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SCHIP funds or at least cover Medically Needy spend-down to a certain extent since the matchrate in SCHIP is much higher than in Medicaid.Lessening the Cost of EMTALAThe legal obligation imposed by federal legislation requiring Medicare-participating hospitals toprovide care to individuals with “reasonable emergencies” regardless of their ability to payresults in significant fiscal losses to most hospitals. The Emergency Medical Treatment andLabor Act (EMTALA) of 1985 requires hospitals participating in Medicare to medically screen allpersons seeking care in hospital emergency departments, and to provide the treatmentnecessary to stabilize those determined to have an emergency condition, regardless of income,insurance, or immigration status. 422Currently, hospitals and other providers must absorb the costs associated with this care for theuninsured or underinsured. Hospitals serving a “disproportionate share” of medically indigentpeople receive Disproportionate Share Hospital (DSH) funds to help offset lost revenues. TheMedically Needy Medicaid program also offers participating states some relief to this financialburden. The program allows additional individuals, including adults with children under the ageof 18 years, to receive Medicaid coverage to assist with high medical bills after “spending down”to Medicaid eligibility by having their medical expenses offset their excess income.In 2003, the 78th Texas Legislature elected to discontinue participation in the spend-downprogram. Reinstating the Medicaid Medically Needy program could offer help to reduce the costof EMTALA to hospitals. Reinstating the program for the “1931” population (parents of childrenunder 18 years of age) could be done with little difficulty. Including non-parent adults mightrequire additional review to establish revenue neutrality. Revenue neutrality could potentially becompromised if the inclusion of the non-parents limited the amount of DSH funds available.Future StudyOne area for future study is the possibility of modifying the asset test in Medicaid — especiallyfor Medically Needy spend-down, if reinstated, but also more broadly. Another area needingmore study is the nature of both the small group and individual health insurance markets. Thereis little information about the individual market in Texas in terms of rates, margins,characteristics of those insured and other factors. Study of this market may well be warranted.Similarly, in the small group market the potential impact on rates and availability of insurance orreducing the extent to which rates can vary with manual adjustments needs to be investigated.Texas has many opportunities to cover more uninsured people and remedy its place as theworst state in the nation for the percentage of people with health insurance, but there are manycomplex issues involved and doing so will take compromise and perseverance.AcknowledgmentsThe authors wish to thank the following people for their help with this project: Kristine Niemeyer(Senior Program Coordinator, LBJ School of Public Affairs) for contributing the profile of Maine,Kelly Shanahan (LBJ School graduate student) for contributing the profile of Colorado, and themembers of the Task Force on Access to Health Care in Texas for their feedback.C-35