County Indigent Care programs fill coverage gaps left by Medicaid restrictions: evidence from Texas

Abstract

Introduction

Medicaid restrictions exclude some low-income adults, especially in nonexpansion states and among immigrants. Local governments are payers of last resort. Texas offers an important case study: state law requires counties to maintain Indigent Care programs to extend healthcare coverage for uninsured low-income residents, yet no recent report describes their structure.

Methods

We cataloged programs in all 254 counties, using publicly available data, contact with county officials, and a state open records request, characterizing reporting, eligibility, and services, along with estimates of uninsured working-age adults in counties with broader eligibility and services, overall and by county metropolitan status.

Results

Required annual reports were unavailable for 144/254 (57%) counties, and 19/254 (7%) had eligibility or benefits inconsistent with state law (minimum eligibility of 21% of federal poverty level—FPL; $30 000 of care including prescription and skilled nursing). 39/254 (15%) set income eligibility ≥138% FPL, reaching 50% of uninsured adults but only 14% of uninsured adults in nonmetropolitan counties. 5/254 counties (2%) combined higher income thresholds with broad service availability; all were metropolitan, containing 47% of uninsured adults statewide.

Conclusion

Indigent Care reaches those excluded from Medicaid, but eligibility and services varied widely, and more generous programs were only in metropolitan counties.

Background

Medicaid is a major source of health insurance for low-income adults in national coverage estimates, but eligibility is limited by state expansion decisions and federal restrictions based on immigration status. These federal limits are especially consequential in non-expansion states. In 2023, Texas had the highest proportion of uninsured adults in the country, with 21.6% of working-age (19-64) adults lacking coverage.¹ In Texas, childless, non-pregnant adults are ineligible for Medicaid unless they are disabled, even at very low incomes. However, upwards of 18% of some county hospital patient populations may be “non-qualified” immigrants federally barred from receiving health benefits by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996² and thus excluded from Medicaid despite income eligibility.^3,4 Generally, qualified immigrants include lawful permanent US residents and refugees, while non-qualified immigrant categories include undocumented immigrants and other lawfully present noncitizens, such as students. As a result, financial responsibility is often shifted to safety-net providers and local governments to fill the coverage gap.^5,6

This part of the healthcare safety-net is poorly described, and Texas is an important case study because of the magnitude of uninsured adults in the state. The Texas County Indigent Health Care and Treatment Act, enacted in 1985,⁷ required counties to finance Indigent Care programs for qualifying low-income residents. The Act was intended to replace the prior “inequitable and unstable delivery system” that revolved around individual county hospital charity care, hampering the ability of low-income Texans to receive medical care.^8-10

The statute established minimum requirements, including coverage of basic services such as primary care, family planning, and hospital care; income eligibility for residents up to at least 21% of the Federal Poverty Level (FPL); and minimum benefit levels of up to $30 000 a year or 30 days of combined hospital or skilled nursing facility days, whichever is reached soonest. Counties and Indigent Care programs have the discretion to exceed these minimums and adopt broader eligibility, additional services, and offer other benefits.

Local financing arrangements can vary. Some counties support hospital districts that separately levy property taxes and may fund more comprehensive care by using this additional source of revenue to support healthcare services for the uninsured. Unlike Medicaid, Texas Indigent Health Care Programs (hereafter, Indigent Care) must extend eligibility to all county residents who meet minimum income eligibility established by state law, but have the discretion to expand eligible income levels. As a result, these programs may provide a local coverage pathway for residents excluded from Medicaid, but their reach and generosity depend on county-level implementation.

Despite the potential importance of these programs, there is little systematic information about their eligibility structures, covered services, and program compliance. We therefore sought to assemble a comprehensive, cross-sectional mapping of Texas Indigent Care programs. We then analyzed the structure and extent of clinical care access afforded by these programs.

Methods

Indigent Care Act

The Indigent Health Care and Treatment Act requires each county to offer a basic health care financing system for uninsured indigent residents, though there are no specific mandates on actual enrollment. These Indigent Care programs can be operated by the counties directly or through hospital districts and public hospitals. In addition to the minimum threshold for household income and total annual coverage requirements, the legislation also specifies required minimum clinical services, including 3 prescriptions per month. Although other provisions have been updated since passage, these are the minimum benefit requirements that remain in place today.⁷ We outline specific provisions of the legislation as of 2026 in Appendix Table S1.

Data collection

From February to October 2025, we cataloged each county Indigent Care program using publicly available information on state and program websites. We first searched county, hospital district, and public hospital websites for current eligibility, application forms, and covered services information. We contacted county and hospital officials to obtain missing information and resolve discrepancies. We used records from the state to supplement remaining gaps in data. When sources conflicted, we used the most recent information verified by the responsible county program. Because of the complexity of extracting and collating structured data across multiple sources, 2 study-team members independently reviewed the final county-level coding to ensure accuracy.

The state legislation requires monthly and annual financial and program reports (Forms 3072¹¹ and 3086,¹² respectively) to be submitted to the Texas Health and Human Services Commission County Indigent Health Care Program. These reports document the total number of clients served, total expenditures, and the FPL level for income eligibility. Additional reporting requirements include notice of program eligibility changes and documentation of optional services covered (Form 3083).

We used as search terms: “[Name] County” + “Texas” + “Indigent Healthcare” OR “Indigent Care Program” for each county to find income eligibility thresholds.

In November 2025, we filed a Texas Public Information Act request for Forms 3072, 3083, and 3086, Form 3069 (Health Care Services Record), and Form 3088 (Request for State Assistance Funds) to the Texas Department of Information Resources.¹³ A single request was made for information pertaining to all 254 counties. The request was fulfilled in December 2025.

Email inquiries were then sent to the county treasurer for each of the remaining counties without available Indigent Care program information, with treasurer email addresses sourced from a directory maintained by the County Treasurers’ Association of Texas.¹⁴ To simplify our request and avoid overwhelming local officials, we limited emailed requests to 2 forms: 3086 (End of Year Financial Report) and 3083 (Optional Services Provided). Up to 2 emails were sent to each county official.

For each county, we defined whether program reports were unavailable or incomplete, and whether county officials responded to our inquiries. If officials referred to others that did not lead to confirmed program criteria, we noted this as well. Finally, we noted whether counties reported any annual numbers of program enrollees.

Hospital Districts are distinct, separately taxing entities that are approved by county voters.¹⁵ Counties can have multiple hospital districts, but multiple counties can also join to create a shared hospital district. From state reports, we identified county property tax levies from 2024¹⁶ and isolated those to the hospital districts to report on the total levied dollars per county.

We included county public hospitals only when they were responsible for the county's Indigent Care program. Other public hospitals that did not maintain Indigent Care would primarily offer charity care as part of their nonprofit status. While charity care is an important facet of safety-net financing, it largely serves to mitigate medical debt for care that has already occurred,¹⁷ not operate as access to more comprehensive care. For this reason, we did not separately catalog public hospitals that were not responsible for county Indigent Care.

We used US Census data to assemble the most recent year (2023) with a complete set of population statistics, including county-level sources of health insurance and rates of uninsurance (from US Census Small Area Health Insurance Estimates), total population, and metropolitan vs nonmetropolitan county status.^18-20 Metropolitan counties are those that contain a portion of a metropolitan area (eg, the Austin-Round Rock metropolitan area exists across Bastrop, Caldwell, Hays, Travis, and Williamson Counties—all designated as “metropolitan county”). We used a list of metropolitan counties maintained by the Bureau of Labor Statistics.²⁰ For our purposes, nonmetropolitan status was a county-level proxy for rurality and was intended to identify the bulk of rural residents within those borders.

Statistical analysis

We used descriptive characteristics to map Indigent Care programs (counts/percentages, medians/interquartile ranges). We estimated the per-capita hospital district tax levy between metropolitan and nonmetropolitan counties. We identified counties with broad service and income eligibility (program generosity), with income eligibility comparable to Medicaid-expansion states (up to 138% FPL or greater); no cap on annual dollar amount of care; availability of primary care (including obstetrics/gynecology and behavioral health) plus a broad array of specialty care (≥10 specialties available); and pharmacy benefit without a cap on prescription count or dollar amount. Finally, we narrowed to counties that met all prespecified criteria to define a subset offering broad eligibility and services. We then characterized reporting, eligibility, and reported services and estimated the proportion of uninsured adults residing in counties with broader program features, overall and by metropolitan status.

After ensuring access to primary care, pharmacy, hospital, and behavioral health, Medicaid network adequacy rules do not specify a required number or list of specialties,²¹ resulting in substantial variability in defining adequate specialty access.²² Because of this, we assessed the availability of 18 prespecified specialty services (cardiology, dental, dermatology, endocrinology, gastroenterology, hematology, infectious disease, nephrology, neurology, oncology, orthopedics, otolaryngology, podiatry, pulmonology, rheumatology, transplant services, urology, vision services). Availability was scored when a specialty was either based in the hospital system or as part of a visiting specialist program in an affiliated clinic. We classified programs as having broad specialty availability when at least 10 specialties (more than half) were available. We lowered this threshold from 10 down to 5 specialties in sensitivity analysis.

The University of Texas Southwestern Medical Center Institutional Review Board deemed this study non-human research (Y2-24-004).

Results

Data completeness, program reporting

Our website search identified 132/254 (52%) counties with income eligibility threshold or services information. The Public Information Act request provided information for 34/254 (13%) additional counties. We emailed county officials up to 2 times for the remaining 88/254 (35%) counties, but only 37/88 (42%) responded with the requested information.

Although the state legislation mandates annual reporting of the number of enrollees, program eligibility criteria, and spending,⁷ these reports were not regularly submitted. As such, information on Indigent Care programs was incomplete. Of the 254 counties, 43 (17%) made both an application and a list of covered services publicly available on a website, while 131/254 (52%) had neither available. Per our state open records request, 144/254 (57%) did not submit annual financial reports (Form 3086), and 123/254 counties (48%) did not provide the state with either annual or monthly reports (Forms 3086 or 3072) at any time during fiscal years 2022-2025. The state official confirmed that these were all the available reports—missing reports had simply not been submitted. For 75/254 counties (30%), we were unable to determine income eligibility thresholds from our sources. Only 24/254 counties (9%) were able to report annual numbers of program enrollees across all sources.

We identified 19/254 counties (8%) with eligibility or benefits that appeared inconsistent with a statutory provision of the Indigent Care legislation. These included 3 counties that confirmed by email having no program; 2 with an income eligibility at 8% FPL, below the minimum of 21%; 7 that imposed a US citizenship requirement; 4 counties that capped annual expenditures below $30 000; and 3 counties that did not cover specific mandated services (2 did not cover any prescription medications, and 1 did not cover skilled nursing facilities).

Indigent Care program characteristics and geographic variation

We identified a total of 148 hospital districts across 123 counties, with a total levied amount in 2024 of $4.48 billion. 172/254 (68%) counties were nonmetropolitan. These nonmetropolitan counties contained 3 282 934 of the 30 719 247 (11%) state population and 407 568 of the 3 943 892 (10%) uninsured adults.

Hospital districts were more common in nonmetropolitan counties: 94 of 172 (55%) nonmetropolitan counties had a hospital district, compared with 29 of 82 (35%) metropolitan counties. Additionally, 108/172 (63%) nonmetropolitan counties had a hospital-based Indigent Care program compared to 40/82 (49%) metropolitan counties. Among counties with hospital districts, the per-capita tax levy was substantially higher for nonmetropolitan than metropolitan counties (median $333 vs $120).

Program income eligibility and covered services varied widely (Table 1, Figure 1). 52/254 counties (20%) set income eligibility at 100% FPL or higher, including 39/254 counties (15%) that set eligibility at 138% FPL or higher (up to 400% FPL). Multi-county compacts or other intercounty agreements covered residents in 21/254 counties (8%). Since most counties (240/254 or 94%) did not specify an annual dollar cap on covered medical care, variation in the potential reach of county programs was determined primarily by income eligibility, pharmacy benefits, and specialty availability.

Table 1.

Texas County Indigent Health Care program characteristics.

	Counties (n = 254)	County populationa, median (IQR)	Uninsured adults residing in counties, n (%)	Uninsured adults residing in nonmetropolitan countiesa, n (%)
Hospital district within county, b  n (%)	123 (48%)	14 038 (5200-34 012)	2 541 179 (64%)	179 038 (44%)
Publicly available information, c  n (%)
Fully available	43 (17%)	58 829 (19 222-243 168)	1 638 348 (42%)	83 810 (21%)
No information available	131 (52%)	9751 (3180-30 532)	789 616 (20%)	186 008 (46%)
FPL for eligibility, n (%) d
Income eligibility threshold not confirmede	75 (30%)	6693 (3183-22 649)	192 309 (5%)	74 390 (18%)
≤21% FPLf	115 (45%)	22 978 (10 706-56 974)	1 022 416 (26%)	243 114 (60%)
22%-100% FPL	24 (9%)	46 539 (9845-209 919)	650 221 (16%)	21 085 (5%)
101%-200% FPL	24 (9%)	16 920 (8186-69 040)	1 231 327 (31%)	28 358 (7%)
201%-400% FPL	16 (6%)	24 915 (9151-50 278)	759 831 (19%)	30 541 (7%)
Multi-county compact, n (%)	21 (8%)	13 877 (5686-32 582)	123 926 (3%)	25 814 (6%)
Restricted eligibility on immigration status, n (%)	7 (3%)	114 931 (40 374-154 285)	145 120 (4%)	11 388 (3%)

Source: US Census estimates, 2023; US Census Small Area Health Insurance Estimates, 2023; US Census Metropolitan and nonmetropolitan counties, 2023; authors’ analysis of data from Texas county and county hospital websites, email correspondence with county officials, and a state open records request.

County Indigent Health Care Program legislation requires coverage up to $30 000 and eligibility of up to 21% FPL to county residents of any immigration status, as well as annual reporting on enrollment, expenditures, and program characteristics to the state office.

Abbreviation: FPL, federal poverty level.

^aUS Census estimates, 2023; US Census Small Area Health Insurance Estimates, 2023; US Census Metropolitan and nonmetropolitan counties, 2023 (172 out of 254 counties were nonmetropolitan); uninsured adults = uninsured working-age adults (19-64).

^bHospital District is a separately taxing entity. Because counties can have multiple hospital districts, the number of hospital districts is 148.

^cFully available = link to application and list of covered services available on county or hospital website; no information available = neither link to application nor list of covered services available through county or hospital website, regardless of whether information was eventually found in state reports or via county officials.

^dSource: publicly available reports, state open records request fulfilled in November 2025; confirmed or backfilled with direct contact to county officials.

^eNo information published, submitted to the state, or available from correspondence with county officials.

^f110 counties clearly identified at 21%, 2 counties at 8%, and 3 counties confirmed no program in existence.

Figure 1.

Household income eligibility thresholds for Texas County Indigent Care programs. Description: Eligibility threshold for county indigent healthcare program as % of Federal Poverty Limit per publicly available data and email correspondence with county treasurers. Source: Authors’ analysis of data from Texas county and county hospital websites, email correspondence with county officials, and a state open records request; figure generated using MapChart (https://www.mapchart.net/usa-counties.html).

Table 2 displays population and uninsured adults represented by counties with broad eligibility and service availability in Indigent Care programs. The 39/254 (15%) counties with at least 138% FPL eligibility represented 47% of the state population and 50% (1 981 312) of the uninsured adults in 2023. We found 41/254 counties (16%) with no identified cap on pharmacy benefit, representing 51% of the state and 55% (2 187 066) of the uninsured. 14/254 counties (6%) had broad availability of specialty care (≥10 of 18 specialties), though this covered 47% of the total population and 50% (1 962 032) of the uninsured.

Table 2.

Population reach of selected county Indigent Care program features.

	Counties (n = 254)	Total county populationa, n (%)	Uninsured adults residing in countiesa, n (%)	Uninsured adults residing in metropolitan countiesa, n (%)	Uninsured adults residing in nonmetropolitan countiesa, n (%)
Household income eligibility ≥138% FPL	39 (15%)	14 381 382 (47%)	1 990 967 (50%)	1 932 259 (55%)	58 708 (14%)
No identified cap on medical care benefitb	240 (94%)	29 613 075 (96%)	3 836 754 (97%)	3 447 442 (97%)	389 312 (96%)
No identified cap on pharmacy benefitc	41 (16%)	15 637 099 (51%)	2 187 066 (55%)	2 125 896 (60%)	61 170 (15%)
Access to broad specialty cared	14 (6%)	14 210 320 (47%)	1 962 032 (50%)	1 938 892 (55%)	23 140 (6%)
Broad program (met all criteria)	5 (2%)	13 184 550 (43%)	1 850 425 (47%)	1 850 425 (52%)	0 (0%)
Total	254 (100%)	30 719 247 (100%)	3 943 892 (100%)	3 536 324 (100%)	407 568 (100%)

Source: US Census estimates, 2023; US Census Small Area Health Insurance Estimates, 2023; US Census Metropolitan and nonmetropolitan counties, 2023; authors’ analysis of data from Texas county and county hospital websites, email correspondence with county officials, and a state open records request.

Abbreviation: FPL, federal poverty level.

^aUS Census estimates, 2023; US Census Small Area Health Insurance Estimates, 2023; US Census Metropolitan and nonmetropolitan counties, 2023 (172 out of 254 counties were nonmetropolitan); uninsured adults = uninsured working-age adults (19-64).

^bCounty program did not explicitly indicate an annual dollar limitation to covered care.

^cCounty program explicitly included a description of pharmaceutical coverage but did not state a limit on number or total dollar amount of spending. The remainder of counties either did include a cap on spending or count of medicines or did not convey information on any pharmaceutical coverage benefit.

^d≥10 specialties out of 18 offered by Indigent Care program. Included both specialists based in a county's hospital and visiting specialists in a clinic affiliated with that hospital. Included specialties: cardiology, dental, dermatology, endocrinology, gastroenterology, hematology, infectious disease, nephrology, neurology, oncology, orthopedics, otolaryngology, podiatry, pulmonology, rheumatology, transplant services, urology, vision services.

Only 14% (58 708 of 407 568) of nonmetropolitan uninsured adults resided in counties with income eligibility up to ≥138% FPL; 15% (61 170) resided in counties with no identified cap to pharmacy benefit, and 6% (23 140) resided in counties with availability of broad specialty care.

Programs with broad eligibility and services

Finally, when we applied all criteria for broad eligibility and service availability, we identified 5/254 counties (2% of all counties), which contained 43% of the state population and 1 850 425 (47%) of the statewide uninsured working-age adults. All 5 counties were metropolitan and contained 52% of the uninsured adults in metropolitan counties. No nonmetropolitan county met all criteria for a broad-based Indigent Care program.

This result was not sensitive to our specialty-availability count threshold. Lowering the threshold for broad specialty care from at least 10 to at least 5 increased the number of qualifying counties from 5 to 8 and modestly increased the proportion of uninsured residing in these counties from 46.9% to 47.5%. The proportion of rural uninsured residing in counties with broad specialty care increased from 0% to 2.2%. (Appendix Table S2).

Discussion

The Texas County Indigent Care program was characterized by limited reporting, wide variation in income eligibility and available clinical services, and a marked divide between metropolitan and nonmetropolitan counties. Nineteen county programs appeared to be inconsistent with at least one statutory requirement, whereas only 5—all metropolitan counties—fulfilled criteria to be classified as having broad eligibility and service availability. Although these 5 counties contained 47% of uninsured adults in the state, uninsured adults in nonmetropolitan counties generally faced substantially narrower program options.

Our findings relating to nonmetropolitan counties are notable because hospital districts were more common in these counties, but the broader income eligibility, pharmacy benefit, and specialty care were available to much smaller proportions of the uninsured adults residing in nonmetropolitan counties.

Interim state government reports have been published on the County Indigent Health Care Program⁹ in the distant past, but there has been no examination of the program in over 20 years, and we believe our work to be the most complete reporting in the modern era. The most recent is a report from 2004 by the Texas House of Representatives Research Organization that provided information on the number of Texas counties receiving state supporting funds.⁹ However, the report is not comprehensive. The bulk of the report reviews the Indigent Care legislation but did not include data on services provided, income eligibility, or other county-level features that we report here.

Other states⁶ and municipalities (notably New York City)²³ have visible and large Indigent Care programs that can provide robust clinical care.²⁴ For example, Georgia's Indigent Care Trust Fund integrates funding from the federal government, state appropriations, provider fees, and other sources, then routes these funds to providers who disproportionately serve indigent patients.⁶ Unlike Texas, this program does not appear to include a county-level mandate. New York City's program lists broadly similar services to those mandated by Texas (primary care, inpatient care, prescriptions), with a set of eligibility criteria.^5,23 Nevertheless, the scope of these programs nationally is less clear and infrequently reported.²⁵

Although Texas has not yet opted to expand Medicaid with increased Federal Medical Assistance Percentage from the Affordable Care Act, federal restrictions to Medicaid eligibility by immigration status^2,4 underscore the ongoing need for Indigent Care in states across the country. It is difficult to estimate the number of individuals excluded from Medicaid by immigration status vs income, but the most recent estimates suggest that expanding income eligibility in Texas would cover an additional 766 000 individuals,²⁶ which is less than one-fifth of the state uninsured population. States need practical policy solutions to cover those who are ineligible for Medicaid, especially as state-only funded options for Medicaid eligibility expansion are few and unstable,²⁷ supplemental Medicaid payments may be insufficient, and additional federal Medicaid eligibility restrictions are set to be enacted by the beginning of 2027.^28,29 As such, counties that impose a citizenship requirement for Indigent Care eligibility may weaken the availability of coverage and care for these individuals.

We also note that in their maximal form, county Indigent Care programs can operate as integrated health systems—both payer and provider for a circumscribed population. The comprehensiveness and quality of care in these settings deserve greater study compared to other coverage types and health systems.³⁰ Additionally, since less-populated counties can form multi-county compacts to jointly fund Indigent Care, but few exist, incentives to encourage formation of these or larger hospital districts may be an important policy mechanism for consideration.

In conjunction with local financing, Medicaid Disproportionate Share Hospital (DSH), directed, and other supplemental payments are intended to support hospitals serving large numbers of Medicaid and uninsured patients to support the cost of uncompensated care for safety-net health systems. However, federal reports have found weak alignment between state DSH allotments and uncompensated care burden and the provision of essential safety-net services.^31,32 In Texas, where coverage for uninsured residents relies heavily on county Indigent Care programs, hospital districts, and safety-net health systems, payment policy could more explicitly recognize systems that provide coordinated primary, pharmacy, specialty, hospital, and follow-up care—not simply hospitals with high patient volumes. Better alignment of supplemental payments with the scope and continuity of care provided to uninsured populations may strengthen safety-net capacity.³³ Although our study identified $4.4 billion available from hospital districts to fund uncompensated care, this is likely an underestimate because it does not include general revenues spent by counties without a hospital district. A fuller accounting of the costs of uncompensated care should also be balanced by the improved health delivered.

Alternatively, strengthening hospital charity care policies and state legislation¹⁷ encouraging their use can reduce medical debt and patient costs of care, but they are not equivalent to enrollment in a coverage program providing availability of primary and specialty care, as well as pharmacy and hospital benefits. Policies aimed solely at writing off medical debt do not address access to the full range of necessary medical care.

These findings should be interpreted with some limitations in mind. First, program information was incomplete and may be differentially available by hospital-district status or county size, potentially biasing our estimates. Second, our top-line estimates of uninsured who reside in counties with program features do not account for individual income eligibility or actual enrollment. Next, metropolitan status is a county-level proxy and may miss rural residents living within these counties (ie, rural residents living outside of the metropolitan area in a metropolitan county). Apparent statutory inconsistencies were based on available documents and correspondence, not regulatory review. Finally, availability of specialty care does not capture important dimensions such as timeliness of access.

Conclusion

County-financed programs are an overlooked source of health care services for low-income residents excluded from Medicaid. However, eligibility, available services, and public reporting varied greatly by county and favored residents of metropolitan over nonmetropolitan counties. Clearer state oversight and reporting are needed. Future work should compare Indigent Care programs to Medicaid on access, financial protection, and outcomes and examine how other states structure Indigent Care to mitigate coverage gaps.

Supplementary material

Supplementary material is available at Health Affairs Scholar online.

Funding

Arthur Hong was supported by the American Cancer Society (DBG-25-1374401-01-HOPS) and the Texas Health Resources Clinical Scholar Program.

Data availability

Please contact the corresponding author for use of study data.