Herbert Cotto, who works at the Port of Galveston, does not have health insurance.

Galveston County’s number of uninsured residents has been cut in half in the past decade. But that bit of local progress pales when viewed within the context of national and state trends and the lack of attention given to the uninsured problem by state leaders in Texas.

Texas has the highest number and the highest rate of uninsured people in the nation, ranking 51st after all other states and Washington, D.C., according to the federal Agency for Healthcare Research and Quality. Galveston County fares better than much of the state with 13 percent or a little less than 44,000 residents under age 65 uninsured, compared with 19 percent across Texas. The national average is 11 percent.

But drawing the attention of state legislators to so many uninsured Texas residents is difficult at best, local health care officials said.

Dr. Ben Raimer, who spends a lot of time at the legislature as senior vice-president for health policy and legislative affairs at the University of Texas Medical Branch and president of the United Board of Health overseeing the Galveston County Health District, has been entrenched in health care delivery for all Galveston County residents for many years.

“Texas still leads the nation in the number of uninsured and that’s a discussion that didn’t move forward in the debate this session,” Raimer said.

Education reform took center stage at the legislature, making great strides forward while taking actions to extend health insurance to more Texans languished, he said.

“With Medicaid eligibility the way it currently is — there’s no broadening of availability to any of our citizens — we still face record-breaking numbers of uninsured individuals,” Raimer said.

And as with Texas, so goes Galveston County.

Galveston County and the state will face an entirely new strain on its medical services and on families without a health care safety net should Texas have its way and succeed at overturning the Affordable Care Act, often called Obamacare, in federal court this year.

An estimated 14,000 people in Galveston County held policies through the Affordable Care Act marketplace in 2018, according to Texas’ Center for Public Policy Priorities.

A panel of three federal judges at the U.S. Fifth Circuit Court of Appeals in New Orleans this month heard arguments about why the Affordable Care Act should be struck down, an effort led by Texas’s Attorney General Ken Paxton after a federal judge in Dallas last year declared the act unconstitutional.

The fifth circuit justices will hand down their opinion later this year.

Complicating that possibility is Texas’ refusal to expand Medicaid to a large number who fall within an income gap too little to qualify for Obamacare subsidies and too much to qualify for Medicaid. Expansion of Medicaid by states was enabled by the Affordable Care Act, passed in 2010, and has been adopted by 34 states.

In Galveston County, 13,000 would become eligible for Medicaid if Texas were to expand eligibility to those with incomes below 138 percent of federal poverty level, as permitted by the Affordable Care Act, according to the Center for Public Policy Priorities.


Raimer pointed out a community-based approach in Galveston County that has made great strides in closing the gap of health care services for uninsured and underinsured since Hurricane Ike. In that time, the county’s uninsured rate has fallen to about half what it was in 2008.

Galveston County residents who live at 100 percent or less of the federal poverty level — $12,752 for a single person and $24,858 or less for a family of four — can generally find services at the county’s Coastal Health & Wellness Centers, clinics offering primary care services to uninsured and underinsured people for discounted rates based on financial screening.

“As of May 31 this year, we’ve seen 5,630 unduplicated patients who had no insurance or were underinsured,” said Ashley Tompkins, spokeswoman for the Galveston County Health District that runs the clinics in Galveston and Texas City. “That’s 70.2 percent of all patients served.”

Galveston County also funds an indigent health care program for secondary and tertiary care — conditions requiring a specialist, hospitalization, invasive treatment or surgical procedures — to the tune of about $2.5 million a year, according to the county operating budget. A little less than half of that money goes to Clear Lake Regional Medical Center for services to uninsured and Medicaid patients, according to county attorneys.

Additionally, the county maintains an indigent care fund set up in 2010 with somewhere between $9 million and $10 million in it, though taxes levied for that purpose post-Hurricane Ike have been lowered and diverted to pay bond debt services in recent years, said Randall Rice, county auditor.

In 2018, the indigent health care program served 660 patients, Tompkins said. To be eligible for the program, patients must first be enrolled as patients at the county health clinics.

St. Vincent’s House hosts a free clinic in Galveston and other community groups provide aspects of care to uninsured people who can find them.

But often, working people who don’t qualify for indigent care programs or for federal assistance find themselves uninsured, not enrolled or unaware of local programs and at risk of a range of problems associated with not being insured.


Herbert Cotto works at the Port of Galveston in traffic control, helping the 10,000 or so cruise ship passengers passing through most weeks onto and off their ships. It’s a good job for Cotto, who moved to Galveston from Brooklyn six years ago.

But until he has been at the port for 90 days working at least 40 hours a week, he’s not eligible for health insurance, he said, and he and others compete for those hours.

Cotto previously worked at Walmart and had insurance until his hours there got cut back to the point he could no longer pay his bills, he said. For much of the past year, Cotto, 58, has been uninsured, he said.

“I try not to get sick,” he said. “If I got sick, I’d use home remedies.”

Sometimes getting sick is unavoidable. A strep infection in recent months led Cotto to an emergency room visit to the University of Texas Medical Branch, rather than wait for an appointment at a clinic and risk missing work.

“I have a bill there now for $1,500 and all I had was strep throat,” he said. “All they did was look in my mouth and give me a penicillin shot in my butt.”

Like many who fall into the gap between government-assisted insurance and private insurance, Cotto makes too much to qualify for Medicaid and not enough to pay high medical bills while waiting for his employee insurance to kick in.

“If I get sick, I have to just pay the bill out of my pocket,” he said. “Then I can’t afford anything else.”

In 2016, Texas ranked second only to Mississippi in the prevalence of adults who hadn’t seen a doctor in the last year because of cost, according to a Kaiser Family Foundation study.


In Texas and in Galveston County, children fare better than adults, with about 10.7 percent of Texas youngsters uninsured, compared to 23.5 percent of adults aged 19-64.

The difference is mostly due to availability of public insurance, Medicaid and Children’s Health Insurance Program or CHIP for children. But even by that measure, children in Texas rank at the bottom of U.S. states with the worst uninsured rate for children and teens, according to the 2019 KIDS Count survey by the Annie E. Casey Foundation.

Even if families can find coverage for their children, without insurance of their own they can face severe consequences, like avoiding treatment when sick and facing a high risk of medical debt. In Galveston County, 61 percent of the uninsured are members of working families.

In 2017, three in 10 uninsured adults under 64 said they were paying off at least one medical bill over time, according to the Kaiser Family Foundation. Nearly 59 percent interviewed by the foundation reported being contacted by a collection agency for medical bills, and more than half said they’d had problems paying household medical bills in the past year.

If the Affordable Care Act is struck down, with it goes the option for Texas to expand Medicaid, as well as the health care insurance policies of some 14,000 Galveston County residents. In Texas, the number of uninsured under 65 could increase from 4.6 million to 6.4 million, according to the Urban Institute.

“It has to begin to affect the decision makers themselves before things change,” Raimer said. “When the health of society impinges on the ability to hire good people in the workplace, that’s a force that will draw attention.”

Either that or a collective outcry based on the embarrassment and shame of having so many uninsured, Raimer said. Social Security came about that way, when people were so embarrassed by conditions for the elderly, Raimer said.

“That’s honestly— and I’m speaking as a person who teaches health policy — the only way things change,” Raimer said.

“At some point, we’re just going to have to say we’re not going to tolerate that anymore.”

Kathryn Eastburn: 409-683-5257; kathryn.eastburn@galvnews.com.

(18) comments

Bailey Jones

Mr. Trump promised us the best health care we've ever seen, at a cost lower than we can believe. Of course, that was before he discovered that "Nobody knew health care could be so complicated".

IMHO, in the richest country in the world, the difference between being wealthy and being poor should be a matter of whether you drive a Lexus or ride a bike, whether you own a big house or rent a tiny apartment, and whether you shop at the Galleria or the thrift store, not whether you live or die.

I'll sit back now and watch while the abysmal insurance coverage in Texas gets blames on immigrants and Democrats.

Carlos Ponce

We could have had a better health plan..... But Senator (you know who) voted against his own promised aye vote.

Bailey Jones

Trump Kool-Aid, Carlos. All that TrumpCare bill would have done is repeal the individual mandate. Which means that your "better health plan" is just ObamaCare without the individual mandate.

Carlos Ponce

"All that TrumpCare bill would have done is repeal the individual mandate." HR 1628, the Health Care Freedom Act" did FAR MORE than repeal the individual mandate. See text:


Bailey Jones

"the Health Care Freedom Act" did FAR MORE than repeal the individual mandate." No, it didn't. But it do did a LITTLE more - it defunded Planned Parenthood, it eliminated the employer mandate, it temporarily raised the cap on HCAs, it gave states the "freedom" to limit coverage, it banned the medical device tax for three years, and it cut funding for the Centers for Disease Control and Prevention. Health care solved!

Carlos Ponce

It would have done far more than what you mention.

Paul Steele

“I have a bill there now for $1,500 and all I had was strep throat,” he said. “All they did was look in my mouth and give me a penicillin shot in my butt.” What a ripoff. Time to manage/control medical cost please.

Carlos Ponce

"Time to manage/control medical cost please." Unless you're in a "grocery store desert" when you shop, you select a store with the best prices. Why not the same for health care providers? Competition through price posting would lower costs.

Strep Throat Treatment:

Provider A: Cost $500

Provider B: Cost $100

Provider C: Cost $750

Provider D: Cost $1500 - You picked this one. Maybe because you like the magazines in the waiting room?

"Just because you've become a grown man now

There's still some things that you don't understand now

Before you ask some doctor for some care now

Keep your money for as long as you can now"

My mama told me, you better shop around

Oh yeah, you better shop around" - Apologies to Smokey Robinson[beam]

Gary Scoggin

Gee, Carlos, I never knew it was this easy. In the real world, though, I think you have to consider things like...

-Am I on a medical plan that forces me to a certain doctor.?

-Can I actually get a cost estimate before the doctor sees me, at which point I already owe her money?

-What will the non-doctor costs - drugs, hospitals, etc. -- be?

-What am I being charged as a cash payer versus any discounts i can negotiate?

-Is my condition acute enough that I don't have time to shop around? (Like with strep throat, maybe.)

-Do I have an established relationship with a particular physician?

-How long do I have to wait to get an appointment outside of a urgent care setting?

Or I suppose we could just take advice from a 60 year old Motown song.

Carlos Ponce

"Shopping around" means you take the things you list under consideration.

Jim Forsythe

If the ACA is done away with, a person does need to worry because they can just call around for the best price? Unless a program is passed, why would you do away with one that covers many people? If we do strike down ACA it will be back to 14,000 more Galveston County residents depending on the ER for their health care.

"If the Affordable Care Act is struck down, with it goes the option for Texas to expand Medicaid, as well as the health care insurance policies of some 14,000 Galveston County residents. In Texas, the number of uninsured under 65 could increase from 4.6 million to 6.4 million, according to the Urban Institute."

Herbert Cotto needs to be applauded for making sure he was able to do his job, because he took care of his health needs quickly, and did not have to miss work. Not may options on the weekend, except some type of ER. Tell them you are shopping around and see how well that would work.

Carlos Ponce

Federal district court Reed C. O'Connor has already struck down the law as un-Constitutional. Congress should work on a replacement ASAP. But alas, the current House wants to ride that dead horse.

Jim Forsythe

If the ACA was dead, then it could not be alive. Does this ruling include all appeals? The House and the Senate are set up to require more than 50% pass bills. A President should be able to promote good bills with both sides of the isle. If nothing is passed, why do away with what we have?

Reed C. O'Connor has already struck down the ACA many times, so what is different this time?

Carlos Ponce

All District court decisions can be appealed. That's why it's still partially in effect pending the outcome. Doesn't look good for ACA.

Jim Forsythe

So the ACA is not a dead horse.

Carlos Ponce

The judicial climate says the ACA is terminal.

Jim Forsythe

Over 70 Republican-led attempts to repeal the ACA ,and it's still ticking. The reports of ACA's death are greatly exaggerated

On February 3, 2015, the House of Representatives added its 67th repeal vote to the record (239 to 186). This attempt also failed

The Tuesday, February 2, 2016 vote, with a tally of 241–186, was the 63rd attempt by the House.

After the July 27, 2017 vote on the Health Care Freedom Act, Newsweek "found at least 70 Republican-led attempts to repeal, modify or otherwise curb the Affordable Care Act since its inception as law on March 23, 2010

Carlos Ponce

The ACA is as good as dead. It is un-Constitutional. The only reason it passed SCOTUS review last time is now gone.

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