Texas hospitals’ citizenship count once again focuses on the uninsured

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When Gov. Greg Abbott ordered hospitals to ask patients about their citizenship status this summer, the intent was clear: to place the costs of caring for undocumented immigrants on the Biden administration and demand reimbursement from Texas taxpayers.

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

Starting November 1, hospital patients will be asked about their citizenship status. Abbott’s order does not say patients are legally required to answer the question. However, according to the Texas Hospital Association (THA), care will not be interrupted for patients who answer this question or not.

“The bottom line for patients is that this does not change hospital care,” said Carrie Williams, THA spokeswoman.

Several hospitals contacted by The Texas Tribune declined to discuss how they will comply with the order. Next March they will release the data they have collected or risk losing their payments from the state’s Medicaid health insurance for low-income people.

“Hospitals across the state are working to figure out how to comply with reporting guidelines and meet the state’s deadlines,” WIlliams said.

The move by Abbott’s office is the latest by Texas officials to demonstrate an unequal financial burden on states due to illegal immigration, a move supported by the conservative think tank Texas Public Policy Foundation (TPPF).

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

However, there are doubts as to whether Texas will be able to provide a solid cost figure without many caveats.

Data has shown for years that undocumented immigrants who do not have access to health insurance, including Medicaid, tend to use hospitals less often than U.S. citizens who are uninsured – hospitals in Texas spend $3.1 billion annually, according to the THA dollars for uninsured care that is not reimbursed. Even emergency spending on Medicaid, which covers hospital costs for undocumented immigrants under certain circumstances, has declined over the past five years. And Florida’s efforts to answer the same undocumented question about patient care have failed.

“This executive order is designed to discourage people from taking advantage of any public welfare programs,” said Lynn Cowles, health and food justice program manager at Every Texan, which advocates for better health care in Texas. “It’s pretty classic anti-immigrant rhetoric that won’t produce any new insights from the data collected by (Texas) Health and Human Services.”

The uninsured and uninsured undocumented immigrants in Texas

Texas leads the nation in the number of uninsured residents, and most of them are citizens. Data also already shows that immigrants are less likely to seek medical treatment than U.S. citizens.

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

The state also has a large number of undocumented immigrants. According to the 2022 American Community Survey, 2.8 million Texas residents are undocumented immigrants, about 10% of Texas’ total population of 30 million.

So what is the share of undocumented residents in the total uninsured population in Texas? It’s a difficult question that Charles Miller, a former policy and budget adviser under Abbott who now works at Texas 2036, a political organization, has tried to answer. He says that based on available data, his group estimates that about 14% of the uninsured in Texas, about 680,000, are undocumented residents.

“While we do have a fairly large population of uninsured, undocumented people, that is not the majority,” said Miller, director of health and economic stability policy at Texas 2036. “So when we talk about who the majority of the uninsured are, that will be “Be people who are here legally.”

Abbott’s order may bring Texas closer to the true cost, but even Florida’s 2023 law requiring hospitals to inquire about their patients’ citizenship status has failed to produce a solid answer. State officials there claim that unlicensed residents cost Florida hospitals $566 million, but that figure does not take into account any payments for that care, such as: B. Medicaid reimbursements from the federal government or patients paying their bills out of pocket. The Florida Policy Institute estimates the far smaller but not insignificant cost at $21.3 million when payments and reimbursements are taken into account.

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 approximately $57 billion.

Treating uninsured patients accounts for about 2% of hospital costs in Texas, according to an analysis of hospital data by the National Academy for State Health Policy. Medicaid covers about 12% of these hospital costs.

Typically, undocumented immigrants are not eligible for comprehensive Medicaid health insurance.

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

Since 2010, under the Affordable Care Act, states have had the option to expand their Medicaid program if they agree to cover 10% of the costs. Not doing so means Texas will turn away more than $5.6 billion in federal tax dollars each year and lose the opportunity to provide health insurance coverage to an additional 1.4 million Texans. Again, most of this uninsured care burden is due to citizens being uninsured.

However, uninsured, undocumented residents may be eligible for emergency Medicaid, which does nothing more than stabilize a patient. But that undocumented immigrant patient would have to be a child, elderly or disabled person whose family income is low enough to meet Texas’ strict Medicaid criteria.

Experts agree that most uninsured, undocumented patients eligible for emergency Medicaid in Texas hospitals are undocumented children.

However, according to the Texas Health and Human Services Commission, emergency Medicaid spending fell from $382 million in the fiscal year ending August 2019 to $334 million in fiscal year 2023. The number of patients receiving this emergency Medicaid has also dropped from about 75,000 to 70,000.

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

Responsibility for emergency funding for Medicaid lies with the federal government. From fiscal year 2017 to 2023, state and federal governments paid a total of $27 billion for Medicaid emergency services. Of that, states accounted for $9 billion, according to an Oct. 2 letter from the Congressional Budget Office to Texas Congressman Jodey Arrington, a Republican from Lubbock.

Beyond the emergency Medicaid program, it’s difficult to know exactly how much other resources go toward caring for undocumented immigrants — and how much undocumented immigrants spend out of pocket or who among them has private insurance. It is also not clear whether this citizen survey project can better answer this question.

Despite the likelihood of the data being scrutinized, Blair, the TPPF grantee, says Abbott’s order will hopefully give taxpayers better insight into how their money is being used.

“We think this shows transparency at the Texas Public Policy Foundation about what is actually happening,” Blair said. “This way there are no conspiracy theories about the true cost to our hospital systems and then to taxpayers.”

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