As Texas reviews key parts of its health and human services system, the next question is: how well are the structures connecting policy, financing, delivery, and local implementation equipped for the challenges ahead?

Texas’s health and human services system operates at extraordinary scale, consisting of two main state agencies: the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).

HHSC provides services and support to more than 7.5 million people each month through almost 200 programs. In fiscal year 2024, HHSC reported $70.8 billion in total expenditures, including $25.9 billion classified as off-budget expenditures such as supplemental Medicaid payments and SNAP benefits. 

DSHS operates on a different scale and with a different mission, focusing largely on public health. In fiscal year 2024, DSHS reported $1.21 billion in expenditures and approximately 3,800 public health professionals, about 1,600 of whom work in communities, regional clinics, laboratories, and the state’s tuberculosis hospital. Its reach reflects Texas’s decentralized public health structure. While 176 local health departments operate across the state, 189 counties rely on DSHS and its public health regions for most public health services, and all 254 counties rely on DSHS for at least some services. 

These numbers illustrate both the scale of Texas’s health infrastructure and the degree to which its parts are dependent on one another.

A system built around function

Texas confronted a similar question a decade ago. In 2015, the 84th Legislature enacted Senate Bill 200, significantly reorganizing the state’s health and human services system. The legislation followed a Sunset review that identified “blurred accountability, ongoing fragmentation of similar programs and services, and organizational misalignments.”  The resulting reforms consolidated major functions within HHSC, maintained DSHS around its core public health mission, and required HHSC to organize major operations along functional lines. 

The premise was important: organizational structure affects how programs operate and ultimately how Texans experience services.

A decade later, many of these institutions are again under review. The current Sunset cycle includes HHSC and DSHS, along with the Texas Health Services Authority, Texas Maternal Mortality and Morbidity Review Committee, Perinatal Advisory Council, and Public Health Funding and Policy Committee, among others. Public testimony on these health and human services entities is currently scheduled for November 18. 

These reviews appropriately focus on the performance and future of individual entities. Taken together, they also provide a useful vantage point from which to ask a broader question: How well does Texas’s health and human services system function across organizational boundaries?

Several signals from Texas’s current health challenges help frame that question.

Administrative burden accumulates across handoffs

Primary care provides one example. Prior authorization, credentialing, quality reporting, and related administrative requirements can reflect federal standards, state policy, Medicaid administration, health plan processes, and practice-level operations. Each participant has distinct responsibilities, while the cumulative experience occurs at the practice level.

This is not a new concern. The 2015 Sunset review specifically named “fragmented provider enrollment and credentialing processes as administratively burdensome” and identified broader fragmentation in Medicaid administration and data management. 

Recent work through the Texas Primary Care Consortium has continued to surface the importance of the infrastructure beneath these requirements: where greater consistency may be possible, how information moves between organizations, and where unnecessary variation can be reduced without weakening appropriate oversight.

The underlying challenge is one of alignment across multiple accountable actors.

Statewide investment ultimately depends on local infrastructure

The same dynamic appears in rural health. Texas was awarded $281.3 million for the first year of the federal Rural Health Transformation Program, the largest first-year state award announced by CMS. 

The opportunity extends beyond the amount invested. Rural communities operate through different combinations of hospitals, hospital and health districts, FQHCs, independent clinicians, local governments, public health entities, and community organizations. Their capacity to organize and sustain health services varies considerably.

DSHS’s own description of the public health system illustrates this variation. Local governments determine whether to establish health departments and which services they provide, while DSHS regions fill gaps and provide surge capacity and specialized expertise.

New rural investments will enter this existing landscape. Their long-term effectiveness will depend in part on the infrastructure connecting statewide strategy, regional capacity, and local implementation.

That raises practical questions about who can coordinate investments, where shared priorities are established, how local assets are used, and how successful approaches are sustained beyond individual funding streams.

Affordability crosses organizational boundaries

Health care affordability extends the same pattern across financing and delivery. The Texas House Select Committee on Health Care Affordability has been charged with examining cost drivers that include administrative and regulatory burden, insurance design and cost sharing, market structure, payment policies, consolidation, transparency, and prescription drug costs. 

These factors are influenced by different parts of the health system. Health plans, health systems, clinicians, employers, pharmaceutical companies, government programs, purchasers, and consumers each affect the resulting cost of care.

For Texans, however, those individual decisions ultimately converge into a single experience: whether care is accessible and affordable. Improving that outcome therefore requires both clear responsibility within individual organizations and mechanisms for understanding how decisions interact across the system.

Functions for the next decade

Across primary care, rural health, public health, and health care affordability, several functions continue to emerge.

Alignment can reduce unnecessary variation and help policies, financing, and operations work more coherently across organizations.

Local implementation capacity can help communities translate statewide strategies and resources into approaches suited to their own health infrastructure.

Shared accountability can allow organizations with different responsibilities to use common information, understand their respective roles, and assess whether collective efforts are improving outcomes. The structures supporting these functions will not necessarily look the same.

Some may reside within existing state agencies. Others may involve common standards, stronger regional infrastructure, data-sharing arrangements, public-private partnerships, or neutral coordinating mechanisms that connect organizations without replacing their individual responsibilities.

The principle is straightforward: form follows function.

Texas’s 2015 health and human services reorganization reflected that principle by reorganizing major responsibilities around the functions the state needed at that time. The current Sunset review process provides another opportunity to consider the capabilities Texas will need over the coming decade.

With significant investments underway and persistent challenges in affordability, workforce, primary care, rural health, public health, and maternal health, the strength of individual institutions will remain essential. So will the infrastructure connecting them.