Texas continues to hold the unwelcome title of the most “uninsured” state in the country, according to a new report by the Commonwealth Fund, a non-profit organization.
The report ranks the Lone Star State dead last for health insurance coverage and second-worst overall in healthcare “system performance.”
The study found that 22% of working-age Texans had no health insurance as recently as 2023, the highest rate in the United States. Despite some small boosts to those numbers after the rollout of the Affordable Care Act (ACA) in 2013, which helped reduce the state’s uninsured rate by about eight percentage points, nearly one in five Texans still lack any healthcare coverage.
According to the study, one significant reason behind the stubbornly high uninsured rate is Texas’ ongoing complications surrounding the expansion of Medicaid under the ACA, a move that 40 states have adopted, as well as the District of Columbia. As of 2025, Texas is now one of just 10 states still opting out.
Yet, opponents of the act could argue that the ACA represents an over-expansion of federal power into the healthcare industry. By mandating individual coverage and heavily regulating insurance providers, the ACA could be seen as undermining free-market competition, leading to higher premiums and fewer choices for consumers.
Regardless, the lack of access to health insurance carries significant consequences.
Nearly 18% of Texans reported skipping needed medical care last year due to concerns about cost, which is also the highest rate of “delayed care” data in the country.
Despite these grim statistics, the report also highlighted some silver linings in the Lone Star State’s healthcare system.
For example, Texas ranks 11th in the nation for childhood vaccination rates, with more than 70% of children receiving all recommended immunizations as of 2023. A number that stands out considering recent public health challenges, including one of the largest measles outbreaks in recent American history, as previously covered by The Dallas Express.