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Texas has more uninsured people than any other state, whether you count in raw numbers (about 5.4 million) or in the uninsured percentage of the total population (18.4%). But it’s one of only a dozen states that hasn’t expanded its Medicaid program.

Whether lawmakers suddenly change their mind about that program or not, they still have a problem to solve: How do they get health insurance, or cheaper health care, for all of those people?

Every two years, somebody in the Texas Legislature attempts to get the state to expand its Medicaid program. Democrats have tried it. Republicans have tried it. But every year, the Legislature turns a collective deaf ear to the efforts. Texans in Congress even tried going around the state government to get it done, to no avail. Expansion comes with a 9-to-1 match, meaning the federal government spends $9 for every $1 a state contributes.

And states that take part have lower numbers and rates of uninsured people.

According to the U.S. Census Bureau, 8.9% of adults were uninsured in 2020 in states that had expanded Medicaid. In the states that hadn’t, including Texas, the uninsured rate was 17.6%. In 2019, 18.4% of Texans were uninsured, according to the state comptroller’s office. That was the highest rate in the country, and double the national average of 9.2%. When the numbers are limited to just those Texans under age 65 — who aren’t eligible for Medicare, for instance — the percentage of uninsured in the state swells to 20.8%.

Before the 2021 legislative session, a group of experts urging the state to join the federal program argued that doing so would contribute $75 million to $125 million to the state budget every two years. It would also, they argued, reduce uncompensated care in hospitals and emergency rooms, and would encourage preventive care, early detection and improved disease management.

“In addition, the infusion of billions of external dollars into the Texas health care system each year will have downstream positive effects on the economy,” they wrote.

Expanding Medicaid isn’t the only way to solve the problem, but the state isn’t doing much else to try to cut into the number of Texans who don’t have insurance.

One argument over the years is that uninsured Texans can get care in emergency rooms and hospitals. A common counter-argument is that insuring more people would be cheaper in the long run, and better for their health. And Texans have to pay either way: The bills for that so-called uncompensated care are footed by other patients and taxpayers who pay for those medical facilities and the care they provide through their own medical bills and local hospital taxes.

And, according to the people who study these things, expanding Medicaid would be a better deal for taxpayers. “We estimate that 954,000 newly eligible adults would enroll in an expansion, bringing approximately $5.41 billion in federal dollars annually to the state,” they wrote.

Other conservative states were initially against expanding Medicaid, too, but that resistance has thawed over the years. Now, only a dozen states, including Texas, continue to opt out. During last year’s regular session — as in the procession of sessions before it — Texas lawmakers voted it down.

So, no Medicaid expansion for Texas — a familiar result every time lawmakers have considered it through the last three presidencies.

But it’s just a program, one possible solution to a perplexing public policy predicament that remains unsolved and apparently beyond the abilities of the Texas state government.

Almost 1 in 5 Texans don’t have health insurance, the worst numbers in the country, and we’ve been at the bottom of that barrel for a long, long time.

Disclosure: The Texas Comptroller of Public Accounts has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.