On Monday, Governor Greg Abbott took to Twitter to boast. “Texas is one of the most prepared states for public health disasters in the U.S.,” he tweeted, linking to a report that had been written up by a San Antonio TV station. This was reassuring news. Except that if you clicked through to the report, it turned out to be a cursory survey conducted by a website called QuoteWizard, which has something to do with the insurance business. The report culled info from a second report by a different organization, which assessed states’ preparedness for “diseases, disaster, and bioterrorism.” In the report, Texas ranked twentieth of fifty.

QuoteWizard aside, it is hard to make the case that Texas’s health care system is well prepared for a disaster of the magnitude that epidemiologists say COVID-19 may prove to be. We may well get lucky: the virus may recede over the summer, or someone could quickly generate an antiviral treatment for those who get sick. But we can’t count on those things. If the worst case scenario comes to pass, Texas is going to rue its many years of refusing to address its medical shortcomings head-on: its bounty of uninsured people, its epidemic of hospital closures, its inability to guarantee a standard of care in its nursing homes, and its shortage of doctors, among other issues. It’s a set of problems that the state government has at best appeared indifferent to, and in many cases has made worse.

1. Texas has the highest number of uninsured people of any state in the nation.

Almost one in five Texans, some five million people, lack health insurance, according to census data. That’s the highest number and rate in the country. In 2010, Congress came up with a plan to cut down on the number of uninsured across the country. They offered states a lot of federal money to expand Medicaid, which helped close the gap in states that did so. Texas leaders, however, have refused to accept it, and the result has been a sicker, poorer state.

The large uninsured population also leaves Texas poorly prepared for an epidemic. If the virus spreads throughout the state, the ideal situation is one in which people are able to get access to a doctor who can test them, give them counsel, and sort them—into a self-quarantine in mild cases, or emergency care in severe ones. Instead, Texas has a situation in which millions of people may not seek help if sick for fear of the cost.

2. Texas has seen an epidemic of hospital closures, leaving it poorly prepared to deal with a surge of critically sick people.

If more people need emergency care than hospitals have room for, the mortality rate of a virus like the one that causes COVID-19 spikes. A rough measure of the capacity of hospitals to cope with a situation like this is hospital beds per capita. At the top of the list, Japan has around 13 hospital beds per one thousand people. South Korea has 12. The average rich country has about 5.5 beds. Texas has 2.3 beds, just under the U.S. average. 

That’s better than some states. But the shortfall in hospital capacity has gotten serially worse in the past decade thanks to a wave of hospital closures. More hospitals have closed in Texas since 2010—twenty-six—than in any other state. And while hospitals have closed all over, the hardest-hit communities have been rural ones. Almost half of the state’s rural hospitals operate at a loss and are a few bad shocks away from closing, and new Medicaid rules proposed by the Trump administration in February threaten hospitals’ viability even more. More and more people in the state exist in an emergency care desert, with limited or no access to the kind of care that would be necessary if COVID-19 started to run riot. 

One major contributing factor to Texas’s hospital closing spree is the state’s failure to expand Medicaid. But the Legislature has also stood by as emergency care capabilities have weakened all over the state.

3. Texas has a considerable and widening shortage of doctors.

Texas ranks forty-first of fifty states when it comes to physicians per capita. Like the hospital closures, this is a problem that especially afflicts rural counties. As of 2019, 33 of the state’s 254 counties had no physician at all. By 2030, the gap between the number of doctors the state has and what the Department of State Health Services estimates it ought to have is anticipated to grow by 67 percent.

When people are unable to see a doctor, they’re more likely to bring their problems to emergency rooms—which, as previously mentioned, are also disappearing. That means a medical system with less slack in case of an emergency. The Legislature has taken action over the years to try to stem the shortfall, and new medical schools have popped across Texas up in an attempt to woo practitioners here. But not enough has been done, and significant bottlenecks, like limited state funding for residency programs, remain.

4. Texas’s nursing homes are underperforming and underfunded.

COVID-19 affects people unequally. Younger people may not have a hard time with it, but mortality increases sharply with age. Dr. Peter Hotez of the Baylor College of Medicine recently told Congress that the disease was an “angel of death” for the elderly. Nursing homes and senior care facilities are places of considerable danger as the virus spreads.

Texas has some of the worst nursing homes in the country, and they’ve been poorly regulated—and poorly funded—by the state government for many years. The federal government ranks nursing homes from one to five stars. In a report from 2015, 28 percent of Texas nursing homes were given the lowest possible rating, one star. (Just 7 percent of nursing homes in California were given the same rating.) One in four Texas nursing homes has been cited for severe deficiencies by the feds. In 2015, inspectors cited Texas nursing homes for 17,466 violations, but the state Department of Aging and Disability Services took “enforcement actions” in only forty cases.

Two-thirds of Texas nursing home residents are provided for by Medicaid, and low reimbursement rates, set by the state, have created a kind of tiered system. At nursing homes that survive on Medicaid reimbursements, staff turnover is high and quality of care is low. If COVID-19 spreads to the point where it starts to enter these spaces, the results will be grim.

5. Texas has a lot of service employees who can’t help but work while sick.

One of the most important things to do to slow the transmission of illness is to get people to stay home when they’re sick. But many workers aren’t able to take sick days, unless the government mandates them. Many people face the choice of keeping their communicable diseases at home or paying rent. Often, they choose to pay rent.

In 2018, when Austin and San Antonio debated whether to mandate that employers give their workers paid sick leave, one of the arguments supporters made was that consumers should be happy to pay a little more for burritos if it meant the line cook wasn’t sneezing in your food. And, indeed, one 2017 study found that cities with paid sick leave mandates see a 40 percent reduction in cold and flu disease rates compared to cities without.

But Austin and San Antonio’s sick leave ordinances were fiercely opposed by business groups, and got tied up in courts. They’re opposed by state leaders, and the Lege unsuccessfully tried to gut them last year. There’s a lot of evidence these policies stem transmission of flulike diseases, but they haven’t gone into effect even as the virus is spreading here. 

6. The state’s health agencies don’t have a great track record.

There are surely a lot of smart, competent, caring people working at the Texas Health and Human Services Commission and the agency it oversees, the Department of State Health Services. But the underfunding and lack of attention paid to HHSC and DSHS by state officials are perhaps best demonstrated by the fact that, in 2018, the agencies’ offices became overrun by rats, mold, and vermin.

The mold became such a threat to DSHS employees that the agency had to move hundreds of employees to new digs. Hundreds of rats swarmed the headquarters of the HHSC. In other words, until recently—and perhaps still—the people whose job it is to help contain COVID-19 worked in conditions approximating a medieval plague ship. That’s to say nothing else of the contracting scandals, errors of leadership, and other crises that have afflicted the agencies under the watchful eyes of the Legislature.

7. There’s a remarkable level of denial about all this from state leaders.

Abbott has had five years to put in work on these issues, and he hasn’t done much. That’s why his tweet bragging about the state, with the threat of a wider outbreak looming, felt especially dispiriting. To be sure, none of the problems above are unique to Texas: they’re just more of a problem here than in many other places. 

It all sounds quite bad—you might say, suboptimal. Why have some of these problems not been fixed yet? The answer is simple: In good times, they mostly affect the poor and the powerless. In Texas, like America, rich people get pretty good health care, and the poor don’t. If state leaders’ parents were in Medicaid-funded nursing homes, you can bet they’d fix those reimbursement rates.

And that’s fine with a lot people, as long as we’re talking about diabetes and cancer. But a good old-fashioned epidemic—here’s hoping it doesn’t come to pass—forces us to grapple with a fact that’s easy to forget in good times: Your well-being is inextricably linked with everyone’s well-being. A sicker society overall makes it easier for sickness to spread. We’ve made our bed. Now let’s see how long we’ll have to lie in it.