Visits to Texas emergency rooms for avoidable reasons improved in 2021. Adults reported better health compared to 2019. Texas drug deaths, though higher than in years past, remained below the national average.
But the state’s health care quality — and access — worsened for women, communities of color and low-income Texans. Childbirth complications increased and fewer children had a pediatrician’s office to call their own.
By many metrics in an annual scorecard compiled by a nonprofit health research foundation, Texas is barely moving the needle. That’s a bad place to be when the needle is sitting at 48th out of 50 states and the District of Columbia.
The Commonwealth Fund’s annual scorecard of state health systems, released last week, ranked the states based on seven broad health categories that address affordability, preventive care and racial disparities. The nonprofit research foundation’s 2023 report also included data specific to women’s and reproductive health for the first time.
Texas’ showing was more varied across the categories, though the state never managed to crack the top half of the ranking. It fared best in the healthy lives section, coming in at 29th overall and second among four southwestern states. The section measured deaths from drugs, alcohol and suicide as well as metrics on smoking and obesity.
In income disparity, Texas ranked 45th. In prevention and treatment of disease, 48th. In reproductive and women’s health, 49th — beating out only Mississippi and West Virginia.
Texas ranked dead last in access and affordability, an unsurprising result given that the state consistently reports the highest percentage of uninsured residents of anywhere in the U.S.
The data reflect people’s lived experiences, said Amy Raines-Milenkov, associate professor of public health in the department of pediatrics and women’s health at the University of North Texas Health Science Center at Fort Worth.
“I think of a friend who was trying to get care and going to [federally qualified health centers], which offer great services, but she made just a little too much for that. Her job doesn’t offer her benefits. People are just stuck, and they’re suffering,” Raines-Milenkov said.
The scorecard paints a dark portrait of health care in Texas, especially for Black and brown communities, and low-income Texans. Though not included in this report, abortion bans and the future of women’s health shroud the discussion of well-being in Texas, especially with the recent one-year anniversary of the Supreme Court’s overturning of Roe v. Wade.
A majority of Texas health indicators saw no change or worsened between 2019 and 2021, the most recent full year of data that Commonwealth Fund used for its rankings. Of the nearly 50 indicators with comparable trend data, 17 improved, 12 worsened and 20 remained about the same.
Here’s where Texas’ health landscape advanced, where it didn’t and what researchers say can still be done to right the course of future health care access.
Where care is bad
The COVID-19 pandemic played a large role in worsening metrics not only in Texas, but across the country.
“By now we know the ways COVID-19 reverberated across all aspects of state health systems, and we still see its effect in this report,” said Jesse Baumgartner, senior research associate at The Commonwealth Fund. “We found large increases in deaths early in life from preventable and treatable causes in all states.”
Once again, Texas stood out: Rates of avoidable deaths surged more than 35% here and in Louisiana, Mississippi and New Mexico. Arizona experienced the steepest rate increase, with a 45% hike in avoidable deaths between 2019 and 2021.
The percentage of people accessing routine health care declined across a number of categories. About 43% of Texas adults did not go to the dentist in 2020, up from 40% in 2018. More than a quarter of adults reported not having a usual source of care in 2021, while only 17% of adults across the U.S. reported the same.
Nearly half of Texas children had no primary care physician in 2018 and 2019, compared to only 40% of children in 2020 and 2021.
Regular doctor visits declined during the early months of the pandemic, creating alarm over missed diagnoses often caught during routine screenings. Doctor visits are largely back to their pre-pandemic norms, as are many cancer screenings.
Texas experienced a rate of 31 maternal deaths per 100,000 live births between 2019 and 2021.
Maternal mortality increased significantly nationwide, in part because of COVID-19. The virus was implicated as a contributing factor in more than 30% of maternal deaths in 2021, Baumgartner said.
Complications in labor and delivery worsened significantly between 2018 and 2020, both in Texas and nationally, although those changes were felt more by women of color. Black Texans experienced labor and delivery complications at nearly double the rate of white Texans.
Addressing care disparities between racial and ethnic groups requires more than just expanding access to care, said Kyrah Brown, assistant professor and director of the maternal and child health equity lab at the University of Texas at Arlington.
“Access to high-quality, respectful care, that’s a very important distinction,” Brown said. “We have to have protocols in place that help standardize care and ensure that all women, no matter what your race or ethnic background is, receive the same level of care.”
Mental health — and mental health care access — sparked particular concern among researchers.
Texas ranked 44th for children who did not receive needed mental health care and 47th for adults. Mental health professionals are increasingly hard to come by, and many don’t take Medicaid.
Preventive screenings before mental health conditions deteriorate into a crisis situation is critical for lessening the burden on both the health system and patients.
“We need to be able to have access to providers that could detect mental health problems like depression before they get really difficult and really hard to manage, and traumatic for the families and the individuals involved,” Raines-Milenkov said.
Where care is getting better
The state of health care in Texas isn’t all doom and gloom. Some metrics, especially in the avoidable hospital use section, improved between 2019 and 2021.
Potentially avoidable emergency department visits and 30-day hospital readmission rates dropped for adults. Only 16% of adults between the ages of 16 and 64 reported fair or poor health in 2021, compared to 20% in 2019.
Texas ranks 50th in the percentage of adults who forewent care because of costs, but that rate improved from 19% in 2019 to 16% in 2021.
Health insurance rates in Texas rose during the pandemic because of a COVID-era rule that prohibited states from disenrolling people from Medicaid. That policy has since ended, meaning more than 1 million state residents may be without health coverage in coming months. Only 10 states, including Texas, have not adopted a Medicaid expansion that would allow more people to enroll in the federal insurance program.
Drug overdoses increased nationwide, but Texas is still doing better than the U.S. average. Texas had 17 drug overdose deaths per 100,000 people, compared to 32 deaths nationally. Texas also reported lower-than-average alcohol-related deaths.
Researchers at Commonwealth Fund and Texas universities said the latest health scorecard doesn’t mean the country and state should devolve into panic. It should instead be used as a benchmark for examining differences between states while simultaneously looking to the future.
“As always, evidence demonstrates that federal and state policies matter, and the variations we see don’t occur by happenstance. That being said, there are basic actions that can reverse these disturbing trends,” Commonwealth Fund president Dr. Joseph Betancourt said in the report.
Investments, especially in women’s and mental health, can increase access to care. About 50% of Texas counties don’t have a practicing OB/GYN while nearly all counties are designated as mental health professional shortage areas.
“Ultimately, it’s cost-effective for the health care system and insurance companies to prevent the exacerbation of any chronic conditions that exist,” Brown said. “There’s a financial benefit and a quality-of-life benefit.”