Demographic shift causing Harris County to explore community-based health care[/caption] The system Harris County uses to provide indigent health care services is changing as more low-income individuals and families move from the city of Houston to the suburbs, due in part to the city's gentrification. Ten years ago, many of the suburban areas in the county traditionally did not have a great need for a publicly funded health care system, said Laurie Glaze, executive director of One Voice Texas, a Houston-based network of private and nonprofit groups working to ensure health needs of all Texans are addressed. "Even in areas like Cy-Fair, as our community pushes out beyond [Loop 610] and Beltway 8, we're seeing a much greater need for community services in these outlying areas," she said. "We're seeing a lot of rebuilding inside Loop 610, which is pushing out low- to moderate-income families." In addition, the state's rejection of a federal expansion of Medicaid—which would have provided health care coverage to 500,000 Harris County residents—puts a strain on the county's financial resources to provide these services since it relies solely on property tax revenue to fund its indigent health care system. "If the burden remains on the property taxpayers of Harris County and we're not allowed access to federal funds, that will constantly put pressure on the quality of health care," Harris County Judge Ed Emmett said. "We're stuck: We're mandated to provide services, but the only revenue is property tax dollars."

Suburban poverty

The Harris Health System, formerly known as the Harris County Hospital District, was created in the 1960s when legislation was passed requiring counties to foot the bill for indigent health care. Since its inception when Ben Taub General Hospital and LBJ General Hospital opened, the system has changed a great deal, with more of a focus now on creating neighborhood clinics in the county, Emmett said. "Decades ago, you could say, 'This is the part of the county where poor people live,' but that's no longer the case," he said. "I've started using the phrase, 'suburban poverty.' For those people to have access to care, there needs to be outlying clinics in [precincts 3 and 4]. You can't assume everyone in the suburbs has insurance or adequate access to health care." Harris County faces another distinct challenge as unincorporated areas such as Cy-Fair will boast a higher population than the city of Houston by 2018, Emmett said. "There is huge growth in the northwest quadrant of Harris County," said Ken Janda, CEO of Community Health Choice, a nonprofit that provides health insurance to low-income populations. "More hospitals are being built and doctors are moving out there, but it's slower than we like." While Houston's inner-city areas such as the Third Ward traditionally had large low-income populations, those areas are becoming more gentrified with newer homes being built. Conversely, lower-income populations are becoming more prevalent in the suburbs, Janda said. "I carry around ZIP code maps all the time and say poverty isn't an inner-city issue anymore," Janda said. "The whole area between I-10 and Hwy. 290 outside of Hwy. 6 has quite a number of low-income individuals. That area signed up more subsidized people [for President Barack Obama's health care law] in Harris County than anywhere else."

Medicaid expansion

Citing high costs to implement the program, the state of Texas rejected a federal Medicaid expansion in 2013 that would have provided coverage to 1.8 million individuals in Texas. "Even though the federal government pays most of the cost, the expansion still ends up putting a serious strain on the state budget over time," said state Rep. Allen Fletcher, R-Cypress. Medicaid is a state and federally funded program that provides payments for medical services for low-income families, pregnant women, the elderly, blind and disabled. "When Texas opted not to expand Medicaid, it left most of the same group of people who never had coverage before with no opportunities for coverage," Glaze said. "The way health care coverage was written is that you had to be at a certain income level for coverage under the Affordable Care Act. If you were under that income level, you were supposed to qualify for Medicaid. The intention was to get people coverage with a subsidy through the exchange or through Medicaid." Although Medicaid serves nearly 600,000 people in Harris County, many more do not receive coverage because they do not meet income requirements in Texas. More than 1 million residents, or 29 percent of the population, in Harris County are uninsured, according to the U.S. Census Bureau.

"Decades ago, you could say, ‘This is the part of the county where poor people live,’ but that’s no longer the case." –Ed Emmett, Harris County Judge

Reasons for the high rate of uninsured residents vary, from small employers not offering insurance to part-time workers who do not qualify for coverage to people remaining willfully uninsured. Additionally, some of the poorest residents cannot afford to sign up through the Affordable Care Act. The biggest block of uninsured people in Houston is low-income adults who would be eligible for Medicaid in other states, but not Texas, Janda said. "We cover 240,000 children in our health plan, and the vast majority of their parents are uninsured and too poor to be eligible for subsidies in the exchange and don't work for an employer that offers insurance," he said. "We advocate for trying to cover entire families. For the last two and a half years, I've [not understood] why we can't explain to state leaders why the Medicaid expansion would benefit [our residents]." In October, the Harris Health System submitted a budget with a $14.8 million deficit for fiscal year 2015-16, which is not expected to improve next year, said Dr. Ericka Brown, administrator and vice president of Harris Health Ambulatory Care Services. "If we had the Medicaid expansion, [the deficit] would not be an issue for us," she said. "Because we're a safety net organization, every dollar that we get specifically goes to patient care. That $14.8 million comes off the backs of Harris County residents." Even though the county has a safety net through the Harris Health System and other qualified health centers, the capacity of that net is not enough to meet the needs of all uninsured people in the county, Janda said. "We have a great opportunity to draw down federal dollars to get people covered, which is cheaper than waiting until they get sick and go to the emergency room," he said. "We're missing the chance to do that."

Moving forward

In the future, Emmett said the county should focus on establishing medical homes and neighborhood clinics as opposed to more brick and mortar hospitals. "We need to put our resources into clinics, and they need to be able to be easily moved," he said. "It could be that this year an area may have well-insured folks, but in 15 years it could be a suburban slum where we need a clinic." Emmett also said the county will need to form some type of regional health care system to replace the patchwork of county hospital districts. "There's nothing sacred about a county line," he said. "It's about a single mother in Fort Bend County who has an infant who spikes a fever in the middle of the night. They're probably going to come into Harris County and seek health care, and that's understandable. I think we need to come up with a regional system that's funded by the state." Glaze said as demographics change, there will be challenges due to an increased number of people who do not qualify. "When you look at the growth in the county and you look at the services that must be provided through the county budget, something is going to have to give," she said. "We won't be able to maintain infrastructure while the county assumes more and more of the cost of uninsured health care."