When Coverage Stops Functioning as Access: A New Test for Texas Health Investments

January brings renewed attention to insurance coverage and to major new investments aimed at strengthening rural health systems. In Texas, these conversations unfold against a familiar backdrop: the state continues to have one of the highest uninsured rates in the nation.

But a quieter and more consequential shift is accelerating alongside this long-standing challenge. Texas is entering a period where traditional coverage metrics and lived access are beginning to diverge, where enrollment remains visible, yet the ability to use coverage is increasingly constrained.

This shift matters not only for families and employers, but for how successfully new rural health investments translate into real-world impact.

A Growing Gap Between Coverage and Access

Open enrollment this year offers a clear signal of mounting affordability pressure. Based on payer filings in the federal rate review database, the proposed median gross rate change across the Texas ACA marketplace for 2026 is +34.7%. With enhanced premium tax credits not extended, many consumers, particularly those who relied on those subsidies, are likely to experience a sharper increase in out-of-pocket premium costs.

Similar pressures are evident in employer-sponsored coverage. National analysis of ACA-compliant small-group plans projects a median proposed premium increase of approximately 11% for 2026. For small and mid-sized employers, these increases often translate not into dropping coverage, but into higher deductibles, greater cost-sharing, or narrower networks.

In practice, coverage frequently remains in place. Access does not.

National surveys consistently show insured individuals delaying or avoiding care because of cost – skipping visits, prescriptions, or follow-up. At a certain point, rising cost-sharing means coverage stops functioning as access, even though enrollment numbers appear stable.

This is the defining feature of underinsurance, and it is becoming harder to see if we should rely only on coverage counts.

Why The New Rural Health Investments Will Reveal This First

The Rural Health Transformation Grant represents one of the most significant commitments to rural health Texas has seen in years, creating real opportunity to strengthen care delivery in communities that have long been under-resourced.

These investments are timely, necessary, and aligned with longstanding needs. They also arrive at a moment when coverage dynamics are shifting in ways that will shape their effectiveness.

From a system perspective, rural health investments may act as an early stress test for whether coverage is still doing its job. Where coverage is usable, expanded services, workforce capacity, and care coordination should translate into earlier engagement and better outcomes. Where coverage is not, delayed care and financial strain are likely to persist—even as infrastructure improves.

When high uninsurance rates coexist with rising underinsurance:

• Preventive and routine care is postponed
• Demand concentrates at later, more acute stages
• Rural and safety-net providers absorb increasing operational strain

In this environment, the risk is not a lack of investment or effort, but that success is measured in deployment rather than in access.

A Closing Reflection

As attention remains focused on enrollment counts and funding levels, the more fundamental question persists: Does the coverage landscape in Texas, taken as a whole, enable people to seek care when they need it, and allow new rural health investments to achieve their intended impact?

THI’s monthly Texas Health Lens blog offers independent, Texas-focused insights on complex health issues. If this perspective is valuable to you, consider supporting our work as a monthly donor.