Comprised of 31 cities and covering over 871.28 square miles,¹ Dallas County is Texas’ second most populous county and the eighth in the nation, and plays a pivotal role in its economic development and success.² Dallas’ economy employs about 1.31 million individuals - 33%of this workforce has at least a college degree. Retail trade, healthcare and social assistance, and construction are the largest industries. In 2017, Dallas County had over 860,000 professionals in management, finance, computing, architecture, engineering and sciences, and over 430,000 professionals in education and health services.^2-3 Between 2016 and 2017, employment in Dallas County grew at a rate of 1.63%, from 1.28 million to 1.31 million employees.³

Historically, Dallas County’s strong economy has maintained an unemployment rate consistently below the state and national rates (see figure 3). The county’s median household income in 2017 was $53,626 compared to the U.S. median $57,652.²

¹ United States Census Bureau available at: https://www.census.gov/quickfacts/fact/table/dallascountytexas/PST045217\

² Dallas County available at: https://www.dallascounty.org/Assets/uploads/docs/plandev/englishdcbook.pdf

³ Data USA. https://datausa.io/profi le/geo/dallas-county-tx/#about

While much of Dallas County benefits from a strong economy, there are several geographic areas that struggle with severe poverty or pockets of economic instability and the social ills that accompany a lack of resources including significant health disparities. Many of the ZIP codes within these underserved areas have suffered from these disparities for decades.

This CHNA uses a SocioNeeds Index (SNI) score to identify zip codes that offer the greatest challenges and opportunities for addressing health disparities. SNI is a measure of socio-economic need based on ZIP Code data and is calculated from 6 indicators: poverty, income, unemployment, occupation, education and language. The indicators are weighted to maximize the correlation of the index with premature death rates and preventable hospitalization rates. Zip codes are given an index score ranging from 0 (lowest need) to 100 (highest need) which is then ranked from 1 (lowest need) to 5 (highest need).⁴ The darkest area in the Dallas County (SNI) map⁵ reveals an expansive geographic area with high socio-economic need and where health disparities are more likely to be present.

⁴ Conduent. Community Health, Health and Hospital Systems. Available at: https://www.conduent.com/solution/community-population-health/community-health-assessment/

⁵ Health North Texas. SocioNeeds Index. Available at: http://www.healthyntexas.org/index.php?module=indicators&controller=index&action=socioneeds

The median property value in Dallas County of $148,300 is 23% below the national median value of $193,500 and home ownership (50.5%) is below the national average of 63.8%.¹ According to an economic assessment by the Communities Foundation of Texas, in 2018, 34% of Dallas County households spent over 30% or more of their income on housing. Likewise, 50% of renters spent more than 30% of their income on rent. ⁶

⁶ Center for Public Policy Priorities, Communities Foundation of Texas. Dallas Economic Opportunity Assessment. Available at: https://www.cftexas.org/dallas-economic- opportunity-assessment

Since 2011, the average housing price has steadily increased, whereas home sales have remained consistent for the past three years.

In Dallas County, approximately 81% of the population ohas some form of health insurance coverage:

• 9% Medicare
• 2% Medicare Dual Eligible
• 15% Medicaid
• 47% Private - Employer Sponsored
• 5% Private - Direct
• 3% Private - Exchange
• 19% Uninsured

Source: IBM Watson/Truven Health Analytics 2019

As depicted in Figure 7, employer sponsored plans have been the main source of health coverage since 2013 in Dallas County, followed by Medicaid.

The uninsured rate in Texas is 1.75 times higher than the national rate. On the left, Table 3 shows the percentage of insured noninstitutionalized residents in Dallas County (77.9%) is below the Texas (81.8%) and national (89.5%) coverage rates. Analysis conducted by the Congressional Budget Office

(CBO), found that groups with a high likelihood of lacking health insurance include:
• People in families with income below 200% of the Federal Poverty Level,
• Hispanics,
• Young adults, age 19 to 34 years,
• People in families in which the adults worked either part-time or only part of the year, or
• Individuals in fair or poor health status who are significantly more likely than others to be uninsured for longer periods.⁷

Hispanics in Dallas County have the lowest rates of coverage with just 64% of that population having health insurance.

⁷Texas Medical Association. Texas is the uninsured capital of the United States. More then 4.5 million Texans - including 623,000 children lack health insurance - 2018. Available at https://www.texmed.org/uninsured/

As of September 2019, Texas is one of 14 states that has not expanded Medicaid enrollment under the ACA. Figures 8 and 9 below show the steady decline in the number of Medicaid enrollees in Dallas County between 2016 and 2018. The Texas Medicaid system includes STAR, STAR+PLUS, STAR Kids, STAR Health programs and the Texas Dual Eligible Integrated Care Demonstration Project. In Dallas County, Amerigroup, Molina Healthcare of Texas, Parkland Community Health Plan, Superior HealthPlan and Children’s Health are the managed care organizations that manage these services on behalf of the state.

Figure 10, shows that combined, Amerigroup (45%) and Parkland Community Health Plan (35%), provide insurance coverage to 80% of Medicaid enrollees in Dallas County.

Texas Health and Human Services describes primary care physicians as those who indicate they have a primary specialty of general practice, family practice/medicine, internal medicine, pediatrics, obstetrics and/or gynecology, or geriatrics and are a sub-set of direct patient care physicians. Dallas County’s ratio of population to primary care physicians’ ranks 18th among Texas counties. In North Texas, where Dallas County sits, demand is expected to continue outpacing supply for primary care physicians between the years 2017 and 2030. The number of primary care physician FTEs is expected to increase over that period by 1,514 while demand is expected to increase by 1,840 primary care physicians FTEs. The shortage of primary care physicians is expected to grow by 90% which indicates continued challenges for Dallas County in terms of access to primary care services. ⁸

⁸ Texas Health and Human Services. Department of State Health Services. Texas Projections of Supply and Demand for Primary Care and Psychiatrists, 2017 – 2030. July 2018.

The Compendium of U.S. Health Systems 2016 defines a health system as an organization that includes at least one hospital and at least one group of physicians who provide comprehensive care (including primary and specialty care) and are connected with each other and with the hospital through common ownership or joint management.⁹ Table 4 is a list of health systems located in Dallas County.

Hospitals and health systems serve as anchor institutions within local communities. In addition to their role safeguarding the health of local community hospitals also play a role as an employer and contribute significantly to the local economy.¹⁰ Table 5 provides a list of Dallas County hospitals by city while Figure 13 shows the geographic distribution of hospitals within the county.

⁹ Agency for Healthcare Research of U.S. Health Systems, 2016. Available at: https://www.ahrq.gov/chsp/data-resources/compendium.html

¹⁰ Robert Wood Johnson Foundation. Culture of Health Blog. Hospitals as Anchor Institutions for Community Investment. Available at https://www.rwjf.org/en/blog/2017/03/can-hospitals-defy-tradition.html