For Elizabeth Davila, a 67-year-old San Antonio resident and part-time receptionist at a local church, keeping ahead of health care costs for herself and her three grandchildren is a daily financial burden. Her youngest granddaughter was diagnosed with diabetes in the fifth grade, and all four family members are covered by Medicaid, the nation’s largest health insurance program that covers low-income people.

Davila says she isn’t certain how much longer she will need to work to maintain health insurance coverage for her family, in addition to paying off an existing bill from a recent surgery. Davila is close to retirement age, but must continue working to make the reduced payments for her grandchildren’s insurance plans.

“It worries me. My granddaughter can’t survive without her medication,” she said. “It’s difficult because I’m raising three grandchildren and one of them is in college already.”

Davila is one of hundreds of San Antonio residents who struggle to afford health insurance. The percentage of those with health insurance dropped slightly in San Antonio last year, the latest U.S. Census bureau data shows.

The percentage of San Antonians who had health insurance dropped 0.4 percent from 83.9 percent in 2016 to 83.5 percent in 2017, according to the data released Thursday. Meanwhile, the percentage of uninsured San Antonio residents increased over the same time period by 0.25 percent to 16.5 percent, or 246,363 people.

Texas has the largest percentage of uninsured residents in the country at 17.3 percent, the data shows. The percentage marks the highest in Texas since 2014.

Income is the No. 1 predictor of whether or not a person has health insurance, said Anne Dunkelberg, associate director for the Center for Public Policy Priorities (CPPP), an Austin-based nonprofit that analyzes state-level socioeconomic data.

One reason that could explain the drop in coverage in Texas cities, Dunkelberg said, is the state’s decision to opt out of Medicaid expansion – the primary source of health insurance for many low-income adults – in 2012.

“We’re one of the 16 states that haven’t done Medicaid expansion,” she said. “When you look at the 14 states where uninsured rates got worse, 10 of the 14 are those states that haven’t expanded Medicaid.”

Seniors below the poverty line, adults with disabilities, and women who are pregnant during coverage are eligible for Medicaid. Expansion of medicaid would expand eligibility to uninsured adults and children whose incomes are at or below 138 percent of the federal poverty level, according to the National Alliance on Mental Illness.

“The bottom line is that this had the effect of driving up premiums and deductibles for those who don’t get subsidies,” she said.

San Antonio reflects similar patterns as the state and county for income brackets who are uninsured, where those making less than $25,000 have the lowest percentages of coverage.

According to the Census data, 76.9 percent of those making less than $25,000 in San Antonio have health insurance, compared to upwards of 82 percent for those making $50,000 or more. In Bexar County, the percentage of those making less than $25,000 who have health insurance is 77.2 percent.

The map below shows the percentage of the population with health insurance by zip code for San Antonio in 2016, the most recent year for which figures are available.

The zip code 78202, which includes the Government Hill neighborhood, shows the lowest percentage of insured people – 69 percent. The areas where the most residents have insurance include military bases, like Lackland Air Force Base, and much of the North Side.

“It’s not surprising that we’re seeing insurance rates [of coverage] go down in these areas,” said Tiffany Hogue, policy director at the Texas Organizing Project, a nonprofit group focused on health care access. “You can see in low income communities of color there’s a higher rate of the uninsured. They experience lots of overlapping realities, people working in low wage jobs, or [those who] are impacted by the criminal justice system.”

Hogue said these experiences combined with a lack of internet access or internet skills were common barriers to low-income communities being able to obtain insurance.

While organizations like the Texas Organizing Project continue to grapple with health insurance affordability for Texas’s low-income residents, Davila wonders how much further beyond retirement she will need to work to keep up with her health care costs.

“Will this mean that I have to work until I drop dead?’ she said. “It seems that way. I’m just trying to make it day by day.”

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Emily Royall

Emily Royall is the Rivard Report's former data director.