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Why the state of health care in Dallas is both remarkable and disappointing

Residents can get world-class medical care or be stranded with no coverage and serious conditions. Little wonder that just miles apart, life expectancy varies by over 20 years.

The state of health care in Dallas is remarkable and disappointing at the same time, and usually not in the same places.

At Baylor University Medical Center near downtown, 14 babies have been born to moms who received a uterus transplant. Baylor’s cutting-edge program was the first in the U.S. to deliver a baby and has become the nation’s largest.

Kayla Edwards, who was born without a uterus, delivered Indy Pearl at Baylor just over two years ago.

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“God has moved mountains for us to get her,” Kayla told the Today show soon after the birth. “It’s amazing.”

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It’s also part of a longer story of medical innovation, a 30- to 40-year journey to perfect organ transplants and develop anti-rejection drugs, said Jim Hinton, CEO of Baylor Scott & White Health. The company’s flagship hospital has performed over 1,000 heart transplants, the most in North Texas, and it’s one of the 10 largest heart transplant programs in the country.

“It speaks to the clinical culture of this organization,” Hinton said. “And uterine transplant is the next application of that culture.”

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About 5 miles west of Baylor’s sprawling campus, just beyond Benito Juarez Park, nearly half the residents don’t even have health coverage. The uninsured rate is roughly five times higher than the national average, which means residents are far less likely to have a family doctor to help them detect cancer early or manage serious health conditions.

About 3 miles north of Baylor, in one of Highland Park’s most affluent areas, the uninsured rate is a microscopic 0.3%.

The contrast between half going without coverage and nearly everyone having it isn’t limited to health insurance. The median household income in different parts of Dallas can be just as stark, with some areas earning 10 times the annual amount of others.

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The prevalence of serious illness, such as coronary heart disease, reflects similar disparities. In the worst areas, residents are eight times more likely to have the condition.

These factors and more, including education, income, family structure and public safety, all contribute to the state of health and health care in Dallas. Taken together, they add up to a troubling bottom line: a gap of 20 years of life, depending on where you live.

In a census tract just west of Southern Methodist University, home to about 1,800 households, the average life expectancy is 86.4 years.

About 7 miles to the south, in a census tract with about 500 households near Oak Cliff Cemetery, the average life expectancy is 64.2.

“We look at this data a lot, and I get pretty emotional because it’s such a stark difference,” said Steve Miff, CEO of the Parkland Center for Clinical Innovation in Dallas. “It’s disturbing, it’s humbling, it motivates me to want to do something more.”

PCCI is a nonprofit research and data analytics company that identifies the most vulnerable communities around Dallas, which helps local providers target health initiatives. Parkland Hospital & Health System and Dallas County Health and Human Services have used the data to find the areas most in need of COVID-19 vaccination clinics and mobile mammography units.

‘A city of disparities’

Dallas County has about 94 ZIP codes, but PCCI breaks down data and demographics into smaller geographies: 529 census tracts. Those provide a more focused picture of the risks to communities, ranging from COVID-19 threats to late-stage cancers to maternal mortality.

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They also reveal an extreme level of income inequality. In five census tracts in northern parts of Dallas, median household incomes topped $250,000 a year in 2018. In 10 largely southern areas, the median was about $21,000. In a census tract that includes Fish Trap Lake Park, about 4 miles west of downtown, median household income was $13,033, according to PCCI.

“Families are forced to prioritize: Do I put food on the table for my family or use the money to buy my prescriptions?” Miff said.

Addressing basic needs matters most, but forgoing medicine or a doctor’s visit contributes to higher rates of disease and mortality, which ultimately reduce life expectancy: “They’re all interrelated, and they all cascade,” Miff said.

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He believes disparities widened in the past decade despite Dallas’ economic growth. Then the pandemic amplified the hardships and vulnerability of many neighborhoods, Miff added.

For a family of three with one child, the poverty threshold was just over $20,500 in 2019. In Dallas, 18.9% of residents lived below the poverty line that year, compared with 13.4% for the nation. And geography makes a big difference.

In ZIP code 75225, which is north of downtown and includes University Park, the poverty rate was 3.3%. But in ZIP code 75210, southeast of downtown and including Fair Park, 35% lived below the poverty line — a share over 10 times greater.

How to reconcile such contrasts between the haves and have-nots?

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“In Dallas, we are a city of disparities,” said Dr. Dimple Sureka, community philanthropy officer at Communities Foundation of Texas. “There are folks who have great access to health care and there are great resources within our community, and that is wonderful to celebrate. But at the same time, we have individuals and communities being left behind.”

The region has several large hospital systems, including Baylor Scott & White, Texas Health Resources and Medical City, and they’re generally busy and profitable. In normal times, they’re highly competitive. During the pandemic, they collaborated regularly on the response to the public health emergency and helped the region withstand several waves of COVID-19 cases.

They also led the way with vaccine mandates. Baylor, the state’s largest not-for-profit hospital system, was the first local system to require vaccines for all employees and contractors, and others soon followed. When the policy was announced in July, about 71% of Baylor employees were vaccinated. By the Oct. 1 deadline, 98% were inoculated.

The University of Texas Southwestern Medical Center, a leader in academic medicine, is a research powerhouse that trains thousands of doctors and specialists every year. The faculty includes four Nobel Prize winners and dozens of acclaimed scientists and investigators.

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Its Clements University Hospital has been the No. 1-ranked hospital in Dallas-Fort Worth for five consecutive years. It was ranked among the top 25 hospitals nationally in eight specialties, including brain, heart and cancer care, according to U.S. News & World Report.

‘The burden is not evenly shared’

Parkland, the only public hospital in Dallas County, provides much of the health care safety net for the uninsured and those covered by Medicaid. That’s a potential customer base of over 1 million people, and Parkland sees about 300,000 individual patients a year, said Dr. Fred Cerise, Parkland CEO.

In 2019, over 80 hospitals in Dallas-Fort Worth earned a combined $3.14 billion, according to analyst Allan Baumgarten, who publishes the Texas Health Market Review. Profits were nearly three times higher than a decade earlier during the Great Recession.

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Margins vary widely, in part because the costs of treating the uninsured and those on lower-paying Medicaid plans fall more heavily on certain providers. At Parkland, profit margins were 9.6% in 2019. At the other end of the spectrum, Medical City’s two large hospitals in Dallas and Plano racked up margins of 37% each — and the two facilities earned a combined $667 million in 2019, the market review reported.

“There is a fair amount of uncompensated care in Dallas and the burden is not evenly shared, not by any measure,” Baumgarten said.

Parkland had $670 million in uncompensated care and unreimbursed costs for the year ended September 2020, according to Medicare hospital cost reports. That was six to 10 times more than some of the area’s largest private hospitals, including Baylor University Medical Center, which had $113 million in unreimbursed costs; Medical City Dallas at $67 million, and Texas Health Presbyterian in Dallas at $64 million, Baumgarten said.

Parkland’s reported total in the Medicare filing doesn’t include unreimbursed costs for providing physician services, take-home drugs and health care for the Dallas County jail system.

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Health care is a powerful economic force here. Over 272,000 people work in health care and social assistance in the Dallas-Plano-Irving metro division. Since 2000, the segment has added jobs at nearly triple the rate of the rest of nonfarm employment.

Since 2011, over 23.5 million square feet of space has been built for hospitals, clinics, urgent care centers and medical offices. That’s the most health care space added among all major Sun Belt metros, according to real estate services firm Transwestern, and it represents billions of dollars in investment.

In a 2019 community health needs assessment by Parkland and Dallas County, many of the disparities in health outcomes and mortality rates were broken down by geography and socioeconomic factors. A handful of ZIP codes south of downtown — 75210, 75216, 75217 and 75241 — “have virtually every negative indicator,” the report said.

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The report included a map of the geographic distribution of hospitals in the Dallas areas, and 23 facilities were north of Interstate 30 compared with five to the south. That snapshot had 2017 data, and health care construction in northern areas has been accelerating. A map in Baumgarten’s review shows an even higher concentration of hospitals in the north.

Those areas have faster population growth, higher family incomes and more residents with commercial insurance. Prosper, for example, is the site of two new children’s hospitals under construction just 3 miles apart. And two other major children’s facilities are relatively nearby.

The appeal? Prosper’s population has more than doubled in the past decade, and 96.5% of residents under age 65 have health insurance, according to census data. Median household income in Prosper is almost three times higher than in Dallas.

‘The shadow of capitalism’

Parkland’s report on health needs doesn’t elaborate on the distribution of health care investments around Dallas, at least not beyond publishing the map. So what’s the message?

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“It’s a reflection of health care in our country,” said Cerise, who’s been leading Parkland since 2014. “We live in a profit-driven health care sector. And when people do their business planning, that’s what they’re looking for.”

Dr. Christopher Crow, a family physician and leading advocate of improving primary care, put it another way: “It’s the shadow of capitalism.”

People aren’t eager to put medical centers in the southern sector, he said, for the same reason many aren’t eager to build pharmacies and groceries there: It’s harder to make investments pay off in an area with low incomes and many uninsured.

UT Southwestern is building a full outpatient medical center at RedBird Mall, and Parkland has opened a clinic there, too. Parkland also has sprinkled clinics throughout southern Dallas to increase access.

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Such efforts are essential and admirable, Crow said, but there’s a larger context: “Those are taxpayer-supported organizations, right?” he said. “They’re built to take that on.”

Crow is CEO and co-founder of Catalyst Health Network in Plano, which has 1,000 primary care physicians who care for about 1.5 million lives. He’s teaming with Baylor to bring primary care to underserved residents, especially in southern Dallas.

He likes to recount that medicine was developed and refined in battlefields so it’s really good at saving people. Those skills and experience are on display every day in Dallas.

“The hardest things in the world — we’re great at, world class,” Crow said. “We’re just not good at keeping people healthy.

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“The fact that life expectancies are over 20 years apart [in some areas]? Unacceptable, flat-out unacceptable,” Crow said. “We can’t be waiting until people fall through the cracks and end up in the emergency room.”

Dallas County ranks low on many measures of health, especially compared with its neighbors. In a key metric related to length of life — potential years lost through premature death — Dallas County’s loss is 66% higher than Collin County’s.

Dallas has more preventable hospital stays and a smaller share of residents getting flu vaccinations and mammogram screenings, according to County Health Rankings & Roadmaps, a University of Wisconsin program that publishes data on factors influencing health.

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‘It’s going to take some time’

In a metric reflecting quality of life, 23% of Dallas County residents said they were in poor or fair health, more than a third higher than in Collin, Denton and Rockwall.

“To put it in one word, there’s a lot of variation across North Texas in the health and well-being of our population,” said Barclay Berdan, CEO of Texas Health Resources, the region’s top hospital operator by market share.

Berdan, who has been with Texas Health since 1986, said many enduring disparities are rooted in racism and social and economic factors.

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“It’s a reflection of decades of differences in how those communities have had access to resources,” Berdan said. “It’s a reflection of the racial disparities that have certainly been evident for a long time. You know, it took 400 years to get us in this spot, and it’s going to take some time to get out.”

Disparities in health appear across many dimensions, including geography, race, income, education and more. In Dallas County, 21% of children live in poverty, three times the share in Collin, according to County Health Rankings.

The poverty rate for Black and Hispanic children in Dallas County approaches 30% — two to three times higher than the rate for whites and Asians.

Collin County also has stark differences by race despite having a median household income of nearly $97,000. Black and Hispanic children in Collin are three to six times, respectively, more likely than white children to live in poverty.

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Factors that lead to poverty often correlate with poor health outcomes, and they’re sometimes described as social determinants of health. PCCI, the data analytics company, considers 26 factors in assessing a community’s vulnerability, and results don’t always line up as expected.

Among the 10 local census tracts with the longest life expectancy are two tracts that rank among the worst for cancer. One possible explanation: Residents in those areas have regular checkups and screenings so they’re more likely to detect cancer early, which could reveal a higher prevalence.

But mortality rates from cancer, adjusted for age, are generally much higher in underserved areas, led by ZIP codes south and southeast of downtown Dallas, according to the community health assessment.

Those neighborhoods in the south generally lag on income, education, employment and health insurance. PCCI also cites other social drivers, including affordable housing, child care, neighborhood stability, green space and internet connectivity.

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Broadband service became more crucial during the pandemic after many children had to go to school remotely and their parents started working from home. Many doctor visits also were conducted virtually.

The surge in telemedicine was one of the most striking developments of the pandemic. Baylor Scott & White said its team has had over 1 million virtual visits since the pandemic began, and the number of unique patients using the service rose nearly 100 fold in two years.

‘One of the worst-connected cities’

Telemedicine has great potential to reach underserved communities and reduce the gaps in access to care. Many in Dallas don’t get paid sick days so they can’t afford to miss work to see a doctor. Public transportation can take so long that it becomes a barrier, too.

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But broadband falls into the same patterns that emerge with other social determinants of health, said Jasmin Tiro, a professor in the department of population and data sciences at UT Southwestern Medical Center.

“Accessing and participating in telemedicine is harder in our area because we are one of the worst-connected cities in the country,” Tiro said. “And it’s disproportionately affecting certain neighborhoods and populations.”

In Dallas, two-thirds of Black residents and 72% of Hispanics had broadband internet service in 2019 compared with over 90% of whites, according to census data. College graduates also were much more likely to have broadband.

The disparities by geography can be huge. In a census tract near I-45 and East Overton Road, about 6 miles south of downtown Dallas, 16% of residents had broadband in 2019. In a census tract just west of SMU, 90% had broadband.

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Even if broadband were widely available, Tiro said, some people couldn’t take advantage because they lack technological literacy.

“Broadband access is just part of this; they need to have the skills to navigate” online, said Tiro. That includes the ability to sort through misinformation.

Parkland has developed a way to reach a vulnerable population that often slips through the cracks: recent moms facing the prospect of losing Medicaid coverage. The first year after birth can be a tenuous time, especially for women in vulnerable ZIP codes in southern Dallas, Parkland said, and reducing maternal and infant deaths is crucial during that period.

In October 2020, Parkland launched a program to extend maternal care by having workers provide regular home visits and phone checkups. A year later, over 1,200 mothers had enrolled, including more than 72% of those eligible by August, according to a Parkland scorecard.

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“Home visitation programs for new mothers have an impact not only on the baby’s health, but also on early childhood development,” said Cerise, the CEO.

Nurses demonstrate how to interact with children and read to them, which can improve future educational performance, he said. They discuss family planning, including spreading out births, and that can boost financial prospects.

“It’s so much more than just going to check someone’s blood pressure,” Cerise said.

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‘It just has to be affordable’

Of all the ways to improve lives — and improve health — expanding access to care is near the top. Health insurance alone won’t guarantee that people get a doctor or follow advice on chronic conditions or eat a more nutritious diet.

But it’s one place to make real progress, in part because Texas does such a poor job on coverage. Over 5 million Texans are uninsured, millions more than the next-closest state, California — which has 10.5 million more people.

The pandemic has revealed great demand for coverage. Through August, just over 1.4 million Texans had enrolled and paid for insurance through HealthCare.gov, the federal marketplace for individuals and families. That’s an increase of nearly half a million customers since 2019, and it’s easily the state’s highest enrollment yet.

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Over the past two years, Texas’ percentage gain in enrollment was more than double the increase nationwide and was higher than any state. The big enabler: higher federal subsidies that made it cheaper for people to enroll and stay with their existing plans. The Biden administration also beefed up marketing and outreach efforts.

“People want health insurance, people value health insurance — it just has to be affordable to them,” said Elena Marks, CEO of Episcopal Health Foundation in Houston, which focuses on improving community health.

The state’s Medicaid rolls also are projected to add over 1 million people during the pandemic. Credit a federal policy that prohibits states from throwing people off Medicaid while the public health emergency continues.

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In Texas, Republican lawmakers have repeatedly refused to expand Medicaid, a key plank of the Affordable Care Act that extends coverage to the working poor. The feds cover 90% of those costs through taxes being paid in part by Texans.

GOP leaders also haven’t encouraged residents to get coverage through the federal exchange, even though federal subsidies offset premiums and copays for the vast majority of enrollees.

Having health insurance is “foundational,” said Tiro of UT Southwestern, because it’s crucial to accessing care and expert advice. She pointed to the challenge of persuading hesitant patients to get COVID-19 vaccines.

“What’s the No. 1 thing we tell people to do? Talk with your doctor,” Tiro said. “What if you don’t have a doctor?”

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After the pandemic hit, many barriers to health care were torn down, at least temporarily. Deductibles and copays were waived for COVID-19 testing and treatment, at least in the early months, and vaccines are still free.

Workers were encouraged to quarantine if they had symptoms, and their pay was covered — whether or not they had paid sick days.

All this was done to protect public health and the citizenry. And if those efforts saved lives during a health emergency, what does it say about improving everyday life?

“When we have the resources, that makes a difference,” said Dr. Philip Huang, director of Dallas County Health. “In other situations and other times, perhaps that’s a model for how things should be.”

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» Read previous installments of State of the City.