Professor says Texas' insurance complexity and coverage gap underpin high prices

Ken Yanda, a professor of population health at the University of Houston College of Medicine, told the Select Committee on Health Care Affordability that the U.S. insurance marketplace is structurally complex and that Texas’ decision not to expand Medicaid has left a sizable coverage gap.

"It's actually worse in Texas, because we did not, fully implement the Affordable Care Act, and so we have, a lot of people that are still in that...Texas coverage gap, which is about 1,000,000 people," Yanda said. He framed the insurance system as multiple concentric layers—suppliers, purchasers, and middlemen—that interact with varying regulatory regimes and produce price complexity.

Yanda described how different channels—employer-sponsored plans (fully insured and self-funded), Medicare Advantage, and the ACA marketplace—create distinct purchasing rules that influence premiums and access. He said recent subsidy reductions drove some enrollees to cheaper (bronze) plans with much higher deductibles, which preserves coverage but raises patients' out-of-pocket risk.

Why it matters: Yanda argued that the coverage gap and market fragmentation shift costs to providers and consumers and blunt competitive pressure. Committee members pressed him on policy responses, including the financial and political tradeoffs of Medicaid expansion and targeted subsidy strategies.