The Texas health Care Primer

Transcription

1 The health Care Primer REvISEd 2011 The Center for Public Policy Priorities is a 501(c)(3) nonpartisan, nonprofit policy institute committed to improving public policies to better economic social conditions of low- moderate-income Texans. CPPP pursues this mission through independent research, policy analysis development, public education, advocacy, coalition building, technical assistance. We pursue this mission to achieve a BETTER TEXAS. Eva DeLuna Castro Senior Budget Analyst Anne Dunkelberg Associate Director Stacey Pogue Health Policy Analyst F. Scott McCown Executive Director Methodist Healthcare Ministries is a faith-based, 501 (c)(3), not-for-profit organization whose mission is Serving Humanity to Honor God by improving physical, mental spiritual health of those least served in Southwest conference area of The United Methodist Church. MHM supports policy advocacy programs that promote wholeness of body, mind spirit. Miryam Buja Public Policy & Advocacy Manager Ed Codina, Ph.D. Director of Planning, Research Policy Joe Babb Executive Director Pilar Oates Executive Director Kevin C. Moriarty President CEO

2 Mental Health America of. Turning Corner: Toward Balance Health care Reform is a in basic human Mental right Health It Services. is unjust to Feb. construct or perpetuate barriers to physical wholeness Task We Force also for recognize Access to Health role Care of governments in. Code in ensuring Red: The that Critical each Condition individual of has Health access in. to those April elements 2006, necessary 2008 to update. good health. Comptroller of Public Accounts. The United Uninsured: Methodist A Hidden Church Burden on Employers Communities. April Social Principles Department of Insurance. Working Toger for a Healthy, State Planning Grant: Interim Report. September (Federal Health Resources Services Administration grant.) Health Human Services Commission. CHIP in Perspective (The Pink Book ). January th ed. Health Institute. Long-Term Care in : Policy Implications. November Health Institute. Long-Term Care Primer. October LTC_PRIMER_FINAL_with_logo 2_.pdf Table of Contents Foreword... 3 Health Care: The Economic Context... 4 How is Health Care Paid For in?... 6 How does State s Health Care Infrastructure Compare to Or States?... 8 Who is Insured? Who has Employer-based or Or Private Insurance? Who is Working Uninsured? Why More People Don t Buy Health Insurance on Their Own Why More Employers Don t Provide Health Insurance Who Gets Medicare? Who Gets? CHIP Income Eligibility Comparisons Caseloads versus Costs How will Health Care Reform Change Delivery of Health Care in? The Health Care Primer Updated March 2011 Center for Public Policy Priorities, 2011 You are encouraged to copy distribute without charge. Who is Served by Local Public Health Care Spending? What is Counties Role in Providing Health Care? What are Federally Qualified Health Centers? What Major Gaps Exist in Public Programs?

3 Conclusion Disabled elderly Immigrants This primer presents a brief but broad picture of health care in Health to enable Care readers Access to Issues contribute Specific to federal, to Children state,... local debates 46 about improving access to health care. We hope this primer has Health successfully Care Access informed Issues you, for as well Children as engaged Adults you to participate in Receiving future discussion Leaving action. Cash Assistance It is clear that health care is a vital part of economy; a Health significant Care job-based Access Issues benefit Specific consumer to Indigent out-of-pocket Care... expense; 50 a major fiscal challenge for taxpayers all levels of Why government Inadequate serving or No Insurance elderly; persons is a Problem with a disability; children; for low-income Individuals uninsured Families or underinsured... Texans. Unfortunately, 51 even with huge sums of money spent by consumers, employers, Why Inadequate public sector, No critical Insurance health is a care Problem services remain beyond for reach Employers of too many... Texans. 52 Why Nationally, Inadequate signs or of No progress Insurance can be is a seen, Problem even just one year after for State enactment Local of national Taxpayers health... care reform. But this update comes 53 in middle of a legislative session during which is still Conclusion reeling from... effects of a global economic recession. In face 54 of an historically large revenue shortfall of at least 27%, legislators Suggestions are considering for Furr massive Reading cuts to, CHIP, 55 or public health programs which would severely harm Texans access to health services leave billions of federal dollars for health care unspent. These state cuts to health care are being considered even though already ranks very low on almost any measure of state or local government per capita health spending, also ranks poorly on indicators such as share of uninsured residents or residents living in poverty. But even if some of worst cuts to or CHIP are reduced or avoided entirely, much work remains to be done before we can say that adequate investments have been made in health of our current future workforce in ensuring that elderly disabled Texans get medical attention y need. The picture painted by this primer should help you to underst full implications of health care access in, to feel a level of compassion that stirs you to st up be counted as an active concerned member of our society. 54 Suggestions for Furr Foreword Reading Anor The Center publication for Public by Policy CPPP Priorities with support (CPPP) of Methodist Healthcare Ministries, (MHM) entitled are pleased Top Five: to release Key Steps anor to update Make of our Most of Health Reform, Care Primer. is available The primer online was at first issued in files/3/mhm_shortpaper_4page_new.pdf has been reprinted distributed This electronically brief report to identifies thouss decisions of readers. that As two nonprofits must make working to properly to improve implement life in health care communities, reform. our partnership in creating this primer was natural. CPPP researches advocates ways to improve You economic may also want social to conditions consult of following low- for moderate-income more information on Texans; critical MHM, health through care issues health confronting services, programs, : public policy advocacy, directly touches lives of those least served. The Access Project. Providing Health Care to Uninsured in : This primer A Guide is designed for County to give Officials. readers September an introductory overview of factors shaping Texans to care. We define access as uninsured_in_tx.pdf ability to obtain health services in a timely manner to have an adequate infrastructure of health care professionals facilities Center willing for Public able to Policy serve Priorities. those needing What medical Every Texan attention. Should Readers Know: of Health this primer Care will Reform be better Law. able June to contribute to federal, state, local debates about how to improve that access. Center Anor for goal Public of this Policy primer Priorities. is to paint What a picture Is a Health beyond Insurance numbers Exchange? facts conveyed. March 2, Knowledge brings responsibility. We hope that knowledge in this primer will prompt readers to reach into ir hearts not only find compassion, but ask: Is this kind of Institute society in of which Medicine, I want National to live? Academy Is it wise of that Sciences. many of Insuring children America s on whom we Health: will depend Principles for our future Recommendations. state economic viability are work hard at full-time jobs, yet do not get health insurance without health care? Is it fair that a significant number of Texans coverage provided to ors? Institute of Medicine, National Academy of Sciences. America s Uninsured If public policies Crisis: reflect Consequences values in for action, Health we must Health ensure Care. that our values are heard. For our values to be heard, we must speak out. Consequences-for-Health--Health-Care.aspx MHM CPPP ask you to st up be counted, to actively engage in issues that challenge your values so that our society reflects your principles. CHIP Payment Access Commission. Report to Congress on CHIP. March

4 Why Inadequate Personal or Health No Insurance Care Expenditures is a Problem as a for Employers Percent of Economy, 1980 to % When workers or ir children lack health insurance, y are less U.S. likely to have medical conditions diagnosed treated. This can lead to increased absenteeism turnover; reduced productivity; increased 10% workers compensation, disability, or health care costs; impaired job performance. Not all of se costs can be quantified, even when y can be, cost (to employer) may still be lower than cost of providing health insurance to 5% workers ir dependents. This is particularly true for low-wage part-time employees, who are less likely to be insured than are high-wage or full-time employees. % of Gross Product 0% Increasing 1980 availability of employer-provided coverage 2005 (or of 2010 employer support for public programs) will require a better understing on part of business leaders or policy makers What of a few is key Bought points. with Health Care Dollars, 2004: $105.5 billion total First, having insurance means workers are more likely to be in good health, to have increased earnings Nursing home productivity associated with good health, to remain with care, 5.3% employer Dental, rar 4.6% than going to work for a competitor. Physicians/ or professionals 31.1% Drugs or nondurables, 13.1% Home health care, durable products, all or, 8.1% Second, a lack of insurance is damaging to rest of labor force local health care provider infrastructure. Third, if uninsured end up getting health care that is eir more expensive than it would have been if y saw a doctor sooner, or that y cannot fully pay for mselves, cost of this care will be shifted to or payers, including private-sector employers taxpayers in general. Families USA estimates that in 2005, cost of employer-based family coverage in was $1,551 higher due to unpaid costs of health care for uninsured Texans. Hospital care, 37.8% Why Health Inadequate Care: The or Economic No Insurance Context is a Problem for State Local Taxpayers In 2004, $105.5 billion spent on personal health care in Families accounted USA for estimates 11.7% of that uninsured Gross State Americans Product (GSP). pay out-of-pocket As shown in for at top least chart, one-third health (35%) care spending of cost became of health a much care larger services part y of receive. economy The remaining during cost of 1980s. health It care stabilized received in by uninsured at 11.0% ends of GSP up being decreased covered primarily slightly after by local, that. state, Starting in federal 2001, taxes, health or through care spending higher premiums once again paid exceeded by those overall who are economic insured. growth, Economists estimate although that this two-thirds trend was to more three-fourths pronounced of nationally cost of health than in care. provided to uninsured Americans is directly converted into higher hospital The bottom charges chart shows higher private different health services insurance products premiums. on which health care dollars are spent. Almost 70% goes to hospitals to Studies physicians. also show that health when care people spending are not looks covered similar by to U.S. or CHIP, average, y except tend to that use only or 5.3% health of care services such dollars are spent as public on nursing hospital home care, emergency compared rooms that to 7.4% for are much U.S. more average. expensive. Not only does this increase cost of health care, it also means that local communities The state Comptroller pay se higher of Public costs Accounts without has estimated benefit of that federal every matching non-state funds dollar that (from a federal or CHIP or or would out-of-state draw down. source) spent in on health care generates $3.51 in overall spending. Increased Conversely,, CHIP, when children Medicare have consistent coverage of access Texans to a would doctor, refore medical not only costs reduce per child need can for actually local government decrease. In funding one analysis of indigent by care programs, Children s it Hospital would also CHIP increase HMO (health economic maintenance impact of organization) health care industry. Houston, claims decreased at least 20% for children continuously enrolled for a year or longer. SOURCES: State Health Accounts data, Centers for Medicare A 2003 study by economist Ray Perryman estimated that for Services; Comptroller of Public Accounts, The Impact of State every $1 in state tax revenue that is cut from CHIP, Higher Education System on Economy, December local taxes go up 51 cents; local health care providers will have 53 cents of uncompensated care; state tax revenue falls by 47 cents; $2.81 in federal funds is lost. Or negative effects cited by Dr. Perryman include higher health insurance premiums or health care costs, decreases in retail sales or private-sector economic activity. SOURCE: U.S. projections for are from September 2010 estimates. State Health Accounts data, February 2007, Centers for Medicare Services

5 Health Care Estimated Access Sources Issues of Specific Funding to for Indigent Care Health Care in 2004: $105.5 billion total The results of an 18-state study show that even with a safety net of local hospitals health clinics to treat uninsured, significant Consumer Federal barriers to health care remain, such as cost-sharing out-of-pocket, Medicare, requirements, high prescription medication costs, or financial 20% 20% burdens that discourage indigent from seeking future care. SOURCES: problems continued. State Health Accounts, Centers for Medicare Services, February 2007; U.S. Census Bureau, State Local Government Finances 2004; Comptroller of Public Accounts, Health SOURCE: Care The Spending, Access March Project, 2001; Paying CPPP for estimates. Health Care Figures When do You re not add to 100% Uninsured: because How of rounding. Much Support Does Safety Net Offer?, January Or Federal, 1% For example, two-thirds to three-fourths of rural residents who were prescribed drugs as a result of seeking outpatient or emergency room (ER) hospital care said that y were unable to pay full cost of medications. About 30% said y did not get all of ir Federal, 9% medications because of an inability to pay. Those using urban or suburban hospital ERs were most likely State to report that hospital staff did not offer to look into financial, 6% assistance options on ir behalf. When assistance was offered, it was more likely to be an installment plan, rar than discounting or Employer & State Or, waiving individual medical bill. 2% insurance & Local Govt., workers' 3% About half comp., of 36% uninsured who received Charity, care 2% said y had unpaid bills or or debt to health care facility. Of those, half said ir debts would keep m from going back to facility if ir health Why How Inadequate is Health Care or No Paid Insurance For in? is a Problem for Individuals Families Personal health care spending in totaled $105.5 billion in People 2004, who latest support year limiting for which estimates government s are available. role in providing Private a health public care employers safety(36% net for of health uninsured care spending) or underinsured individual often downplay consumers (20%) importance combined of having paid for coverage, well arguing half of that all health those care who in, can t according pay can instead to an estimate go a local by health state clinic, Comptroller emergency of room, Public or Accounts. community Employers health center. spending However, is primarily negative for health health insurance consequences premiums of workers being uninsured compensation have been costs, well while documented. individuals Major spend studies, health care as summarized dollars on premiums, by Families co-payments, USA, have found direct that, payment compared of to health insured: care bills, prescription drugs, or out-of-pocket costs. Federal, Uninsured state, children local government adults are programs less likely combined to have annual account for 41% exams of health or preventive care spending, care. as Uninsured shown in adults chart are at less left. The federal likely contribution to be screened is almost for cancer, three times heart disease, large as state diabetes. local governments Uninsured share adults combined, are less likely because to follow of federal up on spending recommended on Medicare medical tests. or care, are more likely to end up being hospitalized unnecessarily as a result of an untreated condition. It is important to note that while source of public spending is taxes Uninsured or people government with arthritis, revenue, heart lion s disease, share high of blood se health care pressure, dollars ends or up in chronic private conditions sector. Wher are less likely it funds to public have employee se conditions health insurance cared for benefits through or visits programs to a health for low-income provider or people, medication. public health care spending consists of payments to insurers, hospitals, physicians, pharmacists, or health care providers. Uninsured people are sicker die prematurely compared to Charity those with consists insurance. of public Families private USA estimates hospital charity that annually, care; physician almost charity 2,150 working-age bad debt; Texans pharmaceutical die prematurely companies due to charity a lack programs; of health coverage. medical services funded by nonprofit groups. It is not When same as hospitalized, all health care spending uninsured for get fewer uninsured. substard According to a survey services by than those Department provided to of State insured. Health They Services, are also nonpublic charged hospitals more alone than accounted 2.5 times what for over people $2 billion with insurance ( often uncompensated refore, negotiated care (charity discounts) care are bad billed debt, for adjusted hospital for services. cost-tocharges ratios) in One study estimated that in 2007, almost two-thirds (62%) of bankruptcies were due to medical bills, unaffordable mortgages to pay for health-related debt, income loss due to illness or injury. Being underinsured was more common than being uninsured for those seeking bankruptcy protection. The elderly women (especially single heads-of-households) were most affected by ir inability to pay off medical debt. 517

6 Health Care Trends Infrastructure in Poverty Rankings in or Cash Assistance Recipients Millions Per 100,000 population: U.S. Rank Hospital beds, th EMTs paramedics, th Physicians, th Registered nurses, th Dentists, th Dental hygienists, th SOURCES: Kaiser State Health Facts; Occupational Employment Statistics, U.S. Bureau of Labor Statistics. 1.0 Cash Assistance (AFDC/TANF) Primary Care Health Professional Shortage Areas, 2010 SOURCES: Poverty data from U.S. Census Bureau, Current Population Survey, Annual Social Economic Supplement; caseload data from Health Human Services Commission Department of Human Services, operating budgets annual reports Texans Below Poverty Line No 0.00 shortage to areas 1.00 One 1.00 or more to 2.00 Entire 2.00 county to 2.00 How Health does Care Access State s Issues Health for Care Children Infrastructure Adults Compare Receiving to Or Leaving States? Cash Assistance Compared When to or was states, created in has mid-1960s, a relative scarcity its benefits of certain were kinds available of health only to care recipients professionals. federal/state The table cash at left assistance a shows ranking welfare in program bottom known third after of 1996 states as when Temporary number Assistance of physicians, for nurses, Needy Families dentists, (TANF). or In health 1972, care federal personnel law also is adjusted created for total Supplemental population Security of state. Income (SSI) to provide cash assistance to certain elderly poor people with disabilities. Receiving SSI or Even being with eligible lower for TANF rates still of health automatically care personnel, qualifies however, someone health in care jobs for are, an important but in part addition, of many state economy. or categories Private-sector of health individuals care services have been employed made eligible almost for 1,116,000 Texans by federal in 2009, with expansions combined annual late 1980s earnings of or $62 billion. changes Health to federal services law. share of Specifically, private-sector certain low-income earnings children is 10.2%, slightly parents; higher pregnant than ir share women of private-sector ir infants; jobs (9.4%). certain elderly state disabled local persons governments are eligible for employed anor even if 128,800 y do health not receive hospital TANF workers SSI. in 2009, with an estimated annual payroll of $6 billion. While enrollment has grown since 2001, AFDC/ Analyzing TANF cash assistance state s health caseloads care infrastructure have plummeted requires since looking In below November state-level 2010, of data to local availability caseload of health 3.2 million care professionals. people, fewer Federal than 1% designations were adults on such TANF, as Medically fewer Underserved than 4% Area were children or Health on Professional TANF. Anor Shortage 66% were Area or are used low-income to identify regions children, where 1% were health foster professionals children, 9% are in were short elderly, supply. 16% In November were adults 2010, or children 66% of with a disability, counties, 4% or 168, were were pregnant wholly women, designated fewer as primary than 1% medical were poor care parents shortage not areas; receiving 109 TANF counties cash were assistance. dental care shortage areas; 194 counties were mental health care shortage areas. Rising In addition, caseloads hundreds of subcounty costs can lead areas particularly to increased support in urban for state areas TANF such or as Harris, Bexar, policy changes Dallas that counties have directly or been identified indirectly as attempt needing to discourage more medical providers. participation The chart by at left children. shows However, counties because that were cost wholly of covering or partially aged designated disabled as patients having a is shortage much higher, of primary removing medical children care from providers in November will not change ( Areas underlying can factors be census driving tracts, long-term neighborhoods, growth in or cities; population groups costs. In such 2010, as low-income average residents; monthly or managed institutions care such cost as for a prisons.) disabled/blind recipient was $684, over four times cost for nondisabled children ($165 per month), more than twice cost for TANF parents ($311 per month). SOURCES: U.S. Bureau of Economic Analysis; U.S. Census Bureau, State Local Government Employment Payroll; U.S. Health Resources Services Administration. 49 9

7 Health Care Texans Access by Age Issues Insurance Specific to Status, Children 2009 Millions Children make up a larger 34% share uninsured of population than y do 15.0 of most or states. In 2009, 28% of Texans were under 18, compared to U.S. average of 24%, giving second youngest population. Children 5.0 million in are also much more likely to be Uninsured 10.0 poor uninsured. had 7th highest child poverty rate in 2009, 17% at 24.4%, uninsured highest share of children (under 19) uninsured in , at 18% well above Medicare 1.3 million 4.5% U.S. average of 10%. uninsured 5.0 In absolute terms, employer-based insurance coverage for 110,468 children peaked in 2000 at 3.4 million. By 2009, 383,000 fewer children had employer-based coverage, compared to Job-based coverage levels - seen before 2001 economic recession. Under to over Children s enrollment stood at almost 1.2 million in August 1995, n fell each year after that to a low of 976,000 in August Insurance In 2000, Status children s in 2009, U.S. enrollment (All Ages) started growing again because of simplified eligibility procedures, outreach 0% 25% 50% 75% 100% efforts, a worsening economy. By August 2002, 1.35 million children were served U.S by ; by August 2005, child enrollment had reached 1.82 million. However, it fell to 1.72 million by October 2006 because of problems with eligibility determination system, remained relatively flat for two years. In October 2008, as effects of TX Great Recession began to be felt in, children s enrollment began a steady climb, reaching 2.3 million in Fall Almost 3 million children are projected to be enrolled by SOURCE: U.S. Census Bureau, Current Population Survey, Annual Social Economic Supplement, Top chart does not show small amount May 2000 of people climbed covered by rapidly, federal peaking military health at about care 529,000 or non-employerbased private insurance, shown in bottom chart as or insurance. in May Top eligibility chart includes determination CHIP coverage system in (starting December category 2005), for Texans drove under Job-based /CHIP Medicare only Or insurance Uninsured Changes made by 2003 Legislature to Children s Health Insurance Program (CHIP) reduced number of children served benefits package. CHIP enrollment began in in The 2003 cuts, followed by problems related to changes in enrollment down to 291,530 in September Starting in September 2007, CHIP enrollment resumed steady growth, reaching pre-2003 levels by November 2010 (527,4300 enrolled). Who is Insured? Insurance Status of Children In millions Of 8 $69 billion spent on health care in in 1998, Comptroller of Public Accounts estimated CHIP that $4.7 billion paid for Medicare, Military, health care for Or Insurance uninsured, while almost $65 billion in health care was 6 for insured Texans. On average, this equaled $967 in health care spending per uninsured Texan, compared to $4,296 for a Texan with health insurance. Being insured is clearly linked to having access to 4 health care (as measured by spending) Uninsured for average Texan. Three-fourths of Texans do have health insurance, primarily through 2 ir employer or a government Employmentbased program Medicare or. Residents aged 65 or over are most likely to be insured. In 2009, 91.2% of Texans 65 over were covered by Medicare; only 4.5% of senior Texans lacked insurance of any kind in Among working-age Texans (19 to 64), primary source of NOTE: CHIP include children up to age 18; or categories coverage is employment-based insurance, covering 52% of se are for children 17 younger prior to Employment-based means adults. child But is insured because through a family member s Medicare job. coverage for workingage adults is low (7% 3%, respectively), Texans in this age group are most likely to be uninsured (34% in 2009). Among children, 45% were covered because a family member had employment-based insurance, remainder had or CHIP coverage (37%) or no insurance at all (17%) in SOURCES: U.S. Census Bureau, Annual Social Economic Supplement ; Health Human Services Commission. Public Nearly Health two-thirds Safety of Net Finally uninsured Begins children to Work have Again incomes for below Children: CHIP income Despite limit growth of 200% in of total number federal of poverty uninsured line. Texans between Adjusting 2008 for undocumented 2009, number immigrant of uninsured children who children are excluded in actually from declined from CHIP, this million means to roughly million. half of Like adults, children uninsured continued children to qualify lose coverage for se through programs employer-sponsored but are not enrolled. insurance, but increased coverage through CHIP have more than has made highest up for uninsured that loss. rate 26.1% in 2009 in nation. The U.S. average is 16.7%, or almost 50.7 million uninsured A nationwide. combination Over of higher 6.4 million recession-driven Texans were eligibility uninsured in notable improvements in state eligibility enrollment systems have yielded These single-year a substantial estimates increase of in uninsured children s Texans people CHIP lacking enrollment. any kind of In health last coverage half of for 2009, an entire calendar enrollment year are system from reduced Census delays, Bureau s errors, Current backlogs, Population allowing Survey (CPS), children s source of insurance statistics safety cited net above. to perform Or as studies it should show that helping Texans families are also in need more during likely hard to lack economic insurance times. for shorter or longer periods of time

8 Unlike For example,, a March states 2009 CHIP Families programs USA are study required estimates by federal that law to nationally, include legal 33% immigrant of nonelderly children. Americans 86.7 Thus, legal immigrant million people children in were uninsured who entered for all or U.S. part after of 2007 August are Of se covered uninsured by people, CHIP three-fourths if y meet (74.5%) income went without stards. coverage In addition, for 6 under or more months. One-fourth CHIP statute, (25.3%) state-funded of 86.7 CHIP million benefits were are uninsured provided for during entire five-year 24-month bar period. on Persons federal funding. who go for longer periods without insurance tend to have lower incomes, be in fair or poor The health, Children s or be middle-aged Health Insurance (who have Program higher Reauthorization rates of chronic Act of 2009 disease). gave states choice to provide CHIP to legal immigrant children without a five-year delay, triggering language in For, law directing Families USA state estimated to take that federal about funding 9.3 million should it become nonelderly available. individuals 44% expects of to all fully residents implement under 65, shift highest to covering rate lawfully U.S. were present uninsured children for in some or all of CHIP 2007 with full federal Almost match 81%, in or million, of se Texans went without coverage for 6 months or more. Most (83%) were part of family with one or Undocumented more workers. Immigrants: The estimated 1.45 million to 1.75 million undocumented immigrants living in face numerous barriers The 9.3 to million health nonelderly care access. Texans Undocumented who experienced immigrants a spell have of never being been uninsured eligible over for a 24-month or period CHIP, in in Families 1996, federal USA study welfare is reform much larger furr than restricted state s undocumented 6.3 million immigrants nonelderly uninsured access to in certain 2010 Current or federal Population public Survey, benefits. because pool of Texans with no insurance includes people who remain uninsured for long periods National of time, health as well reform as ors under who regain Affordable coverage Care at Act some of point But, does not while provide some for Texans any additional uninsured access in 2007 to regained public or coverage private health in 2008, a insurance new group coverage of different for undocumented individuals lost immigrants. coverage in To sum up: Texans are at higher risk than or Americans of being uninsured Services for both funded short through longer periods. federal Maternal Child Health Block Grant (Title V), Family Planning (Title X), Primary Care Block Within Grant, (see Federally chart at Qualified right), Health estimated Center percentage funds may of nonelderly restricted residents based with on immigration no health insurance status. is highest in communities not be along U.S.-Mexico border, in metro areas of Houston, Federal Dallas, law also Fort mates Worth. Border-area that no restrictions economies may are be more placed likely on to federal, lack state, type or of local higher-paying benefits providing jobs that emergency would eir care offer (including employerbased coverage, or mental pay high health enough emergencies), salaries so immunizations, that workers could labor/delivery diagnosis purchase insurance treatment coverage of communicable for mselves illnesses, ir families. or programs Border areas delivered are also at likely community to have much level higher necessary than to average protect life or unemployment safety. rates larger shares of residents who are low income (below 200% of federal poverty line) Nonelderly State local Residents governments With are No allowed Health to Insurance, provide health 2009 services to undocumented residents beyond those mated above; a provision of federal Abilene law requires that new (post-1996) 19.2 state laws be passed to reauthorize Amarillo such programs Ans 26.8 State Policy Austin-Round Debates: RockBills filed during most 22.1 recent legislative Beaumont-Port sessions Arthur have included several proposals none 25.9 of which 39.6 passed to Brownsville-Harlingen furr limit non-citizens access to health social services. College However, Station-Bryan a great diversity of opinion 18.0 exists on issues related to immigration; Corpus Christi for example, large segments of 26.6 s business Dallas-Fort community Worth-Arlington support comprehensive immigration 26.0 reform. While it is Dallas-Plano-Irving clear, based on bills already filed for session, that debate of se El Paso issues will continue to take place, it is 30.9 not clear wher Fort any Worth-Arlington significant changes in state policies will gain majority 24.8 support. Houston-Sugar L-Baytown Killeen-Temple-Fort Hood Federal Update: Since July 2007, federal law requires most U.S. Laredo 36.5 citizens enrolled in or applying for to prove ir Longview 24.3 citizenship. (Prior to that date, legal immigrants already had to Lubbock 21.9 provide ir official immigration documents to enroll in.) Lufkin McAllen-Edinburg-Mission The 2007 requirement was expected mostly to create problems for Midl eligible U.S. citizens who lack ready access to a birth 23.6 certificate, as Odessa well as create new fears or confusion resulting in lower enrollment 30.7 San Angelo by qualified persons in families made up of U.S. citizens 24.8 foreign San Antonio -born non-u.s.-citizens Sherman-Denison 26.9 Provisions in Texarkana 2009 federal reauthorization of Children s 25.5 Health Insurance Program Tyler allow states to use federal 24.9 Social Security Administration Victoria database to electronically verify 27.1 U.S. citizenship. The WacoHealth Human Services 20.7 Commission was slated to begin Wichita using Falls this in February Rural U.S. Average 17.2% % SOURCES: U.S. Census Bureau; 2009 American Community Survey. Uninsured rates are shown for under-age-65 population by micro metropolitan statistical area or division

9 Immigrants Factors explaining General: lower has rate 3.8 of million employer-based foreign-born residents, health insurance third largest coverage number in of immigrant residents (after California New York) among states. Immigrants in are much less likely to be insured through, Medicare, or U.S. any or source of coverage than are native-born residents. Average About ASSOCIATED 1.2 million WITH foreign-born MORE residents ACCESS of have become naturalized Manufacturing U.S. citizens. jobs as They % of are all jobs, uninsured at a higher 9.4% rate 10.5% (31%) than 2009 are U.S.-born residents of (22%). More than half (60%) of 2.6 million immigrants in who Workers represented by a union, % 13.6% are not U.S. citizens legal permanent residents, undocumented immigrants, or foreign-born residents are uninsured, a rate almost Private-sector three times workers as high in as a that union, for native-born 2009 residents. 3.1% Still, 7.2% as chart below illustrates, non-citizens, both legal undocumented, ASSOCIATED are only one-fourth WITH LESS (1.6 ACCESS million) of uninsured. Compared Involuntary to or part-time large workers states with as similar % of demographics, 14.6% 14.3% has by part-time far highest labor force, percentage July (over % in 2005) of children of immigrants who are also uninsured. This is true despite fact that children Agriculture/mining of immigrants, jobs more as often % of than all jobs, not, are U.S. 2.8% citizens 1.8% 2009 Citizenship Status of Uninsured Texans, 2009 Construction jobs as % of (Total: all jobs, 6.4 million) % 6.8% Percent of workers in low-wage jobs, 2008 Percent of business employment in 2008 accounted for by firms Not a U.S. Citizen 24% 24.4% 24.1% with fewer than 20 employees U.S.-born Naturalized 22.9% 24.7% Citizen citizen with fewer than 50 employees 70% 39.5% 41.2% 6% SOURCES: Bureau of Labor Statistics; Bureau of Economic Analysis; Economic Policy Institute; Population Reference Bureau; County Business Patterns American Community Survey, U.S. Census Bureau; Unionstats.com, Barry T. Hirsch David A. Macpherson. SOURCE: U.S. Census Bureau, Current Population Survey, Annual Social Economic Supplement, Who thus eligible has Employer-Based for CHIP or or on Or same Private terms as any or Insurance? U.S. citizen child. Many children live in families that include U.S. citizens, legal immigrants, undocumented members: onefourth 2009, of 50% all of Texans children under live 65 in years mixed of age families had health (one insurance or more In through parent is ir a non-citizen, own or a family eir member s legal or undocumented), job, considerably below one-third U.S. of average children of 59%. in low-income (Only New Mexico families had (below a lower 200% rate of of employer-based poverty line) are insurance mixed coverage.) families. Making matters worse, ever since 2001 economic downturn, trend has been for a smaller share Immigrants of Texans Not to get Cause health insurance of through Uninsured ir Ranking: job. In 1999, As 61% mentioned of Texans earlier, under immigrants, 65 had employer-based wher legal health or unauthorized, coverage, are compared much more to likely 68% of to Americans be uninsured on than average. are U.S.-citizen residents. But if state estimates are adjusted to remove non-citizens from Texans equation, private still firms ranks with worst up to in 24 terms employees of uninsured were most residents, likely to lack with coverage: 4.7 million 47% children of workers adults 21.4% at se small of employers population were uninsured lacking health in insurance At firms in with 25 to In 99 comparison, employees, California s 36% of workers U.S.-citizen were uninsured. rate Even is 14.5%; at firms New with York s 100 to is %. employees, though, 27% of workers were uninsured. Thus, low rate of Legal Immigrants: Federal law lets states choose wher or not to employer-based coverage cannot be attributed solely to provide to legal permanent residents based on ir U.S. percentage, or share of employment, of small businesses in state. entry date. Only Wyoming did not continue for those who (On both those scores, is very similar to national averages.) arrived before enactment of 1996 federal welfare reform law. Thus, legal immigrants in who were in U.S. before August Factors that do explain lower rate of employer-based coverage 22, 1996, are eligible for on same basis as U.S. include a higher share of workers employed involuntarily at parttime jobs (i.e., y cannot find full-time jobs); a lower share of citizens. manufacturing However, is higher one of share seven of states* construction that do not provide farming jobs; to legal low rates immigrants of unionization, who arrived all after of which August make 22, 1996 workers ( after less likely immigrant to have completes employer-based a federal health 5-year insurance. bar on participation). Federal law requires all states to pay for emergency care for Employers orwise-eligible who provide immigrants health under insurance Emergency benefits to ir workers, program, workers so opting who to receive provide m, full got federal benefits tax subsidies allows totaling states to $151 draw billion down federal in 2009, funds according to cover to prenatal federal care, Office prevention, of Management primary care, Budget.* chronic In comparison, care. In 2001 Medicare outlays Legislature in 2009 passed totaled a $437 bill to billion; provide post-1996 legal immigrants Children s with Health Insurance coverage, Program but cost $269 legislation billion was in federal vetoed funds. by governor. * OMB estimates cost of tax expenditures on health insurance (including medical savings accounts, but not workers compensation) by determining amount that would be required to provide taxpayer same * The after-tax or states income are Alabama, as tax Mississippi, expenditure. North Dakota, Ohio, Virginia, Wyoming

10 What Major Gaps Exist in Public Programs? Working-Age Texans with No Health Insurance in Disabled Elderly: Several large gaps in public health care system exist for Texans who (Total: are 4.9 elderly million) or who have a disability. This is a problem because fewer elderly Texans are insured, Not in labor more live in poverty, force than elderly people in U.S. on average. 27% One major health care gap for elderly that Congress has taken steps to address is prescription drug coverage. A Part D drug benefit was added to Medicare in 2003, helping many seniors but Employed creating donut hole problem for ors. This is a gap in 63% coverage that beneficiaries with high drug costs face. The Affordable Care Act of 2010 began closing donut hole in 2010 will completely Unemployed eliminate it by % Remaining policy challenges include out-of-pocket costs that grow faster than retirees fixed incomes; impact that federal deficits may have on Insurance Medicare program; Status of Working-Age access to affordable quality long-term care. The Medicare nursing home benefit is very Millions Texans by Income, limited of people in most cases is not an option for those needing longterm care. Medicare pays for a nursing home only after someone has been 10.0 hospitalized, for only 100 days for each incident (or spell ) of illness. Insured 7.5 Anor major gap exists Uninsured for elderly disabled Texans who are receiving 5.0 monthly Social Security Disability payments but are still in two-year waiting period required before Medicare coverage can begin. 2.5 If people in this situation have incomes low enough to qualify m for Supplemental Security Income (SSI), can help with - medical costs; orwise, y have to find anor way to pay for ir medical Below 100% bills. of The Affordable 100 to 200% Health of Care Above Act 200% may of also poverty poverty poverty help some adults who become disabled by creating a voluntary longterm care insurance program by October Uninsured rate: 62% 54% 21% Various indicators point to unmet needs in for health care for SOURCE: elderly, U.S. Census for Bureau, elderly Current disabled, Population than Survey, in Annual U.S. on Social average. Economic For example, Supplement Census 2009 Bureau data Working-Age show that is in defined , as 19 to only 64 years 90% of old, 62 to-74-year so se charts old exclude Texans workers were who insured, are under compared 19, or 65 to over. U.S. average of 95% for this age group Texans Who is 65 Working over have a Uninsured? poverty rate of almost 12%, compared to 9% for elderly Americans on average, in Texans aged 65 A popular over were misconception also 1.2 times is that as likely only people as senior who citizens are jobless nationwide lack in health 2009 insurance. to have a self-care It is true that difficulty, 57% of ambulatory unemployed difficulty, working-age cognitive Texans in difficulty were uninsured, versus 29% of employed Texans who were uninsured. However, being employed still leaves workingage Texans quality with of a care 29% is chance issue of being, uninsured. which has Anor median way wages to Finally, for look personal at same home statistics: care aides employed for account home health for almost aides that two are out not of three much uninsured higher than working-age federal Texans minimum (see wage top chart ($7.25 at an left). hour in July 2009). Several factors explain why so many working Texans are uninsured. SOURCES: One is that AARP limits Public on Policy Institute; eligibility U.S. in Census federal Bureau, law have American Community excluded many Survey adults Current from that Population safety net Survey, program: Annual namely, Social Economic childless adults Supplement 19 to years old, unless y are pregnant or disabled. policy decisions made by have furr limited program s ability to serve working-poor parents. Median Wages even Hourly from Wages a part-time, of Home low-paying Care job make Workers, most 2009 adults ineligible for because of very stringent state income requirements for adults. only covers parents with incomes below 20% of poverty, or $308/month U.S. Average for a working parent with two children. At minimum hourly wage of $7.25, working $9.46 $9.85 even $ hours a week would disqualify a parent from continuing to receive. $8.21 $7.50 In $ , when statewide unemployment averaged 7.6%, one-third of adults under 65 were low-income (below 200% of poverty, or $36,620 $5.00 for a family of three). Most low-income workers have earnings that are not low enough to fall below adult income $2.50 cap, but not high enough to enable workers to buy health insurance for mselves or ir dependents, even if ir employer is willing able to share cost. Half (54%) of working-age $0.00 Texans between 100 to 200% of poverty were uninsured in , compared to Personal 62% of those Home below Care poverty. Home Health Aide Aide Texans with incomes above 200% of poverty have a much better SOURCE: chance of U.S. being Bureau insured, of Labor even Statistics, though in Occupational total numbers, Employment re are Survey more uninsured May in this income group (2.0 million) than among poor (1.25 million) or or low-income (1.6 million uninsured). In , 21% of working-age Texans above 200% of poverty had no health insurance

11 What Monthly are Household Federally Budget, Qualified Two Health Parents/One Centers? Child, 2007 Federally Qualified Health Centers (FQHCs) are Health a type of Percent public or nonprofit primary health clinic funded Monthly by Insurance federal Bureau Increase of Primary Health Care. FQHCs budget/taxes FQHC look-alikes, Premiums which Needed are to without health (employee Cover not federally funded, are also called insurance Community Health share) Centers, Premiums are Abilene cited often as a key part of federal $2,174 plans to improve $335 Americans 15% access to health care. has a state-funded incubator grant Amarillo 2, program to help more communities apply for FQHCs, federal Austin-Round state Rock governments have earmarked 2,990 funds 309 to exp 10 or start Beaumont-Port FQHCs. But Arthur federal funding has 2,117 not been maintained 344 at Brownsville-Harlingen peak level, wher in or 1,972 nationally Until Bryan-College 2004, FQHCs Station received federal funds 2,624 through 309 various programs 12 created Corpus over Christi years: Community or 2,473 Migrant Health 344 Centers; 14 Health Dallas-Plano-Irving Care for Homeless; Public 2,917 Housing Primary 344 Care; 12 Healthy El Paso Schools, Healthy Communities. 2,286 These were 344 consolidated 15 into one cluster which brought $121 million to in Fort Worth-Arlington 3, This is a significant increase from $44 million in 1993, but federal FQHC Houston-Baytown-Sugar grants are still only L 0.1% of 2,909 health care 344 spending. 12 Killeen-Temple-Fort Hood 2, In Laredo 2009, 65 FQHC grantees served almost 2, , Texans 12 throughout state. About 56% of FQHC clients are Longview 2, uninsured. Along with federal private grants, FQHCs get revenue Lubbock from private insurance, Medicare, 2,259, 339 CHIP. 15 Compared McAllen-Edinburg-Pharr to national average, 2,295 FQHC revenues 260 are much 11 more Midl dependent on patient fees government 2,192 grants, 339 much 15 less Odessa dependent on or private 2,115 insurance Community San Angelo Health Centers provide comprehensive 2, primary health 15 care San Antonio residents with financial, geographic, 2,725 or cultural 293 barriers 11 to care. Sherman-Denison CHCs may also provide transportation, 2,534 translation, 344 preventive 14 care, Texarkana mental health, dental services. 2,241 These health 344 centers are 15 public or nonprofit agencies created by local residents governed Tyler 2, by consumer-majority boards of directors representing communities Victoria served. Health centers generally 2,387 require 344 payment 14 for services Waco from patients, according to ir 2,358 ability to pay Wichita Falls 2, FQHCs are critical providers of care, serving all residents requesting care SOURCE: not Center excluding for Public persons Policy based Priorities, on Family immigration Budget status. Estimator, As of September 2010, FQHCs could be found in 102 counties Why More FQHCs People are most Don t heavily Buy concentrated Health along Insurance U.S.-Mexico on Their border Own in South East. While FQHCs serve significant numbers in San Antonio, Austin, El Paso, ir presence in Health Dallas, insurance Fort Worth, costs vary Houston widely is depending limited. on where a beneficiary lives, what ir medical history or condition is, FQHCs provide primary care benefits to ir clients, but y do what benefit level is chosen. As a result, it is difficult to determine not provide specialty care or hospital care. Thus, any plan to exp exactly how much income a family needs to be able to buy its FQHCs as a way to provide coverage to uninsured must also find own health insurance. a way to fund provide access to specialist hospital care. One attempt to estimate local health coverage costs is Family Budget Federal Estimator FQHC (FBE), Funding released for by, Center for Public Policy In million Priorities $ in The FBE uses cost of family coverage under $160 Employees Retirement System (ERS) health plan for state government employees to model a metro-level cost of insurance for workers with employer-sponsored coverage.* For a two-parent, one $120 child family, monthly budgets rise 10% to 16%, depending on metro area, if employee s share of premium costs is included. $80 The FBE also provides estimates of health insurance costs for workers without employer-sponsored coverage (not shown in $40 table at left); household budgets increase by 30% to 42% if health insurance premiums are included. $ Family budget increases to cover cost of health insurance are inversely Community linked Health to how Ctrs. high Migrant or low Workers or, non-medical Public Housing/Homeless costs of living are. For example, in table at left, Fort Worth-Arlington has How highest FQHCs non-medical were Funded, household 2009 expenses (mainly because of housing (% from each child source) care costs); adding $344 for premiums U.S. requires Average only a 11% increase. In contrast, residents of lower-cost areas such as Federal Wichita Grants Falls would need a 16% increase in 28.0% ir family 21.9% budgets to cover $344 for employee s share of health 25.5 insurance Medicare *ERS Or is Public largest Insurance employee group in ; smaller 3.1 employers 2.9 individual Private Insurance purchasers of health insurance would face 3.5 much higher 7.3 costs than amounts used in FBE. Thus, FBE estimates should be Patient Self-Pay/Fees interpreted as minimum, not average, cost of health insurance. Foundation/Private Grants/Contracts State/Local Grants/Contracts Or Revenue SOURCES: U.S. Census Bureau; Kaiser State Health Facts