HOUSTON — The state must improve access for children's care and fix other problems in its $11 billion Medicaid system that provides medical coverage to more than 1.7 million low-income Texans, a judge has ruled.

U.S. District Judge William Wayne Justice ruled that the Texas Health and Human Services Commission has not lived up to a 1996 agreement to make major changes in the Medicaid system.

Justice's 175-page order could trigger sweeping changes in the state's program, prompting it to back off a plan to push most poor people into managed care and to raise reimbursements to dentists who treat Medicaid patients.