Texas, for instance, ranks last of all 50 states in overall access to mental health care, according to the nonprofit Mental Health America. The ranking is based on available data on measures such as the shares of adults and children with mental health issues who have been unable to receive treatment.

Among the reasons why: Texas is one of a dozen states that still have not expanded Medicaid, the public health insurance program that covers poor and low-income Americans, and which is the country’s single largest payer for mental health services.

Texas officials’ refusal to expand Medicaid does not appear to be rooted in public welfare nor fiscal responsibility concerns. The federal government has offered holdout states billions of dollars in incentives to expand Medicaid, most recently through last year’s American Rescue Plan. These incentives would, on net, cause state revenue to come out ahead, even after accounting for Texas’s new spending obligations if it were to make more residents eligible for public insurance. Expanding Medicaid would also reduce costs for hospitals that currently provide a lot of uncompensated care for uninsured patients.