Making Poor Choices: Abbott’s Recent Chilling Attack on Access to Health Care
When it comes to the health and well-being of Texas children, Texas Gov. Greg Abbott decides the direction of the Lone Star State and has for 10 years now. Unfortunately, when it comes to public education, child nutrition, and child health, the Governor often makes choices that are detrimental to Texas kids.
His latest move threatens both the health of children and the Lone Star State’s largest children’s hospital simply because one of the hospital’s physicians, Dr. Tony Pastor, used a short TikTok to express concerns about the Governor’s executive order demanding that Texas hospitals collect citizenship data from all patients they serve.
To understand the chilling implications of Gov. Abbott’s executive order, it’s essential to place it in the broader context of Gov. Abbott’s decade-long track record of actions and inactions that harm the health and well-being of Texans, including children.
For years, Abbott and the Texas Legislature have repeatedly rejected the offer of hundreds of billions of dollars over the years in federal Medicaid dollars through the Affordable Care Act (ACA) to expand coverage to uninsured adults. Texas is among just 10 states across the country that continue to refuse this funding, which could positively transform the lives of hundreds of thousands of Texas, strengthen the State’s medical infrastructure, and boost the economy.
Consequently, Texas consistently has had the highest number and highest rate of uninsured residents in the country. According to data from the U.S. Census Bureau, the uninsured rate for Texas children was 11.9% in 2023, which is more than twice the uninsured rate of 5.4% for the nation. For adults ages 19-64, the Texas uninsured rate was 21.7% or nearly twice that of the 11.0% national rate.
The Governor’s failure to expand Medicaid has been compounded by Texas’s aggressive approach to removing people, who were enrolled in Medicaid during the declared “public health emergency” during the COVID pandemic, from health coverage. According to reporting by the Texas Tribune and ProPublica:
Texas officials acknowledged some errors after they stripped Medicaid coverage from more than 2 million people, most of them children. . . Nearly 1.4 million of those who lost coverage were disenrolled for bureaucratic reasons like failing to return a form or completing one incorrectly, not because they weren’t eligible.
The impact has been devastating, particularly for children. As reporters Eleanor Klibanoff and Lomi Kriel explain:
Among them were children forced to forgo or postpone lifesaving operations such as heart surgeries, said Dr. Kimberly Avila Edwards, an Austin pediatrician and Texas representative for the American Academy of Pediatrics. Children with severe diseases such as sickle cell anemia, as well as those with neurodevelopmental delays and autism, also unnecessarily lost critical care.
Alternatives That Improve Rather Than Harm the Health of Texans
Rather than cutting health coverage and imposing new burdens, there are clear solutions available to Gov. Abbott to improve the health of children and families:
Expand Medicaid: Texas should take the federal ACA’s Medicaid expansion for low-income adults.
Streamline Enrollment for Children: Texas should simplify and reduce administrative barriers to increase the health coverage of children who are eligible for either Medicaid or the Children’s Health Insurance Program (CHIP) but remain unenrolled.
An example of the latter option would be to pass legislation introduced by Rep. John Bucy (HB 321) and Sen. Nathan Johnson (SB 238) that is supported by Texans Care for Children and would use data from a family’s SNAP application to determine whether children are eligible for but unenrolled in Medicaid or CHIP.
This legislation uses what is known as “express lane eligibility”[1] to eliminate unnecessary and duplicative bureaucracy and paperwork requirements for children to get the health coverage they are eligible for. As Texans Care for Children points out, “Other states, including Alabama, South Carolina, Louisiana, Iowa, and Georgia, have successfully implemented similar policies.”
The Executive Order’s Choice of Harm Over Improvements
Instead of improving the health of Texans, Gov. Abbott has chosen to impose new administrative and bureaucratic paperwork burdens on hospitals to collect and report on patients’ immigration status. His executive order, modeled after legislation passed in Florida and signed into law by Florida Gov. Ron DeSantis, does nothing to improve the health care for Texans and puts division over care.
This is not an inconsequential decision. By requiring hospitals to collect and report on the immigration status of patients, Abbott’s order creates a "chilling effect," where immigrant families will likely delay and avoid seeking critical medical care, including care for their children, out of fear of reprisal. For decades, immigrants have feared accessing medical care out of fear of being reported to immigration officials.
When I worked at University Medical Center in El Paso (a public hospital located along the U.S.-Mexico border) back in the 1990s, it was shocking but not uncommon to find people who had passed away in the parking lot of the hospital, as they had waited too long for their conditions to worsen to the point that their emergency circumstances would demand immediate attention.
Dr. Pastor said in the TikTok video he deleted after the threat by Gov. Abbott:
You should come to a hospital if you are sick, you should get healthcare if you are sick. . . We are going to keep advocating for our patients because that is why we went to medical school and not to be. . .ICE [Immigration and Customs Enforcement] deportation people.
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Dr. Pastor’s assurance that Texas Children’s Hospital, its doctors, nurses, and other medical professionals will care for sick children, regardless of their ability to pay or immigration status, is keeping with medical ethics but also federal law, the Emergency Medical Treatment and Labor Act (EMTALA), which prohibits the denial of emergency care to patients in need. Even Gov. Abbott acknowledges this fact in his executive order.
Dr. Pastor also correctly informed people that they did not have to answer questions about their immigration status to obtain care.
If Gov. Abbott was truly concerned about the health and well-being of Texas’s children, he would withdraw the executive order and discontinue threatening the funding to both Texas Children’s Hospital and Baylor College of Medicine. Politicians should neither play politics with the health and well-being of children nor create a “chilling effect” that prevents children from getting health coverage.
A Chilling Effect on Access to Care
The "chilling effect" of these policies is well-documented and deeply troubling. Research compiled by the Kaiser Family Foundation (KFF) highlights the detrimental impact of tying immigration status inquiries to health care services. When families fear questions about their immigration status, they are more likely to forgo care, even in emergency situations.
The KFF brief underscores several key consequences:
Delayed or foregone care for children with chronic conditions or acute illnesses, leading to avoidable complications and higher costs in the long run.
Increased fear and confusion, even among U.S. citizen children in mixed-status families, who may be legally entitled to care but avoid seeking it due to misinformation or fear of family separation.
Worsened maternal and child health outcomes, as parents avoid prenatal and pediatric care, vaccinations, or regular check-ups.
KFF also highlights the “chilling effect” these types of orders have on “the states’ economies and workforces.”
Studies, including that by the Texas Comptroller, find that immigrants “contribute more to Texas than they cost the state.”
As for Texas Children’s Hospital and Baylor College of Medicine, they should be supported and not threatened. Nobody violated any laws or mandates by the Governor here – not Dr. Pastor, Texas Children’s Hospital, Baylor College of Medicine, nor the thousands of children who receive health- and life-saving treatment from those medical providers. All that Dr. Pastor did in the video was to affirm medical ethics and his passion, which is to promote the health and well-being of children and to inform parents about their right to obtain health care services for their kids.
Instead of harm, Gov. Abbott should do something positive for children, such as taking action to address the abysmal reality that Texas has the highest rate of uninsured children in the country and ranks a pathetic 43rd in overall child well-being in the 2024 KIDS COUNT Data Book.
Furthermore, the Governor could help address the shortages in rural Texas to help women get prenatal care and deliver a baby.
These are examples of things the Texas leaders could do to improve the lives of babies and children. Again, this is a choice.
The Executive Order’s Flawed Premise
One of the most misleading premises of Governor Abbott’s executive order is the implication that care provided to undocumented immigrants imposes an undue financial burden on the state’s health care system. In reality, the federal government already provides multiple streams of reimbursement to states for uncompensated medical expenses, including care for undocumented individuals. These programs ensure that hospitals can maintain financial stability while fulfilling their ethical and legal duty to treat all patients in need, regardless of their immigration status.
Here’s how some of these reimbursement mechanisms work:
1. Medicaid Federal Matching Assistance Payments (FMAP)
Medicaid operates as a federal-state partnership, with the federal government covering a significant share of program costs through FMAP. For Texas, the federal government pays 60% of Medicaid expenses, ensuring that hospitals serving Medicaid patients receive critical financial support.
2. Medicaid Emergency Services for Undocumented Immigrants
Under federal Medicaid rules, undocumented immigrants are ineligible for federally-funded Medicaid coverage. However, due to efforts by Rep. Henry Waxman (D-CA) and Sen. John Chafee (R-RI) that Sen. Lloyd Bentsen (D-TX) agreed to in the 1980s,[2] hospitals can be reimbursed for lifesaving treatments, such as those provided in emergency rooms or during childbirth, regardless of a patient’s immigration status. This funding helps offset unreimbursed uncompensated care costs for hospitals.
3. Medicaid and Medicare Disproportionate Share Hospital (DSH) Payments
Hospitals that serve a high number of low-income and uninsured patients also qualify for Disproportionate Share Hospital (DSH) payments through Medicare and Medicaid. These payments help offset the cost of uncompensated care, providing essential financial stability to safety-net hospitals across the Lone Star State. In 2020, Texas received over $1.3 billion in federal Medicaid DSH payments in FY 2024.
Unfortunately, Medicaid DSH funding is scheduled for $8 billion in cuts beginning on Jan. 1, 2025. If Gov. Abbott is truly worried about the uncompensated care absorbed by Texas hospitals, he should demand that his legislative delegation restore that funding. If the funding is reduced, Texas would absorb a disproportionate share of those cuts.
In addition to Medicaid, Medicare also provides funding to hospitals that treat a disproportionate number of low-income and uninsured patients. These payments help mitigate the financial impact of treating undocumented patients and ensure that health systems remain solvent.
4. Texas’s Medicaid Delivery System Reform Section 1115 Waiver
Texas’s Medicaid waiver includes a Delivery System Reform Incentive Payment (DSRIP) program, which was specifically designed to reduce uncompensated care costs while improving health care delivery. Although Gov. Abbott seems to have forgotten, he recognized the benefits of the federal government’s waiver back in April 2022 when he said the “waiver extension allows Texas' 1115 Waiver, originally approved in January 2021, to continue for the next 10 years and ensures that Texans will have access to crucial healthcare funding, including funds for uncompensated care.” The waiver provides $3.8 billion in funding to providers to compensate for uncompensated care.
Moreover, Texas hospitals successfully won a lawsuit that provides them additional Medicare DSH dollars based on the spending in their Medicaid waiver.
The various federal streams of funding demonstrate that resources are in place to address uncompensated care. Thus, Abbott’s executive order and threats to Texas Children’s Hospital and Baylor College of Medicine appear more politically motivated than fiscally justified. Furthermore, if he were truly concerned about uncompensated care costs, he would take action so that Texas would no longer lead the nation in the number and rate of uninsured.
Children at the Crossroads of Policy and Ethics
Unfortunately, Governor Abbott’s executive order and threats to Texas Children’s Hospital and Baylor College of Medicine undermine children’s health and the medical providers who serve them. As the Florida experience shows, policies that tie immigration status to health care access sow fear, confusion, and harm. Politics should never be weaponized to jeopardize the health and futures of children.
Children should never be used as political pawns. Their health and well-being should not be used as leverage in ideological or political battles. We urge Gov. Abbott to withdraw his executive order and, instead, adopt a commitment to equitable health care for all Texas residents, including its children. Texas should do better and strive for excellence.
Every child deserves the chance to thrive, grow, and receive the care they need, free from fear, discrimination, or threat.
ENDNOTES
[1] “Express lane eligibility” is a Medicaid option available to states to simplify and streamline the enrollment of children into health care coverage using income or other data from other public programs, such as SNAP. The bipartisan federal legislation was sponsored by Sens. Jeff Bingaman (D-NM) and Richard Lugar (R-IN) and enacted as part of the Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law No. 111-3).
[2] Morgan, D. (1994, Jan. 30). Medicaid Costs Balloon Into Fiscal ‘Time Bomb.” Washington Post. Accessed via https://www.washingtonpost.com/archive/politics/1994/01/30/medicaid-costs-balloon-into-fiscal-time-bomb/46e28dfa-9168-43d1-97fc-4dc5a280894e/. The article reads, “Bentsen found himself caught between constituents who feared that liberalization would accelerate migration from Mexico and public hospitals in El Paso, and California pushing for Medicaid reimbursements for the care they were providing anyway. In the end, he accepted a compromise that allowed Medicaid reimbursements for the emergency care of illegal immigrants, including childbirth costs.” (In full disclosure, I was working at that public hospital in El Paso advocating for the funding at the time.)
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