Why more Texans will be enrolled in ACA health plans in 2024 than ever before, according to federal officials?

More Texans than ever are signing up for low-cost or free health insurance under the Affordable Care Act, and more than one in nine Texans will be covered by government-subsidized health plans through 2024, according to federal health data released Wednesday.

In a state with the largest number of uninsured residents in the country, public health advocates are seeing an encouraging trend: the number of Texans enrolled in ACA programs is up 37% to nearly 3.5 million from last year's numbers.

Since 2020, enrollment in ACA plans in Texas has more than doubled, and it is among the states with the fastest growth in enrollment over the past three years. These plans first became available in 2014 and were designed to offer more health insurance options to people whose income is not low enough to qualify for Medicaid coverage but who cannot get coverage through their workplace.

"It's a huge success," Carla Martinez, a senior policy analyst at Every Texan, a left-leaning political group, said in a prepared statement.

According to the federal Centers for Medicare and Medicaid Services, also known as CMS, ACA enrollment is at a record high, with more than 16.3 million people signing up for these plans. Nationwide, the number of Americans signing up for ACA plans has doubled since the program began in 2014.

"We've made record progress in expanding coverage and lowering health care costs for American families, saving them money and giving more Americans the peace of mind that comes with affordable health insurance," President Joe Biden said in a statement released Wednesday.

State health policy observers attribute the significant increase in ACA enrollment in Texas to the removal of about 2 million Texans from Medicaid rolls - part of a nationwide effort to return the bloated program to normal levels after restrictions imposed during the pandemic.

According to CMS, about 2.4 million people enrolled in the ACA were previously enrolled in Medicaid or Children's Health Insurance Programs.

Supporters say the growth is likely due to efforts by state and federal lawmakers to increase access, outreach and enrollment on HealthCare.gov, which is performing well in the federal marketplace.

According to Biden's statement, about 4 out of 5 people looking for an ACA health insurance plan found one for $10 a month or less.

"Texans obviously want affordable and comprehensive insurance, and when you provide that insurance - and it's easy to learn about and easy to sign up for - they sign up in droves," said Stacey Pogue, a health policy analyst at Every Texan, a progressive think tank in Austin.

According to the federal government, Texas residents saved an average of $560 on the annual health premiums they pay for coverage on the ACA marketplace. That savings, according to the White House, was due to federal tax dollars spent on health care subsidies and premium tax credits under the American Recovery and Reinvestment Act of 2021 and the Inflation Reduction Act of 2022.

"We are pleased to see the federal government's investment paying off, and millions of people in Texas and across the country are now getting the insurance they need to stay healthy," said Martinez, a spokesperson for Every Texan. "It's clear that our elected officials can improve access to affordable health care by making it a priority."

In 2021, state lawmakers from both political parties unanimously supported efforts to boost the effect of federal subsidies and make some insurance plans in the marketplace more affordable.

"Importantly, it showed that the Texas Legislature is interested and can work together on innovative solutions to help us address our chronically high uninsured rate," said Charles Miller, senior policy advisor with the advocacy group Texas 2036.

Texas currently leads the nation in the number of uninsured residents, with nearly 5 million people living here without health insurance, nearly double the national average.

And while public health advocates and policymakers often agree that there is no single solution to high rates of uninsurance, they disagree on how to address it.

For more than a decade, progressive public health advocates, as well as lawmakers on both sides of the political axis, have been pushing for Texas to expand access to Medicaid to include adults with disabilities and children. In their view, the move could reach about 800,000 more Texans whose income is too low to qualify for the ACA marketplace program but too high to qualify for Medicaid.

Opponents argue that the existing Medicaid system is already broken and should not be expanded. They insist that federal benefit programs do not provide the best care and that solutions should be expanded beyond Medicaid.

They believe the focus should be on creating jobs with workplace plans, finding innovative ways to cover Texas residents, creating a state-run health care marketplace exchange to replace the state's HealthCare.gov exchange, incentivizing prevention to reduce the need for serious treatment, and overhauling the current system to lower the cost of care.

Many uninsured Texans have middle-class incomes and are not eligible for Medicaid, and for those who are eligible but not enrolled in the program, advocates say one problem may simply be affordability and awareness.

Pogue said simplifying the Medicaid enrollment process for those who are eligible so that it is not as complicated as it is today would help increase enrollment significantly.

The 2022 Texas 2036 study found that between 2.7 and 3.5 million uninsured Texans are eligible for free or subsidized health insurance through existing ACA, Medicaid, or Children's Health Insurance Program (CHIP) subsidies, but do not participate.

Theories explaining the reasons vary, but include lack of awareness, inability to afford even ACA plans, lack of access to resources to help with the complicated enrollment process - or few opportunities to go through the cumbersome, time-consuming process - and distrust of government health care.

Proponents say a state-run health care exchange could help Texas simplify the enrollment process by attracting people who may be distrustful of the Affordable Care Act (also known as Obamacare).

By 2024, 18 states, including Kentucky, California and Idaho, and the District of Columbia will have their own exchanges, covering about 4.9 million people next year.

Creating a state-based marketplace will allow Texas to simplify the enrollment process and make it more attractive to those who don't trust a system run by the federal government.

"Some approaches to reducing Texas' uninsured rate are only possible if Texas establishes and operates a state exchange," Miller said. "Creating a state exchange would not only provide Texas with the administrative flexibility to implement individualized solutions, it would also provide a revenue stream to pay for such policies and efforts." The key to success, he said, will be in the details.

"While we believe the state exchange has great potential, it is fair to say that there are risks if it is not organized properly," he said. "It's important not just to do it, but to do it right."

An attempt to do so during the last legislative session never got a committee hearing, where opponents argued, among other things, that the idea was unnecessary.

The federal marketplace is certainly working well - given enrollment successes - so the time and energy it would take to create an entirely new system should be directed toward other solutions that would complement the ACA's impact and improve overall coverage rates, Pogue told The Texas Tribune.

She said this includes not only Medicaid expansion, but other creative approaches, both large and small, such as making it clear to immigrants that seeking health insurance for their children does not jeopardize their legal status.

"The question is not 'what level of government should run this?" said Pogue. "The question is, what do you want to do? What is the goal? "