Much is known about what influences the health of a community, including individual health behaviors as well as social and economic determinants of health. Health equity has been defined to mean that everyone has a fair and just opportunity to be as healthy as possible. Being un- or under-insured puts people at serious disadvantage when it comes to access to health care and potential for positive health outcomes.

The Affordable Care Act (ACA, or Obamacare) provides an opportunity for states to expand health coverage to low-income families through the Medicaid program. Multiple recent analyses demonstrate that Medicaid expansion is having an especially positive impact in rural areas in expansion states. Many expansion studies point to improvements across a wide range of measures of access to care. Finally, research shows that Medicaid expansions result in reductions in uninsured hospital or other provider visits and uncompensated care costs, whereas providers in non-expansion states have experienced little or no decline in uninsured visits and uncompensated care.

Texas is one of 13 states that has chosen not to expand Medicaid. The majority of states not participating in Obamacare expansion are in the Deep South, and these states are also the states in the lowest quintile in overall health as ranked by United Health Foundation. (The state of Texas ranks 37th in overall health in the United States.)

That’s not to say the state doesn’t spend a lot of money on health care. According to the Comptroller’s office, health care spending represents nearly half the state budget — $42.9 billion in fiscal 2015 — spread across various agencies. Seventy percent, or $30.3 billion, went to spending for Medicaid and CHIP. That spending also includes direct support of various institutions.

For example, the University of Texas MD Anderson Cancer Center, which markets itself heavily as “the nation’s top hospital for cancer care for 14 of the past 17 years” and “one of the nation’s top two hospitals for cancer care every year since the (“US News & World Report’’ America’s Best Hospitals) survey began in 1990,” has an operating budget of $5.2 billion and more than 20,000 employees. Of that $5.2 billion, 4% — $210.1 million — is general revenue appropriated by the state.

As a radiation oncologist, I practice in the shadow of MD Anderson, even though I live 120 miles north of the Texas Medical Center. It is a long shadow. That shadow is often comforting, like an old friend. But it is a shadow that discriminates with strict financial barriers and selective insurance contracts. There is a joke in the medical community that the first and most important biopsy you get at MD Anderson is a wallet biopsy — no pay, no play.

MD Anderson does participate in the Texas Medicaid Program and has a financial assistance program for cancer patients who meet residency and certain financial eligibility requirements. Uncompensated care in fiscal year 2018 at MD Anderson totaled only $170.4 million, certainly less than the $210.1 million appropriated by the state and less than 3.3% of their operating budget. ‘’Modern Healthcare’’ looked at the proportion of charity care provided by the country’s 20 biggest not-for-profit hospitals and hospital systems by revenue in 2015 and 2016 and found that the average proportion of operating expenses devoted to charity care was 5.21%.

In fiscal year 2017, MD Anderson provided care to a mere 420 people who primarily had no insurance and who met their financial assistance program requirements. That is barely one unique patient a day at an institution that sees 141,600 patients a year. MD Anderson’s first core value is: “Caring: By our words and actions, we create a caring environment for everyone.” But not everyone gets in.

MD Anderson has a huge and wealthy donor base as well. As just one example, their Moon Shots Program, launched in September 2012, has received $464 million in private philanthropic commitments so far. In 2018 alone, 9.5% of their budget — $498 million — came from restricted grants and contracts and philanthropy.

Let me say, I am in awe of the research that comes out of MD Anderson. They have every right to be proud of their No. 1 ranking and of having a Nobel Prize-winning scientist on staff. The knowledge that comes out of an institution that sees 141,600 patients a year is staggering. The training of health care providers, including at Harris Health System facilities, is excellent. But I grieve when Texas residents who need the care MD Anderson can provide are prevented from going there.

Ultimately, quality health care is not just about rankings; it must be about access to care as well. As a state-supported institution, MD Anderson needs to loosen its requirements for providing uncompensated care and be willing to negotiate and accept reasonable contracts with insurance providers, especially Medicare Advantage and Obamacare plans. After all, a hospital cannot be “best” if it isn’t best for all. (That is not to let insurance providers off the hook. I have no doubt they shy away from contracting with MD Anderson, knowing less expensive care can be had elsewhere.)

The state should require minimum levels of charity care and insurance plan participation when hundreds of millions of state dollars are being allocated. State legislators, in view of the substantial economic and health benefits associated with the expansion of Medicaid, should invest in increased health insurance coverage in Texas via the Affordable Care Act. And finally, health care ranking organizations like “US News & World Report’’ should include access to care and charity care metrics when ranking hospitals. These are the right — and equitable — things to do.

Dr. Sid Roberts is a radiation oncologist at the Temple Cancer Center in Lufkin. He can be reached at sroberts@memorialhealth.org. Previous columns may be found at angelinaradiation.com/blog.