Dan Keemahill, Texas Tribune

'They're coming in sicker': Doctors alarmed as Trump's crackdown becomes a health disaster

After missing her chair and falling on the tile floor during a child’s birthday party last October, the 54-year-old Edinburg woman begged: “Don’t take me to the hospital.”

Her head was throbbing and sharp pain stretched down her back. The woman, an undocumented immigrant, told herself she'd have to brave through it. Immigration enforcement officials have detained two of her distant family members and deported another to Mexico, and she feared that going to a hospital would make her an easy next target.

“It’s not worth the risk,” said the mother of four, who would only speak on the condition of anonymity for fear of being deported.

The woman has lived in South Texas for 27 years — half of her life so far. She moved to Texas from Reynosa, her hometown, after her brother-in-law was murdered on the street. All of her children are citizens and when she fell, all she could think about was: “I don’t want to be separated from my family,” she said.

She’s one of many in Texas who have been avoiding hospitals over fear of immigration enforcement at both the state and federal level, according to public health experts. Gov. Greg Abbott ordered hospitals in November 2024 to start asking patients about their citizenship status, a question patients may decline to answer. Facilities track responses and submit that information to Texas Health and Human Services.

The data, limited to 10 months, suggests that undocumented immigrants may be increasingly foregoing health care.

In November 2024, Texas hospitals reported about 30,000 visits from undocumented immigrants. In a matter of months, that dropped by 32% to 20,345 visits in August.

During the same period, the number of visits by patients legally present in the U.S. increased by 14%. Self-identified undocumented patients comprised about 2% of all reported visits statewide, and dozens of hospitals reported no undocumented patients.

Experts blame the decrease in hospital visits by undocumented immigrants on the government’s strict enforcement of immigration laws.

Fulfilling his promise to carry out the country’s largest deportation program, Trump last year lifted a federal policy that limited arrests of immigrants in sensitive locations such as hospitals, along with churches and schools. Federal immigration officers have been seen staking out hospitals in other parts of the country. Although agents have not been confirmed near Texas hospitals, many immigrants are not taking the risk.

“Substantial shares of immigrants are saying they have avoided seeking medical care due to immigration related fears,” said Drishti Pillai, the director of immigrant health policy at KFF, a health policy organization that regularly surveys immigrants about policies that affect their health care access.

While undocumented immigrants have always used health care significantly less often than the general population, she said, new policies, such as Texas’ hospital citizenship question, have made it worse.

“We are seeing an exacerbation of some of these challenges,” Pillai said.

Abbott has insisted that the data produced from his executive order proves public funds are paying for the health care of undocumented immigrants. While hospital visits by undocumented immigrants dropped during the 10-month period, the average cost per visit by them increased about 50%, from $3,409 in November 2024 to $5,100 in August.

Abbott did not require hospitals to report how much visits by patients legally present in the U.S. cost taxpayers.

“For too long, Biden-Harris open-border policies forced Texas taxpayers to foot the bill for over a billion dollars in healthcare costs for individuals in the country illegally,” said Andrew Mahaleris, Abbott’s press secretary. “Texans should not have to financially support medical care for illegal immigrants.”

Abbott’s order has produced less-than-conclusive data because it depends on whether undocumented immigrants are willing to self-identify as such.

Since patients aren’t required to answer questions of their citizenship under Abbott’s order, the drop in the number of visits from patients self-identifying as undocumented immigrants could also be because fewer patients are choosing to answer the question. But, it is impossible to know that from the data.

Even so, immigrant rights groups and health care policy experts say they are seeing more Texans like the Edinburg woman who are sick and in pain but wait to seek hospital and other medical care. Undocumented immigrants are also delaying preventive care, such as cancer screenings, prenatal check-ups and vision exams. Pillai fears delay in any care could lead to worse health conditions and prognoses, and more expensive medical bills.

Dr. Ryan Padrez, an associate director at Stanford University’s Center on Early Childhood, said he’s especially concerned about the long-term impacts on children. It’s common in mixed-status families that children are citizens and parents are undocumented, and if adults are avoiding hospitals, they probably aren’t taking their children to medical clinics either, he said.

“They’re not putting themselves or their child at risk,” said Padrez. “Families are choosing to delay care for now.”

Since the Edinburg woman’s fall last year, she said “not a day goes by that I don’t experience some type of headache.” She had vision problems for a couple weeks after the incident and months later, still suffers from dizzy spells and some memory loss, she said. She’s been placing ice packs at the back of her neck daily to reduce pain, but so far, it’s only offered temporary relief.

“When state and federal governments design and implement immigration policies and enforcement to force communities into hiding, under threat of violence,” said Lynn Cowles, director of health and food justice for Every Texan, a Texas policy group, “whole communities suffer.”

Regional differences

In Texas, people have reported staying home as much as possible to avoid being targeted by police or immigration officers, and only going out for essential trips like to work or to buy groceries.

The drops in hospital visits from some undocumented patients, according to the Tribune’s analysis, were reported across the state, but some of the steepest declines were in hospitals near the Mexico border, including Edinburg.

Doctors Hospital of Laredo saw a nearly 48% decline in visits from undocumented patients, from 1,700 visits in November 2024 to 889 in August. South Texas Health System in Edinburg saw a 52% drop in visits during the same timespan by undocumented patients, from 1,127 to 538.

Declines weren’t limited to border hospitals. Dallas County Hospital District reported more than 4,000 undocumented hospital visits in November 2024, and that declined by more than a third in August.

All three hospitals declined to provide a comment for the story.

The Tribune contacted eight other hospitals across the state, including major facilities in Austin, Houston and San Antonio, asking them to explain their reported drops in visits from undocumented immigrants. Most hospitals did not respond and others declined to be interviewed. The Texas Hospital Association, which represents more than 85% of the state’s acute care hospitals, also declined to comment on the data.

Often fixtures in hospitals and clinics who help connect patients to resources, social workers are having trouble tracking down patients after an appointment, said Will Francis, executive director of the National Association of Social Workers chapters in Texas.

“Social workers will never accomplish what the client needs if they are afraid having a conversation will get them in trouble later on,” he said.

Many immigrants — not only those who are undocumented — are delaying medical care over concerns about being mistaken for an undocumented immigrant and being illegally detained, experts said.

There’s been several cases in Texas in which people lawfully in the country, such as DACA recipients, have been detained by ICE. About 1 in 7 immigrants avoided medical care over fear of immigration enforcement, according to a November KFF survey.

“Regardless of immigration status, we are seeing substantial shares of immigrants say that the current policy environment and immigration related concerns have led to negative health impacts for both immigrants and their children, the majority of whom are U.S. citizens,” Pillai said.

Immigration enforcement has blocked people from getting medical care, at hospitals and elsewhere. Last year, an 11-year-old with a brain tumor and her family were detained while traveling to Houston for a surgery. Immigration enforcement agents stopped them at a border checkpoint in Sarita, a town south of Kingsville, and the family was eventually deported.

No trust

A slow public health clinic is typically not a good sign, said Phil Huang, the director of the Dallas County Health and Human Services, especially during the back-to-school season.

By August each year, Huang said the line for back-to-school vaccines usually snakes outside the clinic’s doors and congests the waiting room. But last year, he said, “we didn’t see that.” In 2024, the county administered 16,412 vaccines, he said. Last August, Dallas County’s public health clinics administered 9,578.

In Texas, uninsured children, regardless of citizenship status, can get vaccinated at low or no cost. Because his clinics don’t ask for patients’ citizenship status, Huang suspects many of his patients are undocumented immigrants and ties the dramatic drop in county-administered vaccinations to concerns about immigration enforcement. Employees have told him that patients have been more hesitant to share routine, personal information with them, and that many have asked whether that data was being used to help ICE locate them.

The drop in vaccinations “is disheartening,” said Ann Barnes, president and CEO of Episcopal Health Foundation, a public charity based in Houston.

“The very systems that are supposed to be there to help are now not trusted,” she said.

Trump gave deportation officials access to Medicaid data last year, which public health officials say has had a chilling effect on emergency room and other hospital visits for undocumented immigrants across the country. People are now fearful that the information hospitals collect will be weaponized against them and passed along to ICE. Undocumented immigrants, however, don’t have access to federal health care coverage unless it's a medical emergency.

Barnes said one of the primary options for health care for undocumented immigrants and their families has been federally qualified health centers since they’re required to serve anyone in their service area, regardless of income or immigration status. She said it makes them a crucial safety net for the community.

Three months after her fall, the Edinburg woman said her head injury got so painful that she decided in January to go to the University of Texas Rio Grande Valley’s Health Center to get checked — a clinic she said she’s trusted for years.

But recent reinterpretations of “federal public benefits” bars undocumented immigrants from certain programs that federally qualified health centers offer, including certain mental health programs, substance abuse programs and family planning. Even though they will still have access to essential services, such as check-ups, screenings, immunizations and child visits, undocumented immigrants are opting not to come into these centers altogether.

Instead of going to federally qualified clinics, undocumented immigrants are most likely leaning on nonprofits and charity clinics with limited resources for their health care, Barnes said.

Tara Trower, deputy CEO for CommUnity Care Health Centers, which runs federally qualified clinics in Austin, said they’re offering telehealth options for those concerned about going in person, including undocumented immigrant patients. They also implemented a telehealth system that doesn’t require patients to provide information that can be used to track them down, adding an extra layer of security for undocumented patients who fear their whereabouts could be given to immigration enforcement.

“We are actually seeing a record number of patients again this year, using this method, but we also hear the concerns,” she said.

Trower said her organization is making more effort to reschedule appointments for patients and battle misinformation about these centers sending patient information to ICE. A couple years ago, Trower said a “Know Your Rights” information campaign by the organization helped patients learn about what protections they have.

“They feel safe coming in for care here because we don’t ask for anything, we deliver care regardless,” Trower said.

Long-term impact

In the Texas-Mexico border county of Hidalgo, hospitals reported a more than 40% drop in visits from undocumented patients in August compared to November 2024. Dr. Ivan Melendez, a family practice doctor serving as the county’s chief medical officer, said more patients are waiting longer before seeking treatment.

“They’re coming in with a higher level of acuity, they’re sicker,” he said.

He said patients in the Rio Grande Valley, the southernmost tip of the state, more often than before are calling hospital officials ahead of time to ask whether ICE is there.

When people wait too long to flag health problems, their chances of recovering quickly or at all shortens, said Padrez. And if people are avoiding hospitals, he’s worried they’re also avoiding preventive health care services.

“We have a script for how this played out a few years ago, during the COVID-19 pandemic,” he said.

People stayed away from health clinics and children missed key routine check-ups during the height of the pandemic, Padrez said, and not too long after “we saw skyrocketing rates of under-detected or under-treated mental health needs like anxiety and depression.”

There’s an important window during a child’s early years when doctors look out for early signs of diseases or developmental delays, he said. Treatment for those conditions, such as therapy, are often more successful when children start them at a very young age.

Huang with Dallas County said Texas is ripe grounds for recurring public health crises if undocumented people continue to avoid health care. Last year, the state faced a record-breaking measles outbreak that started in West Texas and an 11-year high in whooping cough cases. This year, at least 170 cases of measles have been reported statewide, concentrated mostly in federal detention centers in West Texas.

“We are more vulnerable to outbreaks… We might see other preventable diseases further down the road,” he said.

For years, the woman in Edinburg has a work permit and has been employed as a home health aid for an elderly woman, making sure she is well fed, cleaned, and that her health is taken care of. As she now faces her own health struggles, she said she won’t stop continuing to care for someone else’s well being.

“I leave my house every day with a lot of nerves, praying and asking God to let me come back home,” she said. “To let me get to my job and let me come back home safely.”

Disclosure: Episcopal Health Foundation, Every Texan and Texas Hospital Association 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.

This article first appeared on The Texas Tribune.

Texas school board defies state Republicans to strip chapters from textbooks

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

In 2022, conservative groups celebrated a “great victory” over “wokeified” curriculum when the Texas State Board of Education squashed proposed social studies requirements for schools that included teaching kindergartners how Rosa Parks and Cesar Chavez “advocated for positive change.”

Another win came a year later as the state board rejected several textbooks that some Republicans argued could promote a “radical environmental agenda” because they linked climate change to human behavior or presented what conservatives perceived to be a negative portrayal of fossil fuels.

By the time the state board approved science and career-focused textbooks for use in Texas classrooms at the end of 2023, it appeared to be comfortably in sync with conservatives who had won control of local school boards across the state in recent years.

But the Republican-led state education board had not gone far enough for the conservative majority on the school board for Texas’ third-largest school district.

At the tail end of a school board meeting in May of last year, Natalie Blasingame, a board member in suburban Houston’s Cypress-Fairbanks Independent School District, proposed stripping more than a dozen chapters from five textbooks that had been approved by the state board and were recommended by a district committee of teachers and staffers.

The chapters, Blasingame said, were inappropriate for students because they discussed “vaccines and polio,” touched on “topics of depopulation,” had “an agenda out of the United Nations” and included “a perspective that humans are bad.”

In a less-publicized move, Blasingame, a former bilingual educator, proposed omitting several chapters from a textbook for aspiring educators titled “Teaching.” One of those chapters focuses on how to understand and educate diverse learners and states that it “is up to schools and teachers to help every student feel comfortable, accepted and valued,” and that “when schools view diversity as a positive force, it can enhance learning and prepare students to work effectively in a diverse society.”

Blasingame did not offer additional details about her opposition to the chapters during the meeting. She didn’t have to. The school board voted 6-1 to delete them.

The decision to strip chapters from books that had already won the approval of the state’s conservative board of education represents an escalation in local school boards’ efforts to influence what children in public schools are taught. Through the years, battles over textbooks have played out at the state level, where Republicans hold the majority. But local school boards that are supposed to be nonpartisan had largely avoided such fights — they weighed in on whether some books should be in libraries but rarely intervened so directly into classroom instruction. Cypress-Fairbanks now provides a model for supercharging these efforts at more fine-grained control, said Christopher Kulesza, a scholar at Rice University’s Baker Institute for Public Policy.

“One of the things that would concern me is that it’s ideology pushing the educational standards rather than what’s fact,” he said.

The board’s actions send a troubling message to students of color, Alissa Sundrani, a junior at Cy-Fair High School, said. “At the point that you’re saying that diversity, or making people feel safe and included, is not in the guidelines or not in the scope of what Texas wants us to be learning, then I think that’s an issue.”

With about 120,000 students, nearly 80% of whom are of Hispanic, Black and Asian descent, Cy-Fair is the largest school district in Texas to be taken over by ideologically driven conservative candidates. Blasingame was among a slate of candidates who were elected through the at-large voting system that ProPublica and The Texas Tribune found has been leveraged by conservative groups seeking to influence what children are taught about race and gender. Supporters say the system, in which voters cast ballots for all candidates districtwide instead of ones who live within specific geographic boundaries, results in broader representation for students, but voting rights advocates argue that it dilutes the power of voters of color.

Blasingame and others campaigned against the teaching of critical race theory, an advanced academic concept that discusses systemic racism. Most of the winning candidates had financial backing from Texans for Educational Freedom, a statewide PAC that sought to build a “stronghold” of school board trustees “committed to fighting Critical Race Theory and other anti-American agendas and curriculums.” The PAC helped elect at least 30 school board candidates across the state between 2021 and 2023, in part because it focused on anti-CRT sentiment, said its founder, Christopher Zook Jr. “You could literally go out and say, CRT, you know, ‘Stop critical race theory in schools,’ and everyone knew what that means, right?” he said. “The polling showed that that messaging works.”

Shortly before Blasingame and two fellow conservatives won election in 2021, Texas lawmakers passed a landmark law that sought to shape how teachers approach instruction on race and racism. The law, which aimed to ban critical race theory, prohibits the “inculcation” of the notion that someone’s race makes them “inherently racist, sexist, or oppressive, whether consciously or unconsciously.”

Blasingame made no mention of the law when she pushed to remove chapters about teaching a diverse student body, but pointed to it as the reason for her objection in text messages and an interview with ProPublica and the Tribune. Though Blasingame acknowledged that one of the chapters had “very good presentation on learning styles,” she said removing the whole chapter was the only option because administrators said individual lines could not be stricken from the book.

The textbook referred to “cultural humility” and called for aspiring teachers to examine their “unintentional and subtle biases,” concepts that she said “go against” the law. The school board needed to act because the book “slipped through” before the state’s education agency implemented a plan to make sure materials complied with the law, Blasingame said.

State Board Chairman Aaron Kinsey, who is staunchly anti-CRT, declined to say if he thought the body had allowed textbooks to slip through as Blasingame suggested. Kinsey, however, said in a statement that contracts with approved publishers include requirements that their textbooks comply with all applicable laws. He did not comment on Cy-Fair removing chapters.

Cy-Fair appears to have taken one of the state’s most aggressive approaches to enforcing the law, which does not address what is in textbooks but rather how educators approach teaching, said Paige Duggins-Clay, the chief legal analyst for the Intercultural Development Research Agency, a San Antonio-based nonprofit that advocates for equal educational opportunity.

“It definitely feels like Cy-Fair is seeking to test the boundaries of the law,” Duggins-Clay said. “And I think in a district like Cy-Fair, because it is so diverse, that is actively hurting a lot of young people who are ultimately paying the cost and bearing the burden of these really bad policies.”

The law’s vagueness has drawn criticism from conservative groups who say it allows school districts to skirt its prohibitions. Last month, Attorney General Ken Paxton filed a lawsuit against the Coppell school district in North Texas and accused administrators of illegally teaching “woke and hateful” CRT curriculum. The suit points to a secret recording of an administrator saying that the district will do what’s right for students “despite what our state standards say.” The lawsuit does not provide examples of curriculum that it alleges violates state law on how to teach race. In a letter to parents, Superintendent Brad Hunt said that the district was following state standards and would “continue to fully comply with applicable state and federal laws.”

Teachers and progressive groups have also argued that the law leaves too much open to interpretation, which causes educators to self-censor and could be used to target anything that mentions race.

Blasingame disputes the critique. A longtime administrator and teacher whose family emigrated from South Africa when she was 9 years old, she said she embraces diversity in schools.

“Diversity is people and I love people,” she said. “That’s what I’m called to do, first as a Christian and then as an educator.”

But she said she opposes teaching about systemic racism and state-sanctioned efforts to promote diversity, equity and inclusion, saying that they overemphasize the importance of skin color.

“They seed hate and teach students that they are starting off behind and have unconquerable disadvantages that they will suffer all their lives,” Blasingame said. “Not only does this teach hate among people, but how could you love a country where this is true?”

The assertion that teaching diversity turns students of color into victims is simply wrong, educators and students told the news organizations. Instead, they said, such discussions make them feel safe and accepted.

One educator who uses the “Teaching” textbook said the board members’ decision to remove chapters related to diversity has been painful for students.

“I don’t know what their true intentions are, but to my students, what they are seeing is that unless you fit into the mold and you are like them, you are not valued,” said the teacher, who did not want to be named because she feared losing her job. “There were several who said it made them not want to teach anymore because they felt so unsupported.”

The board’s interpretation of the state’s law on the teaching of race has stifled important classroom discussions, said Sundrani, the student in the district. Her AP English class, a seminar about the novel “Huckleberry Finn,” steered clear of what she thinks are badly needed conversations about race, slavery and how that history impacts people today.

“There were topics that we just couldn’t discuss.”