Texas is a vast state, with regional differences in geography, population size, and demographic and socioeconomic characteristics. This section provides an overview of these variations and the existing challenges related to health care availability and access, as well as cultural literacy and effectiveness in meeting the health needs of Texas mothers, children, and their families.

 

Geography

Texas is the second largest state in the United States (behind Alaska) in terms of land. The Lone Star State encompasses approximately 262,000 square miles, and accounts for 7.4% of the total U.S. land area. The land area of Texas is equal to the land area of all six New England states and Ohio, New York, Pennsylvania, and North Carolina combined. Texas has a larger land area than any single country completely contained in Europe including France and the Ukraine. The longest straight-line distance in Texas is 801 miles from the northwest corner of the Panhandle to the extreme southern tip of Texas on the Rio Grande below Brownsville. With the large north-south expanse of Texas, Dalhart, in the northwestern corner of the state, is closer to the state capitals of Kansas (430 miles), Colorado (310 miles), New Mexico (200 miles), Oklahoma (275 miles), and Wyoming (390 miles) than it is to Austin (470 miles), its own state capital. The greatest east-west distance is 773 miles from the extreme east-ward bend in the Sabine River in Newton County to the extreme western bulge of the Rio Grande just above El Paso. This east-west expanse is so large that El Paso, in the western corner of the state, is closer to San Diego, California (630 miles) than to Beaumont (740 miles), near the Louisiana state line; Beaumont, in turn, is closer to Jacksonville, Florida (680 miles) than it is to El Paso.

 

The geography of Texas is as varied as it is large. Texas includes 254 counties that are classified as either rural or urban (Figure 3.1), with 88.7% of the population residing in urban counties. The five largest metropolitan areas in Texas are located around the cities of Houston, San Antonio, Dallas, Austin, and Fort Worth, and these areas encompass multiple counties. Given the immense size of Texas, the distance that some individuals, especially those living in rural counties, must travel to receive health care services can be a significant challenge to accessing and receiving those services.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Population

Just as the Texas geography is varied, so is the distribution of its population (Figure 3.2). Differences in race/ethnic composition, along with the high percentage of foreign-born residents, present particular cultural literacy and effectiveness challenges when it comes to meeting maternal and child health needs.

 

Figure 3.2

 

 

Texas also has the second-largest state population in the U.S. (behind California), with an estimated population of over 27 million in 2017. Texas has been one of the fastest-growing states in the nation since 2010, according to U.S. Census annual estimates. There has been an 12.6% increase in the Texas population from 2010 to 2017. The Texas Demographic Center predicts that by 2050, the population in Texas will exceed 47 million people. The majority of Texans live in the northeast, east, central, south, and gulf coast regions of the state (Figure 3.2).

 

Race/Ethnicity

Counties with the highest proportions of Hispanic populations are primarily located in the southern and western regions of Texas, along the Texas-Mexico border. In 2017, six major cities in Texas were located in counties where over 50% of the population were Hispanic: San Antonio, Corpus Christi, Brownsville, Laredo, El Paso, and Odessa (Figure 3.3).

 

Figure 3.3

 

Regional concentrations of the Black population in Texas (Figure 3.4) were quite different from that of the Hispanic population. Counties with the highest proportions of Black populations in 2017 were largely concentrated in the northeastern, eastern, and north gulf-coast regions of the state. The Black population along the Texas-Mexico border was estimated to be slightly above 30,000 in 2017.

 

 

 

Figure 3.4

 

Foreign-Born

Texas had a higher percentage of foreign-born residents (16.9%) compared to the nationwide average (13.4%) in 2013-2017. More than 63% of foreign-born residents in Texas were not United States citizens. Just over 69.0% of foreign-born Texas residents were born in Latin American countries – 17.8 percentage points more than the national average. Therefore, it is not surprising that 35% of Texans spoke a language other than English at home in 2013-2017. Almost 30% of Texans spoke Spanish at home, compared with 13.2% of U.S. residents. Texas border counties had high percentages of foreign-born residents in 2012-2016, as did several other counties in west and northwest Texas (Figure 3.5). Counties containing the non-border cities of Houston, Dallas, and Austin also had high concentrations of foreign-born residents. Given these demographic and social variations, the DSHS Community Health Worker (CHW) program has increased the number of certified CHWs to address the need for cultural literacy and effectiveness.

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3.5

 

 

Age

According to 2013-2017 American Community Survey data, Texas has the third youngest population in the United States, with a median age of 34.3 years, behind Alaska (median age 33.5 years) and Utah (median age 30.3 years).

 

In 2017, Texas had the second-largest proportion of the population being children younger than 18 years old (26.3%) in the nation. About 7.2% of the Texas population were younger than 5 years old, 14.7% were 5 to 14 years old, and 4.3% were 15 to 17 years old. Texans younger than 22 years of age accounted for 30.6% of the total population in 2017.  Border counties in South Texas had high percentages of individuals younger than 22 years old, as did several counties in the Texas Panhandle (Figure 3.6).

 

Women comprised half of the total population in Texas in 2017. However, women between 18 and 44 years of age accounted for about 18% of the total population (Figure 3.7). For the most part, urban counties with large metropolitan areas (including counties containing the cities of Dallas-Fort Worth, Houston, San Antonio, Austin, and El Paso) had the highest proportions of women in their childbearing years.

 

 

 

Figure 3.6

 

Figure 3.7

 

In addition, the 2016-2017 National Survey of Children’s Health (NSCH) estimated that 16.5% of Texas children ages 0-17 had a special health care need. Of those children identified as Children with Special Health Care Needs (CSHCN) within Texas, 37.1% were Hispanic and 22.2% were Black.

 

Socioeconomic Characteristics

Socioeconomic characteristics such as income and poverty, education, unemployment, and crime are added challenges for meeting the health needs of mothers, children, and families in Texas. The presence of adverse socioeconomic factors (such as low income/poverty, low educational attainment, high unemployment, and high crime rates) in a community are important risks for the life course of the individuals within that community.

 

Income and Poverty

Income inequalities exist within different areas in Texas and largely reflect gender and race/ethnic differences. In 2013-2017, the median household income in Texas was $57,051, which was slightly lower than the national median household income of $57,652.

 

To determine who lives in poverty, the U.S. Census Bureau uses a set of income thresholds that vary by family size and composition. If a family’s total income is less than their determined income threshold, then that family and every individual in it is considered to be in poverty. These poverty thresholds are used throughout the mainland U.S. and do not vary geographically; however, they are updated each year to account for inflation.

 

According to 2013-2017 U.S. Census Bureau American Community Survey five-year estimates, Texas as a whole had a higher proportion (16.0%) of people living below the Federal Poverty Level (FPL) than the national average of 14.6%.

 

Among the adult population aged 18 and older in Texas, counties with a large proportion of adults living below the FPL in 2013-2017 were concentrated in the Texas-Mexico border region. Several counties in east Texas, north central Texas, and the Texas Panhandle also had high rates of adults living below 200 percent FPL (Figure 3.8).

 

Figure 3.8

 

It was estimated that about 17.5% of the adult female population lived below the FPL in Texas in 2013-2017. Counties in the Texas-Mexico border region had high rates of women living below the FPL, as did several counties in rural East Texas, west of Fort Worth, and between Lubbock and Amarillo in the Panhandle (Figure 3.9). The fastest growing major metropolitan areas – Austin, Houston, and San Antonio – had a relatively low proportion of women living below the FPL.

 

Figure 3.9

 

 

Poverty, lack of health care coverage, and limited access to providers are root causes of many health disparities in Texas. In 2012-2016, Texas had a greater proportion of children younger than 5 years of age living in poverty (below 100 percent FPL) than the nation as a whole (24.8%) (Figure 3.10). The highest poverty rates among young children were seen in the rural areas of Texas, as well as those counties around the cities of Brownsville, Laredo, Amarillo, and Tyler.  Also, 22.6% of children younger than 18 years of age lived below 100 percent FPL in Texas, compared to 20.0% in the nation (Figure 3.11). Many of the counties with the highest poverty rates for this age group were located in south Texas, east Texas, and the Panhandle.

 

 

 

 

Figure 3.10

 

Figure 3.11

 

 

Education

Lower educational attainment is associated with poverty, and is consequently related to poor health outcomes. Among those 25 years and older, a greater percentage of both men (17.7%) and women (13.7%) in Texas had less than a high school education in 2013-2017, compared with men (15.3%) and women (11.4%) nationwide. Over 30 percent of Texas residents aged 25 and older had a high school diploma or equivalent as their highest level of educational attainment, and 8.4% had a bachelor’s degree or higher.

 

Educational attainment levels are not evenly distributed throughout the state. There were four counties where the educational attainment of a bachelor’s degree or higher was 40%-50% among individuals 25 years of age and older: Denton and Collin counties outside of Dallas, Fort Bend county outside of Houston, and Travis county in central Texas (part of the Austin-Round Rock metropolitan statistical area). Counties where less than 10% of the people aged 25 years and older had a bachelor’s degree or higher were largely clustered in south Texas, west Texas, and east Texas.

 

Unemployment

While Texas had a higher percentage of adults without a high school diploma compared to the nation as a whole, it had a lower rate of unemployment (3.7%) than was seen nationwide (4.1%) in 2013-2017. Even among persons aged 25-64 without a high school diploma, Texas had a lower rate of unemployment (6.6%) compared to the national average for this educational attainment group (10.0%). As was seen nationwide, the Texas unemployment rate decreased as education level increased. The unemployment rate in Texas was as low as 2.9% among those with a bachelor’s degree or higher in 2013-2017.

 

Crime

Crime impacts the physical and behavioral health and wellbeing of mothers, children, and their families. Neighborhood crime can be detrimental to the safety of children, creating unstable living environments. By assessing communities where crimes occur, it is possible to identify areas at high risk and help prevent adverse consequences. In 2017, Texas’ index crime rate was 2,991.68 crimes per 100,000 persons.

 

Texas index crime statistics include two major categories of crime: property crimes and violent crimes. Property crimes consist of burglary, larceny-theft, and motor vehicle theft. The 2017 property crime rate was 2,553.95 crimes per 100,000 Texans. The highest property crime rates in 2017 were primarily localized within and surrounding the larger cities of Texas (Figure 3.12).

 

 

 

Figure 3.12

 

 

Violent crimes included in the uniform crime report index crimes include murder, rape, robbery, and aggravated assault. The violent crime rate was 437.74 crimes per 100,000 Texans. The highest violent crime rates in 2016 were primarily concentrated near the larger cities of the panhandle: Odessa, Lubbock, and Amarillo (Figure 3.13). Houston, Dallas, San Antonio, Corpus Christi and surrounding areas also had a high concentration of violent crimes.

 

Figure 3.13

 

Violence within Texas families has also been recognized as a growing threat to the safety of Texans. The Uniform Crime Report indicated 195,315 family violence incidents in Texas in 2017. Although the largest percentage of family violence was between other family members (45.3%), family violence also occurred among spouses/couples (38.7%) and within parent-child relationships (16.0%). Females were more likely to be victims in family violence. Of the victims whose gender was known, 28.4% were male and 71.6% were female. The 25-29 age group had the highest number of victims in family violence.

 

Mobility/Migration

Moving or relocating is one of life’s most stressful events, and can impact individual health and well-being. The Texas School Survey of Substance Use shows that students in grades 7 to 12 living in their current school district for three years or less are more likely to use illicit drugs than those living there more than three years.

 

Out-of-State Mobility/Migration

Four Texas metropolitan areas (Houston, Dallas, Austin, and San Antonio) together added more people than any state in the country (except for Texas as a whole) between 2016 and 2017. The population in these four metropolitan areas increased by more than 350,000 people in a year.

 

Among these four fastest-growing areas in Texas, about 2% to 3% of the population consists of people who moved to the area from out of state (out-of-state migration). Some rural counties also had high levels of out-of-state migration in 2013-2017, particularly in the parts of the state bordering Oklahoma and the Panhandle, as well as in west Texas (Figure 3.14). The majority of Texas counties, however, had little to no new residents from other states.

Figure 3.14

 

The oil and gas industry is concentrated in three areas of the state (Figure 3.15). A few counties with a large number of approved oil or gas wells in 2016-2017 also had high out-of-state migration. The jobs created from the oil and gas industry may be contributing to the migration of people into these areas.

 

Figure 3.15

 

In-State Mobility/Migration

Another aspect of mobility is the number of people who move within or between counties in Texas. While out-of-state migration may reflect job growth, mobility of populations within a county and between counties is more complicated.

 

Counties with universities and colleges in Texas had among the highest rates of within-county relocations over a one-year period. College Station, Austin, Lubbock, and San Antonio are home to four of the ten largest universities in Texas, which can partially explain the high rates of within-county relocations in these areas. College students tend to move often within the same county to take advantage of lower rents.

 

Within-county mobility in Texas may also be associated with poverty and household type. Within-county mobility over a one-year period is positively correlated with a poverty rate below 100 percent FPL (r=0.30), such that census tracts with higher rates of poverty tend to also be census tracts with higher within-county mobility. Similarly, census tracts with higher rates of female-headed households tend to be census tracts with higher within-county mobility (r=0.19).  Between-county mobility, however, is negatively correlated with the rate of female headship. Census tracts with higher rates of female-headed households tend to have lower between-county mobility (r=-0.21).

 

Health Care Coverage and Access

Health insurance and access to health care are fundamental to the health of Texans. A major finding that emerged from the Title V stakeholder meetings was that limited access to health care is a widespread concern. For CSHCN, lack of financial support or no health insurance was a top reason parents said they could not receive care for their children.

 

For administrative purposes, each of the 254 Texas counties is assigned to one of 8 public health regions (Figure 3.16). Public Health Region 1 (PHR 1) is administered from a regional office in Lubbock. Public Health Region 2/3 (PHR 2/3) is administered from a regional office in Arlington. Public Health Region 4/5 North (PHR 4/5N) is administered from a regional office in Tyler and Public Health Region 6/5 South (PHR 6/5S) is administered from a regional office in Houston. Public Health Region 7 (PHR 7) is administered from a regional office in Temple. Public Health Region 8 (PHR 8) is administered from an office in San Antonio, Public Health Region 9/10 (PHR 9/10) is administered from an office in El Paso, and Public Health Region 11 (PHR 11) is administered from an office in Harlingen.

 

Figure 3.16

 

 

 

Health Insurance

Texas led the nation in the proportion of the population without health care coverage in 2013-2017, with 18.2% uninsured. The national average was 10.5%. Texas also had higher proportions of uninsured children, uninsured women of childbearing age, and uninsured individuals living below 200 percent FPL than the corresponding uninsured percentages for these groups nationwide. In Texas, 7.9% of children younger than 6 years old were uninsured, and 27.3% of Texas women aged 19 to 44 were uninsured. Furthermore, 31.4% of Texans living below 100 percent FPL were uninsured. In addition, 2016 NSCH data showed that 13.4% of CSHCN ages 0-17 in Texas had no health insurance or had periods of no coverage during the year prior to the survey, compared to 6.7% nationally.

 

Counties with high proportions of uninsured children younger than 6 years of age were concentrated in west Texas between Odessa and San Antonio, and in the Panhandle (Figure 3.17). The Texas-Mexico border regions and several counties outside Lubbock and Waco had high proportions of women aged 19 to 44 without health insurance (Figure 3.18).

 

Figure 3.17

 

Figure 3.18

 

 

Access to Health Care

Given the size of the state and the vast distances between points of care for health services in rural areas, access to care in Texas can be a challenge. There were 21,746 primary care physicians (74.1 per 100,000 population) in Texas in 2018, which was an increase from 18,834 primary care physicians (70.6 per 100,000 population) in 2013. Thirty-four counties still had no primary care physicians in 2018 (Figure 3.19).

 

Figure 3.19

 

The total number of obstetricians (OB) and/or gynecologists (GYN) increased from 2,483 in 2013 to 2,640 in 2017. However, the density of OB/GYNs in Texas decreased from 18.5 OB/GYNs per 100,000 females in 2013 to 18.2 per 100,000 females in 2017. A total of 151 counties had no OB/GYN in 2017 and 53 counties did not have a local dentist.

 

The Health Professional Shortage Area (HPSA) designation employs a ratio of population to primary care physicians to determine whether or not an area has a shortage of physicians. The ratio threshold is 3,500:1 and is reduced to 3,000:1 in areas with high needs, such as at least 20% of population below poverty level or more than 20 infant deaths per 1,000 live births. Areas that exceed these ratios may qualify for designation as HPSAs. Other factors, such as time/distance to nearest source of care and population composition, are also included in the federal HPSA criteria. Recruiting and retaining health care professionals is an ongoing challenge not only in rural areas, but in some urban areas as well. In rural areas, retention of health care professionals is mostly due to population size, but in some urban areas, access is limited because many providers do not accept Medicaid or patients are not enrolled in Medicaid and unable to pay out-of-pocket. Most counties in Texas are designated as either a whole-county or partial-county HPSA (Figure 3.20).

 

Figure 3.20

 

 

Parents who responded to the Title V Community Outreach Survey indicated that finding a mental or behavioral health professional was very or extremely difficult, especially finding those that treat children. The National Association for School Psychologists recommends a student-to-provider ratio of 1,000:1. County-level data for specific student enrollment are not available, but based on the overall population aged 6-18 in Texas counties, the only two counties with a large child population meeting this ratio are those in which Austin and San Antonio are located (Figure 3.21).

 

 

Figure 3.21

 

 

Psychiatrist shortage is also a concern. The HPSA cut-offs for designating an area with a mental health shortage is 30,000 population to 1 psychiatrist, and 20,000 population to 1 psychiatrist in areas with high needs. Some studies suggest that a ratio of more than 4,000 population to 1 psychiatrist likely adversely impacts the availability of mental health care; as of September 2017, only three counties in Texas had a ratio below this 4,000:1 threshold (Figure 3.22). Several counties surrounding major cities, however, met one of the two HPSA cut-offs.

 

Figure 3.22

 

 

Additional challenges exist in identifying psychiatrists who specialize in child psychiatry. It is estimated that there are only about 8,300 practicing child and adolescent psychiatrists in the country. There are almost no child and adolescent psychiatrists in the state practicing outside of major cities in Texas.

 

Emerging Issues

 

Maternal and Child Health Section (MCHS) program staff at both the state and regional levels maintain the placement and expertise to administer both a broad and local approach in addressing current and emerging issues, including Maternal Mortality and Morbidity, infectious disease, and MCH legislation.

 

Texas continues to address Maternal Mortality and Morbidity and survey cases of death and severe morbidity. DSHS was designated as the lead coordinating agency to implement Alliance for Innovation on Maternal Health (AIM) bundles. These bundles are evidence-based toolkits and checklists that birthing hospitals implement to standardize policy and procedures that medical staff use when obstetric emergencies occur. DSHS implements the Obstetric Hemorrhage, Hypertension, and Opioid Use bundles. DSHS uses the Healthy Texas Mothers and Babies Framework, which includes TexasAIM programming, the Texas Maternal Mortality and Morbidity Taskforce, and the Perinatal Quality Collaborative to implement quality improvement measures and increase awareness in Texas.

 

Texas continues to provide assistance and programming to combat infectious diseases. MCHS collaborates with the DSHS Infectious Disease Program to identify existing and emerging opportunities for partnership. MCHS provides subject matter expertise and resources to support infectious disease efforts in Texas.

 

Vaping and Tobacco

 

In September 2019, DSHS issued a Health Alert regarding pulmonary illness and vaping. DSHS continues to investigate severe pulmonary illness among people who have reported vaping, and is working with local health departments, other states, and the Centers for Disease Control and Prevention to better characterize case demographics, clinical characteristics, and exposures. Texas Title V is taking a lead role in addressing the vaping epidemic. Through collaboration with key agency partners including the DSHS Tobacco Prevention and Control Program and the DSHS Environmental Epidemiology and Disease Registries Section, the MCHS is assisting with the development of educational resources and targeted materials. DSHS has updated materials on vaping available on its websites, including a one-pager with information on the vaping epidemic and resources for parents (DSHS home page: https://www.dshs.texas.gov/, tobacco resources: https://www.dshs.texas.gov/tobacco/, vaping resources: https://www.dshs.texas.gov/vaping/).

 

Additionally, Senate Bill 21 took effect on September 1, 2019 and changed the legal age to purchase tobacco products from 18 to 21. Texas Title V is supporting the development of messaging and communications efforts around this legislation. The complete Senate Bill 21 can be found by visiting SB21.

 

Texas 86th Legislative Session

The Texas 86th Legislative Session convened on January 8, 2019, and concluded on May 27, 2019. Of the bills filed during the legislative session, 512 were assigned to DSHS/required analysis from DSHS and 56 impacted MCH. Legislators passed 18 bills that require implementation by DSHS Maternal and Child Health (MCH) programs. 

Important legislation included the creation of a permanent funding mechanism for future newborn screening tests; expanding maternal mortality prevention initiatives; improvements to maternal and newborn health, and the adoption of exceptional item funding that will provide additional funding and staff to help support existing TexasAIM initiatives; a maternal high risk care coordination pilot; and a maternal health education and awareness campaign.

Other legislation recognizes the expertise of the Maternal Mortality and Morbidity Task Force to assist, collaborate and consult with HHSC to address prenatal and postpartum care through Telehealth or Telemedicine, develop family support groups, pilot programs and a workgroup to develop a maternal mortality morbidity registry.  See the attachment summarizing the pertinent bills that passed during the 86th Texas Legislative Session.

List of bills impacting MCH (*= signed into law at time of writing):

HB0025* - Relating to a pilot program for providing services to certain       women and children under the Medicaid medical transportation program.

HB0253 - Relating to a strategic plan to address postpartum depression.

HB0405* - Relating to designating June as Neonatal Abstinence Syndrome Awareness Month.

HB0541* - Relating to the right to express breast milk.

HB0548 - Relating to reporting certain information through the Public Education Information Management System.

HB2255* - Relating to newborn and infant hearing screening results and the provision of information following a screening.

HB3405* - Relating to the establishment of a sickle cell task force.

SB0436* - Relating to statewide initiatives to improve maternal and newborn health for women with opioid use disorder.

SB0559 - Relating to patient records regarding maternal death.

SB0355 - Relating to developing a strategic plan regarding implementation of prevention and early intervention services and community-based care and conducting a study regarding the resources provided to foster parents.

SB0619* - Relating to the sunset review process and certain governmental entities subject to that process.

SB0747* - Relating to the administration of the newborn screening program.

SB0748 - Relating to maternal and newborn health care, including the newborn screening preservation account.

SB0749* - Relating to level of care designations for hospitals that provide neonatal and maternal care.

SB0750* - Relating to maternal and newborn health care and the quality of services provided to women in this state under certain health care programs.

SB1404* - Relating to consent to the disclosure of certain information and to other matters relating to newborn and infant screening tests.

SB2132* - Relating to the provision of information to certain women enrolled in the Healthy Texas Women program.

SB2150 - Relating to the reporting of certain information on maternal mortality to the Department of State Health Services and the confidentiality of that information.