viewpoint

On Healthcare Equity, Texas Takes a Step Backward

A new executive order in Texas that requires hospitals to ask patients for their immigration status jeopardizes health outcomes, compromises economic benefits, and challenges moral imperatives, writes alum Joaquin Moreno (SPH’23) in a new viewpoint.

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Texas hospitals that accept Medicaid or the Children’s Health Insurance Plan (CHIP) are now required to ask patients to reveal their immigration status, after an executive order by Governor Greg Abbott took effect on November 1. The policy mandates that public hospitals across the state also collect detailed information on the cost of care for individuals without lawful presence in the United States. The directive includes tracking the number of inpatient discharges and emergency room visits, which, according to the Texas administration, “impose burdens on the Texas healthcare system… by increasing the costs of medical care for all Texans…” 

At first glance, this policy seems to focus on cost control. But its broader implications—heightened by serious threats of mass deportation by the incoming Trump administration—jeopardize long-term health outcomes, compromise economic benefits, and challenge moral imperatives.

Health Outcomes

Racial and ethnic disparities in health, well-being, and life expectancy are long-standing issues across the U.S. In general, access to preventive services such as vaccines, cancer screenings, and chronic disease management can prevent health problems from worsening—and becoming more expensive to treat. However, individuals without health insurance—which includes many undocumented immigrants—often avoid medical care altogether or rely on costly emergency room visits as a last resort.

Healthcare accrediting bodies such as The Joint Commission and the Centers for Medicare & Medicaid Services have begun holding hospitals accountable for health equity in the care they provide. Strategies such as shifting from fee-for-service models to value-based care and offering financial incentives for preventive services could help address barriers to healthcare access. Ensuring comprehensive healthcare access to all individuals, regardless of immigration status, would improve health outcomes and reduce long-term costs, benefitting entire communities.

Economic Benefits

Investing in preventive care and early intervention brings significant economic advantages, particularly in a country that spends $4.5 trillion annually on chronic diseases. Research has shown that uninsured individuals, including many undocumented immigrants, generally use fewer healthcare services than their insured counterparts. In fact, a report published by the State of Florida’s Agency for Health Care Administration reiterated that unlawfully present patients only account for a fraction of the total healthcare spending. Without access to employer-sponsored insurance, undocumented residents are often left with costly, unsubsidized private coverage as their only option for comprehensive care.

Innovative policies, such as allowing low-income undocumented immigrants to enroll in Medicaid or similar affordable programs—a step already taken by some states—could bridge this gap. Lowering immigration-related barriers to coverage could help reduce healthcare spending while ensuring that more people have access to necessary care.

Social Justice 

Access to healthcare is a basic human right that should be available to everyone, regardless of immigration or socioeconomic status. The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 mandates that all hospitals in the U.S. provide emergency care to all patients, regardless of their ability to pay or insurance status. Governor Abbott’s policy raises critical questions about its true intentions in solely ‘managing costs,’ while completely disregarding the public health of its state.

Public health experts have long stressed the importance of trust between communities and healthcare systems. Policies that deter individuals from seeking care risk eroding this trust, with far-reaching consequences for both patients and tax-payers. If the goal is to improve cost management, more innovative and inclusive approaches are necessary.

For instance, the 2024 Commonwealth Fund State Health Disparities report recommends requiring insurers to collect and report race and ethnicity data, as well as meeting Affordable Care Act requirements for including essential community providers in their networks. These steps could promote more equitable treatment and improve health outcomes for underserved populations—a costly problem for our healthcare system.

Balancing Costs and Equity

At the core of this issue is the balance between maintaining economic sustainability across a healthcare system and fulfilling the moral and public health imperative to provide care for all. While Governor Abbott’s executive order does not explicitly deny care to undocumented individuals, it creates an environment of fear and mistrust, discouraging people from seeking necessary medical attention. This not only exacerbates public health risks, but also drives costs up by perpetuating disparities in underserved populations across the U.S. 

As leaders navigate this critical crossroads, the guiding principle must be clear: equitable care for all is not just a goal—it is a necessity.

Special thanks to Jesus Carreon, JD Candidate at Harvard Law School, for his valuable insights on immigration policy, which informed this discussion.