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UMUC
Texas: A Healthcare
N. Llenas
I. Introduction
i. Target demographic
b. Rationing care
c. Financing care
d. Quality care
IV. Conclusion
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Texas: A Healthcare
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Introduction
Fund’s state scorecard, the room for improvement is endless, but frequently slow
and resisted. While many states fund safety net provisions and stretch out their
hands to the Federal government, Texas collects no income tax and refuses to
increase funding for a larger federal match. This lack of a cohesive effort has
propelled the plight of Texans to the national stage. Residents frequently drive 2
hours to hospitals offering free care, some wait 4-6 hours in emergency rooms
(ER) for ailments easily treated by primary care providers (PCP), and others are
Literature Review
population growth, but few scholarly articles examine the state’s health systems
and the factors that control it. Additionally, many community-led and non-profit
organizations produce reputable studies into the inner workings of the Texas
health system in their efforts to enact change, especially in SCHIP and Medicaid.
Adults with children covered by SCHIP are often left uninsured due to
Those left uninsured find that their employers are less likely to provide insurance,
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and employer-sponsored plans have steadily declined in the past 10 years as
providers in border towns have either closed their doors to additional patients or
moved their practice [ CITATION Fig03 \l 1033 ] prompting lawsuits in the name
states with the lowest Medicaid coverage, access to primary care services was
unattainable for low-income adults, which in turn increased emergency room use
Rationing
and well-paced immigration have led to severe rationing at major medical centers
approval of a ballot initiative, will soon grow into a children’s hospital financed
Quality
by the Commonwealth Fund, finds the state in disrepair, ranking it 49 th. Several
initiatives are in play to bring the state within range of the CMS and JCAHO
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standards for accreditation. Focus on heart failure, surgical infection prevention,
pneumonia and acute myocardial infarctions are a few of the indicators leading
Thesis
The purpose of this paper is to highlight and prioritize the problems ailing
the Texas healthcare system and formulate viable recommendations for change.
natural population growth and net migration. The Census Bureau (2005) projects
that by 2030 Texas will see a 59.8% increase in population and that population,
by 2026. While the demographic shift itself, is not a problem, the results of that
shift do pose problems for Texas and other states such as California, and
Florida, none of which have entered the top 30 overall ranking in the
At of the end of March 2008, Texas Medicaid had 2.86 million residents
enrolled, of which 2.11 million or 73.7%, were children 19 and under. Non-
elderly and non-disabled adults, including pregnant women comprise only 5.8%
450,000 children are covered under the state’s CHIP and CHIP perinatal
program. This figure present a gap in coverage for low-income adults, as Kaiser
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(2007), calculates 2.19 million Texans living at or below 100% of the Federal
The problem lies in the income eligibility set by the state to qualify for
Medicaid coverage. Non-working parents must fall under $2,256 annual income
and working parents, under $4,824 annual income. Compared to the national
restrictive states in the U.S., effectively shutting out large portions of poverty-
gaps for preventative services were as much as 80% greater in states with the
such a situation, the need for access to community safety-net providers and
Rationing
rise in emergency room use has emerged. In Houston, a crowded city with over
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60 hospitals, close to 30% of its residents are uninsured, 68% of those being
emergency room, between 2002 and 2003, were primary care related [ CITATION
often cause overcrowding and long waits. The group Save Our ER’s (2002)
commissioned a survey of Texas hospitals and found that in 2001 hospitals were
diverting 105 hours per emergency room, with only a minority of diversions due
to nursing shortages and 41% diverting ambulances at least three times per
week.
These facts alone have raised awareness to the importance of safety nets;
legislative requirements and the county’s role as decider. Texas counties have
the authority to redistrict facilities, build new ones or create County Indigent
1033 ]. These choices come with resistance from both taxpayers and county
Branch, where administrators are in the process of ending cancer care for illegal
immigrants. This state has seen unreimbursed expenses for illegal immigrants
double and UTMB has been caught in a “perfect storm” according to Dr. John
Other forms of rationing prevail, particularly along the border with Mexico.
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than that of Dallas or Houston. The Medicaid method of reimbursing physicians,
Diagnoses Relate Groups and Standard Dollar Amounts, which depend on case-
permanent DSH status don’t account for inflation and demand and have not
managed to actually pay for actual patient cost [ CITATION Fig03 \l 1033 ].
access is especially hampered, and in the case of Equal Access for El Paso, Inc.
ration care and reject those who have Medicaid. The suit charge that the
scheme used resulted in inadequate access for area residents and does not
Funding
System, non-profits and for-profit centers manage to stay afloat by shifting costs
or changing their case-mix and meeting charity care limits. Public facilities,
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Texas has 120 state or locally owned hospitals, representing 29% of
hospitals in the state [ CITATION The06 \l 1033 ]. These hospitals include the
University of Texas systems and Ben Taub General Hospital in Houston. Their
payer mix is heavily skewed towards public insurance or no insurance at all, with
38% of outpatient visits in 2002 attributed to the uninsured (Regenstein & Huang,
State owned teaching hospitals and general public hospitals have three
Hospital payments are a requirement for federal and state funding to be directed
According to Texas Health and Human Service (2008, p.4), “Texas pays $1.5
billion in DSH per year to 3 state teaching hospitals, 1 state chest hospital, 10
Upper Payment Limits also increase the funding potential for Medicaid
services for Texans. Using Medicare payment structures, “Texas pays $1.6
billion in UPL payments per year for inpatient and outpatient services to eligible
acute care hospitals, over $900 million of which was paid to 11 of the largest
Because these payments are capped based on the Medicaid shortfall and
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Texas: A Healthcare
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rampant in the public university hospitals that were previously mentioned in the
section on “rationing”.
The fact remains that Texas, unlike many states who have income tax,
does not have the guaranteed tax revenue that would offset the effects of
cigarette and alcohol tax, implementing a payroll and income tax (Texas Health
Care for all), or assessing a quality assurance fee (QAF) to for-profit and non-
profit hospitals. The QAF may prove to be the most reliable in that it would “tax
health provider’s revenues so that the state can draw more federal matching
funds and increase payments to those providers” (Center for Public Policy
Quality
TMF Health Quality Institute, a large contractor for CMS and partner with
Institutes for Health Improvement, has been assigned the duty of reforming
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pneumonia and surgical care with antibiotic use, are the primary focus of
achieved between the 4th quarter of 2006 and the third quarter of 2007. Such
improvements include the areas of prophylactic antibiotic use within 1 hour prior
patients (3.3% increase), discharge instructions for heart failure patients (5.3%
hospital arrival (12.9% increase). Although stagnation was found for oxygenation
fibrinolytic within 30 minutes for AMI patients, overall indications for improvement
Association outlined the full efforts of Texas hospitals to meet and exceed the
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MRSA prevention initiative led by the Texas Department of State Health
Conclusion
The Texas healthcare system presents problems unlike any other state.
Increased net migration has left hospitals unprepared and falling behind their
funding year by year. Lax insurance standards have proved to eradicate the
Texas has also left their healthcare systems to become reactive to acute
emergency care has led to severe rationing system wide, even in the case of the
public facilities, which have been tasked to care for the indigent. In some
communities, the use of promotores, can mitigate excessive use of high cost
On April 16, 2008, Texas Governor Rick Perry sent a health reform waiver
to the Department of Health and Human Services, outlining the steps Texas is
parents and caretakers under 133% to 200% FPL and childless individuals under
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100% FPL and will primarily be funded by DSH, UPL, and intergovernmental
transfer funds. Small businesses would also receive premium assistance and
The coverage set forth would effectively insure 2.15 million Texans who
vary based on income and plan selected, participate in health savings accounts
and choose providers and facilities. Texas Health and Human Services projects
hospitals and emergency rooms, shifting that care to community and local
For Texas, this reform is an important step towards reducing the amount
of uninsured and reducing the costs associated. Although, the reform does not
include the assessment of QAF or personal income tax, I recommend that both
being pooled.
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Bibliography
Abaris Group. (2002, May). An Assesment of Houston area ER's. Retrieved October
Begley, C. E., Vojvodic, R. W., Seo, M., & Burau, K. (2006). Emergency room use and
access to primary care: Evidence from Houston, Texas. Journal of Health Care
Census Bureau. (2005, April 21). Ranking of 2000 Census and projected 2030 state
Release/www/2005/stateproj7.xls
Center for Public Policy Priorities. (2008, October 23). Texas health care 2008: What
has happened and what work remains. Retrieved October 27, 2008, from
http://www.cppp.org/files/3/HlthCare_08_FinalScreen.pdf
Code Red Texas. (2006, April). Task Force Synopsis. Retrieved October 27, 2008,
http://www.coderedtexas.org/files/code_red_synopsis.pdf
Equal Access for El Paso, Inc. v. Albert Hawkins, No. 06-50599 (Unites States Courts
14
Texas: A Healthcare
N. Llenas
Figueroa, L. (2003). A Legal analysis of the Texas Medicaid reimbursement scheme
and its effects on the border region. Texas Hispanic Journal of Law & Policy ,
54-75.
Institutes for Health Improvement. (2007, February). Protecting 5 Million Lives from
http://www.ihi.org/NR/rdonlyres/EB78B6DB-0955-4C9C-A9B8-
599E1E53DF6D/0/5MillionLivesCampaignBrochure0207.pdf
Making dream a reality. Retrieved October 23, 2008, from Senator Eliot
Shapleigh: http://shapleigh.org/news/1420-the-children-s-hospital-at-
thomason-hospital-making-a-dream-a-reality
Nichols, D. C., Berrios, C., & Samar, H. (2005, November). Texas community health
www.cdc.gov/pcd/issues/2005/nov/05_0059.htm
Perry, R. (2008, April 16). Waiver Request. Retrieved October 25, 2008, from Texas
http://www.hhs.state.tx.us/medicaid/Waiver_041708.pdf
Regenstein, M., & Huang, J. (2005, June). Stresses to the safety-net: a Public health
15
Texas: A Healthcare
N. Llenas
Medicaid and the Uninsured:
http://www.kff.org/medicaid/upload/Stresses-to-the-Safety-Net.pdf
Severson, L. (2008, August 8). Ethics of Health Care Rationing. Retrieved October 25,
http://www.pbs.org/wnet/religionandethics/week1149/cover.html
Stulz, D. (2008, May 28). THA responds to Waxman Request. Retrieved October 27,
http://www.texashospitalsonline.org/HealthCareProviders/Advocacy/Com
mentLetters/Rep%20Waxman%20response%20ANN%20w-logo.pdf
Suehs, T., & Nolting, K. (2008, August 28). Disproportionate share hospitals (DSH),
upper payment limits (UPL), and medical graduate education (GME) as they
http://www.hhsc.state.tx.us/news/presentations/HAC_082808.pdf
Texas Health and Human Services Commision. (n.d.). Final count- Medicaid
http://www.hhsc.state.tx.us/research/MedicaidEnrollment/meByMonthCo
mpletedCount.html
16
Texas: A Healthcare
N. Llenas
Texas Health and Human Services. (2007, December 5). Texas Outlines Health Care
http://www.hhs.state.tx.us/news/release/120507_HealthCareReform.shtml
Texas Impact. (n.d.). Texas Can Do Better Than This! Retrieved October 27, 2008,
http://texasimpact.org/files/HI_One_Pager_0608.pdf
Texas State Data Center and the Office of the State Demographer. (2006, October
19). Summary of trends in Texas state data center 2006 population projections.
The Commonwealth Fund. (2007, June). State scorecard data tables. Retrieved
http://www.commonwealthfund.org/usr_doc/State_data_tables.pdf?
section=4039 http://www.healthcareforalltexas.org/faq.htm#taxes
The Henry J. Kaiser Family Foundation. (2007). Texas: Health Insurance Coverage of
the Total Population, states (2006-2007), U.S. (2007). Retrieved October 23,
ind=125&cat=3&rgn=45
The Henry J. Kaiser Family Foundation. (2008). Texas: Income Eligibility for Parents
(FPL), 2008 . Retrieved October 23, 2008, from State Health Facts:
http://statehealthfacts.org/profileind.jsp?ind=205&cat=4&rgn=45
17
Texas: A Healthcare
N. Llenas
The Henry J. Kaiser Family Foundation. (2006). Texas: Total Hospitals by Ownership
http://statehealthfacts.org/profileind.jsp?ind=395&cat=8&rgn=45
The Legislative Budget Board Staff for the House Select Committee on State Health
http://www.lbb.state.tx.us/Federal_Funds/Other_Publications/Medicaid_DS
H_Program.pdf
TMF Health Quality Institute. (2007, August). 1st Quarter 2007 Region Reporting.
http://hospitals.tmf.org/Portals/15/Documents/HO/DataRptg/RegionsMap
1Q07.pdf
TMF Health Quality Institute. (2007, May). 4th quarter 2006 region reporting.
http://hospitals.tmf.org/Portals/15/Documents/HO/DataRptg/RegionsMap
4Q06.pdf
TMF Health Quality Intitutes. (n.d.). Hospital activities. Retrieved October 27, 2008,
18
Texas: A Healthcare
N. Llenas
Weissman, J. S., Zaslavsky, A. N., Wolf, R. E., & Ayanian, J. Z. (2008). State Medicaid
coverage and access for low-income adults. Journal of Health Care for the
Wolf, R. (2007, June 18). What does a health crisis look like? See Houston. USA
Today , p. 3.
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