Janek's Scrutiny of U.S. Census Bureau Uninsured Statistics Draws Critics

In an interview at The Texas Tribune Festival last month, newly appointed Health and Human Services Commissioner Kyle Janek made what to some health care observers was a startling suggestion — that the U.S. Census Bureau’s projection that a quarter of the Texas population is uninsured is inflated.

His reasoning was two-fold.

First, he argued the Census Bureau’s American Community Survey — the largest household survey in the U.S., which has a national sample size of 3 million addresses and puts Texas’ uninsured population at 23 percent — asked the wrong question. It asked whether respondents had health insurance now, he said, as opposed to whether they had it at any point in the previous year.

“To say ‘I did not eat a hamburger today’ does not mean I never eat hamburgers, that I won’t have a hamburger tomorrow or the day after that,” he said. “You can’t say, ‘We’ve got this huge population of people who never eat hamburgers.’”

Then he said the uninsured numbers suggest that just because people don’t have a health insurance card in their wallet they don’t have a safety net — when they can get taxpayer-funded care from their local hospital district.

“If Harris County Hospital District, and Parkland Hospital, and the Tarrant County Hospital District, Bexar County Hospital District tomorrow created a card and put it in the wallet of all those people who come to their hospital districts for services, and said, ‘This is your insurance card,’ you would see a dramatically different answer to that question,” Janek said.   

There’s a flip side to his first argument: The Census Bureau’s Current Population Survey, which asks whether respondents had health insurance at any point in the previous year, also puts Texas’ rate of uninsured at about a quarter of the population. That survey is much smaller — it has a national sample size of 100,000 addresses — but is more detailed and conducted by more experienced staff.

“The suggestion that Texas would shoot to the top because of the way the question is asked — I cannot think of any reason why anything would be different here,” said Anne Dunkelberg, associate director of the liberal Center for Public Policy Priorities. “The same conditions exist here that exist in the whole country, except we have more people uninsured, and we’re spending billions of dollars in local property taxes” on hospital care.

Janek’s second argument — that the numbers are inflated because they don’t take into account the care provided by local hospital districts — has drawn critics, too.

Dr. John Holcomb, a San Antonio pulmonologist who chairs the Texas Medical Association’s Committee on Medicaid, CHIP and Access to Care, said there’s simply no comparison between having insurance and seeking care from a hospital district.

“If you really had an insurance policy, it wouldn’t stop at the county line,” he said. “It’s an un-useful form of insurance because it’s not insurance at all.”

And Tom Banning, executive director of the Texas Academy of Family Physicians, said residents of large areas of Texas, particularly South Texas and many rural communities, don’t have the benefit of a hospital safety net system.

In his remarks at the Tribune Festival, Janek acknowledged that hospital districts are an imperfect solution, but said including their services in an uninsured calculation would produce a “dramatically different number.”

“I don’t know what that absolute [uninsured] number is. It depends on how you measure it,” he said. “My job as executive commissioner at Health and Human Services is to make sure we maintain that safety net.”  

Holcomb said the metrics used to determine Texas’ ranks of the uninsured have been used across the nation for decades, and that there’s no second-guessing them.

“No matter which metric you want to use,” he said, “Texas is still in last place.”