Project Summary
Under President Donald Trump's renewed administration, Texas has emerged as a key frontline in the push for aggressive immigration enforcement and widespread deportations. Texas residents – regardless of immigration status – feel the ripple effects in the economy, schools, healthcare systems, courts and public safety services. To better understand these challenges, KXAN spent the first 100 days of Trump’s second term producing “Undocumented,” a comprehensive project diving into the real-life consequences of related policies and proposals.
AUSTIN (KXAN) — A soon-to-be mother didn't go to the emergency room for a concern weeks before giving birth. Instead, her first stop was a community reproductive health clinic in northeast Austin.
Luz de Atabey Midwifery Project's pop-up clinics are every Monday at the Village Place in northeast Austin. (Courtesy Elena Colón)
Elena Colón said it's not uncommon now for clients with similar stories to turn up at the Luz de Atabey Midwifery Project, or LAMP, clinic with an emergency. She explained that since Texas hospitals started asking patients if they are a U.S citizen last fall, many are "delaying care" or even "avoiding emergency treatment.”
EN ESPAÑOL: "¿Es usted ciudadano de los EE. UU.?" Pacientes de hospitales de TX cuestionados, el estado dice que se gastaron millones en indocumentados"We try to make sure they understand the importance of seeking care when it’s urgent, but the fear of having their immigration status questioned is real," said Colón, the executive director of LAMP.
The non-profit works to remove barriers to care and wellness among Black, Indigenous, people of color, immigrants, refugees and LGBTQ+ community members. Colón said along with handouts on prenatal and postpartum warning signs and clear instructions on how to access emergency care, they’re also giving out "Know Your Rights" information.
"It’s just a very stressful time, especially for immigrant families," Colón explained.
‘Millions’ spent on non-citizens
Hospitals across Texas were directed to start collecting data on patients’ immigration status in an executive order Gov. Greg Abbott signed on Aug. 8, 2024.
Executive Order No. GA-46 required hospitals to start collecting information "regarding patients who are not lawfully present in the United States," beginning Nov. 1, 2024, including the number of patients and the cost of care provided to those patients.
More than 30,000 undocumented patients sought medical care in Texas in November, state data showsThe Texas Health and Human Services Commission, or HHSC, which is collecting the reports, released data in late April showing that in November 2024, hospitals had more than 30,000 undocumented patient visits statewide — about 2.5% of all patients. According to the data KXAN analyzed, hospitals spent almost $119 million on care for undocumented patients in that month alone.
Since November, Texas hospitals have been asking patients if they are a "US Citizen." (KXAN Photo/Arezow Doost)
KXAN’s analysis also shows, of the more than 1.2 million emergency department patients and hospital inpatients across Texas in November, a total of 30,265 self-identified as being in the country unlawfully – 2.47% of the total. Almost 1 million patients said they were either a U.S. citizen or in the country lawfully, 81.56% of the statewide total.
While hospitals in Texas are required to ask each patient their immigration status, patients are not required to answer. About 195,000 patients — 15.96% — did not answer the question.
This chart shows the number of patients at Texas hospitals and emergency rooms in November 2024, broken down by immigration status. The vast majority of patients self-reported as either U.S. citizens or being in the country legally. Source: Texas Health and Human Services Commission. (KXAN Interactive/Christopher Adams)
The number of patients who reported they were undocumented is not uniform across the state. Hospitals in Webb County, home to the city of Laredo in South Texas, had the highest share of undocumented patients. Almost 15% of patients in the county self-identified as not being in the country legally. In neighboring Maverick County, 11.4% of patients were undocumented.
Six other counties saw their share of undocumented patients above 5%, including Hartley and Moore counties in the Panhandle, as well as Dallas and Travis counties. Among the counties that had data, 49 reported no patients who were in the country unlawfully.
This map shows the number of undocumented patients at hospitals in each county in Texas, as well as the total costs of providing care to those patients. Source: Texas Health and Human Services Commission. (KXAN Interactive/Christopher Adams)
“Now, Texas has reliable data on the dramatic financial impact that illegal immigration is having on our hospital system. Because of President Trump’s swift action in securing the southern border, illegal crossings have dropped to record lows. Texas is hopeful that his efforts to remove those who entered unlawfully may also cause these healthcare costs to decline,” said Andrew Mahaleris, Abbott’s press secretary.
Hospitals are required to report the data to HHSC each quarter. Future reports will include full quarterly data, with the next one due in June. Annual reports will begin in January.
The governor said the executive order was in response to then-President Joe Biden and Vice President Kamala Harris’ “open border policies.”
“I think there would be every reason why the state of Texas would have the right to sue the United States government, because it is the United States government’s responsibility to pay for any of the costs concerning illegal immigration, and Texas and Texas health care facilities should not bear that burden,” Abbott re-iterated to KXAN in April.
‘We’re not ready to give up’: Central Texas Mom fights for daughter’s citizenshipThe Texas Hospital Association, or THA, said hospitals have complied with the executive order by meeting deadlines and working with the state on clarifications along the way.
“The fact that hospitals are required to collect this data should not be a deterrent for people in need of care. Hospitals remain open and ready to serve Texans’ acute care needs,” said Carrie Williams, chief communications officer with THA in a statement after the data was released. “With 24/7 life-saving care, hospitals are required by law to treat anyone who comes through the door, regardless of ability to pay, regardless of their demographics.”
‘People are fearful’
Kassi Gonzalez with the Texas Civil Rights Project educates the community on 'Know Your Rights.' (KXAN Photo/Arezow Doost)
Hospitals must inform patients that responding to the question will not affect their care. Still, immigrant advocate groups are concerned about the executive order’s impact. The Texas Civil Rights Project, or TCRP, has been educating people about their rights.
“People are fearful,” senior TCRP attorney Kassi Gonzalez said. “We have worked to put out resources to let people know in the community that they have a right to decline to answer this question about their citizenship status.”
Shannon Jamrog, a U.S. citizen, told KXAN she clicked “No Response” when she saw the question pop up at Dell Children’s Medical Center in northwest Austin. She had rushed her son to the ER in March after he fell off his bike and hurt his wrist.
"I just feel it's uncalled for. I don't understand the point of it. I don't understand why any child needs to have that answered to receive care,” Jamrog said.
Citizenship question asked at Dell Children's Medical Center. (Courtesy Shannon Jamrog)
The Central Texas mother shared a screenshot of the citizenship status question asked during the check-in process, which talked about the executive order requirement and asked, “Are you a United States citizen or lawfully in the United States?” A box right under the brief explanation lists three response options: “Yes — No — No Response,” which must be selected before moving on to the next step of the check-in process.
“You seek emergency care for your child and have them have their citizenship questioned when they walk in the door, it takes you back,” Jamrog said. “Why does that matter? Who are you going to tell?”
Dell Children's Medical Center in north Austin is among hospitals asking a citizenship question upon check in. (KXAN Photo/Chris Nelson)
KXAN investigators repeatedly asked Dell Children’s about the screenshot and the data that the hospital is collecting but was directed to THA. Other hospitals, including St. David’s HealthCare and Ascension Texas in Central Texas, also did not respond or have a comment, except Baylor Scott and White Health.
A spokesperson with Baylor Scott and White said it complies with all federal, state and local regulations and requirements and “providing patients safe, quality care is always their priority.”
Push for a Texas law
At a recent hearing at the Capitol, THA told state lawmakers it had concerns related to proposed legislation that would make the governor’s executive order law.
House Bill 2587 would solidify the data collection and the rules surrounding it beyond the executive order and require hospitals to submit the data electronically.
“We would like the legislation to affirmatively state that we are not required to verify patients answers and then, due to the threat of potential security concerns among hospitals that treat a high number of undocumented persons, we will respectfully request that individual hospitals reports not be — be exempt from public information disclosure so they will not be targeted,” said Heather De La Garza-Barone, associate general counsel with THA during a House Public Health Committee hearing in April.
The bill’s author, state Rep. Mike Olcott, R-Fort Worth, emphasized care would not be affected but that the legislation is necessary.
“Since 2005, we've had 181 small rural hospitals close primarily due to uncompensated care,” Olcott explained. “I know there's multiple reasons for that, and the goal of this is simply to know what percentage of that uncompensated care are due to people that are here illegally. I think that helps us make informed decisions on future legislation.”
Texas lawmakers debate bills to curb illegal immigrationWhile HHSC said hospitals are not reporting any individual information to the agency, some wondered if that would always be the case.
“There's no positive duty to disclose that information to ICE, but neither is there any guarantee that it couldn't happen,” said Trudy Taylor Smith, senior administrator of policy and advocacy with Children’s Defense Fund-Texas, who testified against the bill. Smith added it would limit access to health care for children in immigrant and mixed-status families by creating fear that discourages parents from getting emergency medical care.
Florida has a similar law. What does the data there show?
Republican Gov. Ron DeSantis signed a similar provision into Florida law in May 2023, as part of a sweeping immigration bill. Hospitals in the Sunshine State were required to start asking patients their immigration status in June of that year.
The state’s Agency for Health Care Administration, or AHCA, has since released two reports, one with data for the second half of 2023, and another spanning the whole of 2024. In both years, less than 1% of patients self-identified as undocumented.
This chart shows the number of patients at Florida hospitals and emergency rooms in 2024, broken down by immigration status. The vast majority of patients self-reported as either U.S. citizens or being in the country legally. Source: Florida Agency for Health Care Administration. (KXAN Interactive/Christopher Adams)
Last year, about 26,000 people admitted to the hospital in Florida said they were undocumented, while 68,000 patients in the emergency department were not lawfully present in the U.S. In total, of the more than 12.4 million patients statewide, only 0.76% indicated they were undocumented, while 92.5% said they were either a U.S. citizen or in the country lawfully. About 6.7% of patients declined to answer the question.
Miami-Dade County had the highest share of undocumented patients — 2.34% of patients there self-reported they were in the country illegally. Only three other counties — Lee, Manatee and Broward — had a share of patients who were undocumented above 1%.
Meanwhile two counties — Madison and Washington, in the state’s panhandle — reported 0% of patients were not in the country lawfully.
This map shows the number of undocumented patients at hospitals in each county in Florida, as well as the total costs of providing care to those patients. Source: Florida Agency for Health Care Administration. (KXAN Interactive/Christopher Adams)
Similar to the Texas’ executive order, hospitals in Florida are required to report the associated costs of providing health care to undocumented patients. According to the state’s report, Florida hospitals spent more than $659.9 million on “providing care to illegal aliens across the state.”
“The Agency remains dedicated to fulfilling Governor DeSantis’ commitment to protecting taxpayer dollars from being used on individuals who are not lawfully present in the United States,” AHCA Deputy Secretary Kim Smoak said in a press release when the 2024 report was published. “The data confirms that the financial burden of illegal immigration continues to strain Florida’s health care system. We will continue working to ensure that hospitals and health care providers deliver quality services to U.S. citizens.”
The data shows the $659.9 million spent on undocumented patients is a tiny share of Florida’s health care costs overall. In 2024, the state hospitals spent more than $86.8 billion on patient care.
KXAN reached out to the AHCA multiple times to ask how the state plans to use the data and if any changes to health care access will be made. We did not receive a response.
Impact on health outcomes
Democratic Texas State Representative Suleman Lalani, a doctor in the Houston area, has been watching the Florida data and, in an op-ed in the Dallas Morning News after Texas’ executive order, shared concerns.
Lalani said he’s asking lawmakers this session why the state isn’t spending more on preventative care so people have access to health and mental care before it turns into an emergency. He said the executive order only alienates the vulnerable.
"Texans are not coming forward so out of fear, they're not taking care of their illnesses, they're not managing their chronic problems, and it is becoming an emergency overall,” Lalani said, adding that it’s also leading to depression and anxiety.
Austin Public Health echoed those concerns, telling KXAN that ensuring accessible and affordable health care is “essential for both community health and the sustainability of our health systems.”
"Whenever individuals postpone treatment, conditions often worsen, leading to more severe health issues that require costly or emergency interventions. This not only increases health care expenses but also strains our emergency departments,” said APH in an email.
State Rep. Suleman Lalani shared concerns after Texas' hospital executive order. (KXAN Photo/Arezow Doost)
Health advocates also fear that psychological illnesses can present in children of undocumented parents, too. Dr. Damir Utrzan, a licensed family therapist, said while children may not always have the cognitive capacity to verbalize how they feel, it doesn’t mean they don’t have a grasp of what is happening around them.
“The reality is children who are exposed to adversity, more often than not, are aware of what’s going on,” Utrzan said. “By not being honest with them [at] a developmental age, that only serves to perpetuate some of the uncertainty.”
Utrzan is a former refugee himself. His family fled the civil war in Bosnia and came to the U.S. in 2000. His professional experience is extensive: conducting asylum evaluations of detainees in ICE custody while working at Northwestern University’s Center for International Human Rights; working at the Center for Victims of Torture in Minnesota, specializing in psychopathology, developmental trauma and torture rehabilitation; and consulting with the American Bar Association and the American Immigration Lawyers Association to draft affidavits and subpoenas during the detention of minors at the southern border.
'I'm just waiting': Texas immigrant among millions in years-long legal, administrative backlogIf traumatic experiences aren’t addressed early, they can “become encoded in your DNA and get passed on,” Utrzan said. If left untreated, those internalized experiences can manifest outwardly in antisocial tendencies later in life.
He gave the example of a young man from Guatemala who fled violence nine years ago. Utrzan performed a psychological evaluation on him at the time. Almost a decade later, the man is still awaiting asylum, and his lawyer recently reached out to Utrzan again for a reevaluation.
“Throughout that time, he was using drugs. He got arrested. We talked about how that unprocessed trauma and the inability to cope with contextual external circumstances leads people to self-medicate, so good people make bad decisions,” Utrzan said. “But in the eyes of the law, or immigration law at least, it calls into question their moral character, which is one of the conditions of asylum or immigration in the U.S.”
Central Health, Travis County’s hospital district, told KXAN investigators that health care is a fundamental human right.
“Together with our partners, we're dismantling barriers to care, not building them,” a spokesperson for Central Health said. “We fight relentlessly so that every community member receives the quality health care they deserve, creating a stronger, healthier Travis County for all. Because when everyone has access to care, our entire community thrives.”
Texas’ uninsured
Texas has the highest uninsured rate in the nation at 17% — more than double the national average. Five million Texans had no insurance as of 2022, THA reported. In 2023, it said hospitals provided more than $8.1 billion in "charity care" for uninsured people, with more than $3 billion not reimbursed.
Most uninsured Texans are citizens, however. Texas 2036, a non-partisan public policy organization, said, looking at available data, out of about the 5 million people who are uninsured across the state — an estimated 15% are undocumented.
Texas 2036 analyzed state data and found out of about the 5 million people who are uninsured — an estimated 15% are undocumented, as illustrated above. (KXAN Graphic/Wendy Gonzalez)
“Immigration status, in and of itself, prevents you from being able to access insurance. But what we also see is that friends and relatives of individuals who are undocumented sometimes choose not to take advantage of programs that they are eligible for,” said Charles Miller, director of health and economic mobility policy with Texas 2036.
Miller pointed to recent research by the non-profit, which identified people avoiding signing up for programs out of a fear or “concern that their friend, household member, neighbor, would have extra attention drawn to them.” He said they’ve been trying to push education and telling people that if they are eligible, they should seek resources. He explained, currently, about 2 million Texans are eligible for free coverage through the Affordable Care Act or children’s programs like Medicaid or CHIP.
Cost of care is why LAMP provides no-cost or low-cost care to up to 130 people a year through its pop-up clinic, telehealth and home visits. The non-profit explained it’s now also making sure clients know they are safe during a time when they are fearful about their immigration status, emphasizing that no one is turned away.
“We prioritize creating a space where everyone who accesses our services feels safe and supported,” Colón said. “Part of this is sharing clear information about their rights, including those related to immigration status, health, privacy and more.”
Investigative Photojournalist Richie Bowes, Graphic Artist Wendy Gonzalez, Director of Investigations & Innovation Josh Hinkle, Investigative Photojournalist Chris Nelson, Digital Special Projects Developer Robert Sims, and Digital Director Kate Winkle contributed to this report.
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