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

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.