Chapter 6. The Simplification of Children’s Medicaid in Texas By Sufen Zhang Introduction Currently, there are estimated to be 658,000 children in Texas who are eligible for Medicaid but not enrolled. There are some systemic barriers to children’s Medicaid enrollment keeping them from getting insured. Other states have taken some effective steps to streamline and simplify children’s Medicaid enrollment procedures to improve enrollment and reduce the number of uninsured. This chapter contains recommendations to simplify the children’s Medicaid enrollment process in Texas and make it more consumer-friendly. In addition, bills from the 77th Texas Legislature are introduced, along with their possible budgetary impact on state government. Conclusions are reached that the uninsurance rate in Texas will not be greatly reduced unless state government makes efforts to streamline the Medicaid application and enrollment process. Medicaid at the Federal Level Federal Children’s Medicaid enrollment requirements The key requirements for Medicaid enrollment include a signed application, Social Security numbers for applicant children, documentation of immigration status of children who are “qualified aliens,” an income and eligibility verification, and recertification every 12 months. The federal government offers much flexibility to state governments in implementing their Medicaid programs. Medicaid enrollment trend nationwide Medicaid enrollment in the United States experienced a decline from 1997 to 1999. Studies sponsored by the Kaiser Commission have identified the implementation of welfare reform, changes in immigration policy, and high employment rates as the major factors contributing to the Medicaid enrollment decline nationwide. Apart from the nationwide trend of enrollment decline, there are large discrepancies in health care coverage for children across states, for example, only 7 percent of all low- income children in Massachusetts lacked health insurance coverage in 1999, compared with 37 percent of low-income children in Texas.1 Medicaid in Texas In most larger Texas cities, Medicaid for children is provided through private managed care insurance plans, and in most smaller cities and rural areas the state pays doctors and hospitals directly. Medicaid is a partnership between the state and federal government.2 Children who are eligible for Medicaid in Texas Eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP) for children in Texas varies by age and income as follows: • Infants ages 0-1 in families at or below 185 percent Federal Poverty Level (which is $31,543 for a family of four); those who are between 185 percent and 200 percent FPL are eligible for SCHIP; • Children ages 1-5 in families at or below 133 percent FPL (which is $22,677 for a family of four); those who are between 133 percent and 200 percent are eligible for SCHIP; • Children ages 6-19 in families at or below 100 percent FPL (which is $17,050 for a family of four); for those who are between 100 percent and 200 percent FPL is eligible for SCHIP.3 If a family’s income qualifies the child for Medicaid, but its assets exceed the limit ($2,000), their children may not eligible for Medicaid, but may be for SCHIP. Medicaid is the largest program that provides coverage for the poor in Texas. Medicaid enrollment in Texas decreased by 7.6 percent from June 1997 to December 1999, and enrollment in families, the number of children and pregnant women enrolled, decreased by 11 percent.4 From July 1996 to August 1998, the number of children on Medicaid in Texas dropped by 185,000. Children account for almost all the decline in Medicaid rolls.5 The application, enrollment, and recertification practice in Texas Since the spring of 2000, parents can enroll their children in Medicaid or SCHIP through the newly established program called TexCare Partnership.6 The children’s health insurance application process in Texas can be generalized as simple for SCHIP and complex for Medicaid, there is great disparity between the Medicaid and SCHIP application and enrollment processes. When parents want to enroll their children, they send an application to the TexCare Partnership either by calling a toll-free number or filling out and mailing a simple two- page application form. The TexCare Partnership mails asset questions to families if it appears that they are Medicaid-eligible. This practice is in accordance with federal law, which stipulates that before children may be enrolled into SCHIP, they must be screened to ensure they are not eligible for Medicaid.7 This means that a low-income family cannot choose between Medicaid and SCHIP. If the family chooses not to answer asset questions, then they cannot receive Medicaid or SCHIP. Based on the response to asset questions, if the family’s income and resources are not eligible for SCHIP, then the TexCare Partnership sends the family’s application to the Texas Department of Human of Services (DHS) for Medicaid eligibility determination. Once DHS receives a hard copy of the TexCare Partnership application it is date-stamped as received. DHS has up to 45 days to send a letter to the family to schedule a face-to-face interview and complete the rest of the Medicaid application process. If the family successfully completes the Medicaid application process and is certified for Medicaid, it will receive a certification letter.8 In Texas, the parents of children who have enrolled in Medicaid have to go to the DHS office every six months for a face-to-face interview to have their eligibility reviewed and recertified; otherwise, it will be suspended. In addition to recertification, a family must report changes in family income or circumstances to a local DHS office within 10 days. Any fluctuations in family income or resources may risk the children’s eligibility, i.e., they may lose their Medicaid on a month-to-month basis.9 Major barriers to increasing Medicaid enrollment in Texas Currently there are 1.4 million uninsured children in Texas, and among them 658,000 are estimated to meet the eligibility criteria of Medicaid but are not enrolled.10 Are there any inherent factors in Texas’s Medicaid application and enrollment process that create barriers to those who are qualified and keep them away from the health care they need? Does this, in part, account for the fact that the uninsurance rate in Texas has been one of the worst in the country for the past 10 years? The main barriers in children’s Medicaid enrollment are the following: Lack of information and misconceptions Some eligible low-income parents are not aware that they or their children are qualified for Medicaid. They lack basic knowledge about Medicaid eligibility criteria, and do not know who is qualified or how and where to apply. There is confusion about welfare programs among the public. Many of the eligible but unenrolled children are in families that moved from welfare to work in recent years, and their parents are unsure or unaware that their children or they themselves may still be eligible for Medicaid once they have exhausted welfare benefits or have returned to work at low incomes. Even though the 1996 federal law eliminated the linkage between welfare and Medicaid, some parents still mistake Medicaid for a welfare program rather than a health care program. They feel embarrassed to enroll their children in Medicaid. Thus, some eligible children are unnecessarily uninsured because of their parents’ misunderstanding. There also are some misunderstandings about the application process. Some migrants think that they would risk their immigration status if they apply for Medicaid for their children; some single mothers are hesitant to enroll their children because they do not want to or cannot answer questions about the current situation of their children’s fathers. These groups are scared away from the process. Most parents of uninsured children who would be eligible for Medicaid are the working poor. They often are not fully aware of the importance of health insurance and the benefits of Medicaid. They are more likely to take the risk of having their children uninsured. Lengthy and inconvenient application and enrollment determination and re- determination process Current Texas Medicaid application and enrollment procedures were designed in the 1970s for welfare recipients, not for the working poor. Thus, some of the application procedures are inconvenient to working families and prevent them from enrolling their children. Compared with SCHIP, the application procedures, forms, and verifications needed to apply for Medicaid are far more complicated and burdensome. Table 6.1 provides some basic differences between applying for Medicaid and SCHIP Table 6.1. Summary of Forms and Verifications Needed to Apply for Medicaid and SCHIP Medicaid CHIP Total number of forms needed 5-19 1 Total number of verifications needed 7-25 1-4 Total number of forms applicant must sign 3-10 1 Total number of other signatures the applicant must get to apply 4-15 0-1 Adapted from: Anne Dunkelberg and Cathy Schechter, “Every Child Equal: What Texas Parents Want from Children’s Medicaid,” Center for Public Policy Priorities and Orchard Communications, Inc., September 2000, Appendix D. Many parents would rather pay premiums to enroll their children in SCHIP to avoid the application process for Medicaid. But federal laws prevent states from enrolling Medicaid-eligible children in SCHIP, or letting families choose between Medicaid and SCHIP; for most very low-income families, the option is Medicaid or nothing. Face-to-face interview In applying for Medicaid, the applicant must go to the local DHS office for a face-to-face interview. Even though applicants can make an appointment and get a time slot for the interview, they often spend far more time at the DHS office than they expect because of the unpredictability of caseloads. Sometimes they have to return on another day to finish the mandatory Medicaid interview. The fact that at least 88 percent of uninsured children are from working families, and 63 percent have a parent employed year-round and full-time,11 implies that it is difficult and costly for parents to take time off from work for an interview with DHS that takes several hours. Also, in order to continue eligibility and stay enrolled, parents must go to a DHS office for a face-to-face interview every six months for recertification, even if there is no change to their income or assets. Because of this, many parents do not keep their children in Medicaid after the first six months of initial enrollment. Verification and documentation To apply for Medicaid in Texas, an applicant must provide proof of income, child care expenses or child support paid to another household, birth certificate or school records, proof of assets, residence, and domicile,12 past employment history, and other insurance. They must provide up to 14 state-required forms, and provide as many as many as 20 verifications.13 Many parents complain that in order to enroll their children, they have to gather signatures or verifications from their boss, landlord, coworkers, neighbors, and so on. If they fail to gather this intimidating documentation, chances are their children’s application will be turned down. Assets test A family applying for Medicaid cannot have assets whose value exceeds $2,000. These assets include checking and saving accounts; certificates of deposits; cash on hand; individual retirement accounts; notes, bonds, stocks; and land and buildings (other than the homestead).14 Families who apply for children’s Medicaid often do not exceed the limit, but the requirement to prove their financial worth is often a major obstacle.15 In a field survey in Brownsville, a woman testified that after she came a long way to do the interview and collect verifications and documentation, her children were denied enrollment because DHS staff determined that her family’s assets added up to $2,006. Frequent recertification The redetermination process for Medicaid (every six months) is longer and occurs more frequently compared with SCHIP (every 12 months). This means, again, that parents have to take time off from work and probably lose pay to make this appointment after gathering all the onerous resource documentation. Many believe that the current system that forces parents to report any fluctuations in income and reapply every six months undermines Medicaid. It does not provide continuous health care to those who truly need it, and some people are discouraged from reenrolling in Medicaid because of the daunting procedures. More stringent eligibility rules and more demanding application procedures have resulted in difficulty in completing the application process. This is one of the major barriers to increased enrollment among those who are qualified for Medicaid but not enrolled. Many parents feel frustrated by the program and feel that when they really needed help and tried to improve their situations, they could not do it. Taking into account the time needed for appointments, collecting verifications, and completing forms, it is important to note that it often takes 30-45 days for a child’s parents to complete the Medicaid application process.16 DHS reports that the top two reasons children who apply for Medicaid are denied coverage are: 1) missed appointments and 2) failure to provide complete information.17 Lack of consumer-friendly treatment and accurate information from Medicaid agencies Currently, those who want to apply for Medicaid usually go to a local DHS office and are interviewed by caseworkers there. In a Policy Research Project (PRP) field survey in San Antonio, a community clinic staff member reported that some parents received the letter notifying them that they need to show up in the DHS office for an interview the next day. For working families, it is hard to make arrangements to get off work with such short notice. Some parents complained that DHS staff just want them to show up on time, and do not care whether they would be able to request a leave from work or how long they would have to wait in DHS offices (where there are no child-care facilities). Potential enrollees also need to provide documentation showing their assets, income, and other private information. Some applicants feel humiliated or annoyed by the way they are treated at the DHS office and think that the questions they are asked are intrusive and invade their privacy. It was reported that sometimes, they were asked to provide inconsistent documentation, depending on the caseworkers involved,18 causing confusion in the application process and leaving them with the impression that the DHS requirements are unpredictable, and resulting, therefore, in their reluctance to go back to DHS to complete the process. For some, a face-to-face interview by DHS staff is intimidating, and they would rather meet with someone familiar. Many parents have the impression that DHS staff treat them as if they were ineligible, and thus they feel insulted by a lack of trust from DHS staff. The existing barriers in the Medicaid application process have created a challenge in expanding and increasing enrollment, and make it impossible to achieve progress in Texas and to improve its national ranking regarding the proportion of children who are uninsured. A low-income child in Texas is five times less likely to be insured than his counterpart in Massachusetts, where the state income eligibility for Medicaid is higher (200 percent FPL for infants; 150 percent for children ages1-5; 150 for those ages 6-16 and 150 percent for those ages 7-19) than Texas.19 In Massachusetts, face-to-face interviews have been eliminated, assets tests have been dropped, and presumptive eligibility has been adopted. To adjust this situation and to make the Medicaid program serve the qualified people to its fullest extent, initiatives need to be carried out to simplify and streamline the application procedures and to launch outreach campaigns and activities. Simplification Texas cannot make real progress in reducing the number of uninsured children unless it finds the means to dramatically improve the Medicaid enrollment of children.20 Removing systemic barriers to becoming and staying enrolled is critical to assuring that the Medicaid program reaches its full potential for reducing the number of uninsured children.21 Under current federal law and regulations, states have a rather wide range of choices in expanding their Medicaid or SCHIP enrollment. Comparing the minimum federal requirements with the lengthy and burdensome application practices in Texas, it is understandable why so many needy children are kept out of the system. Steps should be taken to simplify the application procedures and enrollment requirements to make them more convenient and straightforward. Some steps that have been proposed by various advocates include the following. Simplify application forms for Medicaid Compared with SCHIP, the application procedures for Medicaid are exceptionally intimidating. The application forms for Medicaid should be simplified to make them similar or even identical to SCHIP. This is critical when a family has one child eligible for Medicaid and another child eligible for SCHIP. Parents who have to navigate between these two programs because of the age-based standards will feel less frustrated if the application procedures for both programs are similar. A parallel structure would decrease the paperwork and reduce the confusion for families with children of different ages. Streamline the proof, verification, and documentation In order to be efficient, attempts should be made to identify the most necessary proof or documentation, and remove the others. Time and cost could be thus saved by both parents and administrators. Medicaid might try to use the same verification process as SCHIP does. Allow mail-in applications and drop face-to-face interviews The fact is that the majority of the children qualified for but not enrolled in Medicaid are from working families, and for them, the face-to-face interview is the most troublesome part. Allowing applicants to mail in their applications, combined with the removing unnecessary proof and documentation, would reduce the likelihood that people might not be able to complete the process. Drop assets test Since most Medicaid-eligible families live on a cash basis and do not have bank accounts, assets tests are not cost-effective for them. According to research by the Robert Wood Johnson Foundation, few Medicaid applicants are denied coverage because of the assets test. Another policy option would be to allow third-party verification of assets. Adopt presumptive eligibility and 12-month continuous eligibility The Medicaid Presumptive Eligibility Option for children was created by the Balanced Budget Act of 1997. Presumptive eligibility allows children whose family income appears to be below the state’s Medicaid income-eligibility guidelines to enroll temporarily in Medicaid, giving families time to complete the formal application process.22 It is a viable option that assumes that people applying for Medicaid are actually eligible unless DHS determines otherwise. This option eliminates the lag time between applying and receiving Medicaid benefits and helps children get routine care and needed medical treatment without delay. Twelve-month continuous eligibility would mean that children would be enrolled in Medicaid for up to 12 months, regardless of changes in income or other family circumstances. Currently, parents must report any change in their income within 10 days, meaning that their children in effect receive Medicaid on a month-to-month basis. With 12-month continuous eligibility, children more likely would fully benefit from the preventive services Medicaid provides and such eligibility would reduce the chance that any necessary medical treatment a child needs will be disrupted.23 Use joint application for Medicaid and SCHIP Since Medicaid and SCHIP have different age-based eligibility processes, families currently are placed in the difficult position of having to navigate two sets of program rules to ensure that all their children are enrolled.24 If joint applications were used, parents would have an easy time applying for coverage for all children in the family and a seamless enrollment process would be guaranteed for working-poor children. Simplification and streamlining in the enrollment and redetermination process of other states Many states have recognized that lengthy application forms and cumbersome submission processes can be roadblocks to families seeking Medicaid coverage. Many states have taken advantage of the flexibility of the current federal regulations and made great progress in streamlining the application and redetermination process, thus increasing overall enrollment. There is significant variation in eligibility, benefits, and provider payment policies from state to state, therefore, because of the flexibility allowed by the federal government. Of the 50 states and the District of Columbia, 40 have dropped face-to-face interviews in children’s Medicaid, or in both Medicaid and the state’s SCHIP program; only six states (including Texas) require an asset test for Medicaid, and 16 states have adopted 12-month continuous eligibility.25 Of the 32 states that have separate SCHIP programs, 28 use joint applications for Medicaid and SCHIP. Five states have implemented presumptive eligibility for children in Medicaid, and three more states have adopted the policy but, as of this writing, have not yet implemented procedures.26 Texas is one of the two states (the other is Montana) that has neither dropped face-to-face interviews or assets tests, nor adopted 12-month continuous eligibility. Some states have redesigned applications so that forms are user-friendly and the questions asked are clear, and unnecessary questions are eliminated. For example, Minnesota replaced a 24-page application form previously used for its annual eligibility renewals with a one-page form; most families receiving Medicaid in Massachusetts now only need to verify their income.27 Indiana, Oklahoma, and Florida have been recognized for their recent successful initiatives to improve Medicaid enrollment of uninsured children. All three of these states attribute their success to marketing children’s Medicaid as health insurance rather than welfare, new shorter mail-in applications with simplified documentation requirements, and no assets test.28 In looking into the experience of other states in children’s Medicaid, it is clear that more accessible and smooth application procedures can play a critical role in boosting enrollment. Recent actions of Texas Department of Human Services Texas DHS recently undertook the following improvements: • Published an agency rule that would allow mail or telephone recertification (not initial application) for families receiving Medicaid only (not yet implemented as of this writing). • Reduced the numbers of verifications and documents required for a Medicaid-only application (domicile, terminated employment, past employment, kinship, birth certificate). Implemented in November 2000. • Developed a more user-friendly revised “1010” (the combined Medicaid-TANF- Food Stamps application). Piloted in the fall of 2000, with an April 2001 target for statewide use. • Changed the documentation required for income verification in a Medicaid-only application to match the SCHIP policy (i.e., the last 60 days).29 Proposed Bills in the 77th Texas Legislature concerning Medicaid Simplification House Bills 825 to 828 have been submitted to the 77th Texas Legislature concerning the simplification and expansion of children’s Medicaid enrollment. The author of these bills is Representative Patricia Gray, Chair of the House Committee on Public Health, and bipartisan coauthors are Naishtat, Keffer, and Coleman.30 HB 825 on continuous eligibility of children for Medicaid: This bill states that 12- month continuous eligibility should be provided for Medicaid-enrolled children under the age of 19, with recertification performed annually or before the child’s 19th birthday. HB 826 on consideration of assets and resources for purposes of determining eligibility of children for Medicaid: This bill would exclude the assets and resources of a person younger than 19 years of age, and those of the person’s parents or other caretaker, for purpose of determining Medicaid eligibility. HB 827 on simplifying the application and eligibility determination process for medical assistance provided to children: This bill would modify the Medicaid application and recertification processes for children under the age of 19 to make them comparable to those of SCHIP. It suggests that documentation and verification be simplified, face-to-face interviews be eliminated, and mail-in applications be allowed. Also, it suggests that recertification be carried out by phone or mail instead of a personal appearance at a department office. HB 828 on application and eligibility for Medicaid: This bill shares the same purpose as HB 827. The specific changes include eliminating face-to-face interviews in the initial application and recertification, allowing mail-in applications, simplifying documentation and verification, and removing assets and resource tests. The first hearing on the above-mentioned bills was held on March 7, 2001. The passage of any of these bills will have a great impact on reducing the number of uninsured children in Texas. The current estimated 658,000 Medicaid-eligible but uninsured children will greatly benefit if Texas makes efforts to take advantage of the current flexibility available under federal law and the strong support for simplification to make Medicaid more consumer-friendly. Overall Benefits and Costs of Simplifying Children’s Medicaid Eligibility Benefits The uninsured are expensive. State and local governments and health care providers lost an estimated $4.7 billion on unreimbursed indigent care in 1999.31 Private and nonprofit hospitals in Texas must, by law, provide emergency care to all patients, regardless of their ability to pay for services.32 The Texas CHIP Coalition estimates that public and private HMOs and public and private providers all would benefit from Medicaid simplification by having more paying patients, reducing bad debt and charity care, and reducing demand for indigent health care services financed by local property taxes. Costs On the other hand, there will be a significant budgetary impact on the state government resulting from implementing the recommended policy changes. The cost of success is the key factor dampening the state’s willingness to embrace policies that would streamline access to children’s Medicaid.33 It is difficult to predict how many parents of the children who are eligible but not enrolled now would be willing to go through the process if they could do this by phone call or mail, without missing work to spend hours in a DHS office, and without first accounting for the value of their every asset, bank account, insurance policy, vehicle, or retirement benefit.34 The Legislative Budget Board (LBB) has released the fiscal notes for the four proposed bills and made estimates about the possible budgetary impact of House Bills 825-828 on the state government of Texas in the coming years (see Appendices A-D). Project Alberto also made some estimates of the possible cost to the government. But since these estimates are based on individual policy changes, the total cost of simplifying children’s Medicaid cannot be obtained by simply adding up individual estimates. As Project Alberto states, there is no way to quantify easily how the policy changes will interact, it is very likely that double counting may have occurred, and the combined cost figures may be overstated. Thus, the actual cost to the state government might not be as high as anticipated.35 Potential benefit and cost resulting from HB 825 Benefit This policy change would make Medicaid similar to SCHIP, saving work for both parents and DHS caseworkers, and would end the current problem of children rolling on and off Medicaid due to small and temporary income fluctuations, and relieve families of having to renegotiate the system frequently.36 The health care benefits of needy children can be maximized from this program. Therefore, the goal of Medicaid to create a medical home and promote consistent preventive care can better be fulfilled. Cost Unlike the other simplification proposals, continuous eligibility is the only one the principal impact of which is reflected for children already on Medicaid. The goal is to extend coverage for those children during a given year. Project Alberto predicts that if this bill is passed, the number of uninsured children in Texas will be greatly reduced, and the bill also will have the greatest financial impact on the state’s budget.37 The LBB estimated in its fiscal notes that implementation of HB 825 would have a negative impact to General Revenue of $249,538,131 through the biennium ending August 31, 2003.38 (See Appendix A.) It is estimated by Project Alberto that 245,685 children would maintain their Medicaid benefits at costs to the state of $57.5 million in 2001 to $65.2 million in 2004.39 Potential benefit and cost resulting from HB 826 Benefit This policy change would make the task of enrolling vastly simpler for both parents and DHS staff, and allow parents to maintain some prudent savings for college and retirement.40 Cost The LBB estimates that 32 percent of SCHIP enrollees are within Medicaid income limits. It is assumed that those 32 percent would shift to Medicaid once the bill is introduced, and Medicaid recipients would increase month-by-month to 104,115 in FY 2002, and to 138,819 in subsequent years. The implementation of HB 826 would have an estimated net negative impact of $97,168,414 to General Revenue through the biennium ending August 31, 2003. (See Appendix B.) According to the study by Project Alberto, during the 12-month period from March 1999 through February 2000, approximately 4.4 percent of the average Medicaid children’s caseload statewide was denied because applicants did not meet the $2,000 assets limit. Project Alberto estimates that approximately 65,000 children would become eligible for Medicaid each year between years 2001 to 2004 if assets tests were eliminated. Total cost to the state government in this case would be $111.3 million over the four-year period. Potential benefit and cost result from HB 827 Benefit Working families would benefit most from this policy change. They will be encouraged by the smooth enrollment process to get their children insured. Administrative costs could also be saved. Therefore, Medicaid enrollment could increase by approximately 5 percent for children ages 1 to 18.41 Cost The LBB estimated that, by eliminating the face-to-face interview, Medicaid recipients would increase by 9,176 month-to-month in FY 2002, 27,734 in FY 2003, and 34,695 in FY 2004. By simplifying documentation and verification, Medicaid recipients would increase by 20,617 in FY 2002, 63,202 in FY 2003, and 80,357 in FY 2004. The LBB concluded, therefore, that the passage of HB 827 would have a negative impact of $74,992,474 through the biennium ending August 31, 2003. (See Appendix C.) It is estimated by Project Alberto that an additional 33,000 children who are eligible for Medicaid but not enrolled would become enrolled in this program each year between the years 2001 to 2004. The estimated cost to the state of Texas would be about $56.5 million in a four-year period. Potential benefit and cost result from HB 828 HB 828 is a combination of HB 826 and HB 827. The LBB estimated that the implementation of HB 828 would have a negative impact of $172,160,888 to General Revenue through the biennium ending August 31, 2003. (See Appendix D.) Conclusions It is widely believed that health care does make a difference. Children without health insurance are less likely, because of financial barriers, to receive immediate medical care and get necessary treatment. These children will be our future, and what Texas will be like in the years ahead is determined largely by the choices made about these uninsured children today. In order to revise its long-standing trend of falling behind in covering children’s health needs, Texas needs to be engaged in a concerted effort and take positive steps to simplify the rules and streamline enrollment procedures, particularly for children. A simple and straightforward application and enrollment process can be one of the most effective tools enabling families to enroll in Medicaid. Also, aggressive outreach could be launched to promote Medicaid and let families know about opportunities for them to apply for coverage for their children, and to understand that some barriers they may have faced in the past have been eliminated or reduced.42 In order to fix the problem of the uninsured in Texas, it is essential to eliminate the existing barriers and encourage poor people to apply for Medicaid to get health care benefits. As long as there is political willingness, creativity, and flexibility to overcome such barriers, Medicaid enrollment of working-poor children will be greatly increased.  Notes 1 The Center for Public Policy Priorities, Working but Poor (Austin, Texas, 1999), p. 9. 2 Texas CHIP Coalition, Exciting New Options for Uninsured Texas Children: TexCare Partnership Connects Families with Affordable Insurance (Austin, Texas, January 2001), p. 1. 3 Texas CHIP Coalition, Texas Children’s Health Insurance Programs: Medicaid, CHIP, and Private Insurance Coverage (Austin, Texas, January 2001), p. 1. 4 Kaiser Commission on Medicaid Facts, Medicaid Enrollment and Spending Trends (Washington D.C.: The Henry J. Kaiser Family Foundation, September 1999), p. 1. 5 The Center for Public Policy Priorities, “Health Policy Fast Facts.” Online. Available: http://www.cppp.org. Accessed: February 25, 2001. 6 Texas CHIP Coalition, Exciting New Options for Uninsured Texas Children: TexCare Partnership Connects Families with Affordable Insurance (Austin, Texas, January 2001), p. 1. 7 Texas CHIP Coalition, Common Questions to Ask about Medicaid and CHIP (Austin, Texas, January 2001), p. 4. 8 Ibid. 9 Texas CHIP Coalition, Wanted: A Simple Process for Insuring Texas Children (Austin, Texas, January 2001), p. 1. 10 Texas CHIP Coalition, Common Questions to Ask about Medicaid and CHIP, p. 1. 11 Center for Public Policy Priorities and Orchard Communications, Inc., Every Child Equal: What Texas Parents Want from Children’s Medicaid (report to The Texas CHIP Coalition, September 2000). Online. Available: http://www.cppp.org/products/reports/ece.pdf. Accessed: February 13, 2001. 12 Ibid. 13 Texas Association of Community Health Centers, Project Alberto, Achieving Health Insurance Coverage For Texas Children (Austin, Texas, January 2001), p. 17. 14 Ibid., p.19. 15 Texas CHIP Coalition, Common Questions to Ask about Medicaid and CHIP, p. 1. 16 Texas Association of Community Health Centers, Project Alberto, p. 5. 17 Ibid., p. 17. 18 Center for Public Policy Priorities and Orchard Communications, Inc., Every Child Equal: What Texas Parents Want from Children’s Medicaid. 19 Genevieve Kenney, Lisa Dubay, and Jennifer Haley, Health Insurance, Access, and Health Status of Children: Findings from the National Survey of American’s Families (Washington, D.C.: The Urban Institute, October 2000), p. 5. 20 Center for Public Policy Priorities and Orchard Communications, Inc., Every Child Equal: What Texas Parents Want from Children’s Medicaid. 21 Donna Cohen Ross and Laura Cox, Making it Simple: Medicaid for Children and SCHIP Income Eligibility Guidelines and Enrollment Procedures (Washington, D.C.: Center on Budget and Policy Priorities, October 2000), p. 5. 22 Ibid., p. 7. 23 Ibid., p. 16. 24 Ibid., p. 13. 25 Texas Association of Community Health Centers, Project Alberto, p. 24. 26 Ibid. 27 NGA Center, Policy Studies Division, State Outreach and Enrollment Strategies to Improve Low-Income Families’ Access to Medicaid, Employment, and Social Services (September 2000). Online. Available: http://www.nga.org. Accessed: January 17, 2001. 28 Center for Public Policy Priorities and Orchard Communications, Inc., Every Child Equal: What Texas Parents Want from Children’s Medicaid. 29 Center for Public Policy Priorities, What are the TDHS Proposals? Online. Available: http://www.cppp.org. Accessed: March 5, 2001. 30 Texas Legislature. Texts of House Bills 825-828. Online. Available: http://www.capitol.state.tx.us. Accessed: March 15, 2001. 31 Health Policy Forum, “The Uninsured in Texas: Policy Brief” (Austin, Texas: Texas Institute for Health Policy Research, September 29, 2000), p. 5. 32 House Research Organization, Texas House of Representatives, “Health Care for Uninsured Texans,” Focus Reports No. 76-5 (Austin, Texas, February 1999), p. 1. 33 Center for Public Policy Priorities and Orchard Communications, Inc., Every Child Equal: What Texas Parents Want from Children’s Medicaid. 34 Ibid., p. 4. 35 Texas Association of Community Health Centers, Project Alberto, p. 22. 36 Center for Public Policy Priorities and Orchard Communications, Inc., Every Child Equal: What Texas Parents Want from Children’s Medicaid. 37 Texas Association of Community Health Centers, Project Alberto, p. 22. 38 Legislative Budget Board, Fiscal note to House Bill 825 (Introduced version), 77th Texas Legislature, regular session (2001), p. 1. 39 Texas Association of Community Health Centers, Project Alberto, p. 22. 40 Center for Public Policy Priorities and Orchard Communications, Inc., Every Child Equal: What Texas Parents Want from Children’s Medicaid. 41 Texas Association of Community Health Centers, Project Alberto, p. 18. 42 Laura Cox and Donna Cohen Ross, Medicaid for Children and CHIP, Income Eligibility Guidelines and Enrollment Procedures: Findings from a 50-State Survey, Preliminary Report (Washington, D.C.: Center on Budget and Policy Priorities, April 2000), p. 4. 17