Texas saw record enrollment growth in both new and returning customers on the Affordable Care Act (ACA) Marketplace for 2024. A number of factors drove these historic gains, including an extension of federal subsidies supporting low-cost coverage and mass coverage loss due to Medicaid unwinding.
By the Numbers
More people enrolled in better plans for this year.
Almost a million new Texans have Marketplace coverage this year, meaning enrollment gains are about the same as the city of Austin’s population. Marketplace enrollment in Texas grew an astounding 44.5% between 2023 and 2024. 1 in 9 Texans are now insured through the Marketplace.
Most Texans signed up for gold plans, and as a state, we had higher-than-average enrollment in gold plans and lower-than-average enrollment in bronze plans compared to the rest of the United States. Bronze plans have lower premiums on average but much higher deductibles and other cost-sharing, which can lead people to put off care or forgo it altogether in fear of high costs. Federal subsidies over the past few years have made gold and silver plans an accessible and attractive option for more people.
Most Texans benefitted from cost-reduction policies and federal subsidies.
Congress has repeatedly funded different financial supports for people using the Marketplace. These subsidies typically fall into two categories:
- Advanced premium tax credits (APTCs) apply to the monthly premium paid to the insurance company to maintain coverage. These are refundable credits applied to federal income taxes.
- Cost sharing reductions (CSRs) apply to the amounts paid when using insurance, such as a copay or coinsurance paid to a provider for care. CSRs are only available to people enrolled in silver plans.
The Inflation Reduction Act extended the subsidies provided by the American Rescue Plan Act, making APTCs and CSRs available again for the 2024 plan year. This extension made these benefits available to more people and resulted in more plans with low or no-cost premiums. These extended subsidies were likely a major driver of the huge Marketplace enrollment in Texas this year. In 2024, 96% of Texans got coverage supported by federal premium subsidies; nearly half (49%) of that 96% also got CSRs they could apply to deductibles, copays, or coinsurance.
Most users comparison-shopped for coverage to find the best deal.
Texans overwhelmingly used Healthcare.gov to compare plans and find the best price and fit for their health care needs. 72% of Texans on Marketplace coverage updated information and shopped to compare plans. This led around half of Texans using the Marketplace to switch plans from last year. Only about a quarter of Texans automatically renewed their coverage without first looking at other available options. In many cases, this is because a consumer knows ahead of time which plan reliably covers a preferred provider in their area.
While federal policies and funding are in place to make gold plans a best option in most cases, for some, a silver plan would lead to better savings and comparable coverage because they qualify for CSRs. Annual changes to federal policy and funding can make choosing a plan daunting, which is why there is federal support for free assistance in navigating the Marketplace.
Better access to enrollment assistance should be funded.
Finding health coverage is stressful. Even navigating employer-sponsored insurance options or choosing the right Medicaid managed care plan can be difficult. How insurance works and what a plan will pay for is variable and confusing. This reality makes the availability of expert help — without financial interest in enrollment outcomes — a vital part of every state’s insurance ecosystem. Though Texas used to fund enrollment assistance support, the state stopped years ago for political reasons and left Texans to rely on the network of federally-funded enrollment assisters in communities across the state. These wonderful groups can help individuals and families assess coverage options, enroll in coverage, and untangle access issues. More funding for more such support across Texas is a key step toward reducing Texas’ highest-in-the-nation uninsurance rate: a staggering 16.6%.
These Numbers Could Change.
There are several threats to Texas’ coverage gains on the Marketplace, including:
- The potential expiration of federal subsidies supporting access to coverage;
- A lack of state funding for qualified enrollment assistance programs;
- Fraud by bad actor agents and brokers illegally leaving people enrolled in more than one plan with limited options to fix their situation; and
- “Junk” insurance-like products offering non-comprehensive coverage mistaken for true, ACA-compliant health insurance.
State and federal funding is necessary to continue to support this progress. Comprehensive health insurance is expensive and health care costs are high — especially when accounting for high inflation. Congress must reauthorize the subsidies that make APTCs and other CSRs more broadly available in order to ensure people can afford coverage. Texas should invest state funds to support enrollment assistance programs to help Texans navigate comprehensive coverage options and find the best plan. Enrollment assistance and coverage information should be available in multiple languages, accessible to people with disabilities, and navigable by households with different eligibility for different programs, including food access programs.