e-Texas e-Texassmaller smarter faster governmentDecember, 2000
Carole Keeton Rylander
Texas Comptroller of Public Accounts

Recommendations of the Texas Comptroller

Chapter 8: Health and Human Services

Encourage the Federal

Government to Expand

“Safety-Net” Programs in Texas


The federal government should expand its federal health-related “safety-net” programs that target low-income persons without health insurance and areas with many residents who lack access to health care services, such as the Texas-Mexico Border region. Other federal safety net programs targeting migrant workers and the homeless, or people with specific conditions such as AIDS and diabetes, should be expanded as well. Federal safety-net programs give communities more choices in designing locally-operated and controlled projects.


A large number of Americans cannot afford insurance. Many of them are the working poor, minority members, foreign-born, or non-citizens. Many live in geographically or economically disadvantaged communities and they are more likely than other populations to receive medical care through a community-based “safety-net” program. The Institute of Medicine defines the health care safety net as “providers that organize and deliver a significant level of health care and related services to uninsured, Medicaid, and other vulnerable patients.”[1]

Core safety-net programs include public hospitals, community health centers, rural health clinics, and programs designed to train or recruit physicians and other medical providers to work in inner-city or rural areas that lack medical services. Texas itself is a safety net provider. According to a recent study by the Comptroller’s office, Texas provided $4.7 billion worth of health care to the uninsured through public and private efforts in 1998. Local governments, private providers, and charities funded $3.5 billion of that amount, state agencies paid for $989 million, and the federal government sent only $198 million to Texas.[2] The federal government funds a number of safety-net programs, ranging from centers that help train health professionals to programs designed to help specific populations, such as migrant farm workers or people with AIDS.

Safety-Net Needs on the Border

All but two of Texas’ 43 Border counties—including all except one county on the Rio Grande—are federally-designated “medically underserved areas” or have portions of their counties so designated.[3] These are areas with a high percentage of elderly residents, high poverty rates, high infant mortality rates, and a lower ratio of primary care providers than the national average.[4] In all, Texas has 176 counties and another 47 partial counties designated as medically underserved.[5]

A 1998 report by the Comptroller’s office concluded that public health strategies that work well in other parts of Texas often fail to address the Border’s unique needs. One such need is for collaboration with Mexican health officials to attack shared problems such as disease prevention programs.

Federal safety-net programs for uninsured persons are critical to border states such as Texas. The high number of uninsured persons in border states is a national problem that requires federal assistance. The statistics below (Exhibit 1) demonstrate why the problem extends beyond an individual state’s border and its capacity to address the needs that exist.

The four US states sharing a border with Mexico are among the top six states with the highest percentages of persons under the age of 65 who lack insurance. All have uninsured rates of more than 20 percent.[6] In 1998, 32.4 percent of persons living in immigrant households lacked health insurance, more than twice the percentage of native persons, according to a recent study by the Center for Immigration Studies. The study also found that immigrants who arrived between 1994 and 1998, including their children, accounted for 59 percent of the growth (2.7 million people) in the uninsured population.[7]). (Internet document.)

Exhibit 1

States with Highest Shares of Uninsured Persons, 1999

Border States

New Mexico
Other States


Source: US Census Bureau.

When an area’s health care system functions poorly, its economy can suffer. Individuals with poor health, particularly chronic untreated conditions, often cannot work, and their families may turn to government programs for health care. The Border’s low rate of private insurance stems largely from its employment profile. A larger share of the Border’s residents work for small employers than elsewhere in the state, and small employers are less likely than larger firms to pay for employee insurance. Similarly, workers along the Border are more likely to work in low-wage jobs than are other Texas residents, and low-wage jobs typically do not include insurance coverage.[8]

The federal government should expand its funding for safety net programs, particularly along the US/Mexico Border. For example, community health centers provide primary care and preventive health care services to areas or specific populations that lack medical services. These centers are nonprofit community organizations focused on providing safety-net medical and associated services to people in medically underserved areas. A number of studies have documented that community health centers provide a cost-effective way to improve access to high-quality care and reduce inappropriate hospitalizations.[9]

In 1999, more than 643 community health centers across the nation provided services for about 8.5 million people. The centers operated more than 3,000 individual health care sites. About 40 percent of the patients treated in these centers in 1998 were uninsured; the centers treated an estimated 8 percent of the nation’s total uninsured population.[10] In all, these centers received an average of about $951,000 apiece in federal grant funding for fiscal 1999.[11] In Texas, 21 counties received an estimated $39.1 million in federal funds for community health centers. Another $10.5 milion went to health centers for the homeless, migrant and seasonal farmworkers, and public housing residents.[12]

More community health centers would be a particular help to Texas’s non-citizen population, of which 56 percent (some 917,000 persons) are uninsured.[13] Urban areas with low rates of employment-based health insurance also would benefit. A recent study by the Commonwealth Fund and the University of California at Los Angeles found a strong relationship between a city’s rate of employment-based health coverage and its overall rate of health coverage and access to care.[14]). (Internet document.) It also found that noncitizens are two to three times more likely than citizens to work for an employer who does not offer any health care coverage.[15] Therefore, expanding federal safety-net services is essential in providing vital community health care services for persons without insurance.


A state resolution encouraging the federal government to expand the number of federally-funded community health centers and other community-based safety-net programs specifically directed to poor and medically underserved communities should be enacted.

An increased number of federally-funded community health centers could alleviate the burden inappropriate emergency room use places on public and private hospitals. Uninsured, poor, and non-native-born residents would receive improved access to a regular source of primary and preventive care. Additional funding from other federal safety net programs, including centers for migrant farm-workers and programs targeting common health problems among underserved populations, would give communities more resources to deal with the unique problems they face.

Fiscal Impact

The savings to state and local governments resulting from these recommendations cannot be estimated. Local entities in Texas could receive additional federal dollars for community health centers or other federal safety-net programs. Additional savings to state and local governments could result from decreased hospitalizations if more low-income or uninsured persons receive preventive care in community health centers instead of emergency rooms.

Increased federal costs for expanding safety-net programs cannot be estimated, but would depend on how much and which programs are expanded.

[1 ] Marion Ein Lewin and Stuart Altman, Ed., America’s Health Care Safety Net: Intact But Endangered (Washington, DC: National Academy Press, 2000), p. 3.

[2 ] Texas Comptroller of Public Accounts, “Texas Estimated Health Care Spending on the Uninsured” (http://www.window.state.tx.us/uninsure/). (Internet document.)

[3 ] Texas Department of Health, Bureau of State Health Data and Policy Analysis, Health Professions Resource Center, Medically Underserved Populations (MUPs) and MUA-Medically Underserved Areas (MUAs) in Texas, (Austin, Texas, May 18, 2000) (http://www.tdh.state.tx.us/dpa/00mua-wc.htm). (Internet document.)

[4 ] National Conference of State Legislatures, Health Policy Tracking Service, “Border/Migrant Health Issue Brief,” Denver, Colorado, July 3, 2000.

[5 ] Texas Department of Health, Bureau of State Health Data and Policy Analysis, Health Professions Resource Center, Medically Underserved Populations (MUPs) and MUA-Medically Underserved Areas (MUAs) in Texas, (Austin, Texas, May 18, 2000) (http://www.tdh.state.tx.us/dpa/00mua-wc.htm). (Internet document.)

[6 ] US Census Bureau, “Health Insurance Coverage: 1999 Table E. Percent of People Without Health Insurance Coverage Throughout the Year by State (3-year Average): 1997 to 1999” (http://www.census.gov/hhes/hlthins/hlthin99/hi99te.html

[7 ] Center for Immigration Studies, Increasing the Ranks of the Uninsured (Washington, DC, July 18, 2000).

[8 ] Texas Comptroller of Public Accounts, “Health: Chronic Conditions,” Bordering the Future (Austin, Texas, July 1998) (http://window.state.tx.us/border/ch08/ch08.html#4). (Internet document.)

[9 ] Marion Ein Lewin and Stuart Altman, Ed., America’s Health Care Safety Net: Intact But Endangered, p. 72.

[10 ] Unpublished data from the Bureau of Primary Health Care, US Department of Health and Human Services, cited in Marion Ein Lewin and Stuart Altman, ed., America’s Health Care Safety Net: Intact But Endangered, p. 61.

[11] US General Services Administration, “93.224: Community Health Centers,” The 2000 Catalog of Federal Domestic Assistance (Washington, DC) (http://www.cfda.gov). (Internet document.)

[12] US Department of Health and Human Services, Financial Assistance by Geographic Area, October 1, 1998 – September 30, 1999 (Washington, DC), pp. 77-147.

[13 ] Texas Health and Human Services Commission, “Demographic Profile of the Texas Population without Health Insurance Coverage,” Austin, Texas, May 2000, Chart III-16 and Chart III-17, accessible through (http://www.hhsc.state.tx.us/cons_bud/dssi/BRT/BRT.htm

[14 ] The Commonwealth Fund and UCLA Center for Health Policy Research, Disparities in Health Insurance and Access to Care for Residents Across US Cities, by E. Richard Brown, Roberta Wyn, and Stephanie Teleki, (Los Angeles, California, August 2000), p. vii.

[15 ] The Commonwealth Fund and UCLA Center for Health Policy Research, Disparities in Health Insurance and Access to Care for Residents Across US Cities, p. 10.

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