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The Uninsured in Texas Policy Brief Health Policy Forum Texas Association of Broadcasters Building Austin, Texas September 29, 2000 Sponsored by: The Robert Wood Johnson Foundation RGK Foundation The Meadows Foundation Amarillo Area Foundation The Don and Sybil Harrington Foundation Houston Endowment, Inc. League of Women Voters Education Fund League of Women Voters of Texas Education Fund TENET Healthcare Foundation P.O. Box 15587, Austin, Texas 78761-5587 Phone: (512) 465-1040 Fax: (512) 453-1267 www.healthpolicyinstitute.org HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 Introduction support action to address the issue. They are uncertain, however, of how to deal H ealth care is one of the most pressing policy issues facing the nation. With rising costs of care and more and more with it, and they do not want to subsidize coverage for the uninsured.8 In addition, the public has some misconceptions about Americans becoming uninsured, many the uninsured. The following section policy experts predict a health care crisis examines some of these common myths unless national and state leaders move and provides a snapshot of the uninsured. quickly to improve access to care. For various reasons, Texas has an The Many Faces of the Uninsured especially difficult problem to tackle. This paper explores some of the unique issues that Texas faces, and some of the T he national profiles of the uninsured offer insight as to who is uninsured in Texas, which closely follows national initiatives underway to decrease the number of uninsured Texans. trends. The Kaiser survey revealed that Despite a booming economy in the most people (57 percent) believe that the United States, the number of Americans uninsured are primarily unemployed or without health insurance has increased from families with no one working. In steadily over the last decade. The healthy fact, the majority of the uninsured (80 economy pushed many low-income percent) are low-wage workers and their workers and the unemployed from welfare family members.9 Analyzing data from and Medicaid rolls, but not into jobs that the U.S. Census Bureau, the Kaiser provided health insurance or sufficient Commission on Medicaid and the pay to purchase it.1 At the same time, Uninsured found that most of the fewer mid- and high-income workers uninsured are adults under the age of 65 received employer-sponsored coverage. who live above the federal poverty level. Thus, the uninsured rate for all earning More than half of the total, national levels rose.2 uninsured population is also white, non- Nationally, the uninsured rate is Hispanic.10 In a separate report, however, approximately 16 percent.3 The problem the Kaiser Commission concluded that in Texas is especially severe. An minorities generally have poorer access to estimated one in four Texans lacks health insurance and preventive care. In fact, insurance,4 more than one million of Hispanics are uninsured at more than whom are children5. What’s more, the twice the rate of whites.11 Immigrants, total number of uninsured is expected to too, tend to lack insurance, as do the poor. increase – both statewide and nationally.6 Even when low-wage jobs provide In fact, the uninsured rate would have insurance benefits for workers, the cost of increased more substantially in the last extending that coverage to their families is four years had the economy not been so more than many workers can afford. strong.7 This trend has social and political Thus, numerous children of working, implications that will affect every aspect insured parents lack coverage. Several of of public health. the initiatives to expand coverage have A survey conducted this year by focused on insuring children, but a lot of the Henry J. Kaiser Foundation indicates parents do not apply for benefits because that Americans are aware of the serious they believe their children are ineligible, problem of the uninsured, and that they or they find the enrollment process too 2 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 confusing.12 Children being raised by low-wage jobs that disqualified them for someone other than their parents also tend Medicaid. In Texas, however, the to be uninsured, as do children living with uninsured rate has remained one of the 13 a single parent. worst in the country for about 10 years.17 Employees of small businesses are This phenomenon indicates that some also at high risk of being uninsured. inherent, permanent factors may account According to one poll, 11 percent of small for the problems the state faces in insuring business owners will discontinue its citizens. insurance coverage for their employees if The areas of Texas with the premiums increase by five percent or highest uninsured rates are, for the most more. Of the employers who provide part, poor counties in the Texas-Mexico insurance, only 56 percent extend Border Region. In fact the 13 Texas 14 coverage to employees’ families. counties with uninsured rates higher than Finally, the Kaiser Commission 30 percent are all in South Texas, near the noted that young adults, particularly men, border, or in sparsely populated, rural are at a high risk of being uninsured.15 West Texas.18 Immigrants, low-wage When uninsured adults were asked workers and Hispanics are all among the why they lacked insurance, groups most likely to be the primary reason was “Nearly one quarter of uninsured, and Latino the expense, but nearly 20 all Texans lack health immigrants continually come percent of adults said that insurance, giving Texas to Texas to fill seasonal they do not believe they the dubious distinction and/or low-paying jobs. of having one of the need insurance. Only highest rates of Accordingly, Texas is likely three percent mentioned uninsured in the to have ongoing problems this as a primary reason, country” providing basic medical care, however. This indicates much less insurance, in some that a small percentage of From SCR6 by Sen. Chris areas. Health and Human Harris and Rep. Bob Glaze the adult population Services Commissioner Don chooses not to purchase Gilbert noted that “the risk health insurance. factors for the uninsured…generally fit Considering who tends to be the Texas demographics.”19 Critics argue uninsured, in part, explains why Texas has that the state could make a much better an especially large uninsured population. effort to enroll the poor in insurance programs.20 Why Are so Many Texans The Wall Street Journal reported Uninsured? that Texas’ uninsured problem is a “relic of the state’s low-tax, low-service T exas has the highest percentage of uninsured residents in the nation. It ranks second among all 50 states in the heritage.” Rather than aggressively enrolling the poor in Medicaid, the state has depended on hospitals and charities to percentage of uninsured children, and provide care for the medically indigent.21 third in the percentage of children below In fact, a primary focus of the state’s 200 percent of the federal poverty level Medicaid program has been to maximize 16 who have no insurance. In most states, federal matching funds for hospitals that the uninsured rate increased as a result of provide such care. This leaves the issue welfare reforms that forced people into 3 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 of providing care for the uninsured at the Medicaid application. The most serious local level. problem will be the cost to the state of Another reason many poor Texas funding a projected enrollment increase of families remain uninsured is that the state about a half million Texans.26 eligibility requirements for Medicaid are In short, the uninsured problem is very stringent. In an analysis of the likely to continue in spite of economic uninsured issue in Texas, Urban Institute prosperity. As the Health Insurance researchers noted that “although the Texas Association of America points out, “As Medicaid program does cover the health care costs have continued to rise as ‘medically needy,’ the income and asset a percentage of family incomes, health limits are so low that very few people insurance coverage is becoming qualify.”22 Low-income adults, except for unaffordable for more middle income pregnant women and the disabled, do not Americans.”27 A weak economy and/or qualify, and Medicare only covers adults increases in premiums could increase the over 65 years old. In 1997 there were rate of the uninsured in Texas. zero childless, non-elderly, non-disabled, Meanwhile, the costs of medical care and non-pregnant Medicaid eligible adults in prescription medication continue to 23 Texas. Even many of those Texans who increase, making it even more difficult for qualify for Medicaid enrollment do not the uninsured to access basic care. enroll because of the eligibility The following section focuses on determination process. some of the problems related to having a Texas Medicaid applicants are large uninsured population and why it is required to prove that they are not only important to reduce the number of cash-poor, but also that they have very uninsured in Texas. limited financial assets, such as cars and home equity. In addition, they have to The Benefits of Benefits: complete a one-hour face-to-face Something for Everyone interview with Department of Human Services staff.24 These two requirements are only part of what makes the eligibility process so daunting, thereby limiting W hen a quarter of the population struggles to access and cannot pay for health care, the impact is greater than enrollment — something that consumer what they suffer. Providing a medical advocates claim the Stakeholders: Benefits of solving the problem: safety net for so state does to limit state Access to preventive care and less many strains the Uninsured financial strain if illness occurs. Medicaid Reduced indigent care costs and health care system, 25 Health Care expenditures. System budgetary shortfalls; Less need for consumers, hospital districts to raise tax rates. In April, the Fewer premium and tax increases communities, Consumers / House Human Public to cover unpaid care for the families and health uninsured. Services Committee Overall improved public health and care providers. In and the House Public Communities money to focus on preventive and turn, all of these primary care. Reduced indigent Health Committee’s care costs. stakeholders will Workgroup on Health Care Fewer charity patients and cases look for Medicaid Eligibility Providers caused by untreated conditions. governmental Public approval; improved public met to review State health, more cost-effective health leadership to ease problems related to Government care, federal dollars to share the the strain and cost streamlining the ensure that the 4 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 safety net does not collapse. This section Amendment of 1997 (BBA) reduced DSH highlights the major problems caused by a funding. Many hospitals districts will large uninsured population and the have to increase taxes to cover budget benefits of reducing the number of deficits created by the unpaid services.33 uninsured. Very often, poor communities with Health insurance is unaffordable high numbers of uninsured rely on local for most uninsured families, so paying for clinics and health centers for care. medical care is also a great burden. Federally Qualified Health Centers, or Consequently, the uninsured are four those that serve a lot of Medicaid or times more likely to report going without uninsured patients, also face reduced needed care, and three times more likely funding due to the BBA. Since Medicaid to report problems paying for care when funding is vital to most of these local they get it. Moreover, those in the poorest facilities, some could face closure or be health are least likely to access care.28 forced to reduce their services greatly. Inability to access primary/preventive care Few dollars are likely to be spent on leads to higher hospitalization rates and health education or public health health problems that are costly to treat, initiatives. but could have been prevented. One study The public pays for the uninsured shows the uninsured to be twice as likely in many ways. If the hospital districts to be hospitalized for diabetes, have to raise taxes to pay for indigent hypertension and “immunizable care, taxpayers cover the costs of care. conditions – all health problems that are Health care providers who provide charity amenable to treatment and care recover losses from other management in a doctor’s private-pay patients, although “The burden of office.”29 providing health care to managed care has limited The uninsured are uninsured Texans falls their ability to do so in recent expensive. Private and on county indigent years.34 non-profit hospitals in health care programs, Doctors are not Texas must, by law, hospitals, and legally required to provide or individual physicians provide emergency care and costs taxpayers an report charity care. Rowland to all patients, regardless estimated two to four and Keenan noted that, of their ability to pay for billion dollars per year” “…much of the cost of caring 30 services. As a result, for our uninsured population From SCR6 by Sen. Chris hospitals lost an estimated Harris and Rep. Bob Glaze has been hidden through $4.7 billion on cross-subsidies from private- unreimbursed indigent care pay patients. With the growth last year.31 of managed care and discounted The state Medicaid program has payment rates to many providers, focused on drawing down federal these cross-subsidies are Medicaid funds to help hospitals that shrinking,…which could serve disproportionate numbers of the ultimately result in reductions in medically indigent (DSH funds). Local the provision of charity care to the hospital districts, however, use their uninsured.”35 taxing authority to raise the matching Given the many groups affected by funds required to draw the federal the uninsured problem in Texas, assistance.32 The Balanced Budget legislators and other policymakers 5 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 recognize the need to address the issue. In Children’s Insurance Programs fact, they may be forced to do so very quickly. Judge William Wayne Justice of The largest program that focuses the U.S. District Court in Austin ruled on insuring children is the federal earlier this month that the Health and Children’s Health Insurance Program, or Human Services Commission failed to CHIP. The State Children's Health comply with a 1996 agreement to make Insurance Program (SCHIP), created by major changes to the Medicaid program. Title XXI of the 1997 federal Social He ordered the state to submit to the court Security Act, is designed to reduce the by next month, a plan to restructure number of uninsured children nationally Medicaid. Nevertheless, the state has by distributing block grants to states over taken measures to provide insurance a period of several years. States can coverage to more Texans, as summarized expand coverage by expanding Medicaid, in the following section. by instituting a separate health insurance program, or by a combination of Ideas and Initiatives expanding and implementing a new program. CHIP targets children with family incomes below 200 percent of the M edicaid is the largest program that provides coverage for the poor in Texas. However, there are other state- federal poverty level.37 Families who earn too much money to qualify for Medicaid, initiated and private programs that help to but cannot afford to buy private health provide coverage. coverage may qualify for CHIP, which is The 71st Legislature created the available statewide. Texas Health Insurance Risk Pool (pool) The Texas Healthy Kids Corp. in 1989, but it was not used until the 75th (THKC) is an initiative to provide Legislature (1997) activated the pool to insurance through private companies to provide uninsurable Texans access to uninsured children. The THKC has health insurance for medical conditions contracted with private insurance that resulted in ineligibility for private companies and health maintenance insurance coverage. Last year, 730,599 organizations (HMOs) to provide Texans were insured through the pool.36 coverage. As of October 1, however, A private, non-profit organization, THKC stopped enrolling children in the Texas Health Care Purchasing contracted plans.38 From now on, THKC Alliance, helps small business owners to will serve as a referral service for families collectively buy group health insurance seeking to insure their children. The for their employees. Through cooperative future role of THKC may depend on the purchasing, small businesses can get 77th Legislature. better insurance rates. The alliance is In April, the Texcare Partnership similar to the Texas Insurance Purchasing launched in Austin. The partnership is a Alliance, a state initiative that began in public-private sector cooperative effort to 1997, but ended only two years later when help low-income families insure their the legislature stopped funding it. The children through the Children’s Health Texas Health Care Purchasing Alliance is Insurance Program (CHIP), Medicaid, and a non-profit corporation owned by its private policies. The Texcare Partnership, members. It is monitored by the Texas of which THKC is a part, matches Department of Insurance. families with insurance policies based on their needs and incomes.39 6 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 Several laws enacted over the last few years have implemented these and • House Bill 710 by Averitt and other initiatives to address the uninsured Sibley revised the existing statute situation in Texas or to improve insurance that created the Texas Health programs, such as Medicaid. Following is Insurance Risk Pool to meet the a list that highlights important insurance- requirements of federal insurance related laws from the last three legislative reform law. The pool was created sessions. in 1989, but never operational. This law implements the pool to 74th Legislature (1995)40 help insure uninsurable Texans. • Senate Bill 10 by Sen. Judith • House Bill 864 by Rep. Brian Zaffirini and Rep. Hugo Berlanga McCall and Patterson requires reformed the state’s Medicaid health benefit plans for college System, primarily by establishing students who are over 21 and Medicaid Managed Care programs under their parent's policy to and using local indigent health provide coverage for an entire care resources to draw federal academic term, even if a student’s matching funds. course load is reduced to part- time. • House Bill 369 by Rep Kip Averitt and Sen. Jerry Patterson eased the • House Bill 1212 by Averitt and regulation of small employer Sibley changed the state’s Small benefit plans, small employer Employer Health Insurance carriers, and health maintenance Availability Act to the Health organizations to increase the Insurance Portability and availability of the health plans to Availability Act and includes small employers. provisions for large employer health benefit plans to conform to • House Bill 997 by Rep. Henry federal law. Cuellar and Zaffirini established the Texas Healthy Kids Corp. as a • House Bill 2913 by Berlanga and pilot program to provide primary Zaffirini requires the Health and care health insurance coverage for Human Services Commission to children younger than 13 years of administer and operate the age who are ineligible for medical Medicaid managed care program. assistance under the state's Medicaid program. 76th Legislature (1999) 75th Legislature (1997) • House Bill 1398 by Rep. Garnet Coleman and Zaffirini authorizes • House Bill 3 by Rep. Hugo the Texas Department of Health Berlanga and Sen. David Sibley (TDH) to administer the Indigent established the Texas Healthy Health Care and Treatment Act, Kids Corp as a statewide initiative widens the scope of mandatory and implemented a funding and optional indigent health care mechanism for the program. 7 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 services, amends eligibility The Blue Ribbon Task Force on the requirements, modifies state Uninsured financial assistance to counties, and establishes reporting Recognizing that the huge number requirements. of uninsured puts Texas’ health care system at risk, the 76th Legislature passed • Senate Bill 445 by Sen. Mike SCR 6 by Sen. Harris and Rep. Bob Moncrief and Rep. Patricia Gray Glaze. The legislation established the created the Texas Children's interim Blue Ribbon Task Force on the Health Insurance Program (CHIP) Uninsured. The nine member task force for certain low-income children. includes three public members, three senators, and three House representatives. • House Bill 820 by Rep. Elliot The chair, Sen. Harris, was elected by the Naishtat and Zaffirini requires the members. Health and Human Services Specifically, the task force is charged Commission to automatically to: review a child's eligibility for medical assistance if the child's • study the unique problems faced Medicaid benefits are lost due to by Texans lacking health the loss of the family's Temporary coverage; Assistance to Needy Families • review demographic trends (TANF) grant. relating to the uninsured problem; • examine other states' programs, • House Bill 1676 by Rep. Rob laws, and systems to address the Junell and Sen. Bill Ratliff creates lack of affordable health coverage; a permanent fund for tobacco • evaluate existing programs in education and enforcement and a Texas that address the uninsured and indigent health care needs, including government, public, and “This emerging health private initiatives; and care crisis poses a threat to our thriving • develop a market-based economy, which in turn improvement plan, including will negatively impact financing tools and models, to all Texans, regardless ensure that Texans have access to of their own health coverage….” affordable health care coverage…. Since October, 1999, the task force From SCR6 by Sen. Chris has met seven times in various regions of Harris and Rep. Bob Glaze the state, including its last meeting on September 13 in Upshur County. Invited permanent fund for children and and public testimony enabled the task public health using the settlement force to hear and collect ideas and money from the class action concerns from a wide variety of experts lawsuit, of which Texas was a and Texans affected by the uninsured part, against several major tobacco issue. A comprehensive compilation of companies. proposals submitted to task force members is available at the Senate 8 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 committees website Advocacy, Inc. supported a sliding (www.senate.state.tx.us/75r/senate/commit/BlueRibbon.h premiums scale for the State High Risk tm). Following is a brief description of Pool and extending small group market selected recommendations for addressing reforms to the individual market. The this issue, categorized by the stakeholder Texas Medical and Texas Hospital group that proposed them. Associations shared their support for the The Texas Association of sliding scale proposal. Businesses and Chambers of Commerce The Texas Medical Association (TABCC) suggested authorizing Medical also proposed targeted studies on Savings Accounts through which particular demographic groups and health employees could set aside pre-taxed issues. Also in support of disease and money to pay for medical needs. With the illness prevention, Blue Cross/Blue Shield support of several other groups urged developing community health representing hospitals, providers, improvement initiatives. consumers and insurers, TABCC also Since students often lack proposed that the state seek a waiver to insurance, the Texas Hospital Association expand CHIP and Medicaid to cover low- with the support of TAHP recommended income working families and to allow requiring students to show proof of employers to offer insurance through the insurance prior to enrollment in a state programs. university or college. Another business group, Small The Texas Health Care Council Business United of Texas, recommended would like to see the market determine allowing small businesses to deduct the what benefit packages include, so that cost of premiums from their franchise they could change rapidly with advances taxes and authorizing providers to initiate in heath care technology. enrollment for Medicaid and CHIP, Finally, Senator Harris’ staff allowing for retroactive enrollment when recommended mandating pricing a person who is eligible cannot pay for guidelines for all providers using a care already received. Also with the percentage of rates negotiated with support of insurers, hospitals and Medicare, Medicaid and/or private plans; providers, the group supported obtaining a waiver to make current simplifying eligibility rules for Medicaid. Medicaid benefits more like coverage The Texas Association of Health available to the public; and creating a Plans (TAHP) proposed consolidating gross receipts tax for patient services to state waiver programs and resources to fund private-public insurance maximize capacity for insuring Medicaid- cooperatives. eligible Texans, and expanding Medicaid Though Texas has one of the most Managed Care. On the other hand, Blue difficult uninsured problems to address, Cross/Blue Shield, proposed seeking an many individual communities are working additional waiver to allow local hard to help their uninsured residents. government to administer CHIP and The next section focuses on one initiative Medicaid to allow communities to meet that focuses on increasing access to health their individual needs. The association care, which is the underlying issue of the also suggested allowing self-employed uninsured population. and part-time workers to buy into the State Risk Pool. 9 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 Communities in Charge Grow?,” Health Affairs, V. 19, No. 4, July/August, The Robert Wood Johnson Foundation 2000, pp. 188-196.. 2 Ibid. (RWJ) funds various local initiatives to 3 Office of Public Insurance Council.(OPIC) support local communities in increasing “Health Insurance Coverage in Texas: Context access to health care and insurance. One and Demographics,” July 6, 1998. 4 of the community access initiatives is Ibid. 5 their Communities in Charge (CIC) House Research Organization. “Health Care for Uninsured Texans,” Focus Report No. 76-5, Program designed to finance and deliver February 4, 1999, p. 1. health care to the uninsured. In Texas, El 6 American Hospital Association. “Study Projects Paso Community Voices, Inc. received Uninsured Reaching 55 Million by 2008.” AHA $150,000 for the next year to implement a News, Dec. 3, 1999. 7 CIC project. Austin also has a CIC Ibid. 8 Reuters Health, as reported by Medscape.com, Program, administered through the “Poll Reveals Misperceptions About the Indigent Care Collaboration. The Austin Uninsured,” May 17, 2000. program received $149,942 for the year 9 Ibid. 10 from RWJ. Hoffman, Catherine and Alan Schlobon. “Uninsured in America: A Chart Book.” Washington, D.C.: The Kaiser Commission on Conclusion Medicaid and the Uninsured, May, 2000, pp. 15- 18. O verall, there are many initiatives to improve the plight of the medically indigent and to increase access to 11 The Kaiser Commission on Medicaid and the Uninsured. “Health Insurance Coverage and Access to Care Among Latinos,” Key Facts, June, 2000. affordable insurance. Nevertheless, the 12 Kaiser commission. “New National Survey uninsured problem persists, and is Finds 9 in 10 Parents of Uninsured Children getting worse. One of the problems is that Eligible for Medicaid Appear Willing to Enroll,” states with a high percentage of uninsured, Washington, D.C. Kaiser Family Foundation, such as Texas, have to spend more per January 11, 2000. 13 Hoffman, et al. capita to bring their percentages in line 14 Healthcare Leadership Council. “Poll Finds with other states.41 It is clear that Uninsured Rate Likely to Rise,” Health Care News economic growth will do nothing to ease and, Information, V7, No. 27, July 21, 2000. 15 the problems the state faces, especially Hoffman, et al. 16 considering that most of the uninsured are OPIC, 1998. 17 Greenberger, Scott S. “Texas Last in Rate of working adults. Uninsured,” Austin American-Statesman, Even as counties, hospitals and September 29, 1998. individual health care providers strain to 18 Texas Health and Human Services Commission. continue providing indigent care, polls “Demographic Profile of the Texas Population show that Americans are unwilling to pay without Health Insurance Coverage,” Division of Research, Planning and Program Evaluation, May, to provide coverage for the uninsured. 2000. Prepared for the Blue Ribbon Task Force on This means that the “patching of the the Uninsured. safety net,” rather than a movement 19 Greenberger. 20 toward wholesale reform or universal House Research Organization, 1999. 21 coverage, is likely to continue. Merle, Renae. “Task Force on Uninsured Considers Host of Solutions,” The Wall Street Journal, June 14, 2000. 22 1 Wiener, Josh; Alison Evans, Crystal Kuntz and Holahan, John and Johnny Kim. “Why Does the Margaret Sulvetta. “Health Policy for Low- Number of Uninsured Americans Continue to Income People in Texas,” Washington, D.C.: The 10 HEALTH POLICY FORUM ON THE UNINSURED – SEPTEMBER 29, 2000 Urban Institute, Assessing the New Federalism Series, 1997. 23 Texas Health and Human Services Commission. Texas Medicaid in Perspective, 3rd. Edition, 1998. 24 Zamrazil, Kristie. “Streamlining Access to Medicaid Coverage,” House Research Organization, Interim News, No. 76-5, May 19, 2000. 25 Ibid. 26 Ibid. This enrollment projection is from the Legislative Budget Board, but has been disputed by those who favor streamlining the eligibility process. 27 Custer, William S. and Pat Ketsche. Health Insurance Coverage and the Uninsured: 1990- 1998, Washington D.C., Health Insurance Association of America, December, 1999. 28 Rowland, Diane and Patricia Seliger Keenan. “The Uninsured: An Old Problem Encounters New Pressures,” Healthcare Forum Journal, January/February, 1998, pp.43-45. 29 Cited in Rowland, et al. The actual study is published in the Journal of the American Medical Association (JAMA), , v. 268, 1992. 30 House Research Organization, 1999. 31 Merle, 2000. This estimate was provided by “the state” to The Wall Street Journal. Other estimates differ. In a House Research Organization report, for example, the figure is $3.6 billion. 32 Wiener et al, 1997. 33 Ibid. 34 Rowland, et al, 1998. 35 Ibid. 36 Texas Department of Insurance. “1999 Annual Report to the Governor,” Texas Health Insurance Risk Pool, June 1, 2000. 37 Pharis, David B. “Policy Research Study of Children’s Health Insurance Coverage,” Austin, TX: Texas Institute for Health Policy Research, July, 1999. 38 http://www.tdi.state.tx.us/consumer/cbo71.html (Health Care Coverage for Children site, Texas Department of Insurance, 2000. 39 www.texcarepartnership.com 40 All of the legislation information is summarized from the actual legislation via the Texas Legislature Online’s bill search engine, http://www.capitol.state.tx.us/capitol/legis.htm. 41 Rand Health. Health Care Coverage for the Nation’s Uninsured: Can We Get to Universal Coverage?” Research Highlights, 1999. 11