Dental Health Care for Children in the Age Group One to Twenty in Nacogdoches - Research Paper Example

Abstract Dental health care of children in the age group one to twenty and the providing of the requisite dental services is a matter of concern in Nacogdoches, Texas. This paper examines the status of dental services available for children in Nacogdoches, Texas through Medicaid and CGIP programs that are meant to provide the essential dental services the children. Analysis of the hindrances in the availability of dental services through Medicaid shows that the main reasons why Medicaid is not popular with dentists is the low reimbursement rates and the frequency with which appointments are not kept in the Medicaid program. Poor knowledge among parents on the need for good dental health among children and the ability of Medicaid to contribute to this requirement lead to parents not keeping Medicaid dental service appointments. A combination of education programs to increase the awareness among parents and enhancement of reimbursement rates for dental services has been found as solutions to remove the hindrances to the availability of dental services to the children the age group one to twenty in Nacogdoches, Texas. Table of Contents 1. Introduction : 4 2. Problem Definition : 4 3. Literature Review : 5 4. Why Dentists do not accept Medicaid : 9 5. Develop Incentive for dentists to accept Medicaid : 10 6. Increase reimbursement rate of Medicaid : 11 7. Educate Parents about keeping appointment and the importance of dental care : 14 8. Criteria Selection : 14 9. Alternative I: Develop Incentive for dentists to accept Medicaid : 15 10. Alternative II: Increase the reimbursement rates of Medicaid : 15 11. Alternative III: Educate Parents about the importance of dental care : 16 12. Projected Outcomes : 17 13. Comparison : 18 14. Deciding the Best Alternative : 18 15. Conclusion : 20 16. Literary References : 22 1. Introduction Children suffering from dental decay are moderately high in Nacogdoches, Texas. Many children suffer either because they have been denied Medicaid or their Medicaid has been delayed. Many of the children in Nacogdoches, Texas are from low-income families, who do not have adequate health care, because their Children’s Health Insurance Program (CHIP) benefits have been cut, even though they are eligible for medical coverage. Many of the poor children residing in Nacogdoches County are on Medicaid, but do not have access to dental treatment on a regular basis. Uninsured children mostly end up attending emergency rooms when they get ill, because they cannot afford to see a doctor or dentist in time. 2. Problem Definition The problem in Nacogdoches is that Children on Medicaid and CHIP programs are not able to find health care providers, who accept them. This occurs in spite of the fact that there are enough dentists to provide dental care to the population of Nacogdoches. The Kaiser Commission on the Medicaid and the Uninsured conducted survey in 2000 with focus on the enrollment and re-determination of for children in Medicaid and CIP programs, which found that five out of seven dentists in Nacogdoches maintained that low reimbursement rates are the reason that they do not accept Medicaid or Chips. (Ross & Cox, 2000). Many people do not consider taking their children to the dentist for regular dental check ups, thereby putting the dental health of many children at risk. The reason for this is that Medicaid has been cut for many residents in Texas, and as a result it is quite expensive for the people to meet the costs of dental care (Best, 2007). There are 20.2% of children in Texas who are lacking dental coverage. Most of the children come from families that cannot afford the health coverage through their employers because the cover is expensive. Arising from these facts, there is need for cost reduction programs of Medicaid in order to reduce the number of uninsured children in Texas. Children need to receive regular medical and dental checkups as well as all treatments that are medically necessary. Adults in Texas also do not receive dental checkups through Medicaid and are limited to three prescriptions a month (Garret, 2008). Although dental benefits are available for children enrolled in Medicaid, only a few receive them. State Medicaid programs are plagued by low rates of participation among dentists and so enrolment in Medicaid does not ensure access to services. The state of Texas reports that less than half of the states’ dentists attended on at least one Medicaid patient in a period of one-year (Kaiser Family Foundation, 2000). Furthermore, most states report that less than 25 percent of the states’ dentists have seen at least 100 Medicaid patients in a one-year period. The low dentist participation in Medicaid programs is said to be because of the overall shortage of dentists. A steady decline has occurred in the proportion of dentists to the general population. Dentists are retiring faster than new ones are entering the practice (Kaiser Family Foundation, 2000). Texas reports both an overall shortage of dentists and a geographic misdistribution, making it difficult to find dentists to treat Medicaid patients. Consequently, most dentists are busy with insured and self-pay patients making it difficult for Medicaid recipients to set appointments (Cuardo et al, 2008). 3. Literature Review The Social Security Act of 1965, created programs such as Medicaid/Medicare, Head Start and Food Stamps (Siegel, Swanson & Shyrock, 2004). The War on poverty intended to reduce the rates of poverty and improve the living standards for the poor. The Medicaid program was created to assist low-income individuals with medical and dental care. Texas started participating in the Medicaid program in 1967. In 1966 Medicaid had only enrolled 4 million people. It now enrolls over 42 million with 2.6 million living in Texas. Medicaid was created to ensure that all citizens had access to quality and affordable medical and dental care. States receive from 50 to 83 percent of the cost of Medicaid from the federal government. Nacogdoches County currently has over 8500 Medicaid participates with 6000 being under the age of nineteen. Swanson & Shyrock, 2004). The need for the children Medicaid simplification has been the major obstacle to the registering in Texas. The issues were spoken out by the Act (SB 43) of the Children’s Medicaid Simplification and were signed into law by the Legislature in Texas in May 2001. The SB 43 recognized different reforms which included doing away with face to face interviews for both submission and re-certification (Eldridge, 2002). Although dental benefits are available for children enrolled in Medicaid, few receive them. The State Medicaid programs are plagued by low rates of participation among dentists. This shows that enrolment in Medicaid does not ensure access to services. The states have reported that fewer than half of states’ dentists saw at least one Medicaid patient in a one-year period. The Kaiser Family Foundation 2000, reports that less than 25% of the dentists in the states saw at least one hundred Medicaid patients over a period of one year. There is a population of about 62,436 in Nacogdoches, with 24.2% being persons under the age of 18 years according to the 2007 Census Bureau statistics collected in Nacogdoches County (U. S. Census Bureau, 2009). The total medical costs paid in Texas for the dental services by Medicaid for children between the age of 1 and 20 years was $104,037,527. The total amount of money that was spent on dental treatment services cost $78,022,179 while on the other hand the prevention services cost $26,015,077. This when calculated gave an average treatment cost of $24.00 per child across the entire state (U.S. Census Bureau, 2008) Texas has the highest rate of uninsured children, it is estimated that 1 out of 4 children in Texas are uninsured. At the same time, many of them that do not have access to dental care services. Dental health services and other services were partially restored in the 2005 Texas Legislation alongside the CHIP program benefits. Premiums for CHIP programs were also reduced but, enrollment of children in Medicaid and CHIP programs were still low This was because the poorly trained staff that was hired used to make serious processing errors which caused eligible children to be erroneously cut from the coverage as a result of a miscalculation of their incomes. Other children had their paperwork lost for which reason; many applications were not finished in time. This had the results of children being delayed from getting their medical coverage. The medical coverage of some children was rejected, making it impossible for them to get coverage for their dental care (Best, 2007). Many families in Nacogdoches and the entire State of Texas depend on the overall health coverage since it helps them save their money in medical expenses. Children should be given Medicaid to help them become productive workers and citizens. Since Texas law requires parents to renew their children’s health coverage twice a year instead of once, Children’s Medicaid coverage has been less effective and more expensive. The application process is time consuming, causing many children to spend several months uninsured (Fenz, 2000). Many children have suffered and still continue to suffer as a result of being denied CHIP and Medicaid coverage in Texas. Children have died while other families have struggled in putting food on the table after losing their health insurance. Some parents take their children across the borders for treatment having lost their cover, which allowed them to go for regular checkups and follow ups. The perception of many people is that denying or delaying medical coverage is a matter of life and death for the children in Texas. This makes parents have to compromise a lot for their children. They do so thinking they have failed yet they are unable to do anything (Texas Association of Community Health Centers, 2002). Dental decay is the one of the most prevalent chronic disease of childhood. Roughly half of U. S. children experience dental caries by age nine and the proportion rises to about 80 percent by age 18. Tooth decay has been found to have a close correlation to poverty. Preschoolers in households with incomes less than 100% of the federal poverty level (FPL) are three to five times more likely to have cavities than children from families with incomes equal to or above 300 percent of the FPL. The GOA (General Accounting Office) reports that 80% of tooth decay is found in just 25% percent of children of which the majority are from poor families (Dunkelberg, 2002). Access to dental care has been found to be very important. The American academy of Pediatric Dentistry recommended that dental check-ups should be done at least twice a year for children. Children with increased risk of tooth decay, unusual growth patterns or poor oral hygiene are advised to be taken to dentists quite often as to help them stay cavity-free. Teeth cleanings was found to remove debris that builds up on the teeth that irritate the gums and cause decay (Blaisi, 2002). Fluoride treatments renew the fluoride content in the enamel, strengthening teeth and preventing cavities while hygiene instructions improve a child’s brushing and flossing, which leads to cleaner teeth and healthier gums. According to the Kaiser Commission 2000, these basic dental services are the most prevalent unmet health need among children, regardless of insurance status. In Texas, there are many reasons which are compelling as to why the undocumented immigrants should be served (Fenz, 2000). The consequences of untreated dental problems can be life threatening. Diamonte Driver was a twelve-year-old boy who resided in Prince Georges County, Maryland. Diamonte died because his mother did not have the means to pay for an eighty-dollar tooth extraction. The infection from his abscessed tooth spread to his brain, resulting to his death. His life could have been saved had he had access to regular dental care. The health Care System spent more than 250,000 before his death. A survey conducted by the national Survey of Children’s Health showed that only 58% of children in poor families received the recommended preventive care as opposed to 82% of children from rich families (Best, 2007). 4. Why Dentists do not accept Medicaid The shortage of dentists is not the only reason why children and low-income patients have trouble finding providers. The State of Texas has an adequate supply of dentists although an insufficient number is concerned with attending to Medicaid problems. (Kaiser Family Foundation, 2000). One of the primary reason dentists do not participate in state Medicaid programs is low rates of Medicaid reimbursement.  High dental practice overhead costs such as facility, equipment, personnel and administration make up 65-70 percent of the earnings of a dentist. It was discovered in the General Accounting Office that most state Medicaid programs reimburse significantly less than a dentists’ normal Typically, Medicaid reimbursement rates do not cover the actual cost of providing services. This makes dentists lose money on each Medicaid patient they see. The more Medicaid patient’s dentists treat, the more difficult it is to operate their practices (Cuardro & Scanlon, 2008). The other reason for low dentist participation is the administrative complexity associated with being a Medicaid provider.  There is a big difference in administrative requirements between the commercial health insurers and the Medicaid programs which demands for additional time and attention from dentists and their staff.  The requirements include state-specific claim forms, prior authorization requirements and cumbersome eligibility verification. This makes the dentists feel overworked by the complex Medicaid claims process, arbitrary denials, slow payment, as well as prior authorization requirements for routine services among others (Curare & Scanlon, 2008). 5. Develop Incentive for dentists to accept Medicaid The state should offer incentives to dentists who accept Medicaid or offer a sliding fee scale to their patients. Several states offer Loan Repayment or Loan Forgiveness Programs to dentists. These programs vary by state and are characterized by many different stipulations. Most states have programs that are limited to a certain number of participants each year. For instance, Louisiana has three types of incentives on offer all at once Louisiana offers higher reimbursement rates for a certain period of time, tax credits, as well as loan forgiveness programs. Connecticut offers a reduced licensing fee to retired dentists who practice in a public health facility. There are many methods that states have utilized to attract dentist to treat those that deserve medical attention. Using a new incentive program could be the key in Texas for getting dental care to the poor population deserving dental care. (Cuardro & Scanlon, 2008). 6. Increase reimbursement rate of Medicaid In context to increased reimbursement rates, there is the need for Medicaid to place a reimbursement rate of about 50% to 60% more than current rates. Dental expenditures were found to account for 25-27% of a child’s health care while Medicaid spending for dental services was only 2.3 % (Cuardro & Scanlon, 2008). Table -1 show the reimbursement rates for fifteen dental services through Medicaid. The table shows the amount of fees charged by a dentist in the 50th and 75th percentile in the state of Texas. Table – 1 Texas Medicaid Payment Rates Procedure description TX Medicaid payment Rate $ TX State 50th Percentile $ TX state 75th Percentile $ Diagnostic Periodic oral Exam 14.72 28 32 Comprehensive Oral Exam 18.02 40 49 Complete X-rays, with bite wings 36.04 65 81 Bitewing X-rays- 2 films 11.93 25 29 Panoramic X-rays film 32.54 65 75 Prevention Prophylaxis (cleaning) 18.75 42 47 Tropical fluoride (excluding cleaning) 7.5 19 22 Dental sealant 18.55 35 39 Restorative Amalgam, 2 surfaces, Permanent Tooth 43.73 91 107.50 Resin Composite, 2 Surfaces, Anterior tooth 52.57 119 135 Crown, porcelain fused to base Metal 264 660 725 Prefabricated steel crown, primary tooth 78.03 146. 175 Endodontics Removal of Tooth pulp 43.93 95 118 Anterior Endodontic therapy 177.99 426 509 Oral surgery Extraction, Single Tooth 33.52 79 92 (Texas Association of Community Health Centers, 2002). Several states have engaged in a variety of efforts to increase provider participation and use of dental services, concentrating mostly on reimbursement rates. A survey conducted by the National Conference of State Legislatures (NCSL) in 2000 found that 23 states had increased Medicaid reimbursement rates for dental services. Five states - Alabama, Delaware, Georgia, Michigan and South Carolina have increased their Medicaid dental reimbursement rates to a level that is 70 percent to 85 percent of dentist’s usual fees (Cuardro & Scanlon, 2008). Higher rates of reimbursement in the three states Alabama, Ohio and Michigan have generated a considerable amount of attention. They have seen an increase in dentist participation and access to care when these states significantly increased their reimbursement rates. In 2000 Alabama increased Medicaid dental reimbursement rates to 100 percent of usual cost.  As a result of these efforts, provider participation increased from 23.6 percent of dentists in 1999 to 30.6 percent in 2002. At the same time, the proportion of participating dentists who were serving a significant number of Medicaid-eligible children increased by 39 percent.  In addition, the number of Medicaid-insured children using dental services increased by 58 percent (Cuardro & Scanlon, 2008). In Ohio, increasing dental reimbursement rates to 75 percent of UCR fees in the state increased provider outreach from 30 percent in 1999 to 32 percent in 2000. However, the proportion of participating dentists who were serving a significant number of Medicaid-eligible children remained constant. This increased the number of Medicaid-insured children using dental services by 11 percent. On the other hand, in Michigan, they enrolled Medicaid-eligible children in a private insurance plan that offered reimbursement rates identical to commercial rates. After only one year, the number of children who were receiving treatment in the program increased by 35.2 percent (Cuardro & Scanlon, 2008). 7. Educate Parents about keeping appointment and the importance of dental care The education of parents on the importance of dental care and keeping dental appointments is very vital. A survey of Texas dentists in 1993 showed that 83% of Medicaid-providers would be able to see more Medicaid patients, if they had less broken appointments. The results of a study at Virginia Commonwealth University showed that out of 1609 Medicaid patients, 247 (15.4%) missed their appointment compared to 367(8.3%) of 4438 non-Medicaid patients. Data from the study indicated that although Medicaid patients accounted for only 26.6% of all appointments, they were responsible for about 40% of all appointment failures with a failure rate of 15.4 % (Cuardro & Scanlon, 2008). 8. Criteria Selection Many other solutions for the problem of poor children on Medicaid not receiving proper dental treatment can be devised. What needs to be stated is that many of the solutions require action from the State Legislation, because each state is responsible for their own policies and procedures regarding Medicaid. The above alternatives could be implemented in several ways to solve the problem children from economically backward families left bereft of the needed dental services (Texas Association of Community Health Centers, 2002). 9. Alternative I: Develop Incentive for dentists to accept Medicaid In Nacogdoches, Texas, there are 16 dentists and of them only 3 accept Medicaid. Therefore, the dentists who accept Medicaid or offer a sliding fee scale to their patients need to be offered incentives. There are several states that offer dentist incentives like Loan Repayment or Loan Forgiveness Programs to dentist (Texas Association of Community Health Centers, 2002). These incentive programs vary by state for example. For instance, Nebraska and Ohio have implemented similar incentives programs that offer repayment programs to graduating students in dentistry. In Nebraska a dentist student can receive up to $20,000 for three years with a maximum of $60,000 for practicing in a dental care service shortage area. Ohio’s incentive program was created through state legislation which offers new graduates $20,000 a year to practice in HPSA (Health Professional Shortage Areas) and provide dental services to Medicaid recipients (Cuardro & Scanlon, 2008). 10. Alternative II: Increase the reimbursement rates of Medicaid The implementation of this alternative calls for Medicaid having to increase reimbursement rates by about 50% to 60%. A Dentist in Nacogdoches, Texas should be allowed to increase their reimbursement rate by providing Medicaid services as a High-Volume Dentist who receives payments of 3.7%. To be considered as High-Volume they would have to perform at least 300 Medicaid services a month with a minimum of 3600 services a year (Texas Association of Community Health Centers, 2002). 11. Alternative III: Educate Parents about the importance of dental care Through the implementation of this alternative the parents would be educated on the importance of dental care and keeping dental appointments on behalf of their children. Many parents that are on Medicaid do not understand the importance of a child seeing a dentist on a regular basis (Cuardro & Scanlon, 2008). Parents would also be educated on the benefits that are offered through Medicaid. Many parents wrongly believe that Medicaid should be used only for emergencies. Recipients of Medicaid would also be educated on the financial losses associated with missed appointments. GETCAP Head Start which is a local Social Services Agency which is funded through The Department of Health and Human Services. Head Start educates parents on the importance of regular dental care. Each child enrolled in Head Start is expected to receive a dental exam every six months. Many of the children enrolled at Head Start have never been to a dentist prior to enrollment. Head Start acts as a partner with a dentist willing to accept Medicaid. Through the education of parents, Head Start has been able to work with dentists willing to accept Medicaid in Nacogdoches County and provide dental homes to these children. Over 95% of children enrolled in Head Start receive dental treatment on a regular basis. 12. Projected Outcomes Evaluation of all the three alternatives shows that each would require approval and participation from dentists who do not accept Medicaid. Increasing reimbursement rates would be the most logical and efficient solution, though the most expensive. Implementing an incentive program would require a lot of planning and would not attract as many dentists as increasing the reimbursement rate. Implementing an educational program for parents would cost about the same as the incentive program and would require the state to do a lot of planning. All the three alternatives would require the cooperation from participants. Since cooperation and participation will be required from participants, developing educational program appears to be the most suitable of the three alternatives (Texas Association of Community Health Centers, 2002). Increasing reimbursement rates and developing an incentive program would encourage more dentists to participate in the Medicaid program, but they would not remain providers, if there is continuous rate of missed appointments. Two dentists surveyed in Nacogdoches reported that missed appointments are the main reason that they stopped accepting Medicaid. Five dentists in Nacogdoches County ranked missed appointments as the second most important reason that they do not accept Medicaid (Texas Association of Community Health Centers, 2002). It would be safe to say that more dentists would participate in the Medicaid program if there were not so many missed appointments. Requiring Medicaid participants to attend educational classes on the importance of getting their children regular dental care would cut down on missed appointments, which would increase the number of dentist that accept Medicaid (Best, 2007). 13. Comparison Pros Increase in the reimbursement rates will attract more dentists to accept Medicaid. Educating of the parents would ensure that more children now access regular dental services (Best, 2007). Cons Increasing reimbursement rate though attractive is the most expensive alternative to implement. The giving of the incentives is an involved process, since it requires a lot of planning. It is however, not capable of attracting many dentists. The education of the parents is costly, since it involves a lot of planning and implementation of programs (Best, 2007). 14. Deciding the Best Alternative Successful efforts have been made in raising Medicaid dental reimbursement rates to reasonable market-based levels. Low reimbursement to dentists for their services has been found by private and governmental reports to be the greatest barrier to the dentists’ participation in Medicaid (Crall, 2008). The table below provides details on success and failures of other states when they increased reimbursement rates. Table – 2 Impact of the efforts by some states to establish market-based Medicaid reimbursement rates State Adjustment to Medicaid Rates (market benchmarks) Changes in Dentists Medicaid Participation Intervals After Rate Increases (months) Alabama 100% of Blue Cross Rates +39% +117% 24 44 Delaware 85% of each dentists submitted charges 1 private dentist to 130 (of 378 licensed dentists) 48 Georgia 75th percentile of dentists’ fees +546% +825% 27 48 Michigan 100% of Delta Dental +300% 12 Indiana 75th percentile +58% 54 Tennessee 75th percentile +81% 20 (Texas Association of Community Health Centers, 2002). At the same time, educating the parents can solve the problem of children in Nacogdoches County or the U.S. not receiving regular dental treatment. It is extremely important that children receive dental care on a regular basis while their parents understand the importance of regular dental treatment. Educating parents who receive Medicaid about regular dental treatment is the only option of ensuring that treatment is received. Reimbursement rates can be increased and incentive program can be developed. However, if parents do not bring the children for appointments, children would still not receive the treatment that is needed. Nacogdoches County and the State of Texas must implement an educational program for Medicaid recipients (Texas Association of Community Health Centers, 2002). The creation of Medicaid was to ensure a solution to the problem of poor people having inadequate health and dental care. Yet it has become a part of the problem. Currently there are only three dental offices in Nacogdoches County which accept Medicaid. Table 3 gives a representation of dental visits over a six-year period of time by Medicaid participants. Over a six year period of time less than 50% of the Medicaid enrollees under age 19 had a dental visit during the year (Eldridge, 2002; Lyndon, 2001). Table – 3 Enrolled children under age of 21 Making Medicaid Dental Visits Year 1998 1999 2000 2001 2002 2003 Number with any type of Dental visit 569,090 644,208 646,083 655,785 761,276 1,001,841 Number Enrolled 1,797,586 1,769,886 1,738,991 1,816,774 2,098,812 2,433,809 (Lyndon, 2001). 15. Conclusion It is evident that many children suffer from dental health problems and require dental services, but do not get them under Medicaid or CHIP programs, thus leaving children from economically backward families bereft of essential dental services. Such a situation has arisen on one side from the unwillingness of dentists to participate in Medicaid programs and on the other side the lack of knowledge among parents on the dental problems of children, the consequences on the health of the children and the benefits that accrue by participating in Medicaid and CHIP programs. Medicaid was founded on the basis of removing inequality in the availability of health services across all sections of the population. For this need to be met among children in the age group between one and twenty in Nacogdoches, Texas, then steps have to be taken to remove the hindrances to better access to Medicaid and CHIPS in Nacogdoches, Texas. Low reimbursement rates make dentists shy of participating in Medicaid and the poor knowledge among parents of dental health needs of children and the benefits that Medicaid can provide in meeting the requirement of dental health among are the two main stumbling blocks in the access to Medicaid and CHIP programs for children in Nacogdoches, Texas. Removing these hurdles through the increase in reimbursement rates for dental services to dentists, combined with educating parents on the dental health requirements for children and the manner in which Medicaid can contribute to this has become essential in Nacogdoches, Texas. However these measures can become a reality only if the administrative authorities of Nacogdoches, Texas are willing to accept the additional fiscal implications and the effort needed in its implementation. Literary References Best, B. 2007, ‘In Harm’s Way: True Stories of Uninsured Texas Children, Children’s Defense Fund Texas [Online] Available at: http://www.cdftexas.org (Accessed on March 24, 2009). Blaisi, J. 2002, ‘Texas Association of Community Health Centers’, Austin, Texas. USA Inc Crall, J.J. 2008, ‘Necessary reforms to Pediatric Dental care under Medicaid’, [Online] Available at: http://domesticpolicy.oversight.house.gov/ (Accessed on March 24, 2009). Cuardro, R. & Scanlon, A.2008, ‘Forum for State Health Policy Leadership’, [Online} Available at: http://www.ncsl.com/ (Accessed on March 24, 2009). Dunkelberg, A. 2002, ‘Children’s Medicaid Eligibility Simplification Bill, SB 43, sent to the Governor. Austin, Texas’, Center for Public Policy Priorities [Online] Available at: www.cppp.org/subcategory.php?cid=3&scid=6 (Accessed on March 24, 2009). Eldridge , J. 2002, ‘Health Care Access for Immigrants in Texas’, Working Paper from the Policy Research Project on Expanding Health Care Coverage for the Uninsured, The Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, [Online] Available at: http://microlib.cc.utexas.edu/lbj/faculty/warner/uninsured/2002_papers/immigrants.pdf (Accessed on March 24, 2009). Fenz, C. M. 2000, ‘The Access Project. Providing Health Care to the Uninsured in Texas’ [Online] Available at: http://www.accessproject.org/downloads/TEXAS.pdf (Accessed on March 24, 2009). Garret, T. R. 2008, ‘Texas Medicaid Deal boost’, [Online] Available at: http://www.dallasnews.com/ (Accessed on March 24, 2009). Kaiser Family Foundation. 2000, State Health Facts Online, [Online] Available at: http://www.statehealthfacts.kff.org (Accessed on March 24, 2009). Lyndon B. 2001, Expanding Health Care Coverage for the Uninsured in Texas. Policy Research Project Series, no. 141, Austin, Texas. Ross, D. C. & Cox, L. 2000, ‘Making It Simple: Medicaid for Children and CHIP Income Eligibility Guidelines and Enrollment Procedures’, The Kaiser Commission on the Medicaid and the Uninsured [Online} Available at: http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13443 (Accessed on March 24, 2009). Siegel, S. J, Swanson, D. & Shryock, H. S. 2004, The methods and materials of demography. West Yorkshire, England: Emerald Publishing Group. Texas Association of Community Health Centers. 2002, ‘Project Alberto/Covering Kids Initiative’ [Online] Available at: http://www.tachc.org/o_pa_main.htm (Accessed on March 24, 2009). U. S. Census Bureau. 2009, ‘Nacogdoches County, Texas’, [Online] Available at: http://quickfacts.census.gov/qfd/states/48/48347.html (Accessed on March 24, 2009). U.S. Census Bureau. 2008, ‘Health Insurance Coverage Status and Type of Coverage by State--All Persons: 1987 to 2007’, Historical Health Insurance Tables, [Online] Available at: http://www.census.gov/hhes/www/hlthins/historic/index.html (Accessed on March 24, 2009). Read More