Health Care in Texas: The Rest of the Story

As Texas governor Rick Perry makes a splash in the Republican presidential primaries, one place where critics are looking for evidence of poor leadership is his record on health care, especially Medicaid and the uninsured. According to a recent article by Noam N. Levey in the Los Angeles Times, Texans’ access to health care is “withering” under Perry. As Levey notes, Texas has the highest rate of uninsured in the nation, over one quarter of the population. This is important, but not in the way Levey believes.

Avik Roy, of The Apothecary blog, has published a comparison of various health-related measurements in Texas and Massachusetts. Drawing upon a number of sources, Roy concludes that those who believe more government spending and regulation is good will condemn Texas’ record, but those who believe in individual choice and limited government will cheer it. But what other costs did Texans pay? Or, as Paul Krugman might frame the question: “How many children died in the street to pay for Rick Perry’s tax cuts for millionaires and billionaires?” The answer is “none.”

More importantly, Texans have decided that it’s better to create more jobs than more Medicaid dependents.

Every year, the United Health Foundation produces America’s Health Rankings, which ranks every state along a number of health-related measurements. Some of these rankings have to do with insurance coverage and government spending. But others have to do with the actual state of people’s health. Tables 1, 2, and 3 show how Texas ranks in inputs to the health system, in outputs for which the health system is (partially) responsible, and in causes of mortality.

Table 1 shows five inputs to the health system. Texas does not rank very highly in these inputs, and it is plausible that below average health spending can (to some degree) explain this.

However, relatively poor rankings for inputs are not reflected in generally poor outputs. Table 2 reports 13 health-system outputs. Texas ranks very well in four outputs, and very poorly in four. For the other five, it ranks in in the middle. Note that the health system is not entirely responsible for these outputs. Other determinants of health play a large role. The lesson? Below average health spending may result in lower inputs, but not necessarily lower outputs.

Finally, we look at four causes of mortality. Table 3 clarifies the picture even more. Texas ranks very well in two important causes of mortality, cancer deaths and infant mortality, and ranks about average in two others.

Given these outcomes, it is not at all clear that Texas’ spending more money on the health system would result in better health outcomes. Indeed, throwing more money at the health system would likely destroy Texas’ competitive advantage in attracting people.

During the period 2000 through 2009, Texas’ population grew by 3.9 million people, according to the U.S. Census Bureau. This accounted for 15 percent of the population growth of the entire U.S. Furthermore, over 700,000 of these were not newborns or international migrants, but residents from other states – most of which had much more expensive Medicaid programs and higher incidence of private health insurance, like New York or Massachusetts. And these people came to Texas because that’s where the jobs are. Even, a liberal watchdog, admits that “the state has added 1,081,900 jobs since December 2000, the month Perry took office. It’s an increase of 11.3 percent during his time as governor. Nationally, employment has gone down in this time frame, declining by 1,295,000, a nearly 1 percent drop.”

Americans clearly value jobs more than Medicaid dependency or the political goal of “universal coverage.” Instead of frittering away his citizens’ prosperity in mindlessly throwing more of their money at Medicaid, or fruitlessly investing political capital in trying to guarantee so-called “universal coverage,” Perry focused on policies that created jobs. Americans have voted with their feet, and they have voted for Perry’s Texas model.

Comments (5)

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  1. Devon Herrick says:

    Texas has done well. It was always an energy center. In the past two decades Texas has become a high-tech center as well.

  2. Greg Scandlen says:

    Interesting, John, but some of these measures seem awfully squishy. Like “geographic disparity.” What in the world can that mean? That Texas has a lot of geography, unlike, say, Delaware? Are the number of dental visits a measurement of anything meaningful? And “preventable hospitalizations” may be a measure of how good the state’s EMT services are.

    The “great unmentionable” in all of these health system comparisons is the proportion of Latinos in a state. Latinos, especially recent immigrants just don’t “get it” about American health care, and the number of uninsured in a state is almost perfectly correlated with the number of Latinos. A more interesting comparison would be (liberal) California with (conservative) Texas.

  3. Joe Barnett says:

    The riposte to the santimonious condemnatory declaration (by Romney and everyone else) that “Texas has an uninsured rate of 25 percent” is, so what?

    That’s a lot of people who are saving a lot of money, and I say, “good for them.” But it has nothing to do with access to treatment for the sick. That should be the focus of health policy, not how many people are enrolled in a health plan.

  4. John R. Graham says:

    @Greg Scandlen:

    Quite right, they are squishy, as are most macro indicators. But I didn’t want to use my own indicators, because people might accuse me of bias. Plus, if indicators are squishy, why would we want the government to invest in increasing the squishy measurements?

    “Geographic disparity” is measured as variance of mortality between counties. So, Greg Scandlen is quite right. Counties are political jurisdictions and states don’t define them as they do to minimize this variance.

    I was thinking of normalizing the proportion of uninsured by adjusting for the illegal population. However, because I don’t think the proportion of uninsured is very interesting (c.f. Michael Cannon’s “Anti-Universal Coverage Club”), I decided to stay away from it.

  5. Avik Roy says:

    On the uninsurance rate, two issues to keep in mind: how those numbers changed over time (, and the differences in population mix (, something John has discussed at length himself.