TEXANS' VIEWS ON HEALTH POLICY
AND EXPERIENCES WITH ACCESS
AND AFFORDABILITY
Findings from the Episcopal Health Foundation
2021 Texas Health Tracking Survey
Prepared by:
Shao-Chee Sim, Elena Marks | Episcopal Health Foundation
Jazmyne Sutton, Eran Ben-Porath | SSRS
MAY 2022
Texans' Views on Health Policy and Experiences with Access and Affordability | 2
TABLE OF CONTENTS
EXECUTIVE SUMMARY................................................................................................................................................................. 3
ISSUES FOR TEXAS LEGISLATURE AND LOCAL ELECTED OFFICIALS ............................................................................ 4
HEALTH CARE ISSUES FOR THE STATE .................................................................................................................................. 7
Top Health Care Priorities ...................................................................................................................................................... 7
Opinions and Experiences with Medicaid ........................................................................................................................ 8
EXPERIENCES WITH HEALTH CARE AFFORDABILITY AND ACCESS ............................................................................11
Health Insurance Coverage .................................................................................................................................................11
Affording Health Care and Medical Bills .........................................................................................................................11
Table 1: Problems Affording Medical Care ...............................................................................................................12
Texans’ Usual Places for Health Care ...............................................................................................................................12
Table 2: Usual Source of Care for Texans ..................................................................................................................13
METHODOLOGY ..........................................................................................................................................................................15
ABOUT EHF ....................................................................................................................................................................................15
ABOUT SSRS .................................................................................................................................................................................15
Citation: Sim, S., Marks, Sutton, J., E., Ben-Porath, E., (2022). Texans’ Views on Health Policy and Experiences
with Access and Affordability.
Texans' Views on Health Policy and Experiences with Access and Affordability | 3
EXECUTIVE SUMMARY
The state of Texas, with its diverse population in terms of urbanicity, income, race and ethnicity, faces a
variety of challenges when it comes to health care access and affordability. Additionally, with the 2022
gubernatorial and local elections on the horizon, residents have many priorities they would like their state
and local elected officials to address. In the 2021 Texas Health Tracking survey, Episcopal Health
Foundation (EHF) and SSRS explored Texans’ views on health care priorities in the state and their
experiences with the affordability of and access to quality care. This report provides analysis of these data
and notes where there are statistically significant differences among key demographic groups. Where
applicable, data from this year’s survey are compared to EHF Health Policy Surveys from 2018, 2019, and
2020
1
.
In the 2021 survey, most Texans expressed support for an increase in spending on health care (58%).
Support is higher among younger adults and those with a connection to Medicaid. Moreover, when asked
about topics they would like to be addressed by candidates for governor and other public offices, three-
quarters of adults said making health care accessible and affordable was a very important topic (76%).
When asked specifically about the health care priorities of the state, the topic ranked by most as a top
priority was reducing the cost of prescription drugs (56%). More than half say lowering health care costs
(54%), access to health insurance (53%), increased funding for mental health (50%), reducing the number
of women who die from childbirth (49%), and access to hospitals in rural areas (49%) should be top priorities.
The majority of Texans have at least a somewhat favorable opinion of Medicaid (64%; 27% Very favorable;
37% Somewhat favorable) and about half say the program is working well (48%). Additionally, nearly seven
in ten residents support expanding Medicaid to cover more low-income adults under the Affordable Care
Act (69%).
This support for Medicaid may be associated with the problems many Texans have affording and accessing
health care. When asked how easy it is to afford basic necessities, health care ranks as one of the more
difficult needs to afford with almost half of Texas adults saying it was very or somewhat difficult (48%). One-
third said they have had problems paying medical bills in the past year (35%) and the majority say they have
skipped or postponed care due to the cost (59%).
1
Sim, S., Marks, E., Ben-Porath E., Sutton, J. (2020). Texas Residents' Views on State Health Policy Priorities. Retrieved from:
https://www.episcopalhealth.org/research-report/new-texas-health-policy-poll-texans-show-sweeping-support-for-expanding-
medicaid/
Texans' Views on Health Policy and Experiences with Access and Affordability | 4
ISSUES FOR TEXAS LEGISLATURE AND LOCAL ELECTED
OFFICIALS
The 2021 Texas Health Policy Survey finds that most Texans would support the Texas state legislature
increasing spending on health care programs (58%). Only eight percent say they think spending should
decrease and 27 percent said spending should stay about the same. Support for an increase in health care
spending is higher among residents under age 65 (60%) in comparison to those 65 or older (52%).
Additionally, Black residents (81%) are more likely to support an increase in health care spending than White
(53%) and Hispanic (58%) residents (Chart 1).
Texans in this year’s survey were also asked what topics they think are important for candidates running for
state and local public office to address in their campaigns. More than three-quarters said making health
care more affordable and accessible is a very important topic for candidates to address (76%).
The only issue receiving more support for an increase in spending was public education with 71 percent
saying they think the state legislature should increase spending in this area. Similarly, a large majority also
say it is very important for candidates running for state and local office to address K through 12 education
(Chart 2).
53%
58%
81%
52%
60%
58%
White residents
Hispanic residents
Black residents
Ages 65+
Ages 18-64
Total
CHART 1: MOST TEXANS SUPPORT INCREASE IN HEALTH
CARE SPENDING
Q: Thinking about priorities in the state budget, do you think the state legislature should increase or
decrease spending on health care programs or keep it about the same?
PERCENT SUPPORTING AN
Texans' Views on Health Policy and Experiences with Access and Affordability | 5
*Don’t know/Refused not shown
Just over half, support an increase in spending on public safety (56%) with 77 percent saying crime and
public safety are very important for candidates to address in their campaigns. Slightly more than half also
support an increase in infrastructure spending (54%) with half also saying it is very important for candidates
to discuss this in their campaigns (53%). However, when asked specifically about preparedness for natural
disasters, seven in ten said this was a very important topic for candidates to address (74%). Climate change
was rated as very important by significantly fewer Texans (42%) (Chart 3). Transportation (38%) and welfare
programs (38%) both received less support for an increase in spending.
38%
38%
54%
56%
58%
71%
10%
19%
5%
5%
8%
5%
45%
37%
39%
37%
27%
21%
Transportation
Welfare programs
Infrastructure
Public safety
Health care programs
Public education
CHART 2: MOST RESIDENTS SUPPORT SPENDING
INCREASE FOR EDUCATION, HEALTH CARE, PUBLIC
SAFETY AND INFRASTRUCTURE
Q: Thinking about priorities in the state budget, do you think the state legislature should increase or
decrease spending on ______or keep it abo
Increase Decrease Keep about the same
Texans' Views on Health Policy and Experiences with Access and Affordability | 6
*Don’t know/Refused not shown
82%
77%
76%
74%
65%
62%
53%
52%
42%
13%
18%
17%
22%
26%
24%
37%
34%
29%
5%
5%
6%
4%
8%
12%
7%
12%
27%
K through 12 education
Crime and Public Safety issues
Making health care more affordable
Preparedness for natural disasters
Child welfare
Immigration
Infrastructure
Unemployment
Climate change
CHART 3: MAJORITIES SAY EDUCATION, HEALTH CARE,
INFRASTRUCTURE, AND PUBLIC SAFETY SHOULD BE
ADDRESSED BY CANDIDATES
Q: How important, if it all, do you think it is for candidates running for office to address the following
issues in their campaign?
Very important Somewhat important Not too/Not at all important
Texans' Views on Health Policy and Experiences with Access and Affordability | 7
HEALTH CARE ISSUES FOR THE STATE
Top Health Care Priorities
When asked about health care priorities specifically, issues involving cost and access tended to rank as top
priorities. The majority say reducing the cost of prescription drugs (56%), reducing the amount individuals
pay for health care (54%) and increasing access to health insurance (53%) should be top priorities. Half say
increased funding for mental health programs should be a top priority (50%). Nearly half also view access
to hospitals in rural areas (49%) and expanding Medicaid to cover more low-income Texans (47%) as top
priorities. About half also say reducing maternal mortality should be a top priority (49%). Access to family
planning and contraception services is a top priority for 44 percent of Texas adults. Fewer Texans think
dealing with the prescription painkiller epidemic should be a top priority (38%). Only one in five say the
state’s top priority should be decreasing spending on health care (21%). In fact, one third say this should
not be done (35%) (Chart 4).
*Don’t know/Refused not shown
21%
38%
45%
47%
49%
49%
50%
53%
54%
56%
28%
46%
25%
36%
33%
40%
37%
33%
33%
35%
13%
10%
12%
8%
9%
6%
8%
8%
5%
6%
35%
5%
6%
8%
5%
5%
Decreasing state government spending on health care
Dealing with the Rx painkiller addiction epidemic
Increasing women's access to family planning and
contraception
Expanding Medicaid to cover more low-income Texans
Reducing the number of women who die from causes
related to pregnancy and childbirth
Improving access to hospitals in rural areas
Increasing funding for mental health programs
Increasing access to health insurance
Lowering amount individuals pay for health care
Lowering the cost of Rx drugs
CHART 4: ACCESS AND COST RANK AS TOP HEALTH CARE
PRIORITIES FOR MOST TEXANS
Q: What about _____? Should that be a top priority for the Texas legislature, important but not a top
priority, not too important, or should it not be done?
Top priority Important but not a top priority Not too important Should not be done
Texans' Views on Health Policy and Experiences with Access and Affordability | 8
Since 2020, fewer Texans rank lowering prescription drug prices as a top priority (56% in 2021; 63% in 2020).
However, more believe family planning services should be a top priority in comparison to 2020 (45% in
2021; 37% in 2020). Fewer also rank reducing maternal mortality as a top a top priority (49% in 2021; 58%
in 2020).
Opinions and Experiences with Medicaid
With access and affordability among the top health care concerns, many Texans continue to have a
favorable view of Medicaid, the government health insurance and long-term care program for certain low-
income adults and children. Almost two-thirds have a very or somewhat favorable opinion of the program
(64%; 27% very favorable; 37% somewhat favorable). The 69 percent of Texans with some sort of connection
to the program either by ever being covered by the program or knowing someone covered tend to have
more favorable views. These groups are also more likely to say the program is working well. However, rates
of Medicaid favorability have significantly declined over the past four years and fewer Texans think the
program is working well (Chart 5).
Texas is one of only 12 states that has not expanded Medicaid coverage under the Affordable Care Act.
Most Texans either mistakenly believe the program has been expanded (19%) or are unsure (41%). When
told that the state has not expanded Medicaid, nearly seven in ten support Medicaid expansion to cover
more low-income adults (69%). Support for Medicaid expansion this year is consistent with 2020. However,
it has significantly increased since 2019 when support was at 64 percent (Chart 6). In fact, over the last four
years as rates of Medicaid favorability have declined, more Texans support Medicaid Expansion (Chart 7).
71%
60%
72%
59%
69%
53%
64%
48%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
Very or somewhat favorable opinion Yes, working well for most Texans
CHART 5: DECREASING MEDICAID FAVORABILITY AMONG
TEXAS RESIDENTS
2018 2019 2020 2021
Texans' Views on Health Policy and Experiences with Access and Affordability | 9
While rates of Medicaid favorability tend to be similar across age groups, race and ethnicity, as well as
income levels, there are significant differences in favorability by political party identification. Democrats are
more likely to have favorable opinions (76%) than Republicans (53%) and Independents (62%). In fact,
favorability among Republicans and Independents has sharply declinced over time. In 2019, 65 percent of
Republicans had a very or somewhat favorable view of Medicaid. This is more than 10 percent higher than
the portion in 2021. Similarly, 72 percent of Independents had favorable opinions of Medicaid in 2019
64% 64%
69% 69%
50%
52%
54%
56%
58%
60%
62%
64%
66%
68%
70%
2018 2019 2020 2021
CHART 6: CONSISTENTLY HIGHER SUPPORT FOR MEDICAID
EXPANSION SINCE 2020
Texans' Views on Health Policy and Experiences with Access and Affordability | 10
compared to 62 percent in 2021. However, there is not a significant change in levels of support for Medicaid
expansion among Republicans and Independents since 2019. Additionally, favorability and support for
exapnsion among Democrats has stayed relatively consistent (Chart 8).
78%
60%
71%
79%
65%
72%
78%
58%
69%
76%
53%
62%
30%
40%
50%
60%
70%
80%
90%
Democrat Republican Independent
CHART 8: DECREASING MEDICAID FAVORABILITY AMONG
REPUBLICANS AND INDEPENDENTS
2018 2019 2020 2021
Texans' Views on Health Policy and Experiences with Access and Affordability | 11
EXPERIENCES WITH HEALTH CARE AFFORDABILITY AND ACCESS
Health Insurance Coverage
Among Texans ages 18 to 64, 29 percent report being without health insurance and almost three-quarters
of those uninsured have been without health insurance for more than a year (73%). This is significantly lower
than the 35 percent who said they did not have health insurance in 2020 but similar to levels in 2019 (31%)
and 2018 (29%). In contrast 14 percent of adults nationwide are currently uninsured.
2
Affording Health Care and Medical Bills
Nearly half of Texans say it is somewhat or very difficult for them to afford health care (48%). More say they
have difficulty affording health care than who say food (29%), their rent or mortgage (38%), or monthly
utilities are difficult to afford (38%). The only cost outranking health care as at least somewhat difficult to
afford is gasoline and transportation costs, with 56 percent of Texans reporting that it is at least somewhat
difficult to afford this expense.
Moreover, one in three have had problems paying medical bills in the past year. More than half have skipped
or postponed some type of medical care due to the cost (59%). Skipping or postponing care due to cost
appears to be more prevalent in 2021 compared to 2020. In 2020, 53 percent reported skipping care due
to cost compared to the 59 percent who report the same in 2021. However, the rates for 2021 are similar
to 2019 (60%) and 2018 (61%). This difference between 2021 and 2020 estimates may be due to fewer
Texans seeking any type of medical care during the height of the COVID-19 pandemic in 2020. In 2021,
health care procedures and appointments that may have been postponed were able to occur again, but
Texans are still facing difficulties with affording care.
These issues with affordability are more common among those without health insurance. The vast majority
of uninsured Texans say it is at least somewhat difficult to afford healthcare (83%) compared to just 38
percent of insured Texans. Uninsured Texans are also more likely to report difficulty paying medical bills
(54%) compared to their insured counterparts (32%). About three-quarters of uninsured Texans skipped or
postponed medical care in the past 12 months (78%) compared to 56 percent of insured Texans.
Younger Texans are also more likely to have difficulty affording health care. Fifty-one percent of Texas adults
under age 65 report that it is somewhat or very difficult to afford health care compared to 32 percent of
adults aged 65 or older. Additionally, 39 percent of adults under 65 have had problems paying medical bills
compared to only 20 percent among those age 65 or older. Finally, 63 percent of adults under 65 have
skipped or postponed care due to the cost in comparison to the 42 percent of adults 65 or older who have
done the same.
Hispanic residents also have more trouble affording health care in Texas. Hispanic residents are more likely
to report that it is difficult to afford health care (58%) than White (41%) and Black (45%) residents. Hispanic
residents are also more likely to say they have had problems paying medical bills (41%) than White (32%)
residents (Table 1).
2
https://files.kff.org/attachment/TOPLINE-KFF-COVID-19-Vaccine-Monitor-November-2021.pdf
Texans' Views on Health Policy and Experiences with Access and Affordability | 12
Table 1: Problems Affording Medical Care
RACE/ETHNICITY
AGE
INSURANCE STATUS
(NON-ELDERLY)
White
Black
Hispanic
18-64
65+
Insured
Uninsured
Very or somewhat difficult to
afford health care
41%
45%
58%
51%
32%
38%
83%
Problems paying medical bills
32%
38%
41%
39%
20%
32%
54%
Skipped or postponed care
due to cost
57%
63%
61%
17%
31%
56%
78%
Note: Adding individual rows may not match NETS due to rounding.
Texans’ Usual Places for Health Care
More than a quarter of Texans do not have a usual place of care or rely on hospital emergency rooms as
their usual source of care (29%) (Chart 9). Findings reveal continued disparities in usual source of care across
race/ethnicity, immigration status, income, and insurance status. Overall, lower-income, Hispanics,
immigrants, and uninsured Texans are more likely than their counterparts to say they have no usual place
for medical care, or they go to the emergency room. Hispanic and immigrant adults are also more likely to
report receiving their medical care from a clinic or health center (Table 2).
Clinic or health
center
18%
Doctor's office
41%
Urgent care
7%
Other
4%
Don't know/Refused
1%
No usual place/
Emergency room
29%
CHART 9: ONE QUARTER OF TEXANS DO NOT HAVE A
USUAL PLACE FOR CARE
Texans' Views on Health Policy and Experiences with Access and Affordability | 13
Table 2: Usual Source of Care for Texans
RACE/ETHNICITY
IMMIGRATION
STATUS
INCOME
INSURANCE
STATUS
(NON-ELDERLY)
White
Black
Hispanic
U.S.
born
Foreign
born
<250%
FPL
250%+
FPL
Insured
Uninsured
NET Have a usual
place for medical
care (not ER)
79%
77%
60%
73%
60%
59%
81%
75%
50%
Doctor's office
52%
50%
27%
45%
25%
29%
51%
44%
19%
Clinic or health
center
15%
17%
23%
15%
29%
21%
16%
16%
24%
Urgent care/
Outpatient/Other
11%
10%
10%
13%
2%
8%
15%
14%
8%
NET No usual
place of care/ER
21%
23%
38%
26%
39%
40%
18%
25%
48%
Emergency room
2%
6%
5%
5%
2%
7%
2%
4%
7%
No place for care
19%
16%
33%
21%
37%
33%
16%
21%
41%
Note: Adding individual rows may not match NETS due to rounding.
For Texans who say they have a usual place of care (70%), most say it is very (61%) or somewhat (25%) easy
for them to travel to the doctor’s office or other facility to receive care. Fourteen percent report having
difficulty traveling to their usual place of care (10% somewhat difficult and 4% very difficult).
Among those with a usual place of care, those who report traveling to that place is a barrier for them are
mostly low-income or don’t have health insurance. Hispanic Texans are more likely than white and Black
residents to report challenges with getting to their usual place of medical care (Chart 10). Uninsured
residents and those with chronic conditions or disabilities are also more likely to report difficulty travelling
to their usual place of care. Additionally, those with incomes below 250 percent of the FPL are four times as
likely as higher-income Texans to say it is difficult for them to travel to their place of care (26% v. 6%).
Texans' Views on Health Policy and Experiences with Access and Affordability | 14
14%
25%
11%
22%
8%
12%
6%
26%
14%
Ages 65+
Uninsured ages 18-64
Insured ages 18-64
Hispanic
Black
White
250%+ FPL
<250% FPL
Total Have Usual Place of Care
CHART 10: LOW-INCOME AND UNINSURED MORE LIKELY
TO SAY TRAVELING TO PLACE OF CARE IS DIFFICULT
Q: How easy or difficult is it for you to travel to the place where you receive your medical care? Is it…?
PERCENT REPORTING SOMEWHAT OR VERY DIFFICULT AMONG THOS
Texans' Views on Health Policy and Experiences with Access and Affordability | 15
METHODOLOGY
SSRS conducted the 2021 Texas Health Tracking Survey on behalf of Episcopal Health Foundation (EHF)
from October 20 through November 18, 2021. The goal of this survey was to understand the perspectives
and experiences of Texas adults regarding their health care and health care policies in the state, with a
comparison to similar studies completed in 2018
3
, 2019
4
, and 2020
5
. For the 2021 Texas Health Policy Survey,
SSRS interviewed a representative sample of 1,203 Texas adults (age 18 or older), reached via landline
(n=352) and cell phone (n=851; including n= 705 who could not be reaching via landline) random digit
dialing (RDD). Interviews were conducted by live professional telephone interviewers in English or Spanish
based on the respondent's language preference.
Weighting is generally used in survey analysis to compensate for sample designs and patterns of non-
response that might bias results. The survey data are weighted to balance the sample demographics to
match estimates for the Texas adult population. The margin of sampling error for this study is +/- 3.5
percentage points for results based on the total sample.
ABOUT EHF
Episcopal Health Foundation (EHF) is committed to transforming the health of our communities by going
beyond the doctor’s office. By providing millions of dollars in grants, working with congregations and
community partners, and providing important research, we're supporting solutions that address the
underlying causes of poor health in Texas. EHF was established in 2013, is based in Houston, and has more
than $1.3 billion in estimated assets. #HealthNotJustHealthCare
ABOUT SSRS
SSRS is a full-service market and survey research firm managed by a core of dedicated professionals with
advanced degrees in the social sciences. Service offerings include the Omnibus Survey, Probability Panel
and other Online Solutions as well as custom research programs – all driven by a central commitment to
methodological rigor. The SSRS team is renowned for its multimodal approach, as well as its sophisticated
and proprietary sample designs. Typical projects for the company include complex strategic, tactical and
public opinion initiatives in the U.S. and in more than 40 countries worldwide. SSRS is research, refined. Visit
www.ssrs.com for more information.
3
Hamel, L., Wu, B., Brodie, M., Sim, S., Marks, E. (2018). Texas Residents’ Views on State and National Health Policy Priorities. Retrieved
from: https://www.episcopalhealth.org/research-reports/
4
Sim, S., Mark, E., Ben-Porath, E., Hachey, E., Su, J. (2019). Texas Residents’ Views on State and National Health Policy Priorities. Retrieved
from: https://www.episcopalhealth.org/research-reports/
5
Sim, S., Marks, E., Ben-Porath E., Sutton, J. (2020). Texas Residents' Views on State Health Policy Priorities. Retrieved from:
https://www.episcopalhealth.org/research-report/new-texas-health-policy-poll-texans-show-sweeping-support-for-expanding-
medicaid/