The Affordable Care Act (ACA) gives states two key choices: Whether to expand Medicaid to cover poor uninsured adults; and whether to establish a state Exchange. No population stands to gain more from these choices than residents of Texas, who experience the nation’s highest uninsured rate. National estimates show that by not expanding Medicaid, the state has foregone coverage for 1.5 million people. County‐level estimates show that in 249 out of 254 counties, the proportion of uninsured adults exceeds 20 percent of the total adult county population. In 31 counties, the proportion of low income uninsured adults exceeds 60 percent of all low income adult county residents. Because Texas has chosen not to establish a state Exchange, its residents are vulnerable to a decision by the United States Supreme Court in King v Burwell that strikes down premium subsidies in states such as Texas, whose elected leaders have decided to rely on the federal Exchange. Should the Court eliminate subsidies in federal Exchange states, an estimated 1 million residents could face the immediate loss of affordable health insurance. County‐level estimates show that in 56 counties, 1 in 25 residents or more could be left without access to affordable coverage. The combined effects of not expanding Medicaid and the potential impact of King v Burwell will hit Texas’ health care system hard. County‐level estimates show that prior to implementation of the ACA, 38 counties experienced hospital annual uncompensated care levels of 50millionorgreater,and4countiesshowedlossesgreaterthan200 million. Texas’ failure to adopt the Medicaid expansion, coupled with the loss of premium subsidies as a result of a decision against the government in King would reverse the progress that has been made in reducing the number of uninsured Texans. Furthermore, hospitals could find that the demand for charity care actually rises, as thousands of previously‐insured people with serious health conditions turn to their hospitals for help. A landmark research study presented to the United States Supreme Court in King by public health Deans and the American Public Health Association documents the relationship between increased health insurance and reduced adult mortality. This research shows that for every 830 adults who gains health insurance, one fewer adult will die annually from preventable causes. This means that of the more than 2 million people potentially adversely affected by Texas’ decisions not to expand Medicaid and to rely on the federal Exchange, approximately 2400 Texans could die annually from preventable causes, with thousands more unable to manage serious health condition
