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share of the match must come from the state (so 60 percent can be local), 2) federal dollarssuch as grant money cannot be used for the state match, and 3) limitations on voluntarycontributions and provider-specific taxes (no contributions allowed and provider taxes cancomprise no more than 25 percent of the state match). 146The Centers for Medicare and Medicaid Services (CMS) has indicated that it will give statesflexibility with waiver design, but any proposed geographic variability in services, such as mighthappen with matching local funds, must meet certain criteria and will be handled on a case-bycasebasis. No currently approved HIFA waivers leverage local funding, but six states requirelocal governments to help finance Medicaid service costs, four require them to help withadministrative costs, and 12 require both (Texas does not require any local participation).Government officials interested in leveraging local funds should do the following: 1) quantify theamount spent by local governments on health care for the uninsured, 2) develop a conceptualmodel for the expansion and present it for comments, 3) solicit public input, and 4) obtain formalapproval from CMS. 147The following table provides financial information for the hospital districts in the five largesturban areas in Texas (not counting the new the Austin/Travis County hospital district). Thoughthese entities represent a majority of the local funding collected for health care, not includedhere are over 100 smaller hospital districts and public hospitals, and over 100 county indigenthealth care programs, which counties are required to have if they are not part of a hospitaldistrict.Table 9. Funding Information for Five Large Hospital Districts, FY 2002Hospital/Hospital DistrictTotal RevenueRevenue fromLocal PropertyTaxesTransferred toState for DSHNet Revenuefrom DSHHarris County Hospital $588,100,000 $315,600,000 $116,093,329 $25,367,343District (Harris County)JPS Health Network (Tarrant $309,668,000 $170,557,000 $22,759,514 $26,749,572County)Parkland Health and Hospital $743,528,000 $310,236,000 $100,442,003 $51,438,695System (Dallas County)Thomason General Hospital $176,229,032 $36,346,435 $26,936,630 $14,037,343(El Paso County)University Health System $371,749,000 $124,078,000 $56,842,156 $19,341,187(Bexar County)Sources: first two columns: Morningside Research and Consulting, Inc., Comparison of Texas Hospital DistrictCosts, Report to the Technical Advisory Committee (August 2002, p. 6), available athttp://www.morningsideresearch.com/HDComparisonAug29.pdf, accessed January 5, 2005. Second twocolumns: Texas Health and Human Services Commission, “Final Non-State DSH Hospitals, 2002” (Excelspreadsheet).Local entities in addition to the three local 1115 waivers described previously are consideringhow to draw down more Medicaid funding. Dallas County Hospital District, for example, hiredHealth Management Associates, who reported that if the State Medicaid Plan could bereworked, the $110 million the hospital district spent on low-income health services inunmatched local funds could be matched by an additional $225 million in federal money.Strategies they believe could draw down additional funds include the following:B-32