Do This and You Will Live

7/31/2019 Do This and You Will Live

1/8Texas Impact 2008 Do is and You Will Live 1

...Do Tis and

You Will LiveA Justice Framework for Health Care

a publication by the Texas Impact Education Fund

Faith communities are deeply involved in health care. Religious groups founded many of the hospital systems in the U.S. and Texas.Congregations and local religious groups have been major providers of care for the poor, as well as providing insurance for their employees.

ere are many suggested reforms for the American health care system. Before we can evaluate reform ideas, we must identify goals for thesystem. As we discuss problems with the current health care system and possible goals for a reformed system, it is important for religiouscommunities to reflect on scriptural interpretations of justice and the importance our faith traditions place on human health.

Just then a lawyer stood up to test Jesus. Teacher, he said, what must I do to inheriteternal life? He said to him, What is written in the law? What do you read there? Heanswered, You shall love the Lord your God with all your heart, and with all your soul,and with all your strength, and with all your mind; and your neighbor as yourself. And hesaid to him, You have given the right answer; do this, and you will live.Luke 10:25-28


2/82 Do is and You Will Live Texas Impact 2008

How are you feeling today? Maybe you ran five miles...or maybe a health

condition keeps you from being active. Maybe you had a full physical and a clean bill of

health, or maybe you didnt get a physical because youreworried something is wrong.

Maybe your own health is fine, but you have aloved one who is seriously ill.

Maybe a co-workers chronic illness is causing youmore work and stress. Maybe an outbreak of flu in your community is

leading to longer waits at the emergency room. Whether we feel fit as a fiddle or under the

weather, we all live within the limits health gives usourown health and the health of others.

Health isnt important only because of what itlets us do. Scriptures tell us that God made peoplein Gods image, and that we are to treat our bodiesas temples. is means that

as individuals we are eachresponsible for taking careof the wonderful body Godhas given us in every way

we can, including exercising,eating healthy food, andmaintaining proper hygiene.It also means that collectively

we must be concerned for thehealth of every member of ourcommunity.

Because health is soimportant to us, we invest alot in it.

We respect health careproviders and believe theyshould be compensated well for their skills.

We prize advances in technology and science thatoffer new ways to keep people healthy or alleviatesuffering.

We dedicate publicfunds to provide healthcare for those who cant

afford it so that the wholecommunity can stayhealthy.

Increasingly, there isconcern that as Americans and Texans, we are notinvesting in health care as effectively as we could be.

While no health care system will ever be perfect, weshould be sure that we are using resources as wiselyas possible and taking as good care of each other aspossible.

Health and Faith CommunitiesCommunities of faith in the U.S. and globally are health

care leaders. Religious orders and denominations foundedmany of the hospitals, universities and other institutionsthat form our health infrastructure. Tithes and offerings ofpeople of faith support care for those who cant afford it, andreligious missionaries crisscross the globe providing health

services to the human community.Religious teachings concerning health include the

affirmations that God cares for our physical being; thatcare for our bodies is one important form of worship; andthat meeting the health care needs of Gods children is animportant charity. Many of Jesus miracles center on healing,and the Jewish scholar Maimonides called the provision ofhealth care an obligation for society. Alleviating suffering isa high calling. As the practice of medicine and our healthcare infrastructure have become increasingly complex, faith

communities have been called

to respond to ethical questionsregarding treatment options; therole of families and communitymembers as caregivers; and theresponsibility each individualbears for their own health.

But all of these historicintersections between faithcommunities and health revolvearound charitythe actions

we take as individuals andcommunities to make up for

inequities in our systems andrelationships. In the Abrahamictradition, charity as aresponsibility of the life of faith

stands distinct from another equally important responsibilityto do justice by reforming systems and relationships toreduce inequities in the distribution of resources and balancepower among all the members of the community.

Today in Texas and the U.S., the foundational questionsregarding health care are questions of justice: Is health care anoptional commodity, a necessity, or a right? Should all peoplehave access to the exact same level of care in every situation?Should resources be distributed within the community toensure that all members of the community receive the samequality of goods and services? Who gets to decide?

All these questions at bottom relate to the core issue ofjus

Providing health care was not just an obligation for the patient and the doctor, but for society aswell. It is for this reason that health care is listed first by Maimonides on his list of the ten most

important communal services that had to be offered by a city to its residents. (Mishneh Torah,Sefer Hamadda IV:23)



distribution of scarce resources. If resources were infinite,everyone could have everything they want all the timebut because they are limited, we must develop systems asa community to ensure that resourcess are divided in waysthat meet our collective and individual needs withoutunduly burdening some members of the community. Inthe area of health care, justice questions are primarilyquestions of health care finance.

A System in Crisisere is broad agreement among politicians, academics,

providers, and the public that the American health carefinance system is in a state of crisis that is getting worsedespite government and private-sector attempts tostabilize it.

Comparative internationaldata show that Americansspend more on health careoverall than residents of

other countries, but receiveless health care per capitathan residents of othercountries. e U.S. is theonly nation in both the24-nation Organization forEconomic Cooperation andDevelopment and NATOthat does not provide somelevel of health insurance forall its citizens.

Compared to other countries, especially consideringour relative wealth as a nation, a large share of Americanshave insecure access to health care services, meaningthat either they cant afford care or that there are few orno providers where they live. And even Americans whohave health insurance or can afford to pay for care aresubject to systemic shortages and failures. For example,patients with insurance can be turned away at theemergency room because it is full of uninsured peopleseeking care for non-emergency problems.

Texas looms large in consideration of the U.S. healthcare system, because Texas is home to a disproportionate

share of Americans who have insecure access to healthcare. If the health care finance system in the U.S.improved access to health care, Texans would benefitdisproportionately.

An Insurance-Based SystemMost health care spending in the U.S. and other

industrialized nations is in the form of insurance, evenwhen the government is purchasing the care. While thereis some direct spending on health care by individuals

and the government, most spending comes in the form ofinsurance premiums.

Most people in the U.S. and Texas have healthinsurance that pays some or all of the cost when they usehealthcare-related goods or services. According to theKaiser Family Foundations analysis of data from the U.S.Census Bureaus 2007 Current Population Survey, about83 percent of Americans under 65216 million out of261 millionhave health insurance of some kind, andalmost 72 percent of Texans under 6515 million out of21 millionhave health insurance of some kind.

Financing health care through insurance pools the costof care for a whole community. Instead of risking personalor household catastrophic financial loss, each individual inthe group pays a set amount to help cover whatever costs

arise in the community. Apatient with insurance doesnot have to consider howmuch a service costs, beyondany co-payment they might

owe, before deciding to seektreatment. Likewise, a doctoror other provider does notneed to consider whether apatient can afford a particulartreatment before prescribingit.

e majority of Americansunder 65 who have healthinsurance, have employer-sponsored insurance. at

means that an employereither their own or that ofsomeone they are related tonegotiates an insurance planon their behalf, and in many cases pays some or all of thecost of the plan. About 61 percent of Americans under65 (159 million) and 52 percent of Texans under 65 (11million) have employer-sponsored insurance.

About 25 percent, or 76 million, Americans haveinsurance through a state or federal government programthat covers people who are deemed to be especiallyneedy, because they are poor or elderly, have exceptionalhealthcare needs, or a combination of the three. About 24percent of Texans, or 5.6 million, are covered through a

state or federal program.e state of Texas buys health care or health insurancefor millions of Texans through dozens of programsincluding state employee insurance, prison health care,and various programs for people with extreme medicalneeds and/or low income. For the 2008-2009 biennium,

Texas appropriated nearly $40 billion for Medicaid, thestate-federal partnership program that primarily serveschildren in low-income families, people with disabilities,and seniors who need long-term care. Texas appropriatedabout $2 billion for the Childrens Health Insurance

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Program (CHIP) for the same time period.As in other states, most of Texas state health

care spending is in the form of health insurancepremiums rather than direct health care services. efuture of Texas health care spendingand thus thestate budgetwill therefore be dependent to a largeextent on national decisions regarding the overallhealth insurance system.

How We Got HereUntil the beginning of the 20th century, health

insurance in every country where it existed was partof an overall system of income support. Medicalcosts were not very high because treatment options

were limited; however, lost wages due to illness andinjury were a real threat to individual households andgeneral economic stability.

Before the industrial revolution,friendly societies, guilds, and

other trade associations providedwage replacement for sick daysthrough member dues. eseassociations were quite extensivein Europe and much less so in theU.S.

After the industrial revolution,workers in European countriesdemanded comprehensivesystems of income support as partof the Socialist movement. In

1888, Germany became the firstcountry to establish a nationalhealth insurance program. e program included

wage replacement as well as covering some costsof medical care. It initially applied only to workersthemselves and gradually expanded to include theirfamilies and then other population groups. OtherEuropean countries followed; by the start of World

War I, all the major European countries had nationalinsurance programs.

In the U.S., guild-sponsored programs were notwell-developed. ere were a few isolated examples

of employer-sponsored health care programs, notablycompany doctor programs for miners and timber

workers in the American West, but health insurancewas essentially unheard of for the American public.

In the late 1800s, American Progressives followedthe lead of European workers and socialist activists incalling on Congress to enact legislation guaranteeing

worker rights and a government-sponsored systemof income supports. e Progressives achieved a

workers compensation program before the start ofWorld War I. In the isolationist environment after

the start of the war, however, social insurance programs, likeother foreign ideas, became suspect. Movement toward abroad American health insurance system stagnated.

During the first two decades of the 20th century, medicalcosts rose dramatically because of advances in medicine leadingto increasing hospitalizations and more expensive diagnosticprocedures. When the Great Depression suddenly reducedthe overall resources available to pay for health care, doctorssuffered from high levels of bad debt, and hospitals were left

with empty beds and unstable revenues.One such struggling hospitalBaylor Hospital in Waco,

Texasestablished a prepaid hospitalization plan for employeeof the Dallas Independent School District. is plan formedthe seed of what eventually became known as Blue Cross, andBlue Cross plans sprang up quickly around the country.

Within a decade of Blue Cross establishment, the U.S.had entered World War II. Blue Cross lobbied successfully

to have health insurancebenefits exempted from

wartime wage controls, so

employers began to pay foremployees health insurancepremiums as a substitute forraising their wages. After the

war, employer-paid healthplans became ubiquitous.In 1940 only nine percentof Americans had hospitalinsurance; by 1966, more than80 percent were covered.

us, when Congressreturned to the question ofincome supports and social

insurance, workerswho were the original target of healthinsurance in Europewere largely covered through privateinsurance, with the uninsured being primarily individuals

who did not have access to employer-sponsored coverage: theelderly, people with disabilities, and the poor.

In 1965, Congress acted to cover the elderly throughMedicare, and people with disabilities and the poor throughMedicaid. Since then, Congress has expanded Medicare andMedicaid to cover more individuals and established the StateChildrens Health Insurance Program for children in low and

moderate-income families. At the same time, however, changesin the economy such as growth in part-time and temporaryjobs have diminished the availability of employer-sponsoredcoverage.

roughout the 20th century health care costs continued torise, fueled by advances in medicine and by increased utilizationstemming, at least in some measure, from the incentivesassociated with insurance. e cost of establishing a nationalhealth care system today would be much greater than the cost

would have been of establishing one early in the 20th century.



When The System FailsIf you are an able-bodied Texan under the age of

65, the odds are about one in four that you will goat least part of this year without health insurance,according to the most recent U.S. Census dataavailable. Your chances of being uninsured arehigher than they would be in any other state in the

U.S.If you do not have health insurance and you

get sick, at a minimum your illness could pose afinancial hardship for you. Because private insuranceis the backbone of the American health care financesystem, your lack of insurance might also have largerramifications for the stability of your communityshealth care infrastructure.

Although your chances of being an uninsuredAmerican are highest if you live in Texas, Americansin general are more likely than people in many

other countries to lack health coverage. is meansthat Americans as a group have less secure accessto health care than people in other countries, eventhough high quality care is available throughout theU.S.

About 17 percent of Americans under 65 andabout 28 percent of Texans under 65 were uninsuredfor at least part of the year during 2007. Texans havea higher rate of uninsurance than other Americans,especially for children. About 11 percent of

American children were uninsured for at least partof 2007, compared to more than 22 percent of Texas

children.Texans account for about eight percent of all

Americans under age 65, but nearly 13 percent ofuninsuredAmericans in that age group. Because

Texas has such a large population and such a highuninsured rate, Texas statistics skewthose for the country as a whole. If

Texas uninsured rate were equal tothe average of the other 49 states, thecountrys overall uninsured rate wouldsignificantly reduced and would beabout one point lower than it is now.

Americans are most likely to beinsured if they live in a family whereat least one member has a full-time,full-year job. e kind of job and howmuch it pays are also important. Jobsthat pay higher salaries are more likelyto come with insurance in most cases,although certain kinds of occupationssuch as construction do not typicallyinclude insurance even though theypay well. Food service jobs are the least

likely to offer health insurance. Employers with more than 200employers and public sector employers are much more likelythan are small, private employers to offer insurance coverage.

Race/ethnicity is a factor in predicting insurance status. InTexas, Hispanics are much more likely to be uninsured thanother race/ethnic groups.

Although the extent of uninsurance in the U.S. is increasinglywell-documented, there are significant differences of opinionabout how big a problem lack of insurance actually is. Tohelp develop a national consensus on the issue, the NationalInstitute of Medicine in 2000 launched a multi-year project toevaluate and consolidate our knowledge about the causes andconsequences of lacking health insurance.

Individual HealthResearch has shown repeatedly that individuals without

health insurance receive less care than do their insuredcounterparts. In particular, the uninsured are less likely tomanage chronic conditions and illnesses effectively and they aremore likely to wait to seek care, so that minor and manageable

conditions become major problems.

Family WellbeingLack of insurance has ramifications for families where one or

more members are uninsured. Recent research has focused onthe consequences for childreneven if they have insuranceiftheir parents are uninsured.

A number of studies reviewed by the Institute show that achilds use of health care services typically corresponds to herparents. Even if the child has health insurance, she still dependson her parent to take her to the doctor. Research shows that aparent who does not use health care services herself will be lesslikely to take her child for health care.

Uninsured parents, like other uninsured adults, are likely todelay treatment and forgo management of chronic conditions.

ey therefore can face increased stresses in providing for theirchildren. Parents may lose income because of a preventable

disability, or be unable to attend to theirchildrens physical needs because of poorhealth.

Community StabilityHigh rates of uninsurance have

destabilizing effects on the health careinfrastructure of a local community. Oneof the most severe and increasingly welldocumented of these effects concernsavailability of emergency room services.

Pervasive lack of insurance can alsolead to shortages in health care personnel,because health care professionals cannotafford to practice in areas where there are nopayors.

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Health and JusticeIf modern medicine did not exist, no one would claim

a right to it. But since it does, and since Americans havedecided that it is valuable enough to us as a communityto mandate investment of public dollars, then it is only

just that everyone in the community benefit equally fromthe publicly supported resource.

Under the current health carefinance system in the U.S.,nearly all Americans pay intothe system, not all Americanshave equal access to the system,and the contributions of eachindividual are not related totheir consumption of healthcare, their need for services, ortheir ability to pay.

It would not be just, however, to step back from

public investment and declare health care a luxurywith no public subsidy, available for purchase only forthose who can afford it. In modern times medicine hasdeveloped practices and infrastructure that materiallyaffect peoples opportunity for self-determinationforexample, children who dont get the same health care asothers have different educational outcomes that impacttheir ability to support themselves in adulthood. us, ifany child has access to health care that reasonably couldbe made available to all, then restricting access to care

creates inequality of opportunity.Currently, everyone in the U.S. who pays taxes,

pays for health coverageif not for themselves, thenfor someone else. Health insurance premiums paid byemployers are not subject to income taxes, so incometaxes for all must be higher to offset the benefit to those

with employer-sponsored coverage. Tax dollars also gotowards providing health coverage for public employeesand certain categories of needy individuals throughprograms like Medicaid, and to to subsidize health

services directly through public hospitals and clinics.American taxpayers spent as much as $200 billion in

2007 to subsidize the purchase of employer-sponsoredhealth insurance. Both workers and employers benefitfrom this subsidy, which exempts premium contributionsfrom income and payroll taxes. Workers whose employersdo not offer health insuranceor who are offered coveragebut cannot afford to pay the premiummust pay taxes to

subsidize the health coverage of higher-wage workers whoare offered employer-sponsored coverage and can afford toaccept it.

e self-employed may deduct their health insurancepremiums from income tax, but not payroll tax, if theydo not have access to an employer-sponsored plan. Inaddition to the tax subsidy for employer-sponsoredcoverage and coverage purchased by self-employed workers,the government subsidizes individuals with health careexpenses exceeding 7.5 percent of their adjusted grossincome by allowing these individuals to deduct their healthcosts (including premiums) on their tax returns.

All taxpayers chip in for the health insurance that isprovided to state, local and federal employees, from thelocal county clerk to the President of the United States.

ese payments are usually counted in the category ofemployer-sponsored private coverage (government asemployer), but they also constitute a form of public, state-sponsored health coverage.

Tax dollars go towards purchasing health care forprisonersthe only Americans with a legally definedright to health care. Tax dollars foot the bill for healthcoverage for military personnel, as well as individuals whoqualify for Medicare, Medicaid, SCHIP and other means-tested programs. College students at public universities whoare offered subsidized health insurance also receive this

benefit through state dollars. us, individuals who fall intospecific categories or meet established eligibility criteria areawarded health coverage that all taxpayers buy.

Large government grants go towards financing research,technology development, and other advances in health care.For example, all taxpayers support breast cancer research,from those in the lowest income bracket to those in thehighest income bracket. Yet when new findings lead to thedevelopment of new treatments, only those taxpayers whocan afford it will benefit.

On one occasion an expert in the law stood up to test Jesus. Teacher, he asked, whatmust I do to inherit eternal life? What is written in the Law? he replied. How do

you read it? He answered: Love the Lord your God with all your heart and with allyour soul and with all your strength and with all your mind; and, Love your neighbor

as yourself. You have answered correctly, Jesus replied. Do this and you will live.Luke 10: 25-28



Reforming the SystemA number of proposals have been put forward to reform

the U.S. health care finance system. Reform proposals arelikely to increase in number and in inventiveness as healthcare costs and quality continue to be major concerns for

Americans.For people of faith, the central question around health

care reform must be justice: Dothe proposed reforms balance boththe distribution of health careresources and the responsibilityfor funding them? For Texans, thecentral question about nationalreform proposals should be theextent to which suggested reformsaddress the unique issues thatleave Texans so disproportionatelyuninsured.

Expanding CoverageMost major health care reform

plans focus on expanding coverage to some or all of thepeople who arent covered currently. Proposals to increasethe number of insured people have two options: theycan propose to cover everyone with benefits similar to atypical plan such as a large employer might offer, or theycan propose covering more people but changing the natureof the insurance package. For instance, a proposal couldsuggest covering only certain kinds of health care servicessuch as hospitalization, but covering them for everyone in

the population.Some people say that the primary goal of insurance

reform should be to provide some minimal level of coveragefor everyone such as catastrophic coverage that doesntcover most routine problems but protects the bearer fromthe high cost of a hospitalstay or expensive course ofdrugs. Others would arguethat health coverage mustbe comprehensive because ifpeople skip preventive servicesthat arent covered, they will experience more frequentcatastrophic health episodes and end up costing the systemmore in the end.

Expanding Private ProgramsStrategies for increasing coverage in the private market

can encourage or require employers to provide insurancefor their employees, or they can encourage or requireindividuals to be insuredif not through an employer thenthrough an individual plan they purchase directly from aninsurer.

Tax credits are one popular proposal for increasing

coverage through the private market. Tax credits canapply to employers or to individuals, and they have canbe applicable to the purchase of any qualified insuranceplan, so consumers can make choices.

Some people argue that mandating coverage is abad idea that would distort the economy. For example,in a state like Texas, more employers than the nationalaverage are accustomed to not providing coverage toemployees. If those employers were suddenly required

to sponsor groups insurance, somepeople argue that employers mightmove away or cut jobs. Mandatingindividual coverage strikes manypeople as an unwarranted governmentintrusion into private life.

Expanding Public ProgramsSome reform proposals focus on

expanding Medicaid, Medicare andthe Childrens Health Insurance

Program (CHIP) to cover new groupsof people or to cover the same groups

at higher income levels. Expanding public programswithout requiring cost-sharing would require increasedtax expenditures.

Buy-in options are popular proposals to expandpublic programs. Buy-in programs allow people whoarent eligible for publicly funded coverage to pay to jointhe program. A buy-in can be an effective way to coverall the members of a family where only some of themembers are eligible for public coverage. However, manypeople argue that for families below certain incomethresholds, even a modest buy-in cost may be enough todiscourage participation.

Texas has one of the nations least generous Medicaidprograms; there are many uninsured Texans who

would be covered under Medicaid if they lived in a

different state. If Congress expanded Medicaid to

cover more population groups but left states significantdiscretion as to how many of the new groups to fund,Texans might still be disproportionately uninsured. IfCongress expanded Medicaid at the federal level andleft states little discretion, Texas would face suddendisproportionate new costs.

Creating New ProgramsSome proposals focus on creating new programs to

cover individuals left out of the current system. Manynew program proposals involve new insurance pools

I do not mean that there should be relief for others and pressure on you, but it is a question ofa fair balance between your present abundance and their need, so that their abundance maybe for your need, in order that there may be a fair balance. II Corinthians 8:13-14


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for individuals and small employers who have trouble findingaffordable insurance in the market currently.

Personal ResponsibilityMany health care reformers say that consumers should

take more responsibility for their own health and managingtheir health costs. Prudent personal health habits can lowercosts for individuals and taxpayers, and tying health costs topersonal savings helps consumers understand the value of thegoods and services they receive.

People can protect their health by avoiding behaviorsknown to be harmful to individual health,such as smoking. Individuals can reducecatastrophic costs associated with a chronicdisease such as diabetes by taking properpreventive steps, and overall fitness cankeep an individuals health care usage downover a lifetime.

But since no one is perfect, every personmakes at least some choices that dont

promote optimal health. A system thatholds every individual to a rigid standard of accountability forself-care would penalize people for mere human frailty.

By separating health consumers from the cost of care,health insurance creates the problems of no-holds-barredmedicine, in which health care providers spare no expense onpatients with rich insurance packages and moral hazard, in

which insurance leads consumers to seek care that they wouldnot seek if they had to pay for it out of their own pocket.

Health Savings Accounts (HSAs) and high-deductibleinsurance plans are designed to reward individuals for making

wise spending choices on health care. ey are intended tocreate incentives for consumers to shop for good prices andtake care of their own health to minimize costs.

Detractors say that HSAs are unfair, because individualswith more income can save more for potential futurehealth care needs. Detractors also point out that HSAs donothing to pool risk. Instead of sharing the risk that oneperson will incur high health costs among all the membersof the community, HSAs exemplify a strategy of going italone, where each person bears the full risk for potentiallycatastrophic costs. And individuals with high out-of-pocketlimits may forego needed treatment for themselves or their

loved ones just to save money.

Other ModelsSingle payer health insurance refers to a system where

a single sourceeither a government or an entityunder contract with the governmentpays for allthe covered health care services for everyone underthat governments jurisdiction, using funds that thegovernment collects through the tax system. epayments can go to providers, to a single publicinsurance sytem, or to a system of privately operatedhealth insurace plans that in turn pay providers.

Under a system of socialized medicine, thegovernment owns hospitals and clinics and controlsday-to-day operation of the health care industry.

Under socialized medicine, healthcare providers are full-fledgedgovernment employees.

Regardless of what reforms wemake to our health care financesystem, we will face difficult choicesReforms that provide universal

access must ration or excludesome high-cost services because of limited funds.But if consumers can go outside the system forservices based on their ability to pay, then equalityof opportunity may be compromised. e choices wemake for our health care system therefore cannot beframed as right and wrong, because any system

will fail to meet all the conditions of justice perfectly.Instead, we must frame health care reform as a

project ofcommunity and balance:

e health care finance system must provide alevel of care to every member of the community thatthose with the most means would consider necessaryfor themselves and their loved ones.

Every member of the community shouldcontribute to the system relative to their means.

e system should serve the community as awhole, not individual members of the community.

e system should create expectations of personalresponsibility while acknowledging the certainty ofirresponsible behavior by individuals.

Reforming our health care finance system offersTexans and Americans an opportunity to love ourneighbors as ourselves through just public policy.

is edition ofJustice Frameworks is funded by Methodist Healthcare Ministries of

South Texas. Opinions expressed in this report are those of the authors and do not

necessarily reflect the views of MHM.

Justice Frameworks is a publication series of the Texas Impact Education Fund,

Bee Moorhead, Executive Director. Texas Impact was established by Texas religious

leaders in 1973 to be a voice of religious social concern to the Texas Legislature.

TEXAS IMPACT

www.mhm.org people of faith working for justice

Texas Impact 221 East 9th Street,Suite 403,Austin,Texas 78701 www.texasimpact.org 512.472.3903

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