{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T14:45:26Z","timestamp":1792075526477,"version":"4.4.0"},"reference-count":33,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2026,10,3]],"date-time":"2026-10-03T00:00:00Z","timestamp":1790985600000},"content-version":"vor","delay-in-days":2,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000048","name":"American Cancer Society","doi-asserted-by":"publisher","award":["DBG-25-1374401-01-HOPS"],"award-info":[{"award-number":["DBG-25-1374401-01-HOPS"]}],"id":[{"id":"10.13039\/100000048","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Texas Health Resources Clinical Scholar Program"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,5]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Medicaid restrictions exclude some low-income adults, especially in nonexpansion states and among immigrants. Local governments are payers of last resort. Texas offers an important case study: state law requires counties to maintain Indigent Care programs to extend healthcare coverage for uninsured low-income residents, yet no recent report describes their structure.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We cataloged programs in all 254 counties, using publicly available data, contact with county officials, and a state open records request, characterizing reporting, eligibility, and services, along with estimates of uninsured working-age adults in counties with broader eligibility and services, overall and by county metropolitan status.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Required annual reports were unavailable for 144\/254 (57%) counties, and 19\/254 (7%) had eligibility or benefits inconsistent with state law (minimum eligibility of 21% of federal poverty level\u2014FPL; $30 000 of care including prescription and skilled nursing). 39\/254 (15%) set income eligibility \u2265138% FPL, reaching 50% of uninsured adults but only 14% of uninsured adults in nonmetropolitan counties. 5\/254 counties (2%) combined higher income thresholds with broad service availability; all were metropolitan, containing 47% of uninsured adults statewide.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Indigent Care reaches those excluded from Medicaid, but eligibility and services varied widely, and more generous programs were only in metropolitan counties.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/haschl\/qxag267","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T11:51:56Z","timestamp":1790855516000},"source":"Crossref","is-referenced-by-count":0,"title":["County Indigent Care programs fill coverage gaps left by Medicaid restrictions: evidence from Texas"],"prefix":"10.1093","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6516-6819","authenticated-orcid":false,"given":"Arthur S","family":"Hong","sequence":"first","affiliation":[{"name":"Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Peter J. O\u2019Donnell School of Public Health, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Cancer Care Delivery Research Collaborative, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Parkland Health , Dallas, TX 75390 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4705-3460","authenticated-orcid":false,"given":"Grant R J","family":"Paul","sequence":"additional","affiliation":[{"name":"Cancer Care Delivery Research Collaborative, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"University of Texas Southwestern Medical School , Dallas, TX 73590 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederick P","family":"Cerise","sequence":"additional","affiliation":[{"name":"Parkland Health , Dallas, TX 75390 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-0001-527X","authenticated-orcid":false,"given":"Abram O","family":"Gordon","sequence":"additional","affiliation":[{"name":"Network Sciences, Inc. , Austin, TX 78759 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7786-8786","authenticated-orcid":false,"given":"Navid","family":"Sadeghi","sequence":"additional","affiliation":[{"name":"Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Cancer Care Delivery Research Collaborative, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Parkland Health , Dallas, TX 75390 ,","place":["United States"]},{"name":"Division of Hematology\/Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua M","family":"Liao","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Peter J. O\u2019Donnell School of Public Health, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-2726-6570","authenticated-orcid":false,"given":"Jenisa","family":"RC","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]},{"name":"Cancer Care Delivery Research Collaborative, University of Texas Southwestern Medical Center , Dallas, TX 75390 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3042-2741","authenticated-orcid":false,"given":"Ethan A","family":"Halm","sequence":"additional","affiliation":[{"name":"Department of Medicine, Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ 08901 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,10,3]]},"reference":[{"key":"2026101510012635500_qxag267-B1","volume-title":"State Health Insurance Coverage: 2013, 2019, and 2023","author":"Conway","year":"2024"},{"key":"2026101510012635500_qxag267-B2","author":"Personal Responsibility and Work Opportunity Reconciliation Act of 1996."},{"issue":"11","key":"2026101510012635500_qxag267-B3","doi-asserted-by":"publisher","first-page":"e1738","DOI":"10.1200\/OP.20.00889","article-title":"Prior frequent emergency department use as a predictor of emergency department visits after a new cancer diagnosis","volume":"17","author":"Hong","year":"2021","journal-title":"JCO Oncol Pract"},{"issue":"7","key":"2026101510012635500_qxag267-B4","doi-asserted-by":"publisher","first-page":"866","DOI":"10.1001\/jamainternmed.2025.0604","article-title":"Landscape of emergency Medicaid and health care coverage for undocumented immigrants in the US","volume":"185","author":"Santos","year":"2025","journal-title":"JAMA Intern Med"},{"key":"2026101510012635500_qxag267-B5","author":"New York City"},{"key":"2026101510012635500_qxag267-B6","author":"Georgia Department of Community Health"},{"key":"2026101510012635500_qxag267-B7"},{"key":"2026101510012635500_qxag267-B8","author":"Task Force on Indigent Health Care"},{"key":"2026101510012635500_qxag267-B9","volume-title":"Indigent Health Care and Treatment Act of 1985: A Burden on Counties?","author":"Soika","year":"2004"},{"issue":"4","key":"2026101510012635500_qxag267-B10","first-page":"54","article-title":"Critical issues confronting public teaching hospitals in Texas","volume":"79","author":"Anderson","year":"1983","journal-title":"Tex Med"},{"key":"2026101510012635500_qxag267-B11","author":"Texas Health and Human Services"},{"key":"2026101510012635500_qxag267-B12","author":"Texas Health and Human Services"},{"key":"2026101510012635500_qxag267-B13","author":"Texas Department of Information Resources"},{"key":"2026101510012635500_qxag267-B14","author":"County Treasurers\u2019 Association of Texas"},{"key":"2026101510012635500_qxag267-B15","volume-title":"Texas Hospital Districts: Past, Present, and Future","author":"McKinney","year":"2019"},{"key":"2026101510012635500_qxag267-B16","author":"Comptroller of Texas"},{"issue":"2","key":"2026101510012635500_qxag267-B17","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1377\/hlthaff.2024.00760","article-title":"Oregon community benefit reform influenced not-for-profit hospitals\u2019 charity care and medical debt write-off","volume":"44","author":"Santos","year":"2025","journal-title":"Health Aff (Millwood)"},{"key":"2026101510012635500_qxag267-B18","author":"U.S. Census Bureau"},{"key":"2026101510012635500_qxag267-B19","unstructured":"US Census . Small Area Health Insurance Estimates, 2008-2023. 2026. Accessed May 10, 2026. https:\/\/www.census.gov\/data\/datasets\/time-series\/demo\/sahie\/estimates-acs.html"},{"key":"2026101510012635500_qxag267-B20","author":"US Census"},{"key":"2026101510012635500_qxag267-B21","author":"Code of Federal Regulations"},{"key":"2026101510012635500_qxag267-B22","author":"Medicaid and CHIP Payment and Access Commission"},{"issue":"5","key":"2026101510012635500_qxag267-B23","doi-asserted-by":"publisher","first-page":"E239","DOI":"10.1097\/PHH.0000000000001915","article-title":"NYC care: a large health care access program for uninsured New York city residents","volume":"30","author":"Jimenez","year":"2024","journal-title":"J Public Health Manag Pract"},{"issue":"2","key":"2026101510012635500_qxag267-B24","doi-asserted-by":"publisher","first-page":"430","DOI":"10.1007\/s11606-024-08983-5","article-title":"Healthcare utilization and chronic disease management for non-Medicaid-eligible patients in a city-wide safety-net healthcare access program","volume":"40","author":"Meltzer","year":"2025","journal-title":"J Gen Intern Med"},{"issue":"3","key":"2026101510012635500_qxag267-B25","doi-asserted-by":"publisher","first-page":"459","DOI":"10.1111\/j.1468-0009.2008.00529.x","article-title":"Local access to care programs (LACPs): new developments in the access to care for the uninsured","volume":"86","author":"Blewett","year":"2008","journal-title":"Milbank Q"},{"key":"2026101510012635500_qxag267-B26","volume-title":"&lt;7-8-21tax-Factsheets-tx.pdf&gt;","author":"Center on Budget and Policy Priorities","year":"2021"},{"key":"2026101510012635500_qxag267-B27","volume-title":"Health Benefits for Immigrant Seniors and Adults","author":"Mautino","year":"2025"},{"key":"2026101510012635500_qxag267-B28","doi-asserted-by":"publisher","DOI":"10.1136\/bmj-2025-086792","article-title":"Insurance coverage and employment after Medicaid expansion with work requirements: quasi-experimental difference-in-differences study","volume":"390","author":"Johnson","year":"2025","journal-title":"BMJ"},{"key":"2026101510012635500_qxag267-B29"},{"issue":"5","key":"2026101510012635500_qxag267-B30","doi-asserted-by":"publisher","first-page":"e143","DOI":"10.1016\/j.amepre.2019.01.005","article-title":"Time to follow-up after colorectal cancer screening by health insurance type","volume":"56","author":"Breen","year":"2019","journal-title":"Am J Prev Med"},{"key":"2026101510012635500_qxag267-B31","volume-title":"Annual Analysis of Medicaid Disproportionate Share Hospital Allotments to States","author":"Medicaid and CHIP Payment and Access Commission","year":"2024"},{"key":"2026101510012635500_qxag267-B32","volume-title":"Hospital Non-DSH Supplemental Payment and Directed Payment Targeting Analyses","author":"Wang","year":"2025"},{"key":"2026101510012635500_qxag267-B33","volume-title":"Medicaid Base and Supplemental Payments to Hospitals","author":"Medicaid and CHIP Payment and Access Commission","year":"2024"}],"container-title":["Health Affairs Scholar"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/advance-article-pdf\/doi\/10.1093\/haschl\/qxag267\/71575827\/qxag267.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/article-pdf\/4\/10\/qxag267\/71575827\/qxag267.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/article-pdf\/4\/10\/qxag267\/71575827\/qxag267.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T14:01:36Z","timestamp":1792072896000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/article\/doi\/10.1093\/haschl\/qxag267\/8860172"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10]]},"references-count":33,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2026,10,5]]}},"URL":"https:\/\/doi.org\/10.1093\/haschl\/qxag267","relation":{},"ISSN":["2976-5390"],"issn-type":[{"value":"2976-5390","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,10]]},"published":{"date-parts":[[2026,10]]},"article-number":"qxag267"}}