Texas’ order to ask hospital patients’ citizenship status renews focus on the state’s large uninsured population

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When Gov. Greg Abbott ordered hospitals this summer to start asking patients for their citizenship status, the intent was clear: to take the cost of caring for undocumented immigrants to the Biden administration and demand Texas taxpayers be reimbursed.

“Due to President Joe Biden and Vice President Kamala Harris’ open border policies, Texas has had to foot the bill for medical costs for individuals illegally in the state,” Abbott said in a statement in August. “Texans should not have to shoulder the burden of financially supporting medical care for illegal immigrants.”

Beginning Nov. 1, hospital patients will be asked their citizenship status. Abbott’s order does not say patients are legally bound to answer the question. However, the care of patients who answer this question, or don’t, will not be interrupted, according to the Texas Hospital Association.

“The bottom line for patients is that this doesn’t change hospital care,” said Carrie Williams, an association spokesperson.

Several hospitals contacted by The Texas Tribune declined to talk about how they will comply with the order. Next March, they will turn over data collected or risk losing their payments from the state’s Medicaid health insurance plan for low-income individuals.

“Hospitals across the state are working to determine how to comply with the reporting guidance and meet the state’s deadlines,” Williams said.

The move by Abbott’s office is the latest by Texas officials to prove an uneven financial burden on states because of illegal immigration, a move supported by the conservative think-tank Texas Public Policy Foundation, also known as TPPF.

“The governor himself wanted to see what costs are now onto the businesses and the hospitals themselves,” said Ammon Blair, a senior fellow for TPPF’s Secure and Sovereign Texas Initiative. “This should not fall on the shoulders of private businesses.”

But there are doubts as to whether Texas will be able to come up with a solid cost figure without a lot of caveats to understand.

Data has shown for years that undocumented immigrants who lack access to health insurance plans, Medicaid included, typically use hospitals less than American citizens who are uninsured – Texas hospitals spend $3.1 billion a year on uninsured care that is not reimbursed, according to THA. Even emergency Medicaid spending, which by design, covers undocumented immigrants' hospital costs in limited circumstances, has gone down in the last five years. And efforts by Florida to answer the same undocumented patient care question have fallen short.

“This executive order is intended to scare people into not using any kind of public benefits program,” said Lynn Cowles, health and food justice programs manager at Every Texan, which advocates for better health care in Texas. “It's pretty classic anti-immigrant rhetoric that will not lead to any new understandings from data collected by (Texas) Health and Human Services.”

Texas’ uninsured and uninsured undocumented immigrants

Texas leads the nation in the number of uninsured residents and most of them are citizens. Data also already shows that immigrants seek health care treatment at a lower rate than U.S. citizens.

Overall, about 18% of the state’s 30 million people are uninsured.

The state also has a large number of undocumented immigrants. According to the Pew Research Center, Texas had 1.6 million undocumented immigrants in 2021.

So how much do undocumented residents make up of the total uninsured population in Texas? It’s a hard question that Charles Miller, a former policy and budget adviser under Abbott who is now with Texas 2036, a policy organization, has attempted to answer. He says looking at available data, his group estimates that about 14% of Texas’ uninsured, about 680,000, are undocumented residents.

“We do have a fairly sizable population of undocumented uninsured, but it is not the majority,” said Miller, director of health and economic stability policy at Texas 2036. “So if we're talking about who is the majority of the uninsured, that is going to be folks who are here legally.”

Abbott’s order may bring Texas closer to an actual cost but even Florida’s 2023 law requiring hospitals to ask the citizenship status of their patients could not get a solid answer. State officials there claim undocumented residents cost Florida hospitals $566 million, but that figure does not account for any payment made for that care, such as Medicaid reimbursement from the federal government or patients who pay their bills out of pocket. The Florida Policy Institute estimates a far lower but not insignificant cost at $21.3 million once payments and reimbursements are included.

But what about Medicaid for undocumented immigrants?

In Texas, taxpayers funded about 31% of the state’s Medicaid program. The remaining almost 70% comes from federal taxes. In 2022, Texas Medicaid spending was about $57 billion.

According to analysis by the National Academy for State Health Policy of Texas hospital data, about 2% of hospitals’ charges are for treating uninsured patients. Medicaid covers about 12% of those hospital charges.

Typically, undocumented immigrants cannot qualify for comprehensive Medicaid health insurance.

Even for American citizens, Medicaid health coverage is tough to get. Texas is one of 10 states that has refused to expand the program to single, childless adults under the age of 65, making it primarily a program for low-income children, the elderly and disabled individuals. In fact, children make up the majority of Medicaid recipients in Texas.

Under the Affordable Care Act, states have had the option since 2010 to expand their Medicaid program if they agree to foot 10% of the cost. Not doing so means Texas is turning down more than $5.6 billion in federal tax dollars each year and the chance to provide health insurance coverage to another 1.4 million Texans. Again, most of that uninsured care burden comes because citizens are uninsured.

However, uninsured undocumented residents can qualify for emergency Medicaid, which will provide enough care to stabilize a patient and nothing more. But that undocumented immigrant patient would have to be a child, elderly or disabled person whose family income is so low it meets Texas’ strict Medicaid criteria.

Experts on this agree that most of those uninsured undocumented patients qualifying for emergency Medicaid at Texas hospitals are undocumented children.

Still, emergency Medicaid spending has gone down, from $382 million in the fiscal year ending in August 2019 to $334 million in fiscal year 2023, according to the Texas Health and Human Services Commission. The number of patients receiving that emergency Medicaid has similarly fallen from about 75,000 to 70,000.

The Houston Chronicle previously reported that in 2023 the state paid hospitals $123 million for emergency care for undocumented immigrants. However, according to Texas Health and Human Services, the latest state data shows Texas taxpayers paid $116 million for emergency Medicaid at hospitals in fiscal year 2023.

The onus of emergency Medicaid funding falls on the federal government. From fiscal year 2017 through 2023, state and federal governments paid a total of $27 billion on emergency Medicaid services. Of that, the states’ portion was $9 billion, according to an Oct. 2 letter from the Congressional Budget Office to Texas Congressman Jodey Arrington, a Lubbock Republican.

Beyond the emergency Medicaid program, it’s tough to tease out exactly how much other funding goes to undocumented immigrant care – and how much undocumented immigrants spend out of their pocket or who among them have private insurance. It’s also not clear whether this citizenship survey project will answer that better.

Even with the likelihood the data will come under scrutiny, Blair, the TPPF fellow, says Abbott’s order will hopefully offer taxpayers a better look at how their money is spent.

“In our opinion, at Texas Public Policy Foundation, it shows the transparency of what is actually happening,” Blair said. “So that way, there's no conspiracy theories on the true cost to our hospital systems and then to the taxpayer.”

Disclosure: Every Texan, Texas 2036, Texas Hospital Association and Texas Public Policy Foundation have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.