.

“Those subsidies — that’s reason No. 1″ for the surge in enrollment, Bouton said.

That bodes well for next month’s enrollment and beyond. In August, Congress passed a climate and health bill known as the Inflation Reduction Act, and it included $64 billion to keep the expanded subsidies through 2025.

The government expects to recoup those costs and more with several initiatives, such as allowing negotiations for certain drug prices.

If the extra support for subsidies had not been extended, many would have faced premium shock. They include 1.1 million consumers whose household income topped 400% of the family poverty level, which is $92,000 for a family of three.

Those higher earners were excluded from subsidies in the past; they’re eligible now if their health plan costs exceed 8.5% of income.

Insurers are raising rates on the exchange to keep up with inflation, and Bouton estimated that prices in North Texas are increasing about 7% to 10%.

Most enrollees will be protected by higher subsidies, he said. But do they realize it?

Getting the word out is a key part of the mission of navigators. They’re trained experts who help people evaluate and apply for plans on the exchange.

For 2019 enrollment, the Trump administration reduced funding to $10 million for the program, down from $63 million in 2016.

A year ago, the Biden administration increased the award to $80 million, quadrupling the number of navigators — and said the investment helped cut the nation’s uninsured rate to a new low. In late August, the government said it would invest nearly $99 million in navigator organizations for 2023 enrollment.

“We are doubling down on investing in community navigators who can help people find the coverage they need,” Chiquita Brooks-LaSure, administrator of the Centers for Medicare and Medicaid Services, said in a statement.

About $2.8 million is coming to the North Texas region this year, Bouton said, and United Way of Metropolitan Dallas is overseeing the grant money. It’s helping train navigators and groups that reach underserved communities.

Many Dallas residents face barriers to getting coverage, Bouton said, because they don’t know how to use or optimize subsidies or choose a plan for their pre-existing conditions.

“Navigators try to remove those barriers,” he said.

“We’re here to help; we’re not selling anything,” said Tikisa Jackson, director of community health at CitySquare, a Dallas nonprofit offering an array of social services. “We’re providing people with the knowledge to make the most informed decision for their families.”

CitySquare has six navigators and plans to hire another, she said, and they emphasize building trust. United Way also uses mobile offices to reach residents and assist them in completing documents.

North Texas has about 39 certified navigators helping people in 16 counties, Bouton said. He encourages residents who are unsure about coverage to call United Way or go to its website to fill out a form requesting free assistance.

Brokers and insurance companies also assist shoppers on, and there will be local health fairs to share information and boost enrollment.

The health law was unpopular in its early years, but support has been strong since 2017. That’s when Republicans tried to replace the law with a “skinny repeal,” and the late Sen. John McCain, R-Ariz., famously voted a thumbs down — keeping the Affordable Care Act in place.

In March, 55% of adults said they had a favorable opinion of the law compared with 42% holding an unfavorable view, according to the Kaiser Family Foundation health tracking poll.

Expanded subsidies and greater outreach should keep drawing more Texans to the exchange, in part because the potential pool is so large, said Stacey Pogue, senior policy analyst at Every Texan, an Austin advocacy group.

Texas has about 5 million uninsured, with about 2 million eligible for subsidies today.

That’s a rich opportunity to improve lives, Pogue said: “There’s a huge demand for coverage when it’s affordable — that’s the takeaway.”

, Business columnist. He covers a wide range of topics.