A high uninsured rate, tough Medicaid regulations, and a lack of services has given Texas some of the highest rates for disease and death.

You don’t want to be sick in Texas.

The federal government’s latest National Healthcare Quality and Disparities Report (NHQDR) gives the Lone Star State some poor grades.

Overall, Texas ranks fourth from the bottom, across all measures, ahead of only New Mexico, Nevada, and Alaska.

Texas also does the worst job in the nation at caring for Hispanics and manages only somewhat better with African-Americans.

Even the rich are affected. In the report, Texas ranks 41st in healthcare for high-income folks.

Texas is home to 4.5 million people without health insurance.

In fact, Texas now has more uninsured people than California, based on U.S. Census data released in September, despite the fact California has nearly 40 million residents compared to 28 million in Texas..

The Affordable Care Act (ACA) made a difference, bringing coverage to 1.2 million Texans and pushing the percentage of uninsured down from 22 percent in 2013 to 16 percent today.

But that’s still the worst rate in the nation.

Most of those newly insured Texans bought a plan through the ACA or directly from an insurer, although the state did little to encourage them.

“Texas opted not to create an in-person assistance program and passed laws that effectively limited the ability of community organizations to help consumers enroll,” writes Dr. Benjamin D. Sommers, assistant professor of health policy and economics at the Harvard T. H. Chan School of Public Health in Massachusetts.

Texas is also one of the 18 states that currently turn down federal dollars to help people who don’t qualify for subsidies to buy a private plan under the ACA and also aren’t eligible for Medicaid under their state’s rules. (Residents of a 19th state, Maine, voted to expand Medicaid, accepting that money in a referendum last week.)

The choice in Texas “has to do with the personality of the governor and lieutenant governor,” Anne Dunkelberg, associate director of the Austin-based Center for Public Policy Priorities, told Healthline.

She pointed out that most professional groups wanted to expand Medicaid.

An analysis published by the Henry J. Kaiser Family Foundation found that 638,000 Texan adults fell into the gap in 2016.

Many of them have children at home. Around three-quarters are people of color.

The public misunderstands this group, says Dunkelberg.

“Most people think everyone in poverty gets Medicaid, and that’s not true. You’ll hear that Medicaid expansion was for childless adults. That’s not true either,” she said. “People assume the uninsured are undocumented folks, but we’re still tied for last place even if you remove the undocumented.”

Medicaid was tight to begin with.

Texas and Alabama are tied for the prize of being the state with the lowest income cap for parents to qualify.

Childless adults who aren’t disabled aren’t eligible at all.

There is no adjustment for medical costs.

To get Medicaid because of a disability, you must not be able to work at all or be within 12 months of the end of your life.

As Dunkelberg explains, that leaves out “hundreds of thousands with mental illness, with multiple sclerosis, or with Crohn’s disease” who can work but earn little.

In California, which did expand Medicaid, the uninsurance rate fell from 17 in 2013 to 7 percent.

Even among insured Texans, up to a third face unaffordable costs if they get sick.

Deductibles are higher in employer plans in the state than in New York and California.

So, Texans aren’t getting all the care they need.

In a survey of 1,000 low-income Texan adults at the end of 2014, Sommers found that half didn’t have a primary care physician.

Nearly a third had put off necessary medical care in the past year because they couldn’t afford it.

If you skip routine care long enough, you run more risk of needing urgent hospital care.

The consequences show up in the NHQDR, which crunches data on more than 200 measures and compares each state to an “achievable benchmark” based on the top performers.

A low-income Texan is two to five times more likely to be hospitalized for diabetes (depending on age and the type of problem) than a resident of a top-performing state, and nearly five times more likely to suffer an amputation.

Asthma is more than twice as likely to put low-income Texas children and teens in the hospital.

Compared to the benchmarks, low-income Texans are also dramatically more likely to land in the hospital unnecessarily as a result of angina, pneumonia, or flu after missing a flu shot.

When they get heart bypass surgery, they’re more likely to die.

High-income Texans get treatment comparable to the nation’s best on a handful of measures, according to the report.

In Houston, for example, you can get nationally top-ranking cancer treatment at the University of Texas.

But hospital admissions for preventable flu, hypertension, and diabetes are high, even for this group.

So are the rates of infection after surgery and trauma during birth.

For people of all incomes, complaints about disrespectful, rushed, and unclear doctors’ visits in Medicare managed care organizations are a problem.

People also say they have trouble getting to see a specialist.

The state now has the highest pregnancy-related death rate in the developed world at more than 35 deaths per 100,000 live births as of 2014.

That compares to 5 in 100,000 in Japan and 3 in 100,000 in Poland.

Medicaid pays for more than half of all Texas births, but coverage for those mothers ends in 60 days.

Most of the women died between two months — when Medicaid coverage ends — and a year after giving birth, according to a task force studying the problem.

The task force recommended extending Medicaid to a year, but a bill introduced to do so didn’t even get a committee hearing.

Another bill, extending coverage and treatment for depression, didn’t come up for a vote.

Drug overdoses accounted for 17 percent of deaths between 2012 and 2015, the taskforce determined.

Although the state has a low rate of drug overdoses overall, the data isn’t gathered in a consistent way from one place to another.

“Everyone close to the issue in Texas is skeptical,” Dunkelberg said.

Of the 20 most troubled cities, 4 are in Texas.

“We have no way to take care of these postpartum women with addiction or mental health issues,” she said.

The opioid crisis, obesity, untreated high blood pressure, diabetes, and lack of coverage are taking a toll on young mothers — and the newborns left behind.

More Texans live in a nursing home than the entire population of Galveston, the barrier island off the coast from Houston.

But nursing homes are poorly staffed and rife with violations.

Last session, the legislature responded by passing a law requiring more training for people providing direct care.

The state has twice the average rate of nursing home complaints in federal data.

When the state regulatory agency finds a violation, it rarely takes enforcement action, according to an analysis by the Texas branch of the American Association of Retired People (AARP).

All this helps explain why a Hispanic nursing home resident in Texas is more than three times as likely to be put in physical restraints, compared to the NHQDR benchmark.

Around the nation, nursing home residents are being sedated with anti-psychotics.

“All of a sudden, people in their 80s and 90s in Texas nursing homes were being diagnosed with schizophrenia,” Amanda Fredriksen, associate state director of advocacy at the AARP in Texas, told Healthline. “People don’t get schizophrenia in their 80s. That’s a way to mask inappropriate use.”

Texas has seen improvement:

  • As of the end of 2016, 17 percent of long-term nursing home residents were on anti-psychotic medications, down from nearly 30 percent at the end of 2011.
  • Texas also ranked 36th in this category among the states.
  • Texas has taken steps to address the national problem of surprise balance billing, when people are hit with large unexpected costs for out-of-network emergency room care.
  • Texas ranks 47th in physician-to-patient ratio, but the numbers are going up.
  • The state has recruited foreign medical school graduates and invested in new medical schools.
  • Texas has also led the way on covering nursing home care through managed care plans for seniors and people with disabilities who can’t afford Medicare premiums.

“We see it as a real opportunity to improve quality of care for nursing home residents, but the jury is out on how well this works,” Fredriksen said.

In Texas, as around the nation, there is more attention for mental health and substance abuse disorders.

“There are innovative things happening, but it’s more in the sense in paying attention to challenges we have, not turning the corner,” Dunkelberg said. “It’s very hard to figure out what’s going to activate Texans.”