A report from Families USA
February 1999

Deep in the Heart of Texas:
Uninsured Children in the Lone Star State

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INTRODUCTION

Congress passed the State Children's Health Insurance Program (CHIP) in 1997 in order to reduce the number of children without health insurance. Nationally, there were 11 million children uninsured throughout 1997, and over ten percent of those children lived in Texas. Texas is one of the last states—and by far the largest state—yet to decide whether it will take full advantage of CHIP to expand opportunities for health insurance coverage in 1999.Doing without insurance coverage is not a problem limited to children in low-income families or families headed by people who do not work. Nine out of ten uninsured children in Texas live in working families. More than half of all uninsured children in Texas are from families with moderate incomes. Most uninsured Texas children live in two-parent families in which the family head has a high school education or more and works full-time throughout the year.This report provides a statistical portrait of the families of children without health insurance in Texas based on the most recent available data from the Census Bureau's Current Population Survey. It also tells the story of three Texas families—why their children lack coverage and what it has meant to the children's health and well-being and their parents' peace of mind.The numbers and characteristics of uninsured children matter. National research, also summarized in this report, shows beyond doubt that uninsured children do not get the health care they need. Texas has the opportunity to insure three-fourths of its uninsured children by expanding eligibility for children's health insurance to families earning 200 percent of the federal poverty level, about $27,000 per year for a family of three. See Figure 1

KEY FINDINGS

• Data compiled by the Census Bureau based on the average of the three most recent Current Population Surveys for 1995, 1996, and 1997 show:
• Approximately 11 million children are without insurance, and 1.4 million of them live in Texas. After California (1.7 million), Texas has the largest number of uninsured children of any state in the country.
• Nationally, 15 percent of all children are uninsured. In Texas, 24 percent of all children are uninsured—the second highest rate of uninsured children in the country after Arizona (25 percent).
• Data about Texas compiled by the Employee Benefit Research Institute for this report, based on the average of the three most recent Current Population Surveys for 1995, 1996 and 1997, show:
• Most of the uninsured children in Texas have parents who work. Of children without insurance, almost nine out of ten (88 percent) live in a family where the head of household works during all or part of the year.
• Of Texas children who are uninsured, six out of ten (63 percent) live in a family whose head of household is employed full-time throughout the year.
• Only half (51 percent) of all Texas children are covered by employment-based insurance. A recent study by the Texas Department of Human Services found that 60 percent of families who left welfare for work were not offered health insurance by their employers.1

A large proportion of uninsured children in Texas are from moderate-income families. Nearly two-thirds of all uninsured children in Texas (64 percent) live in families with incomes above the federal poverty level. Fifteen percent—220,000 uninsured children—have family incomes between 150 and 200 percent of poverty ($20,475 to $27,300 for a family of three in 1998).

• Half of Texas children without health insurance (52 percent) live in families in which the head of household graduated from high school or went on to obtain further education.
• Almost two-thirds of uninsured children in Texas live in two-parent families (64 percent). However, those children who do not live in two-parent households are more likely to be uninsured than children in two-parent households (30 percent uninsured versus 22 percent uninsured).
• Only one uninsured child in six (16 percent) lives in a family whose head of household is covered by employment-based insurance.
• Hispanic children in Texas comprise a majority (56 percent) of the children without health insurance. White non-Hispanic children make up 28 percent; black children, 14 percent; and other children, less than 2 percent of the children without health insurance.
• Nine out of ten uninsured Texas children are U.S. citizens. Almost three-fourths are citizen children living with citizen parents. However, an estimated 240,000 citizen children live with non-citizen parents, and these children are twice as likely to be uninsured as children with citizen parents.

Estimates prepared by Texas State agencies find variation in the rate of insurance coverage among Texas counties. Hidalgo and El Paso Counties have a higher rate of uninsured children than the state average of 24 percent. Dallas and Tarrant Counties have a lower rate of uninsured children than the state average.Research from many sources shows that uninsured children nationwide do not get the health care they need. Uninsured children have fewer physician visits per year, are less likely to receive adequate preventive services and immunizations, and are less likely to be seen by physicians when they are ill. While poverty and minority status also pose significant barriers to care, the biggest barrier is the lack of insurance coverage.

BACKGROUND

Congress passed the State Children's Health Insurance Program (CHIP) in 1997 to address the alarming number of children without health insurance. CHIP gave states the opportunity to offer insurance to children whose parents could not get affordable coverage from their employers but earned too much to qualify for Medicaid coverage.Most Americans get health insurance through their employers. However, as the costs of health care coverage rose over the last decade, employment-based coverage fell, and the rate of decline was faster for children. In 1997, only 60 percent of children nationwide were covered by employment-based coverage—down from 67 percent in 1987.2 In Texas, only 51 percent of all children were covered by employment-based health insurance in 1995-1997. (See Figure 2.) Several factors account for the low rate of insurance coverage in Texas. Nationally, the decline in employer-based coverage was greatest among moderate-income families, those earning between 100 and 200 percent of the federal poverty level.3 Low-and moderate-income workers are less able to afford premium costs, and they are less likely to be offered employment-based insurance.4 In 1996, only 43 percent of workers earning less than $7 per hour were offered health insurance by their employers.5 In Texas, average per capita income is lower than the national average even though rates of employment in Texas are higher.6Workers in manufacturing industries have much higher rates of insurance coverage than other private sector workers.7 Nationally, 22 percent of all workers are in the manufacturing sector.8 However, in Texas, manufacturing accounts for only 13 percent of employment.9 Firm size is another important factor affecting insurance status. Nationally, almost 48 percent of all uninsured workers are either self-employed or working in private sector firms with fewer than 25 employees.10 Workers in private sector firms with fewer than ten employees are uninsured at almost twice the rate of all workers. In Texas, 19 percent of the Texas workforce—one in five—work in firms with fewer than 20 employees.11Expanded Medicaid coverage for younger children protected some children from becoming uninsured as employment-based coverage fell. However, many children live in families that earn too much to be eligible for Medicaid. Many other working families remain unaware that Medicaid coverage for children is available for families that do not receive cash welfare assistance.In Texas, there were 105,000 fewer children receiving Medicaid coverage in June 1998 than in June 1997, with most of the decline occurring in families that were receiving cash welfare.12 However, early evidence shows that most of these children were not replacing Medicaid with employment-based health insurance. A recent study by the Texas Department of Human Services found that 60 percent of families leaving welfare to take a job were not offered health insurance by their employers. Almost 40 percent of families leaving welfare for any reason had unmet health care needs for themselves or their children and reported the need to obtain insurance in order to keep working or get a job.13An increase in the number of the uninsured in Texas means an increasing burden on local taxpayers who support county programs for the medically indigent. On the other hand, for every dollar in Texas Medicaid costs, federal funds pay 62 cents; the state share is only 38 cents. In CHIP, the federal matching rate in Texas is even higher—74 percent federal funding and only 26 percent state funding for every dollar spent on expanding children's health insurance.

HOW MUCH WILL IT COST NOT TO INSURE CHILDREN?
As a pediatrician at a teaching hospital in San Antonio, Dr. Cynthia Beamer knows the costs of not insuring children. Families often delay medical treatment because they don't have health insurance. One of the health problems carrying a high price for delay is appendicitis. The University Health System, where Dr. Beamer sees patients, had nine admissions with a diagnosis of perforated appendix in the space of a week in November 1998. Most of them were teenagers without insurance coverage.Treated early, a child needing an appendectomy will generally be home from the hospital within 48 hours. After the appendix has ruptured, the child can expect a 7-10 day minimum hospital stay; if complications develop, the stay may be as long as a month. Delay also exacts a heavy price on the patient: among the health risks associated with a perforated appendix for girls is sterility. Dr. Beamer described one of her patients, a 15-year-old boy, who had been treating his perforated appendix at home with Pepto Bismol and Alka Seltzer for four days before seeking admission because the family had no health insurance.Interview with Cynthia Beamer, M.D., Assistant Professor of Pediatrics, Department of Critical Care, University of Texas Health Sciences Center, San Antonio, Texas. January 20, 1999.

The Children's Health Insurance ProgramThe State Children's Health Insurance Program offers states federal matching funds to expand health insurance for children in families with incomes at or under 200 percent of the federal poverty level (or higher in certain states).14 (See Table 1.) In Texas, the 1999 matching rate will permit the state to receive $2.81 in federal funds for every one dollar in state spending. Over $564 million in federal matching funds were available to Texas in federal fiscal year 1998 alone.Prior to CHIP, the Medicaid program in every state covered (at a minimum): (1) children under age six living in families with incomes at or under 133 percent of the federal poverty level; and (2) older children born after September 30, 1983, with family incomes up to 100 percent of poverty. (Federal law requires that all older adolescents with family income at or under 100 percent of poverty would have to be covered by 2002.)Over 40 states had already expanded children's Medicaid coverage beyond these minimum levels before CHIP was enacted. Over half the states, including Texas, covered infants (and pregnant women) with family income at or under 185 percent of poverty. With the enactment of CHIP, almost every state has taken advantage of the opportunity to expand insurance coverage for children beyond prior Medicaid eligibility levels. (See Table 2.) As of January 1999, 29 states and the District of Columbia have made a commitment to cover children up to 200 percent of the federal poverty level or higher by using existing Medicaid programs or expanding coverage through CHIP. Only 12 states have failed to expand eligibility beyond 150 percent of poverty, and all but a few of those states, including Texas, have indicated that further expansions are planned. Pending its Phase II CHIP expansion, Texas now ranks with North Dakota and Wyoming as providing the lowest threshold of coverage for children. However, for every uninsured child in North Dakota or Wyoming, there are over 70 uninsured children in Texas.In its Phase I CHIP plan, Texas did expand Medicaid eligibility up to 100 percent of poverty for older adolescents effective July 1, 1998. Texas Medicaid now covers infants to 185 percent of poverty, children age 1 to 5 to 133 percent of poverty, and children age 6 to 18 to 100 percent of poverty. (See Figure 3.) The first meeting of the Texas legislature after the enactment of CHIP was not until January 1999. Senate and House interim committees of the Texas legislature met over the summer and fall in 1998 to study the problem of uninsured children in Texas. The committees recommended that the 1999 Texas legislature raise eligibility for children's health insurance to 200 percent of the federal poverty level. The legislature will have an opportunity to act on the committees' recommendations during the 1999 session that began January 12, 1999.

FINDINGS: THE NUMBER OF UNINSURED CHILDREN IN TEXAS
Texas has both large numbers of children without insurance and a high proportion of children without insurance.

• Texas averaged 1.4 million uninsured children in 1995-1997. This is the second greatest number of uninsured children after California, which had 1.7 million. Texas and California alone account for almost 30 percent of the nation's uninsured children. States with the next largest number of uninsured children, Florida (651,000) and New York (708,000) have fewer than half the uninsured children that Texas does. (See Table 3.)
• Texas has the second highest percentage of children without insurance coverage in the country after Arizona. Nationally, 15 percent of all children lack health insurance; in Texas, the proportion is 24 percent. Other states with high rates of uninsured children are also in the Southwest (Arizona, 25 percent; Nevada, 20 percent; New Mexico, 21 percent; Oklahoma, 20 percent) and South (Arkansas, 22 percent; Florida, 19 percent; Louisiana, 22 percent; Mississippi, 19 percent).

FINDINGS: THE CHARACTERISTICS OF UNINSURED CHILDREN IN TEXAS
Most uninsured children in Texas live in working families.

• The uninsured child population in Texas is comprised primarily of children whose parents work. Almost nine out of ten children (88 percent) live in households in which the family head works full- or part-time. Six out of ten children (63 percent) live with a family head who works full-time for the full year. (See Figure 4.)
• Among families headed by full-year, full-time workers, a majority have employment-based insurance for their children (64 percent), but 22 percent do not. There are 920,000 uninsured children in families in which the head of household is working full-year, full-time. In families in which the head of household is not working, almost a third (32 percent) of children are uninsured.

Brittany's parents can't afford private health insurance, but earn too much for Medicaid.Brittany Martinez, like most seven-year-old children, is healthy but her parents, Linda and Mike, can't stop worrying about what they would do if she needed hospital care. Brittany has no insurance coverage.Her parents both work. Their employers offer health insurance at no cost for their employees, but charge $250-300 per month to cover dependents. With a combined income of less than $20,000 per year, Linda and Mike can't afford to pay the extra costs for family coverage. Just paying for housing, food, clothing, transportation to work, and other household expenses takes almost all of their income.Medicaid financial eligibility requirements are too low to help Brittany. The Medicaid income threshold for a seven-year-old child in a family of three is only $13,650 per year.Interview with Linda Martinez, San Antonio, Texas. January 12, 1999

Most uninsured children's parents in Texas are also uninsured.Most uninsured children in Texas (81 percent) live with a family head who is also uninsured. Only one uninsured child in six (16 percent) live with a family head covered by employment-based insurance.

A large proportion of children without health insurance in Texas are from moderate-income families.In Texas, nearly two-thirds of all uninsured children (64 percent) live in families with incomes above the federal poverty level. Four in ten children without insurance (42 percent) live in families with annual incomes of 150 percent of poverty or higher ($20,475 per year for a family of three in 1998). Fifteen percent—220,000 uninsured children—have family incomes between 150 and 200 percent of poverty ($20,475 to $27,300 for a family of three in 1998). More than one-fourth (27 percent) of the children without health insurance coverage live in families with annual incomes of 200 percent of poverty or higher ($27,300 per year for a family of three in 1998). (See Figure 5.) Rates of health insurance coverage are lowest among families in Texas earning between 100 and 175 percent of the federal poverty level. (See Figure 6.) These are the families who earn too much for Medicaid, but not enough to afford private insurance.

Medicaid no longer pays for Barry's heart medicine since his Dad left welfare for a job that doesn't offer health benefits.Barry Authenreith is five years old and has a heart condition called superventricular tachycardia. He needs medication that costs about $70 per month. Barry doesn't have health insurance anymore.After Barry's mother passed away, his father Gary worked part-time, and received cash welfare. Both he and Barry qualified for Medicaid. Gary went back to school to get a better paying job. He studied computer drafting and got a full-time job earning about $1600 per month (about 175 percent of the federal poverty level).With the added income, the Authenreiths lost their Medicaid benefits. (Child-only Medicaid benefits have an income cut-off of about $1200 per month for a five-year-old child in a family of two). However, Gary's new employer doesn't offer any health insurance benefits, and with Barry's heart condition, the cost of an individual health insurance policy was out of reach.The medication usually keeps Barry's heart rate within normal levels, but last December he had to be hospitalized. Barry's father hasn't gotten the hospital bill yet, and doesn't know where the money will come from to pay it. Interview with Gary Authenreith, Manor, Texas. January 10, 1999.

The majority of Texas uninsured children live in two-parent households.Two-thirds (64 percent) of uninsured children live in households with two parents in Texas, compared to 36 percent living in households with only one parent or no parent. However, those children not living in two-parent households are more likely to be uninsured than children in two-parent households (30 percent uninsured compared to 22 percent uninsured).

Many Texas children whose parents have high school degrees or higher are uninsured.Half of Texas children without health insurance (52 percent) are in families whose head of household graduated from high school or went on to receive further education. Only one out of four (26 percent) uninsured children live in a family whose head of household has no high school education, and approximately one out of five (22 percent) lives in a family whose head of household has some high school, but did not complete a high school education.

The majority of uninsured children in Texas are Hispanic.Hispanic children comprise 40 percent of all Texas children and make up a majority of the children without health insurance (56 percent). White non-Hispanic children constitute 44 percent of all Texas children and 28 percent of all uninsured children. Black children make up 14 percent of uninsured Texas children, and remaining groups account for two percent of uninsured children. (See Figure 7.) Hispanic children not only make up a significant percentage of the population of uninsured children in Texas, they are uninsured at higher rates than non-Hispanic children. One in three Hispanic children (34 percent) are uninsured compared to one in four black children (25 percent) and one in six (16 percent) white non-Hispanic children. (See Figure 8.) Most uninsured children and their parents in Texas are citizens.Nine in ten uninsured Texas children (90 percent) are citizens. Almost three-fourths of uninsured children are citizens living in families in which the family head is also a citizen, but 17 percent are citizens living with a family head who is not a citizen. (See Figure 9.) Citizen children living with a non-citizen family head are at greater risk of being without insurance—40 percent of such children are uninsured, compared to 21 percent of citizen children with citizen parents.Medicaid and CHIP are available to all otherwise eligible "qualified aliens" who entered the country prior to August 22, 1996, as well as certain immigrant groups entering later, and all citizens. However, the complexity of the rules defining "qualified aliens" and fear and confusion about whether public benefits may have adverse consequences for non-citizen family members may account for the low rate of insurance coverage among citizen children in immigrant families.Lack of insurance is an even bigger problem among the estimated 240,000 non-citizen children in Texas, 63 percent of whom are uninsured. The Current Population Survey does not provide enough information to know how many of these children may be "qualified aliens" eligible to benefit from Medicaid or CHIP.County estimates of the number of uninsured children in Texas.The Office of Public Insurance Counsel and the Texas Health and Human Services Commission both developed estimates of the distribution of the 1.4 million uninsured children among the 254 counties in Texas. Both estimates generally agree on which counties have the highest incidence of uninsured children. Among the six largest counties in Texas, Hidalgo and El Paso have the highest rate of uninsured children, and Dallas and Tarrant have the lowest. However, the estimates differ on the variation among the counties.15 (See Table 4.)

LACK OF INSURANCE COVERAGE LIMITS CHILDREN'S ACCESS TO HEALTH CARE SERVICES
Lack of insurance coverage limits children's access to health care services. Children have unique developmental needs that require ongoing "well-child visits," diagnostic screening, and preventive services—such as immunizations—to ensure that they develop into healthy adults. Unfortunately, uninsured children often do not get the care they need, and recent research indicates that the disparity in access to health care for uninsured children has gotten worse over the last decade.16

Jason may have lost his hearing because of untreated ear infections when his family was uninsured.Jason Alvarado is a 17-year-old boy who has no hearing in his right ear and severe hearing loss in his left ear. Now his family can afford insurance benefits, but the doctors say nothing can be done to restore the hearing loss. During Jason's formative years, he had recurrent ear infections that sometimes went untreated because he had no health insurance. Both his parents worked full-time. Jason's mother worked for a nursing home that didn't offer its employees insurance. Mr. Alvarado's employer, a hospital, covered him at no cost but charged over $200 per month for family coverage. With a combined income of about $25,000 per year, they couldn't afford family coverage, but made too much for Medicaid.Mrs. Alvarado remembers that Jason often complained of earaches when he was growing up, but he didn't say anything about the hearing loss until he was a teenager. By that time, Mr. Alvarado had a better paying job and the family could afford to pay $255 per month for family coverage, but it was too late for Jason's hearing. She will never know for certain, but Mrs. Alvarado feels strongly that if they could have taken Jason to a pediatrician on a regular basis his hearing problem could have been detected and treated. Sara Alvarado is now employed by a Community Action program and works with the Texas Health Steps program to counsel mothers of young children to get preventive care, such as hearing tests, for their children.Interview with Sara Alvarado, Tahoka, Texas. January 20, 1999.Research has shown that uninsured children receive fewer health care services than insured children do. Uninsured children have fewer physician visits per year, are less likely to receive adequate preventive services and immunizations, and are less likely to be seen by physicians when they are ill:17Uninsured children are much less likely to receive the medical care they need than insured children. Recent studies have found that uninsured children were six times more likely than children with private insurance to go without medical care.18Uninsured children often do not see doctors for conditions that require treatment and that could cause long-term problems. For example, uninsured children are less likely than children with health insurance to receive care from a doctor for conditions like acute or recurrent earaches and asthma.19Uninsured children are much less likely to have a usual source of care than insured children. One recent study found that uninsured children were six times more likely to lack a usual source of care (24 percent for uninsured children compared to four percent for insured children).20Uninsured children are more likely to delay or go without needed medical care because of financial barriers. Parents of uninsured children were almost five times more likely to delay getting care for their children because of costs than parents of children with publicly funded insurance.21Compared to children with health insurance, uninsured children who experience injuries—even serious injuries—are less likely to receive medical attention. Children without insurance coverage are only 73 percent as likely to have their injuries treated by a medical provider.22

When they are hospitalized for similar problems, uninsured children fare worse in hospitals than insured children fare, and they are more likely to die. One study found that the in-hospital death rate was 1.46 times higher among uninsured white children and 1.88 times higher among uninsured black children when compared to privately insured children.23Hispanic children are the most likely to be uninsured. They are also the least likely to have a usual source of health care, and are almost three times as likely to report being in fair or poor health as white children (eight percent for Hispanic children compared to three percent for white children).24Research by Paul Newacheck and his colleagues reported that lack of insurance coverage was the most significant barrier to gaining access to primary care for children.25 This study, based on the l993 National Health Interview Survey, found that, while poverty and minority status posed significant barriers to gaining access to primary care, the most important barrier was lack of insurance coverage.

While numerous studies have shown the disparity in access to health care between insured and uninsured children, the recent implementation of child-only health insurance programs has allowed some researchers to focus on the impact of newly acquired health insurance on children and families. One such study examined the value of health insurance for children who were uninsured and recently became insured. The study found that becoming insured had a strong, positive effect on children and families.26 Among the results of that study: The proportion of newly insured children reporting any unmet medical need or delay in receiving care declined from 57 percent to 16 percent after having insurance for 12 months.27

• After 12 months of insurance, 99 percent of the children had a regular source of health care, and fewer of them visited the emergency room (a decline from 22 percent to 17 percent).
• Having insurance for their children greatly reduced parents' stress and alleviated family burdens. It also improved the quality of life for children by eliminating restrictions on normal childhood activities that require proof of health insurance, such as after-school sports and summer camp.28

CONCLUSION
This report shows that 1.4 million children in Texas go without health insurance. The potential losses connected to children's lack of insurance are great. If a child develops a chronic health problem while uninsured, it can affect that child's health and well-being for decades to come.29 Failure to provide continuous health insurance coverage to the children in Texas compromises their access to health care. Well-child care, preventive services, and diagnostic screenings are crucial health care services to ensure children's healthy development.

In the years ahead, the number of children without health insurance coverage is likely to grow. Health care premium costs are predicted to increase, and this will likely lead to further declines in employment-based coverage among low- and moderate-wage workers and their children. Further, Medicaid is protecting fewer children as parents leave the welfare system for low-wage employment that does not offer private insurance coverage.The decisions facing the State of Texas in 1999 could not be more timely for the future health and well-being of the children profiled in this report. With a decision to expand health insurance to children living in families with incomes up to 200 percent of the federal poverty level, Texas could cover three-fourths of its uninsured children.

ENDNOTE REFERENCES
1. Texas Department of Human Services, Texas Families in Transition, The Impacts of Welfare Reform Changes in Texas: Early Findings, Austin Texas, December 1998.2. Paul Fronstin, "Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1998 Current Population Survey," Issue Brief, No. 204, Employee Benefit Research Institute, Washington, D.C., December 1998.3. Ellen O'Brien and Judith Feder, How Well Does the Employment-Based Health Insurance System Work for Low-Income Families? Kaiser Commission on Medicaid and the Uninsured, September 1998.4. One recent study found that three out of four families with uninsured children reported that the cost of coverage was the primary reason they lacked health insurance. Paul W. Newacheck, Dr. P.H., Jeffrey J. Stoddard, M.D., Dana C. Hughes, Dr.P.H., and Michelle Pearl, M.P.H., "Health Insurance and Access to Primary Care for Children," New England Journal of Medicine, Vol. 338, No. 8, 1998, 513:519.5. O'Brien and Feder, op.cit.6. John Holahan, Joshua Wiener, and Susan Wallin, Health Policy for the Low-Income Population: Major Findings from the Assessing the New Federalism Case Studies, Urban Institute, Washington, D.C., November 1998.7. Fronstin, op.cit.8. Fronstin, op. cit.9. Texas Workforce Commission, Labor Market Information Department, Covered Employment and Wages, Austin, Texas, 1st Quarter, 1998.10. Fronstin, op. cit.11. Texas Workforce Commission, Labor Market Information Department, Employment by Size Class, Austin, Texas, 1998.12. Administrative data on Medicaid enrollment, 1994-1998, Budget Management Division, Texas Department of Human Services. The decline in enrollment described in the text does not include children receiving Medicaid in the disability or medically needy categories.13 . Texas Families in Transition, op.cit.14. Subtitle IV-J of Public Law 105-33, enacted August 5, 1997 creating Title XXI of the Social Security Act, §§2101 et al.15. No state or national surveys are available that estimate the number of uninsured children in Texas by county. There are census data from 1989 and 1993 about the number of children living below the poverty line by county. There is also information from the Current Population Survey from 1997 and earlier years about the relationship between family income and children's insurance status on a statewide basis. This data can be used in different ways to estimate the number of uninsured children by county.A limitation of both estimates is that neither accounts for the growth in the Hispanic population in Texas since the 1989/1993 census data. The Hispanic population has a lower rate of insurance coverage than the total population; thus both estimates probably underestimate the extent to which children are uninsured in counties with a large Hispanic population.The Office of Public Insurance Counsel finds that poorer counties will have more uninsured children, and richer counties fewer uninsured children than the estimates of the Texas Health and Human Services Commission. The differences between the two estimates can largely be explained by the different methods used by the two agencies.The Office of Public Insurance Counsel related insurance status to just one income level-under 200 percent of poverty-while THHSC used several different income levels. The Office of Public Insurance Counsel results may have overestimated the rate of uninsurance in poor counties where more of those under 200 percent of poverty have incomes low enough to qualify for Medicaid and underestimated the rate of uninsurance in richer counties where more of those under 200 percent of poverty have incomes too high to qualify for Medicaid.The Texas Health and Human Services Commission, on the other hand, adjusted its data in a way that reduced the variation between rich and poor counties. THHSC adjusted its results to reflect the statewide estimates of uninsured children at various income levels that were developed for the three legislative committees making recommendations to the 1999 legislature. The Committees' estimates show a lower number and rate of uninsured children among children under 200 percent of poverty and a higher number and rate of uninsured children among children over 200 percent of poverty than the unadjusted THHSC data.16. Newacheck, et al., "Health Insurance and Access to Primary Care for Children."17. Margaret Edmunds and Molly Joel Coye, Eds., America's Children: Health Insurance and Access to Care, National Research Council and Institute of Medicine, National Academy Press: Washington, DC 1998; Paul Newacheck, Dana C. Hughes, and Miriam Cisternas, "Children and Health Insurance: An Overview of Recent Trends," Health Affairs, Vol. 14, No. 1, 1995, 244:254; U.S. General Accounting Office, Health Insurance Coverage Leads to Increased Health Care Access for Children, GAO/HEHS-98-14, 1997.18. Margaret Edmunds and Molly Joel Coye, Eds., America's Children: Health Insurance and Access to Care; Newacheck, et al., "Health Insurance and Access to Primary Care for Children."19. U.S. General Accounting Office, Health Insurance: Coverage Leads to Increased Health Care Access for Children, op. cit.; Jeffrey J. Stoddard, Robert St. Peter, and Paul Newacheck, "Health Insurance Status and Ambulatory Care for Children," New England Journal of Medicine, Vol. 330, No. 20, 1994, 1421:1425.20. Newacheck, et al., "Health Insurance and Access to Primary Care for Children."21. U.S. General Accounting Office, Health Insurance: Coverage Leads to Increased Health Care Access for Children.22. Mary D. Overpeck and Jonathan B. Kotch, "The Effect of U.S. Children's Access to Care on Medical Attention for Injuries," American Journal of Public Health, Vol. 85, No. 3, 1995, 402:404.23. Jack Hadley, Earl P. Steinberg, and Judith Feder, "Comparison of Uninsured and Privately Insured Hospital Patients: Condition on Admission, Resource Use, and Outcome," Journal of the American Medical Association, Vol. 265, No. 3, 1991, 374:379.24. Robin M. Weinick, Margaret E. Weigers, and Joel W. Cohen, "Children's Health Insurance, Access To Care, and Health Status: New Findings," Health Affairs, Vol. 17, No. 2, 1998, 127:136.25. Paul W. Newacheck, Jeffrey J. Stoddard, Dana C. Hughes, and Michelle Pearl, "Children's Access to Health Care: The Role of Social and Economic Factors," in Ruth E. K. Stein, editor, Health Care for Children: What's Right, What's Wrong, What's Next (New York: United Hospital Fund, 1997).26. Lave, Judith R., PhD; Christopher R. Keane, ScD, MPH; Chyongchiou J. Lin, PhD; Edmund M. Ricci, PhD; Gabriele Amersbach, MA; Charles P. LaVallee, "Impact of a Children's Health Insurance Program on Newly Enrolled Children," Journal of the American Medical Association, Vol. 279, No. 22, 1998, pp. 1820:1825.27. Lave, et al., 1998.28. Lave, et al., 1998.29. Katherine Swartz, "Dynamics of People Without Health Insurance," Journal of the American Medical Association, Vol. 271, No. 1, 1994, 64:66.

CREDITS
This report was written by:
Victoria Pulos, Associate Director of Health Policy, Families USA.

The following Families USA Foundation staff contributed to preparation of this report:
Peggy Denker, Director of Publications
Rachel Klein, Health Policy Analyst
Lana Lee, Health Policy Intern
Justine Zabala, Administrative Assistant

Research from a prior Families USA publication also contributed to this report: One Out of Three: Kids Without Health Insurance, 1995-1996, Families USA 1997.

Families USA thanks the following people and organizations for their contribution:
Craig Copeland of the Employee Benefit Research Institute, who prepared the analysis of three-year CPS data used in this report.The Texas Health and Human Services Commission and the Office of Public Insurance Counsel, for unpublished estimates of uninsured children by county, and the Texas Department of Human Services, for Medicaid enrollment data.Anne Dunkelberg at the Center for Public Policy Priorities in Austin, for her help reviewing a draft of this report.

Special thanks to Gary Authenreith, Linda Martinez, Sara Alvarado, and the many other Texas families who talked to us as well as Dr. Cynthia Beamer. We also thank those who introduced us to the families we interviewed, including Colleen Horton, Family Voices Coordinator in Austin, Elizabeth Ford of Santa Rosa Children's Hospital in San Antonio, Ana Maria Garza of El Centro del Barrio in San Antonio, Jose Camacho of the Texas Association of Community Health Centers in Austin, Diane Gillit of the South Plains Community Action Association in Levelland, and the staff at the People's Community Clinic in Austin, Texas.

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