Texas health care is facing pressure from rapid growth, long travel distances, and the nation’s highest uninsured rate. John Hawkins, CEO of the Texas Hospital Association, says policymakers must stabilize rural hospitals, strengthen the health-care workforce, and keep insurance within reach for families and employers if Texas hopes to maintain a functional system.
Hawkins has led the Texas Hospital Association since 2022. He represents more than 600 hospitals across Texas, from large urban medical centers to small rural hospitals.
Access to care in rural areas is his biggest concern. He says that rural facilities operate with “more uninsured, more government payers,” while Medicaid and Medicare “pay below cost.”
Obstetric units often feel the strain first. “If you can’t attract and retain those folks, it’s hard to keep OB services online,” he says, and health outcomes fall “the further you have to drive for care.”
State lawmakers have stepped in with new investments in OB services, rural rates, loan repayment, and residency programs outside major cities. Hawkins says that training for physicians in rural communities boosts retention because “you’ve got a better chance of staying” where you complete residency.
Adopting more technology is another path to relieve pressure. AI scribes, improved electronic records, and automated documentation tools, he says, “take the pressure off of the actual human staff” and serve as a “force multiplier in a rural hospital,” where every hour of clinical labor counts. Many rural hospitals also serve as community health hubs, offering fitness programs, rehabilitation spaces, and preventive care that keep patients healthier and closer to home.
Texas faces unique pressures in its health care system. “With Texas leading the nation in the number of uninsured, we have a higher uncompensated care burden than any other state,” Hawkins says. Nonprofit hospitals exceed charity-care requirements, but remaining costs shift to private insurers, a burden rural towns cannot easily absorb. Texas’ decision not to expand Medicaid and the high share of small businesses that struggle to offer insurance leave many residents in the individual market.
Hawkins points out that enhanced federal premium tax credits currently help “about 2.4 million Texans” afford coverage. If they expire, premiums rise “about $1,300” on average, and “the attrition would be about 1.3 million,” he says. He warns that the loss of coverage becomes “a hidden tax which makes health care for all of us less affordable,” because uninsured patients still need emergency care and hospitals must absorb the losses.
He encourages lawmakers to consider tax incentives for employers who provide coverage, saying that “economic incentives always work better than mandates.”
Some programs and policies are working particularly well in Texas, Hawkins says. He praises expanded nursing-faculty funding, community-college incentives for “degrees of value,” and apprenticeships for lab techs and phlebotomists that give students immediate entry into the health-care workforce.
On the other hand, there are new pressures. Proposed fee hikes for H-1B visas would have “a devastating effect,” Hawkins says, because hospitals depend on those workers in nursing, medicine, and research. National hospital organizations want medical professionals exempted to protect Texas’ research strength and patient capacity.
According to Hawkins, hospitals are major employers and safety-net providers in every region of the state. They are “very important,” he says, and vital to the future of the Texas economy.