from The Dallas Morning News
Texas' health care entangled in politics, poverty, immigration
By JASON ROBERSON / The Dallas Morning News
Miles Brooks was born in 2002 with end-stage renal disease, or kidney failure, and immediately placed on dialysis. Every night, the DeSoto boy gets hooked up for 10 hours to a machine in his bedroom – his mom, Chinea, connecting the tubes to a catheter in his tummy.
As a child with chronic kidney disease, Miles qualifies for Medicare, but there is still a premium charge for his medical insurance through the federal program. So, on top of what dad Michael Brooks pays at work for the family's health policy, the couple must also come up with $290 every three months for Medicare. They've borrowed from relatives and been late on their mortgage in order to send a check to the government program.
The Brooks family, like a lot of others dealing with a chronic or pre-existing condition, and those without employer-provided coverage, hope the government will step in with a plan to provide universal health coverage or make insurance simpler and cheaper. But in Texas, the state with the largest percentage of uninsured residents in the nation, such sweeping change isn't likely to come soon, unless it arrives from Washington.
Politics, poverty and illegal immigration intersect here to make health care a thornier issue than in most states.
And Texas, with legends of independence and gritty self-reliance, has rarely been at the forefront in creating government entitlements.
The state Legislature isn't set to meet again until January 2009. In the last session, earlier this year, lawmakers voted to spend more on Medicaid and the Children's Health Insurance Program (CHIP), which provide health care for the poor.
But they sidestepped a more wide-ranging proposal to guarantee coverage to all of the state's 23.5 million residents.
A grassroots coalition, Health Care for All Texans, presented a proposal to lump all Texans into a single insurance plan, to be administered by a nonprofit authority set up by the state. Employees, employers and the self-employed would contribute differing amounts to keep it going.
The group outlined the plan at a Texas Legislative Workshop in September 2006. But no legislation was introduced.
Another group, the Texas Health Institute, an Austin-based nonprofit think tank, presented a 12-proposal plan designed to cut the state's uninsured numbers in half (from 5.4 million to 2.7 million). It was projected to cost the state $1.6 billion a year, with another $1.7 billion thrown in by the federal government.
Lawmakers approved some of the 12 proposals, voting to increase Medicaid and CHIP spending enough to extend care to another 300,000. (The federal government, which co-funds the program, has yet to approve the increase.)
Gov. Rick Perry opposes universal coverage but backed two of the proposals that passed.
The first is designed to cut Medicaid waste.
The second, dubbed the "Three-Share Program," is meant to boost coverage among working families who earn too much to qualify for Medicaid but struggle to pay for private insurance. Under Three-Share, the state kicks in $150 a month toward a family's policy, with the employer and worker sharing the rest of the cost.
State Rep. Sylvester Turner, a Democrat from Houston, authored a bill to reduce barriers to CHIP coverage.
He says he would have liked doing more: "Basically, what people like myself and many of the Democrats believe is that if you want a more productive Texas, we have to attend to the human services side of the budget."
"The elected statewide leadership is at best ambivalent about health care," said Kimble Ross, an Austin-based health care consultant who works with Democratic presidential candidate John Edwards.
Jacqueline St. Hilaire, president of the Dallas Association of Health Underwriters, may come close to expressing the Texas consensus on universal health coverage.
"It sounds noble and terrific," Ms. St. Hilaire said. "However, the reality is there's a limited amount of funds that can be spent on health care.
"Forcing people to take insurance, that's kind of un-American," she added. "Even with mandatory auto insurance, everybody still doesn't have it."
U.S. Rep. Michael Burgess, R-Lewisville, who is an obstetrician and gynecologist, has a more upbeat opinion of the Legislature's efforts.
"Sometimes we don't seem like the most agile," he said. "But the reality is, we do get the work done and will get the work done."
Even if Texas legislators were a more liberal bunch, it would be hard to make rapid progress here, Mr. Ross said.
Resentment from people who blame the state's immigrants – fairly or not – for draining charity medical coffers lessens support for any new plan that might boost public spending on the uninsured, Mr. Turner said.
Of course, Texas is not alone in its immigration battle. California – second in the percentage of residents without insurance – has more such immigrants. In 2006, it led the nation, with an estimated 2.8 million, compared with 1.6 million in Texas (No. 2 among the states).
But the continuing flood into Texas is more pressing. From 2000 to 2006, 92,000 illegal immigrants crossed into the state, according to the U.S. Department of Homeland Security.
Illegal immigration and the high rate of uninsured are key differences between Texas and a state like Massachusetts, which kicked off a statewide health care plan in June. More than 94 percent of Bay Staters already had insurance through their jobs, Medicaid or Medicare, according to the Massachusetts Division of Health Care Finance and Policy. That dwarfs Texas' 74 percent.
And then there's poverty. About 3.7 million Texans live below the poverty line – $16,090 for a family of three in 2005.
If you add in those considered low-income (anyone who earns less than twice the poverty line figure, or $32,180), a full one-third of the state's adults under age 65 were either poor or low-income in 2005.
Low-income workers typically have earnings too high to meet Medicaid's adult income cap in Texas, but not high enough to afford comprehensive health insurance, which cost an average $11,480 for a family of four last year.
At the same time, the state has a disproportionate share of the small companies that often don't provide insurance for employees. (Even people whose employer offers health plans are increasingly deciding they can not afford the employee share.)
Of course, the poorest of the poor can turn to Medicaid.
Individual states set the limit on how much someone can earn and still be covered, as well as what doctors and hospitals will be paid, subject to federal approval.
In Texas, Medicaid only covers parents with incomes below 22 percent of the poverty line, which works out to $308 a month for a working parent with two children. Such a parent toiling only 14 hours a week at the current minimum hourly wage of $5.85 would make too much to qualify.
The nation's third-largest publicly traded hospital system, Tenet Healthcare, is based in Dallas. It operates hospitals in 12 states, including Texas and California.
Tenet CEO Trevor Fetter speaks highly of California's Medicaid plan, dubbed Medi-Cal.
"Texas, on the other hand, tries not to cover people and has a stingy program," Mr. Fetter said in a recent interview.
In the upcoming presidential election, health care has emerged as a major issue, so perhaps something will change on the national level after 2008, although many think the first action will come from the more progressive states.
Meanwhile, the Brooks family will struggle to pay for two insurance policies.
And folks like Gloria Newton will go without coverage.
Ms. Newton, a 48-year-old cook living in Mesquite, says she could probably handle the $35 weekly paycheck deductions for the plan offered at her job as a full-time cafeteria worker in Dallas County's Head Start program for preschoolers. But the plan's $1,500 deductible gives her pause. How much use would the policy even be, she wonders, if she has to pay $1,500 in costs before the policy's full benefit kicks in?
Instead, she avoids going to the doctor and pins her hopes on charity care should an emergency arise. She gets her high blood pressure pills at a neighborhood Wal-Mart.
If it weren't for the store's discount drug program, which provides a month's worth of her medicine for $15, she says, she'd be in trouble.
"I'd have to do what I'd have to do to get it," said Ms. Newton, a mother of two grown children working 72 hours a week at two jobs – she puts in 32 hours more at a Sears store. "I'd have to keep working harder to pay for it."
HEALTH CARE ELSEWHERE
Massachusetts, in June, became the first state to mandate universal health care. Residents must sign up for health insurance by Nov. 15 and be covered by Dec. 31. If residents do not comply, they face losing their personal income tax exemption the following year or penalties of up to half the premium cost of the most expensive private health insurance certified by the state. Massachusetts worked with private insurance companies to offer a variety of plans, including some that are subsidized or free to low-income residents.
California's state senate president and the assembly speaker both unveiled proposals last December to expand health care coverage and reform the state's health care system. In January, Gov. Arnold Schwarzenegger announced a sweeping reform plan that would bring coverage to all of the state's uninsured. None of these measures have been passed into law.
Colorado established a Blue Ribbon Commission for Health Care Reform during its 2006 legislative session. The commission is required to make comprehensive health care reform recommendations to the legislature by January 2008. It is sifting through 19 comprehensive proposals received from the public and is to select three to five for further evaluation.
Oregon Gov. Ted Kulongoski announced a plan last fall to cover all the state's children under age 19. Three other groups, the Oregon Health Policy Commission, the Senate Commission on Health Care Access and Affordability, and the Archimedes Movement, are developing health coverage reform plans.
Pennsylvania Gov. Edward Rendell released a reform proposal in January known as Prescription for Pennsylvania, which includes making a basic health insurance plan available to eligible small businesses and uninsured residents through the private insurance market.
SOURCES: Massachusetts Department of Health and Human Services; Families USA; Prescription for Pennsylvania
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