Texas' distinction as the most extreme example of the nation's health insurance crisis was reinforced Wednesday in a new report suggesting the number of uninsured Texans is even greater than previously thought.

A study commissioned by the Robert Wood Johnson Foundation reported that 30.7 percent of adult Texans are uninsured — significantly higher than the 24.7 percent reported by the Census Bureau in 2003.

Both reports ranked Texas' uninsured rate as the highest in the nation.

The new report says 26.6 percent of employed Texas adults are uninsured, also the highest rate in the country.

The problem is growing nationally, the report said, with about 20 million working adults who lack insurance and eight states where at least one in five working adults is uninsured.

The national rate of employed adults who lack insurance is about 16 percent, the report said.

Locally, a report last fall by a public health task force estimated that 31.4 percent of Harris County residents are uninsured.

Business leaders, policy analysts and others who have studied the issue cite several reasons why the problem is so acute in Texas, including high levels of immigration and a heavy concentration of small businesses that lack the resources to provide low-cost insurance to their employees.

Hard to afford
Most of these experts agreed, however, that the large number of low-wage workers is the most powerful factor driving the high numbers of uninsured people in Texas and other southern and southwestern states.

"That is the key underpinning to why most people are uninsured — they work in jobs that pay modest wages," said Stuart Schear, an employee of the Robert Wood Johnson Foundation who is directing Cover the Uninsured Week, an effort to call attention to the problem of uninsured Americans.

Companies that pay low wages are less likely to offer health insurance benefits or to pick up enough of the costs to make insurance affordable for their employees, Schear said.

Workers whose employers don't provide health coverage are confronted with private plans that cost about $10,000 a year — roughly the same as the earnings of a full-time, minimum-wage worker, Schear said.

"There is no way for a pot-washer in the back of a restaurant to afford that," he said.

Rob Mosbacher, a Houston energy executive who chaired a Greater Houston Partnership task force on health care, agreed that the large number of Texans working for low wages in retail or service industries contributes to the problem.

In addition, he said, Texas has a higher-than-average proportion of businesses with fewer than 50 employees.

His task force recommended a number of steps to address the problem, including the development of locally subsidized insurance plans and better insurance products for small employers.

Robert Black, a spokesman for Gov. Rick Perry, said the governor supported legislation in the 2003 session that makes it easier for small employers to join pools that can purchase insurance at lower rates.

The governor continues to work to improve such systems, Black said.

Many factors
Anne Dunkelberg, the assistant director of the Center for Public Policy Priorities, an Austin-based group that focuses on improving economic and social conditions for low- and middle-income people, questioned whether small businesses are a significant factor in the high rate of uninsured Texans.

She said the proportion of small businesses among Texas employers is about average.

"I think our businesses of all sizes are less likely to provide health insurance than the national average," Dunkelberg said. One reason for this, she said, is that labor unions, "which is where employee benefits began," are relatively weak in Texas.

In addition, although the Texas Legislature has improved health coverage for children, it has provided little help for adults, Dunkelberg said.

Though the federal Medicaid program allows states to extend coverage to adults with dependent children, Dunkelberg said, Texas has set the adult income threshold so low — about $188 a month for a family of three — that "almost no working poor adults qualify for Medicaid in Texas."

The foundation study was based on analysis of a 2003 survey by the U.S. Centers for Disease Control and Prevention. Foundation representatives said this survey is probably more accurate than the Census Bureau's because it is based on a larger population sample.