At Lyons & Lyons, we hear every day from Texans harmed by poor access to healthcare. The system was already struggling to meet needs, especially in rural areas. Now, new challenges, including cuts in healthcare reimbursement, the looming expiration of ACA subsidies, and Texas’ ongoing refusal to expand Medicaid, are combining into what can only be described as a perfect storm for further reduced healthcare access in Texas.
Worst Access in the Nation, Even Before the Cuts
Texas has long been at or near the bottom in national health system rankings. The Commonwealth Fund ranks Texas 48th overall in healthcare system performance, citing especially poor access and equity.¹ Nearly one in five Texans is uninsured, the highest rate in the country.² In 2022, more than 18% of adults had no coverage. That’s about one million Texans stuck in the Medicaid 'coverage gap,' who earn too much to qualify for Medicaid but too little to afford private insurance.²
Rural Texas, especially, is in crisis: the state ranks 47th for primary-care physicians and 49th for mental health access.³ More than two dozen rural hospitals have closed since 2010, with many more on the brink. Communities across Texas already struggle to find basic services like obstetrics, pediatrics, and behavioral health care.
Shrinking Reimbursements, Growing Strain
Doctors and hospitals are under ever increasing financial pressure. As one Texas gastroenterologist astutely put it:
“It seems legislation is always favoring the big players and leaving behind physicians and patients. Year after year reimbursements go down. I can’t think of anyone representing physicians on the national level who is making a meaningful impact right now.”⁴
Federal reimbursement reductions always hit smaller and independent providers hardest. Further cuts will just make it worse. Cuts to Medicaid and other programs in 2024–2025, combined with expiring ACA tax credits at the end of 2025, mean Texas hospitals and providers could lose more than $32 billion in revenue in 2026.⁵
Without those supports, uncompensated care will surge by over 25% in some southern states. For Texas, already home to nearly half of the nation’s patients in the uninsured coverage gap, the blow promises to be severe.
Why This Matters for Everyone
It is tempting to think these changes only harm the uninsured. That is flat wrong.
• Uninsured Texans already delay care until they are acutely ill, forcing hospitals and taxpayers to shoulder the most expensive forms of care.⁶
• Doctors and nurses are being driven out of independent practice or rural service because reimbursement cannot keep pace with costs. Independent practices and rural facilities are already merging or consolidating with larger urban systems, or simply shuttering, in preparation for decreased reimbursement.⁴
• Insured Texans also lose because when hospitals and clinics close, everyone’s access disappears. Emergency rooms fill, wait times grow, and costs rise.
The Perfect Storm
Texas was already in last place in providing affordable, equitable healthcare. Now, with shrinking reimbursements, expiring subsidies, and the continued refusal to expand Medicaid, the state is barreling into a crisis that will destabilize the entire system.
The result will be:
- More uninsured Texans left without care.
- More physicians and hospitals forced to close or consolidate.
- More disruption for insured and uninsured alike as the system grows more fractured and fragile.
Bottom Line
This perfect storm will not just hurt the most vulnerable. It will impact all Texans. As healthcare access diminishes, the uninsured suffer first, but insured families, healthcare workers, and whole communities suffer right alongside them.
It is time for all Texans to speak up! Policymakers working to reverse the cuts to Medicaid, extend ACA subsidies, and adopt Medicaid expansion in Texas, are working for all of us!
Sources
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Commonwealth Fund, 2023 Scorecard on State Health System Performance (Texas ranked 48th). Available at: https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance
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Texas 2036, Who Are the Uninsured? (Dec 2023). See also U.S. Census Bureau ACS Health Insurance Coverage Data; Houston Chronicle – “Texas health care system is among worst in the US. Here’s why only Mississippi is worse” (June 2025).
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U.S. News, Best States Healthcare Rankings (Texas ranked 29th overall, with especially low access and mental health scores). https://www.usnews.com/news/best-states/texas
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Gregory Brennan, MD, quoted in Becker’s ASC Review. Available at: https://www.beckersasc.com/leadership/whats-worrying-physicians-about-the-future-of-medicine/?origin=ASCE&utm_source=ASCE&utm_medium=email&utm_content=newsletter&oly_enc_id=8318G0416178J2C
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Urban Institute, Analysis of ACA Premium Tax Credit Expiration (2023; estimated $32.1B revenue loss by 2026).
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Texas 2036 – Who Are the Uninsured? (Dec 2023), demonstrating overuse of ER for routine care due to lack of coverage.
