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arriers, two health plans attempted to increase access by using multilingual case managers tohelp new members navigate their way through the health care system. Members received casemanagers as long as the focus was on health, rather than social or career issues.IV. Conclusions and RecommendationsTexas is faced with significant challenges in providing access to health care for thestate’s uninsured. To help develop local initiatives that address these issues, we have revieweda number of features of local programs that have expanded care and coverage for theuninsured. The state should consider creating a program to provide support of local effort forproducing more coordinated and collaborative health care systems, including direct financialsupport and/or other financial-related incentives for innovations, such as Medicaid payment fornavigator services, technology grants for electronic record systems, or tax credits for privateinsurance plans that integrate coverage with Medicaid. State level support is also needed asseed money to support the development of community-based health insurance plans and toexpand existing successful plans to broader populations and geographic areas.To address the fragmentation and inequity in the existing system will call for broadersolutions such as raising and making more uniform the eligibility and service standards of localsafety nets across the state. Given the regional nature of health care markets and the desire forlocal control, basic services, funding, and eligibility levels could be standardized at the regionallevel. xxxix Under the regionalization approach, urban counties with more sophisticated medicalcenters would be grouped with smaller surrounding counties to build a more coordinated healthcare infrastructure dispersing primary and secondary care more broadly.One of the easiest things the state could do to begin to improve the performance ofsafety net systems is require standardized reporting from all county safety net programs so thatstate and local officials could more accurately understand the features of existing programs,monitor performance, assess unmet needs, and identify the potential impact of innovativestrategies.Texas has limited underwriting requirements for small businesses, which is a majorreason for the gap in coverage of small employers compared to the rest of the country. Untilthese regulations are changed, including movement towards community rating and makingcooperatives a realistic alternative, the number of commercial products available to small groupsand individuals will not be adequate, even with community-based efforts to expand theiravailability. Current law is skewed against small employers, who comprise the majority of Texasemployers and are also the majority of employers not offering health insurance.Some of the best safety nets in the country that are also featured in this report do nothave programs to assist individuals in families with incomes above 200% of the FPL. Hence,local initiatives that target services or coverage to this fastest growing segment of the uninsuredpopulation should be emphasized. This is also an opportunity to offer programs to people whohave money to make a significant contribution to the cost of their own care.It is clear from our review that innovative models of community-based care and coveragehave the potential to significantly expand access to care. Since Texas has maintained a broadstatutory obligation for counties to provide medical care to low-income uninsured persons in thestate, it seems that a comprehensive approach to expanding these models in Texas iswarranted.D-32
AcknowledgmentsThe authors wish to thank Elena Marks and Adele Sweetnam (City of Houston) for editing thepaper, and the members of the Task Force on Access to Health Care in Texas for theirfeedback.Endnotesi Texas Senate Health and Human Services Committee, Interim Report to the 79 th Legislature, December2004.ii Ibid. pg. 64-68.iii White SA, The medically uninsured in Milwaukee: Current problem and future crisis. Wisconsin PolicyResearch Institute. Vol. 12(2): March 1999 (pp.5).iv Norton SA & Lipson DJ, Portraits of the Safety Net: The market, policy environment, and safety netresponse. Assessing the New Federalism. Occasional Paper Number 19: Nov 1998 (pp. 32).v Ibid.vi Ibid, pg 6-7.vii Communities in Action: Best practices on expanding access to health care. National Association ofCounties, 2003.viii Coughlin T, Lutsky A, Bruen B & Guterman S, The Medicaid DSH program and providing health careservices to the uninsured: A look at five programs. Bruen B & Guterman S, Chapter 3: WishardAdvantage: Indianapolis, Indiana. The Health Policy Center: The Urban Institute. Nov 2001: pp. 20-28ix Ibid, Lutsky A & Coughlin T, Chapter 5: Carelink (San Antonio, Texas). pp. 38-47.x Wilson M, Shin P, Regenstein M, & Jones K, An assessment of the safety net in San Antonio, Texas.Urgent Matters (The George Washington University Medical Center, School of Public Health and HealthServices). March 2004.xi Coughling T, Lutsky A, Breun B, & Guterman S, Chapter 2: Denver Health (Denver, CO) by Lutsky A &Coughlin T. Nov 2001 (pp. 12-19).xii Galbow P, Eisert S & Wright R. Denver Health: A model for the integration of a public hospital andcommunity health centers. Medicine and Public Issues, 138(2) 2003 pp 143-149.xiii Andrulis D & Gusmano M. Community initiatives for the uninsured: How far can innovativepartnerships take us? The New York Academy of Medicine: Division of Health and Science Policy; Officeof Urban Populations, pp. 2-52 to 2-63, August 2000.xiv Robert Wood Johnson Foundation, Lessons Learned from Community-Based Models of Care for theIndigent/Uninsured: Financing Mechanisms and Stategies for Integrating Healthcare Services. (Dec2001).xv Norton SA & Lipson DJ. Portraits of the safety net: The market, policy environment, and safety netresponse. Assessing the New Federalism, Occass paper No 19, 9-19, Nov 1998.xvi Bovbjerg RR, Marstellar JA & Ullman FC. Health care for the poorxvii Coughlin T, Lutsky A, Bruen B & Guterman S, The Medicaid DSH program and providing health careservices to the uninsured: A look at five programs. Bruen B & Guterman S, Chapter 6: PlusCare andHealthChoice (Wayne County, MI). The Health Policy Center: The Urban Institute. Nov 2001: pp. 20-28.xviii West, K. Buncombe County Medical Society Project Access. Projects Access Web site. 1999.Available at: http://www.projectaccessonline.org/project_assessment.html. Accessed May 2005.xix Wood, J. Project Access: National Program Project Report. The Robert Wood Johnson Foundationwebsite. 2004. Available at:http://www.rwjf.org/portfolios/resources/grantsreport.jsp?filename=027437.htm&iaid=133. Accessed May2005.xx Simmons, Sandy Coe, Gionfriddo, Paul. 2002 Use/Capacity Report. Indigent Care Collaboration.October 2003D-33
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Appendix ATask Force Members and St
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Hector Balcazar, Ph.D.Regional Dean
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Charles Haley, M.D., M.S.Medical Di
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Michael McKinney, M.D.Senior Execut
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M. Roy Wilson, M.D.PresidentTexas T
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Appendix BMedicaid and the State Ch
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services. There are two broad types
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Mandatory and Optional Covered Popu
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• Nurse-midwife services;• Fede
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Disproportionate Share Hospital Pro
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March 13, 2001, that limited the am
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year from FFY 2002-2004, $4.05 bill
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Medicaid beneficiaries. Section 191
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started in 2001 and 2002 to curb in
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urban and with fewer than 250,000 p
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Protection Act of 2000 and the Medi
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orientation). Recipients of Supplem
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enrollee is assigned a primary care
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Table 7. Texas Medicaid Policy Chan
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Table 8. Texas SCHIP Policy Changes
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families (through the employer’s
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share of the match must come from t
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Reinstating the Medically Needy Spe
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Endnotes1 Texas Health and Human Se
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35 Powers, Pyles, Sutter, and Vervi
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73 Office of Management and Budget,
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113 TexCare, Children’s Health In
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150 Lyndon B. Johnson School of Pub
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States by Groupings with Current El
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Medicaid and the State Children’s
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Graduate Medical Education ProgramA
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needs, however, there is a shortage
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15 Texas Association of Counties,
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ecording and evaluation; physical e
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Medicaid and the State Children’s
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ReferencesAmerican Academy of Pedia
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downloads/bipa.pdf#search='Medicare
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Texas Health and Human Services Com
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Appendix CAn Analysis of Reform Opt
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Encouraged by these low rates, Cong
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Establishing state-only tax incenti
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New York passed the Health Care Ref
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Hospital Cost Containment — Maryl
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dollar spent. 237 Texas spent almos
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Another option for small businesses
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• Medical equipment and supplies,
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pay the premiums for Medicaid benef
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Medicaid to children born after Sep
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Bill of Rights or “TABOR”; and
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The federal share for CHP+ is 65 pe
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SCHIP: increased eligibility in CHP
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• Medical equipment and supplies
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6. Funds obtained through the recov
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Status ReportMaineCare Program Expa
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the federal poverty level. 404 Sinc
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need their jobs as a source of empl
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Endnotes191 Deborah Chollet, Issue
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225 Ibid.226 Maryland Health Care C
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259 Kaiser Family Foundation, State
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Page 124 and 125: 325 Kaiser Family Foundation, State
Page 126 and 127: 361 State Coverage Initiatives, Sta
Page 128 and 129: SCHIP&subcategory=SCHIP&topic=Feder
Page 130 and 131: An Analysis of Reform Options Devel
Page 132 and 133: ReferencesAdvantage Insurance and F
Page 134 and 135: Donnell-Kay Foundation. “Amendmen
Page 136 and 137: Kaiser Family Foundation. Demograph
Page 138 and 139: State Coverage Initiatives. Profile
Page 140 and 141: Appendix DLocal Initiatives to Expa
Page 142 and 143: with more coordinated services that
Page 144 and 145: FinancingSources of revenue include
Page 146 and 147: AdministrationThe Health and Hospit
Page 148 and 149: Until 1993, Denver Health (DH) was
Page 150 and 151: different benefit plans are offered
Page 152 and 153: Cost SharingPatient cost-sharing is
Page 154 and 155: management programs. I-Care promote
Page 156 and 157: the county indigent care plan. Bene
Page 158 and 159: Firstplan xxvi,12Moore County, Mich
Page 160 and 161: Benefits and ServicesEnrollees can
Page 162 and 163: EligibilityAs of 2005, enrollment i
Page 164 and 165: etween $23 and $120 per month. Ther
Page 166 and 167: Healthcare Accountability Act xxxvi
Page 168 and 169: Coordination - When health care age
Page 170 and 171: subsidized initiatives offer exposu
Page 174 and 175: xxi Simmons, Sandy Coe, Gionfriddo,
Page 176 and 177: Table 1 (Continued). Local Care Ini
Page 178 and 179: Table 2 (Continued). Local Coverage
Page 180 and 181: Appendix EEducation and Health:A Re
Page 182 and 183: The human capital approach suggests
Page 184 and 185: etween standardized test scores (St
Page 186 and 187: INTRODUCTIONEducation plays a wide
Page 188 and 189: of children with chronic health con
Page 190 and 191: Implications. Given the current pre
Page 192 and 193: DiabetesPrevalence. Diabetes in chi
Page 194 and 195: Limitations. The cross-sectional de
Page 196 and 197: chronic lung disease, cystic fibros
Page 198 and 199: significant differences between tho
Page 200 and 201: Table 1. Prevalence of Selected Chr
Page 202 and 203: findings of lower test scores are b
Page 204 and 205: al (McKewen et al., 1998) report a
Page 206 and 207: Section 3. School-Based Interventio
Page 208 and 209: mathematics, science and oral expre
Page 210 and 211: Table 4. Summary of Research Findin
Page 212 and 213: etween SES and health is a dose-res
Page 214 and 215: Self-Rated Health. Evidence accumul
Page 216 and 217: economic hardship. One of the skill
Page 218 and 219: Education also improves the stabili
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TABLE 6. SUMMARY OF EXPLANATIONS FO
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According to the Census 2000 data,
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Policy Reports Recommendations (Tot
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Section 2. Recommendations on Schoo
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Childhood ConditionsSchool-based Pr
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Childhood ConditionsDiabetes (n=11)
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eduction in reading test scores com
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Table 10. Estimates of the Cost of
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National Asthma Education and Preve
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REFERENCESAck, M., Miller, I., & We
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Elo, I. T., & Preston, S. H. (1996)
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Kaemingk, K. L., Pasvogel, A. E., G
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Miller, D. S., & Miller, T. Q. (199
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Ross, C. E., & Wu, C. L. (1996). Ed
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Williams, D. R. (1990). Socioeconom
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SAMPLE, DESIGN, & INTERVENTIONACHIE
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SAMPLE, DESIGN, & INTERVENTIONStudy
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SICKLE CELL ANEMIAArmstrong(1996)SA
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SAMPLE, DESIGN, & INTERVENTIONSickl
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SAMPLE, DESIGN, & INTERVENTIONhemog
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SAMPLE, DESIGN, & INTERVENTIONStudy
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Curriculum Content: Statute §28.00
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• HEALTH PROMOTING ENVIRONMENTSch
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• COORDINATION/IMPLEMENTATIONCoor
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Education and Health: A Review and
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Appendix FState Regulation of Healt
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coverage they offer. 14 By 2004 onl
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poor health may make coverage more
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account for most, or even much, of
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More active state intervention in t
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Table 3 (GAO Appendix IV) shows whi
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Appendix GEmergency and Trauma Care
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The treatment of shock prior to sur
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the EMS needs in rural areas of the
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Level IV trauma centers should be a
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Table 2. Trends in Trauma Severity,
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the hospitals were on diversion or
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Representative Delisi was successfu
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Mental Health Access ChallengesCare
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fhttp://www.techproservices.net/his
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oohttp://www.saveourers.org/reports
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Appendix HBrief: Consulate ClinicDe
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In addition, the roundtable discuss
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clinic(s) affiliated with medical s
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Appendix ICommon Abbreviations
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HMOHRQOLHRSAICF/MRIHCTAIOMISSLBBLIU
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Appendix JPresentersDate/Location:
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Appendix KProvider Taxes: A Differe
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were previously categorized as char
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