County Indigent Care Programs Fill Coverage Gaps Left by Medicaid Restrictions: Evidence From Texas

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ID: 330853
2026
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Abstract
Abstract Background Medicaid restrictions exclude some low-income adults, especially in nonexpansion states and among immigrants. Local governments are payers of last resort. Texas offers an important case study: state law requires counties to maintain Indigent Care Programs to extend healthcare coverage for uninsured low-income residents, yet no recent report describes their structure. Methods We catalogued programs in all 254 counties, using publicly available data, contact with county officials, and a state open-records request, characterizing reporting, eligibility, and services, along with estimates of uninsured working-age adults in counties with broader eligibility and services; overall and by county metropolitan status. Results Required annual reports were unavailable for 144/254 (57%) counties, and 19/254 (7%) had eligibility or benefits inconsistent with state law (minimum eligibility of 21% of federal poverty level - FPL; $30,000 of care including prescription and skilled nursing). 39/254 (15%) set income eligibility ≥138% FPL, reaching 50% of uninsured adults but only 14% of uninsured adults in nonmetropolitan counties. 5/254 counties (2%) combined higher income thresholds with broad service availability; all were metropolitan, containing 47% of uninsured adults statewide. Conclusion Indigent Care reaches those excluded from Medicaid, but eligibility and services varied widely, and more generous programs were only in metropolitan counties.
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Authors Arthur S. Hong, G. Richard Paul, Frederick P. Cerise, Abram O Gordon, Navid Sadeghi, Joshua M Liao, Jenisa RC, Ethan A. Halm
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Journal Health Affairs Scholar
Year 2026
DOI
10.1093/haschl/qxag267
URL
https://doi.org/10.1093/haschl/qxag267
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