Dallas, Denton, and Tarrant counties—three of the most populous counties in Texas—have similar percentages of their populations uninsured, but the ways in which they care for their citizens are very different. Texas law requires county governments to offer health care to those who do not have insurance by (1) establishing a hospital district, (2) funding a nonprofit public hospital, or (3) developing a County Indigent Health Care Plan (CIHCP). Dallas and Tarrant counties have hospital districts whereas Denton County has a CIHCP clinic system, known as the People’s Clinic of Denton County. Data on the uninsured and the Behavioral Model for Vulnerable Populations are used to identify the subpopulations most at risk due to a lack of insurance. African Americans and Hispanics were most at risk. Denton County’s primary concerns include providing prenatal care to Hispanic and African American women, and decreasing the African American infant mortality rate.
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Dallas, Denton, and Tarrant Counties are three of the top ten counties in the state of Texas by population. Together they account for an estimated 20% of the population of the state, distributed as follows among the counties: Dallas, 10%; Denton, 3%; and, Tarrant, 7% (2000 U.S. Census, n.d.). The major cities include Dallas, Denton, and Fort Worth, which are located in the northeast region of the state of Texas. The rates of uninsured people in these counties are comparable, as are the rates of uninsured minors, ages 0 to 18. In Dallas County, 23.7% of the general population is uninsured, and 24.4% of minors are uninsured. In Denton County, 20.4% of the total population and 19.5% of minors are uninsured. In Tarrant County, 22.0% of the general population and 22.7% of minors are uninsured. The state of Texas leaves indigent health care up to the individual counties and allows for three possible ways to provide that care. In 1985, the Texas Legislature passed the Indigent Health Care and Treatment Act. This law stated that the counties had the responsibility, at a minimum, to take care of those whose monthly income is below a certain level. Legally, this level is set at 17% of the national poverty line, but the bar is usually set by the Legislature to be higher than this amount. The law requires counties to choose one of three options for the care of their indigent population: hospital districts, public hospitals, or County Indigent Health Care Programs (CIHCP). In 1999, the Texas Legislature reformed the Indigent Health Care and Treatment Act, giving counties more flexibility, more accountability, and new financial incentives to provide quality health care to their indigent populations (Fenz, 2000). Of these options, Dallas and Tarrant County currently have hospital districts, whereas Denton County has a CIHCP.
Health Insurance in Texas
The other information necessary to understanding how health care is provided to residents of these counties is to get a glimpse of how residents of Texas are insured. Health insurance can be divided into two categories based on who pays. Private insurance, which is paid for by employers, individuals, or some combination of the two, has no government funding. Insurance purchased for people by the government using tax dollars is public insurance (Fenz, 2000). In 1999, 57% of Texans were covered by private insurance (Texas Health and Human Services Commission, 2000). Public insurance is paid primarily out of government funds. Most public insurance also requires a small contribution to the cost of the coverage. However, the government will not provide insurance to all of its citizens. To receive public insurance, citizens must meet certain eligibility requirements based on age, income, or disability. These “eligibility standards” are not the same for every government program. The three major public health insurance programs are Medicaid, Medicare, and the State Children’s Health Insurance Program (SCHIP).
Medicaid provides insurance for low-income citizens including children, parents receiving cash welfare, pregnant women, adults and children with severe disabilities, and elderly in need of nursing home care. It is important to note that Medicaid does not provide nursing home care but does provide assistance to those in need of nursing home care. There are two groups that are not covered by Medicaid: low-income childless adults who are not blind or disabled, and low-income adults with children who are not receiving cash welfare (Fenz, 2000). Therefore, the misconception that Medicaid covers everyone who is poor is not true, and shows a gap in the coverage provided by the government. Low-income, nondisabled adults—whether they have children or not—are very rarely covered by Medicaid, and those people form a significant percentage of the uninsured population. Counties are left responsible for filling those gaps in coverage (Fenz, 2000). Medicaid cares for approximately 1.7 million Texans, or 9% of the state population, each month.
Medicare is the other major government-funded health insurance program (Fenz, 2000). It is almost entirely federally funded and administered and provides health insurance for adults over age 65, regardless of income, and selected disabled adults at any age. Medicare purchases coverage for approximately 2 million Texans per month, about 10% of the Texas population. Medicare requires some of the cost to be paid by the people being covered, which can cause problems for low-income elderly. The state helps over 300,000 low-income elderly pay for their Medicare costs. Apart from this assistance, the state is not involved in Medicare.
State Children’s Health Insurance Program
The State Children’s Health Insurance Program (SCHIP) was created by the federal government in 1997 (Fenz, 2000). SCHIP was designed to help states provide health insurance to children whose families have too much income to qualify for coverage through Medicaid. Children ages 0 to 19 with family incomes too high for Medicaid but below 200% of the federal poverty level are eligible for the SCHIP. The Texas SCHIP program began on May 1, 2000, as part of the TexCare Partnership. The TexCare Partnership is a general outreach program that teaches citizens the importance of children’s health insurance and creates opportunities for eligible families to qualify for Medicaid and SCHIP programs. Initial projections indicate that once the SCHIP program develops over the next few years, close to 500,000 children and adolescents will be covered.
The Uninsured in Texas
To summarize, about 57% of Texans are covered by private insurance, and a combined 19% are covered under public insurance programs like Medicaid, Medicare, and the SCHIP. This leaves about 25% of the population of Texas without any health care coverage. The uninsured are roughly even in terms of gender (52% male, 48% female), whereas younger age-groups tend to be disproportionately represented in the uninsured population. People ages 18 to 24 and 25 to 34 make up almost 75% of the uninsured population of Texas, with the 18- to 24-year-olds making up the majority. In terms of race and ethnicity, Hispanics and African Americans also represent a much larger percentage of the uninsured population than the general population. Uninsured Texans are roughly equally distributed among those under the poverty level, those between 100% and 199% of the national poverty level, and those above 200% of the national poverty level. Most of the uninsured population is employed either part-time or full-time, whereas only 1 in 4 is described as being “not in the labor force”(Fenz, 2000).
The Behavioral Model for Vulnerable Populations
The Behavioral Model for Vulnerable Populations was used as the theoretical framework for this study. The original Behavioral Model was developed in the late 1960s to assist in understanding why people use health services. A revised and expanded Behavioral Model for Vulnerable Populations was necessary because the factors that make homeless and other populations vulnerable might also affect their use of health services and health status (Gelberg, Anderson, & Leake, 2000). Vulnerability is defined as the risk of having poor physical, psychological, or social health (Owusu et al., 2005). The model explains why people from various vulnerable populations do or do not seek health care for their health problems. The Behavioral Model for Vulnerable Populations uses three predictor variables: predisposing, enabling, and need variables (Gelberg, Anderson, & Leake, 2000). The predisposing domain includes the social structure characteristics from the traditional model, including ethnicity, age, and marital status, as well as characteristics added for the vulnerable model, including immigration status. The enabling variables include personal resources, such as insurance coverage, employment status, and the presence of a usual source of care; barriers to health care, including transportation; competing needs, requiring people to choose food, housing, or clothing over health care; as well as problems with the paperwork in the health care system. The need variable indicates general health status as perceived by the individual (Owusu et al., 2005).
Applicability to our Problem
As we have already seen in our background research, the number of uninsured who are young and Hispanic or African American is disproportionately represented compared to their proportion in the population. When we analyze the efficiency and effectiveness of health care access through the lens of the Behavioral Model of Vulnerable Populations, we can try to align the gaps in insurance coverage in our counties of interest with the care received by those populations that our research and the Behavioral Model indicates are most likely to be without health insurance and quality health care. The goal of the counties should be to ensure that through the countywide health care initiatives, each person is cared for regardless of age, gender, race, ethnicity, physical disability, or ability to pay. There is a significant gap in the number of people who are uninsured based on these demographics, so the county must work even harder in those groups that are overrepresented in the uninsured population of Texas to ensure that there is no inequity of care among these groups.
The information for this research was gathered from the Texas Department of State Health Services’ website, Data and Reports Query System. Birth, death, and population statistics are available from the years 1999 to 2004. By analyzing these data for the three counties about which we are concerned, we can test the effectiveness of the Denton County Indigent Health Care Program to fill the gaps of the people who fall within this population. Information on the People’s Clinic of Denton County was garnered from a personal interview with the medical director of the clinic on March 28, 2008.
We have seen that one of the largest gaps in the health insurance coverage statewide is for young people. This is the area that we will be examining more closely. Because my area of interest is in young people without insurance, we looked exclusively at people ages 25 and younger. We then look at the other demographic variables that align themselves with the percentages of the population that our model indicates are more likely to be indigent.
Three major areas that we will discuss in our exploration of these county indigent health care programs are prenatal care, infant mortality, and general death statistics. Based on the data from the query system, we can analyze these statistics through the lens of the Behavioral Model.
Prenatal care is important to the well-being and continued growth of the people. Prenatal care is one of the most frequently used health services in the United States, according to data from the 1995 National Medical Ambulatory Care Survey. The National Medical Ambulatory Care Survey estimated that there were 23.3 million prenatal visits to physicians’ offices, outpatient departments, or emergency departments in 1995. Moreover, after general medical examination, prenatal care is the most frequently cited preventive health service (Kogan et al., 1998). Figure 1 shows the percentage of births by race and ethnicity in Dallas County who were born with inadequate prenatal care, according to the Kessner Adequacy of Prenatal Care Index. Figure 2 and Figure 3 show the same information for Denton and Tarrant Counties, respectively. As seen in these graphs, the percentage of births by mothers who have had inadequate prenatal care is much higher in the Hispanic and African American communities, the same groups that are least likely to have health insurance. The average difference between African Americans and White Americans for Dallas County is 7.28% over the 6-year period, whereas the difference in Denton is 7.85%; however, Tarrant County has a staggering 14% average difference between the percentage of White Americans and African Americans having babies with inadequate prenatal care. The gap between Hispanics and Whites over the 6-year period is much greater, at 12% average difference in prenatal care in Dallas County, 18.02% in Denton County, and a little over 20% in Tarrant County.
The first year of life requires a series of important medical procedures and the laying of the basic groundwork for a lifetime of health care, including immunizations. Failure to receive this care can lead to infant mortality. Infant mortality is not something that can be completely eliminated, but the goal should be—as with other death statistics—to make the statistics of those affected by the problem proportionately reflect the total population statistics. Unfortunately, this is not always the case in Dallas, Denton, and Tarrant counties. Table 1 shows the percentage of live births in Dallas County that were White, African American, Hispanic, and Other in 1999 through 2004, compared to the percentage of deaths among infants less than age 1 who were in these same race and ethnic groups. The largest discrepancy occurs among African Americans. For example, in 2004 only 19.9% of live births were African American but 36.8% of infant deaths were African American, compared to 23.4% and 13.7%, respectively, among Whites. The percentage of infants who died before their first birthday who were Hispanic tends to be slightly lower than the percentage of live births that are Hispanic. Table 2 shows the information for Denton County residents. Again, African Americans were found to be overrepresented among the infant deaths in Denton County. In 2004, 6.5% of live births were African American but 22.0% of infant deaths were African American. Table 3 shows the infant birth and death information for Tarrant County. The trend of the African American population being overrepresented in the infant mortality population continued in Tarrant County. Using our Behavioral Model, this would bring us to the question of whether the reason is because they are less likely to have health insurance because they are African American or, because the Hispanics and other races do not have a similar problem, if there are perhaps some other enabling factors in our model that cause African Americans to either not receive or seek out adequate health care for their infants. Whatever the cause, it leads to a disproportionately high infant mortality rate across the board for African Americans compared to Whites and Hispanics.
Implications and Consequences of Data
Our results indicate that Denton County tends to compare favorably with Dallas and Tarrant Counties in terms of the percentage of infants who receive inadequate prenatal care, but there are also many areas where Denton County public health officials should be concerned and should focus additional efforts. In some of these situations, there are minimal options given the constraints of current health care policy. For example, the county is not in a position to directly solve the problem existing with the lack of health insurance among certain populations. However, the county does have the responsibility to ensure that all of its residents have a high-quality health care program. This is important for both humanitarian and economic reasons. Uncompensated care makes up an average of 33.3% ($40.7 billion annually in 2004) of total health care expenditures in the United States. We want to make sure that those who do not have insurance, as well as those that do, are able to work as much as possible. This allows them to make more money, allowing them to get raises to full-time jobs with health benefits for themselves and their families. Even if they are not able to get these promotions, allowing people to work more will allow them to be able to pay for their insurance out-of-pocket, which makes up 26% of health care payments among uninsured residents (Kaiser Family Foundation, 2004). Having a health care program that fully serves as much of the county as possible leads to happier workers and happier voters. This allows citizens to live a comfortable lifestyle and gives them the opportunity to focus more time on their families, work, and home life. Perhaps the first step to reclaiming traditional American values is to make it possible for Americans to take their focus off of things like how they will afford the health care they need for their families, and allow them to put their focus on what they will have at the family dinner table tonight and spending more time with their children.
The Situation in Denton County
Denton County must take steps to make access to prenatal care more equitable. Hispanic and African American mothers have much higher levels of inadequate prenatal care than White mothers. More specific research must be done following the Behavioral Model for Vulnerable Populations to see if there are other enabling factors that prevent these groups from having access to prenatal care excluding the possession of health insurance. The county should take responsibility for making sure that everyone has adequate prenatal care so that every child who is born in Denton County has an equal chance at a successful life. Although Hispanics were typically among the worst groups in terms of prenatal care, their infant mortality rates are comparable to their birthrates. Denton County still has a major problem with infant mortality among the African American community. Although accounting for an average of 5.9% of births in Denton County between 1999 and 2004, African Americans accounted for 17.7% of deaths among residents age 1 and younger. As we look at our data with the Behavioral Model for Vulnerable Populations in mind, we see that there is a relation between those groups that are more likely to have inadequate health care and later mortality rates. This leads to questions about what the county can do with official policy solutions and what the people of Denton County can do to help their fellow citizens.
The Solution in Denton County
In 1966, Flow Memorial Hospital opened in Denton County as a public hospital to serve the people of Denton County. It had 166 beds and was designed to serve as a short-term hospital for Medicare and Medicaid recipients (Hospital Data.com, n.d.). The hospital provided a variety of services ranging from coronary care to inpatient surgery facilities and occupational and recreational therapy. A staff of 42 registered nurses provided care to the indigent population of Denton County. In 1986, Denton County allowed the accreditation certificate to expire for the hospital and switched government funding to a CIHCP. The primarily Republican county officials believed that citizen tax dollars would be better spent by closing the hospital and providing care through the health department than it would raising taxes to improve the existing hospital or fund the building of a new hospital. The Denton County Health Department started offering indigent health care, and eventually the People’s Clinic of Denton County was created.
Denton County Health Department
Without a public hospital in the county, the indigent population of Denton County turned to the Denton County Health Department. Sexually transmitted disease testing and care and tuberculosis testing and care, as well as federally mandated vaccines, are offered for a small fee comparable to the co-pay a person with insurance would pay at a general practitioner for similar services. There is a free prenatal clinic and child-care clinic for those families who live at less than 200% of the federal poverty level (Denton County, 2008). The primary care services and dental services are free to those residents who make less than 150% of the federal poverty level. WIC Food and Nutrition Services are available to citizens who make less than 185% of the federal poverty level. These are very important services offered to some of our fellow citizens who are most in need; however, in our dissection of the uninsured population in the state of Texas, we discovered that roughly one-third of the indigent population made more than 200% of the federal poverty level (Fenz, 2000). For this reason, more must be done to provide quality care to those people who make more than 200% of the federal poverty level but are unable to receive health care due to lack of insurance or some other limiting factor. The Denton County Health Department also provides free health education and environmental education to all of its citizens to allow them to make better decisions for their lifestyles and build a culture of preventive care by educating citizens about choices they can make to have a better health situation, regardless of whether or not they have insurance. Some of the problems that emerged as the Denton County Health Department attempted to provide these services to residents were long wait times and too much work for the doctors and nurses. In the early 2000s, health workers in Denton County started to recognize a need for a clinic outside of the Health Department building to better serve the people of Denton County. A commission was put together to develop a plan for this clinic and figure out how it should be run. From this idea came the People’s Clinic of Denton County. Although it started out as a branch of the Denton County Health Department, by 2005 the People’s Clinic became its own entity with an independent board of directors and a full-time staff of physicians and nurses.
People’s Clinic of Denton County
The People’s Clinic operates on a sliding-scale fee system to fund the clinic in addition to the funding it receives from the county (Clinic Director, personal communication, March 31, 2007). The advantage of this clinic is that it serves not only those who live below 200% of the federal poverty level but also those above that level who do not have insurance. The clinic began as an extension of the Health Department in Denton County to serve more of the indigent and underserved of Denton County. In 2005, the People’s Clinic of Denton County separated from the Health Department and established a board of directors. It has a doctor, a chief financial officer, nurses, a social worker, a family nurse practitioner, and a pharmaceutical assistance program coordinator on the staff. The board of directors is made up of Denton County residents who have experience in the health care field and providing health care at the county level to indigent populations. The People’s Clinic of Denton County provides primary care to those who previously had to receive that care after long waits at either the Health Department Clinic or the emergency room at local hospitals. They provide preliminary testing and diagnostic tests for pregnant women but must send them to Family Health Care, Inc. to receive prenatal care. Family Health Care, Inc. is a nonprofit clinic that has been providing women’s health care to Denton County for about 20 years.
Summary and Recommendations for Future Research
When compared to Dallas County and Tarrant County, Denton County does well in many areas of the health of the population, but there are certain areas where it should focus its energy on better serving its residents. Disproportionate deaths of African American infants are one area of great concern in Denton County. Prenatal care still must be addressed for African American and Hispanic residents. Denton County officials and residents seem to recognize the areas that need greater focus, and have taken action to resolve some of the issues that face their constituents. Data taken after 2004 will be needed to determine whether the changes made at the Denton County Health Department, as well as the establishment of the People’s Clinic of Denton County, have made an impact on the indigent population of Denton County.
- 2000 U.S. Census: Population of Texas counties arranged in descending order. Retrieved July 18, 2008, from http://www.tsl.state.tx.us/ref/abouttx/popcnty32000.html. Texas Department of State Health Services Data Query System.
- Denton County. Home Health Department. Health Department Services. Retrieved July 22, 2008.
- Fenz, C. (2000). Providing health care to the uninsured in Texas: A guide for county officials. Boston, MA: The Access Project. Retrieved July 18, 2008, from http://www.accessproject.org/adobe/providing_health_care_to_the_uninsured_in_tx.pdf.
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