Texas has long carried the highest uninsured rate in the country — but research by Texas 2036 found the reasons why are more complicated than most people assume. In this episode, Charles Miller, J.D., director of health and economic mobility policy for Texas 2036, unpacks what the organization learned when it went directly to uninsured Texans to ask why they hadn't enrolled in coverage many of them could get for free.

He also explains how a bipartisan Texas law called premium alignment has quietly made ACA bronze and gold plans more affordable, what physicians need to understand about how plan metal levels actually affect patient cost-sharing, and why market consolidation — driven by both large hospital systems and insurers — is the central threat to independent practice.

Miller closes with a direct message to independent physicians: if you want that model to survive, you need to make your voice heard on market reform, because the current rules of the game are working against you.

Register now for Physicians Practice's Practice Academy event: Practice Management Track, on March 19, 2026, from 1:00 PM-5:00 PM EDT: https://registration.physicianspractice.com

Music Credits:
Ocean Calm by Cephas - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:31 | Cold open Miller warns that without serious market reform, independent physicians are going to be squeezed out — and says the current rules of the game are what's driving that outcome.

0:31 – 1:59 | Introduction Austin Littrell introduces the episode, plugs the Practice Academy Practice Management track on March 19, and previews the conversation with Miller.

1:59 – 3:24 | Meet Charles Miller and Texas 2036 Payerchin introduces Miller, who explains the organization's two-track focus: expanding health insurance coverage and making the underlying prices of health care more affordable ahead of Texas's 2036 bicentennial.

3:24 – 4:24 | Why Texas made health care a priority Texas has long held the highest uninsured rate in the country — and Miller explains how that designation pushed the organization to look beyond coverage alone and into the broader affordability of the system.

4:24 – 9:01 | Who are the uninsured in Texas? Miller walks through a Texas 2036 research project that went directly to uninsured Texans to ask why they hadn't enrolled. The findings: many didn't know options existed outside employer coverage, and most wildly overestimated what plans would cost — with some eligible for free plans assuming they'd pay $300–$500 a month.

9:01 – 10:00 | Bringing it back to physicians Payerchin pivots to the physician audience, asking whether doctors were involved in shaping the policies that followed — and what the response has been from Texas's medical community.

10:00 – 12:52 | ACA metal levels and what they mean for your practice Miller explains how bronze, silver and gold plan tiers work in practice, why silver plans carry cost-sharing reductions for lower-income patients, and why there's no single filter physicians can use to predict patient cost share based on plan type alone.

12:52 – 14:28 | Premium alignment: the policy making plans more affordable Miller describes the Texas premium alignment policy — a bipartisan 2021 law that enforces the ACA's single risk pool requirement more stringently, effectively drawing in more federal subsidies for bronze and gold plans. Illinois and New Mexico are among the states watching closely.

14:28 – 15:59 | Health care access for undocumented residents Miller separates the question of health care access from government-subsidized coverage, noting that while there is no legal barrier to anyone seeking care, Texas does not extend Medicaid or ACA subsidies to those without legal status.

15:59 – 21:42 | Price transparency: what Texas has done and what's still missing Miller traces Texas's price transparency efforts from 2021 through the most recent legislative session, covering machine-readable files for hospitals and insurers, consumer self-service tools, itemized billing requirements and a new enforceable cost estimate provision for patients shopping for procedures.

21:42 – 22:37 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

22:37 – 29:12 | Market consolidation and the squeeze on independent practice Miller addresses hospital market concentration, vertical integration and the anti-competitive contracting practices — including anti-steering clauses, most-favored-nation clauses and gag clauses — that are limiting physician independence and patient choice. He outlines Texas House Bill 711 and ongoing efforts to preserve competitive markets.

29:12 – 31:01 | What this means for independent physicians Miller and Payerchin discuss the convergence of forces — large health systems and large insurers both exerting pressure — that is making independent practice increasingly difficult to sustain, and why the physician-patient relationship is at the center of the fight.

31:01 – 32:18 | A message to primary care physicians Miller closes with a direct call to action: if independent practice matters to you, get active, make your voice heard, and make sure the groups claiming to represent you actually are.

32:18 – 33:15 | Outro Littrell thanks listeners, plugs the March 19 Practice Academy event, and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.

S1 Ep133: State policy and the future of independent practice, with Charles Miller, J.D., of Texas 2036

Off the Chart: A Business of Medicine Podcast

S1 Ep133: State policy and the future of independent practice, with Charles Miller, J.D., of Texas 2036