Sources: Texas County Estimates
Why are these called “Rough Estimates”? Census estimates are less reliable for Texas’ smaller counties, even when the number of people surveyed is designed to provide reliable estimates for metro areas. Also, estimates of the Texans in the Coverage Gap (those left with no Medicaid eligibility and no Marketplace premium subsidy help) involve modeling (well-educated guesses) to remove ineligible non-citizens from the data. Where there is more than one source of a county estimate, we have provided both to underscore that these are best estimates.
Medicaid Expansion Group: CPPP starts with the U.S. Census American Community Survey (ACS) statewide estimate of total uninsured in Texas. To adjust for individuals who would be ineligible for Medicaid coverage after expansion because of income, age or immigration status, this statewide estimate is reduced, based on the Kaiser Family Foundation’s (KFF) statewide estimate of the proportion of non-elderly adults (ages 18-64) below 138% FPL who are uninsured and who would qualify for expanded Medicaid (29.7%). KFF bases its estimate on the US Census, Current Population Survey (CPS) for 2014. (See Henry J. Kaiser Family Foundation, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update; January 2016.) Finally, CPPP uses the most recent US Census Small Area Health insurance Estimates (SAHIE) county distribution estimates of uninsured Texans ages 18-64 <138% FPL to model distribution of the reduced statewide estimate across counties.
Coverage Gap Group, a subset of the Medicaid Expansion Group: For this model estimate, a range is provided. For the lower range, CPPP starts with the county estimates resulting from the methodology described above, and proportionally reduces estimates to reflect the Kaiser Family Foundation’s estimate that statewide, 58.3 percent of all uninsured adult Texans below 138% FPL are below poverty (<100% FPL) and in the Coverage Gap. For the higher range, CPPP begins with the Kaiser Family Foundation’s (KFF) statewide estimate of uninsured non-elderly adults below 138% FPL who would qualify for expanded Medicaid, based on data from U.S. Census, 2014 Current Population Survey (CPS). This estimate is distributed to the county level using the county distribution estimates of the SAHIE, and then proportionally reduced to reflect the share living below poverty and in the Coverage Gap.
This method produces rough estimates, and will be less precise for smaller-population counties. To underscore this lack of precision, we have provided a range reflecting the Census CPS and Census ACS-based estimates of uninsured adults below 100% FPL in Texas counties.
Economic Impacts :
Costs your County Could Reduce: Spending on Hospital Charity, City/County Unreimbursed Health Care--Hamilton: Billy Hamilton Consulting, Texas Impact, and Methodist Healthcare Ministries of South Texas, Smart, Affordable and Fair: Why Texas Should Extend Medicaid Coverage to Low-Income Adults , January 2013. Sums the 2011 Hospital District or City/County Unreimbursed Health Care Expenditures and 2010 Total Hospital Charity Care Costs collected by the researchers. New Medicaid Revenues would reduce these costs.
What accounts for the differences between these dollar-impact estimates? A key difference between the Hamilton and HHSC-based estimates is that the latter assumes new Medicaid funds are distributed across the counties proportional to where Texas Medicaid spending has been historically. This method reflects the extent to which Texans in Medicaid get health care away from their home county. The Hamilton estimate builds on a county enrollment model commissioned by Methodist Healthcare Ministries and developed by Rice University’s Dr. Michael Cline and Dr. Steve Murdock that adjusts for incomes, immigrant populations, and other factors. This model may better capture counties likely to have especially high or low coverage gains under Medicaid Expansion.
Annual New Federal Health Care Spending, Average 2014-2017--Hamilton: Billy Hamilton Consulting, Texas Impact, and Methodist Healthcare Ministries of South Texas, Smart, Affordable and Fair: Why Texas Should Extend Medicaid Coverage to Low-Income Adults , January 2013.
Annual New Federal Health Care Spending, Average 2014-2017--HHSC: Texas Medicaid’s (HHSC) estimate of state-dollar General Revenue (GR) Medicaid costs to cover these new adults is $1.3 billion GR for the first 4 years, drawing another $23.9 billion in federal match. Texas would spend an average of $784 million a year, drawing over $6.8 billion federal match (for a net gain over $6 billion/year). CPPP distributes HHSC’s average annual estimate across Texas counties in the same proportions as HHSC’s reported 2010 distribution of total Medicaid spending by county.
New Jobs--Perryman: Estimated yearly average over first 10 years of Medicaid Expansion, 2014-2023. The Perryman Group, Only One Rational Choice: Texas Should Participate in Medicaid Expansion Under the Affordable Care Act: Effects on Regions, Local Areas, and Legislative Districts , February 2013.