Nearly one in five people living in Greater Houston lacked health insurance last year, giving the region the highest uninsured rate among major metropolitan areas in the United States, according to new Census Bureau figures released Thursday.

The Houston metropolitan area’s 18.6 percent uninsured rate in 2018 is more than double the national rate of 8.5 percent, and almost a full percentage point higher than the overall rate for Texas — the state with the highest rate and number of uninsured in the country, the figures showed

Put another way, the Houston area last year led the state that led the nation.

Roughly 50,000 more people in the Houston area lacked coverage in 2018 than the year before. Nearly half of those — or about 24,000 — were under 19.

The uninsured rate among children in Houston was 11.6 percent last year, a close second among the most populous metro areas to Dallas, at 11.7 percent, the census data showed.

“It’s disappointing because we like to boast that Houston’s economy is so strong,” said Vivian Ho, a health economist at the Rice University’s Baker Institute for Public Policy. “But if it’s so strong why are there so many people who can’t afford health insurance?”

On HoustonChronicle.com: Texas once again leads nation in uninsured

Houston is not the only Texas metropolitan area struggling with high uninsured numbers. Of the nation’s 25 most populous metro areas, Houston, Dallas and San Antonio held the top three spots. The large metro area with the lowest uninsured rate was Boston at 2.9 percent, according to the Census Bureau.

The impact of a large population without health insurance reaches beyond those without coverage, analysts and health care professionals said. “It affects all of us,” said Porfirio Villarreal, a spokesman for Houston Health Department

Everyone pays

When people are uninsured, he said, they often skip needed care or checkups that could detect underlying health issues, setting up a vicious circle in which delaying treatment leads to worsening outcomes, which in turn means treatment becomes more extensive and expensive - often in emergency rooms. Then, if that treatment goes unpaid it is passed on to hospitals already struggling under the weight of uncompensated care.

That can end lead to higher property taxes to make up for the shortfall at public hospitals, where the uninsured often land.

Dr. David Fleeger, an Austin colon and rectal surgeon and president of the Texas Medical Association, added the cost of caring for the uninsured by doctors, the hospitals and clinics is also ultimately passed on to people with insurance in the form of higher premiums. The uninsured rate “is probably the number one public health issue for Texans and for Texas doctors,” Fleeger said.

Jessica Salazar, a single mother and temporary Houston city employee, would love to have health insurance for herself and her seven-year-old son, but it is simply out of reach. She brings home roughly $2,400 a month and the payroll deduction for coverage is a quarter of that — or about $600. She tries not to skip doctor visits, but every pediatrician visit is $80 plus whatever treatment or medicine is needed. “I do get worried, but I just can’t afford it.”

Taylor Moore, a 19-year-old college student in Katy, worries, too. She has been uninsured since May, when she aged out of the Children’s Health Insurance Program, or CHIP, for low-income children. Her father died about 10 years ago; her mother died last year. Now she is on her own. Living without health insurance only worsens the anxiety issues that haunt her.

“If I get sick, I miss school and I’m paying for school,” she said. “ If I get sick I miss work and I can’t pay my bills,” she said.

Many in the region predict the number of uninsured will climb even higher as even those eligible for coverage through government programs drop off the rolls, particularly within immigrant communities. Those providing health care in those neighborhoods say legal immigrants and their children are skipping care out of fear of losing a chance for citizenship because of new policies enacted by the Trump administration.

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In August, the acting director of the Citizenship and Immigration Services office announced tougher rules for those seeking green cards or visas, making eligibility tied to use or likely future use of government assistance programs, including for health coverage.

Alarming rise

Dr. Sogol Pahlavan, a pediatrician in a low-income, mostly Hispanic Houston neighborhood, has grown alarmed by the rise in children she sees who are uninsured. She said she believes it’s a direct result of stricter immigration policies even though some of the children are U.S. citizens.

About 5 percent of the children at ABC Pediatric Clinic have switched from Medicaid to self-pay. But the reality is that their parents can’t pay so their children often do without.

“They say, ‘I don’t have Medicaid anymore and I can’t afford the doctor charge or the $200 asthma medicine’,” she said, adding that this is deeply troubling because “their asthma is not going to just go away.”

In Texas, enrollment in CHIP has dropped more than 7 percent to about 369,000 in June 2019 from 399,000 in June 2017. Medicaid enrollment in the state has fallen by more than 100,000 to 3.9 million this summer from just over 4 million in the state in 2017.

“If we keep going like this,” said Ho, the Rice University economist, “it’s going to break the back of our health care system.”

Erin Douglas contributed .

jenny.deam@chron.com