Hardly an article or research paper about health care is written that does not focus on the uninsured rate, either in the nation or the state. It is frequently pointed out that Texas leads the nation in the percentage of uninsured, currently reported at about one-fourth of the population. “Insure the uninsured!” is the battle cry, pushing and prodding our legislators to find ways to remove that stigma.
But a closer look at the makeup of Texas’ uninsured reveals that providing health care via an insurance policy for everyone residing here may prove impossible.
In 2006, the U.S. Census Bureau calculated Texas’ uninsured rate at 23.4 percent, or 5.5 million residents. But policymakers are rightfully hesitant to accept that number as the basis for decisions when they find out that it includes persons who were only temporarily uninsured on the day of the survey. But since “temporarily uninsured” is nowhere quantified, we are left with using 5.5 million.
Included in that number are three categories of persons that we can quantify and then remove from the equation – illegal immigrants, those qualified for but not enrolled in Medicaid or Children’s Health Insurance Program (CHIP), and those making more than 200 percent of federal poverty.
The policy discussed here is not about providing health care but about providing a health insurance policy. Health care is provided every day for those three categories – through public health clinics, private doctors’ offices, and through Emergency Medicaid in hospital emergency departments. But regardless of one’s opinion on illegal immigration, Texas taxpayers do not and should not purchase an insurance policy for those not legally in this country.
The next category is self-evident. It would be nonsensical for the state to purchase another insurance policy for people already eligible for, but not enrolled in, Medicaid or CHIP. This group of people has already been offered one policy; what good would be served by providing them a second?
Last are those making more than 200 percent of the federal poverty limit – roughly $50,000 per year for the average family of four. There is no consensus for taxpayers footing the bill to provide insurance to higher-income families; studies conclusively indicate that doing so causes a larger percentage of enrollees to drop private coverage for tax-funded programs.
Removing these three uninsured populations from the calculation leaves only 5.8 percent of the population. Therefore, even if we insured every person eligible through a public program, Texas would still have almost 20 percent of its population uninsured.
Clearly, the objective should be to provide access to health care for the uninsured in the most efficient way possible. The answer will not be easy. But Texas should look for new ideas and innovations and also promote what is already working here.
In 2003, Texas made a significant investment in primary care for this population by establishing an incubator program to spawn more Federally Qualified Health Centers (FQHCs). That $10 million investment brought in more than $30 million in renewable federal funds to the state.
Last year, FQHCs provided primary and preventive medical, dental, behavioral health care, and treatment of chronic illnesses for more than 770,000 residents. Of those, 58 percent were uninsured, but made payments based on a sliding scale according to their ability to pay. FQHCs could easily use 150 more providers now, and with additional capacity, they could serve up to two million more patients.
Another efficient model can be found within the University Health System, Bexar County’s public hospital. Its CareLink program is an innovation that has delivered care yet reduced expensive hospitalizations and emergency visit costs by 80 percent among its target population. The program is not an insurance policy. CareLink encourages or requires personal responsibility in all aspects of health care delivered, including a debt repayment program based on a sliding scale.
These are but two of the innovations that should be explored and promoted, based on maximizing consumer options and demanding personal responsibility. Both of these models provide care for the uninsured rather than an insurance policy, and maximize results for patients while minimizing the cost to taxpayers.
The Honorable Arlene Wohlgemuth is a Visiting Research Fellow at the Texas Public Policy Foundation, a non-profit, free-market research institute based in Austin. She served 10 years in the Texas House of Representatives.