Dan Keemahill, Texas Tribune

Vanessa Melendez had been going back and forth with the state over her family’s Medicaid and food assistance applications for months when the Houston mom learned she was pregnant with her third child. She submitted a new application for Medicaid for Pregnant Women, which covers care during pregnancy and for 12 months after giving birth, last December.

And then she waited.

She didn’t receive any update until she was more than four months pregnant — well into her second trimester — as anxiety over how her baby was doing became overwhelming.

It’s crucial for pregnant women to be seen in the first trimester, which is the first 13 weeks of pregnancy. It allows the doctor to confirm the pregnancy, detect a fetal heartbeat and do some early testing. It’s also when a majority of miscarriages occur.

“It was a lot and I felt like everything was going wrong and I wasn't going to get the help that I needed,” said Melendez, who delivered her son in July. “I'm going to have this baby, and I have no insurance.”

The Texas Health and Human Services Commission has long struggled to process Medicaid applications in a timely manner — within 30 to 45 days, under the federal definition, according to a Legislative Budget Board report released this month. The Centers for Medicare and Medicaid Services scrutinized Texas’ timeliness issues and the feds put the state on a corrective action plan to more quickly process Medicaid and the food assistance benefits, Supplemental Nutrition Assistance Program (SNAP). By the end of 2025, the state was improving its timeliness.

That was, until the One Big Beautiful Bill Act, which passed July 2025, started requiring Medicaid recipients to reapply every six months instead of annually, and prove they are working, trying to work or are volunteering in an effort to address fraud. Even though data from the Texas HHSC has not shown fraud is widespread in Texas, the state’s backlog is climbing back up.

In July, 65% of Medicaid applications were processed in a timely manner compared to 81% a year ago, according to most recent data from Texas Health and Human Services Commission, which administers Medicaid on the state level. The federal government wants 95% of them processed in a timely manner. In August, 211,000 applications were still waiting to be processed by the state.

This has come as Medicaid enrollment nationwide has also sharply declined. In the 11 months since OBBBA passed, there have been 252,000 fewer Texans enrolled in Medicaid, a 6% drop, according to preliminary state caseload data as of June. SNAP enrollment dropped 17% — 597,000 fewer Texans. Children accounted for almost two thirds of the declines.

There were more than 3.7 million Texans enrolled in Medicaid in June, according to latest Medicaid data from the state, and 1.3 million households on SNAP in July.

OBBBA also financially penalizes the state for having a high rate of underpaying or overpaying SNAP and Medicaid recipients, requiring Texas to be more meticulous in its application processing. In April, Texas HHSC officials told lawmakers that they will have to pay $700 million a year to participate in SNAP if they do not bring their error rate down starting in 2027. Similar changes for Medicaid start in 2029.

Together, these new requirements create more administrative burden on HHSC, which has had to provide new training to the 6,000 or so staff members who review both SNAP and Medicaid applications, according to Diane Forester, the director of health policy at Texans Care for Children, a nonprofit child advocacy group. And those changes put new demands on a technological system that was already struggling to keep up.

“Those demands are landing on a system that was already under strain,” she said. “It's not one single cause for the entire backlog, but clearly the system is falling further behind.”

The state health agency did not explain to The Texas Tribune the cause of the backlog or how the agency is addressing it. However, the agency said that the system it uses to process applications, Texas Integrated Eligibility and Renewal System, is not struggling.

“HHSC routinely updates the system to meet federal and state requirements and protect data,” Jennifer Ruffcorn, an agency spokesperson, said. “OBBBA included several provisions that modified eligibility for SNAP and Medicaid. HHSC provided training in these areas to ensure accuracy. TIERS remains a fully functioning eligibility system that supports application processing.”

State Sen. Lois Kolkhorst, who chairs the Senate health committee, said the agency is doing what it is supposed to do to root out and prevent fraud.

“As new tools are put into practice, we will naturally begin processing these applications more efficiently and address backlogs in the program to ensure Texas complies with all federal laws on welfare programs while providing for those who are truly eligible for aid,” Kolkhorst said.

The impact

When Jessica Ballek lost her job in December, she immediately applied for Medicaid and SNAP. Those benefits for her and for her two kids were approved within two days.

Ballek reapplied for SNAP in April, about a month before her deadline, and then she waited. The benefits didn’t arrive in May. This loss happened at a time when she was moving to Chandler, a small town near Tyler in East Texas, for her new job working nights as a private home nurse. Losing SNAP made that transition exceptionally difficult and she relied on food banks when possible. But the food banks sometimes didn’t have enough food, she said.

She called for an update on her application in June and in July. Finally, after nearly five months with no information, she learned her family had lost its SNAP benefits and was told her new job had disqualified her.

The timeliness rate of SNAP redeterminations dropped from 83% in January to 28% in July, the lowest rate in four years.

Now, as she wades through the reapplication process for both of her children’s Medicaid coverage she said she needs because her employer-sponsored insurance is limited, she worries those benefits will also be cut and that she won’t learn about it for months.

“My kids have been with the same pediatrician since they were born and I don’t plan on changing that anytime soon, but that self-pay is going to eat my lunch,” Ballek said.

The delays in Medicaid are contributing to more visits to hospitals and federally qualified health centers, according to officials who run those operations. To cope with the loss of Medicaid, many patients have turned to federally qualified health centers, which can provide healthcare at little to no cost, and emergency rooms.

Emergency rooms across the state have begun to see more people walk through their doors, according to the Texas Hospital Association. And an increasing number of those patients have no insurance whatsoever.

In 2024, Texas nonprofit hospitals gave $14.9 billion worth of medical care to uninsured Texans, according to the Texas Hospital Association. More than 5 million Texans are uninsured, which is more than any other state in the country, according to the latest census data available.

“It’s an expensive situation and not good for anyone,” said Carrie Williams, the chief communications officer for the Texas Hospital Association.

Rural hospitals, especially, rely on Medicaid funding and are always at risk of closure across the country, but changes to Medicaid will exacerbate that.

At a mental health center in East Texas, Keith Kirbow, a nurse practitioner, is worried about rural health across Texas as people lose access to Medicaid.

“I was the chief nursing officer when we closed the critical access hospital in Linden because of lack of funding,” Kirbow said. “I've seen this across the spectrum, from acute care to outpatient. Health care access has been so badly impacted by people not having the ability to pay.”

He’s grateful to work for a health center program that is able to see patients regardless of their ability to pay — thanks, in large part, to grants from organizations like the T.L.L. Temple Foundation and the Episcopal Health Foundation. But not all health clinics have this kind of support or access, Kirbow said.

OBBBA and outdated technology

There has been a longstanding fear that individuals are receiving benefits they don’t deserve from the U.S. entitlement programs, such as SNAP, CHIP and Medicaid — which largely serve poor families and disabled or elderly people.

In a recent Senate health committee hearing, Kolkhorst said HHSC had allowed some people to receive Medicaid benefits for more than 90 days without verifying their eligibility, which includes their citizenship status. She said there were more than 1,800 who received it that were ineligible. This is a small fraction of the millions enrolled in Medicaid.

“Those are real dollars lost and diverted from those who truly need them,” Kolkhorst said. “So of course, we need to be more careful in processing and screening these applications.”

Texas has been proactive about detecting fraud as early as possible, Forester said.

In a recent Office of Inspector General report, the benefits program integrity unit found the state had recovered more than $37.5 million in improper payments made between March 1 and May 31. Of the more than 3,800 cases opened against individuals, 30 were referred for prosecution and 300 were referred for disqualification from the program.

In 2025, the most recent data available, 9% of Texas’ SNAP payments had an error, better than the national rate of 11%. Fraud isn’t the only — or even largest — reason for errors. It was often mistakes, not intentional lies, that led to errors.

However, fears of fraudulent activity, like lying on application forms, have escalated in late 2025 and early 2026 thanks to scandals in Minnesota and California as well as information released from the now shuttered U.S. Department of Government Efficiency. Many states — including Texas — ramped up investigations into their own program administration.

Texas has one of the leanest Medicaid programs in the country, Forester said. This makes it incredibly difficult for her to believe there is widespread fraud in the system.

“We don't have anybody that's capable of holding down a job that is eligible for Medicaid,” Forester said. “I like to remind people: it is mostly poor kids and sick kids, our pregnant moms and some of our elderly.”

However, the system is backlogged, she said.

Every recipient of Medicaid and SNAP has to submit their applications to Texas’ review staff every six months. This means millions of applications are hitting the desks of Texas’ 6,000 or so review staff, Forester said.

They’re working through those applications using the TIERS that was fully operational statewide by 2012, Forester said. And the new requirements are like trying to make 2026 technology work well in a 1980 Honda Accord.

“It's not going to work great because we didn't even know that technology could exist back then. The system is not set up for that,” Forester said.

Texas lawmakers agreed in 2025 to invest more in technology upgrades to address these concerns, Forester said, but to see the full buildout will take years. For example, the HHSC asked to replace its payment system — which is different from the TEIRS system — because the current system would require staff to track more than $3.5 billion manually. That system is expected to be replaced by the end of 2027, according to the Legislative Budget Board report.

More problems on the horizon

Forester believes Texas lawmakers would have done well to develop solutions to upgrade state technology quicker and address the backlog during the interim legislative session. But with the end of 2026 quickly approaching with a hotly contested midterm election on the wings, she has no faith they will do anything.

“We would love to see lawmakers make reducing these delays a priority during the interim and going into the next legislative session,” Forester said. “But there just hasn't been any urgency around this, which is mind-boggling to me. It's great that we're investing in the new eligibility system; that's important. But in the meantime, families cannot wait years for that system to come online.”

While no new federal legislation is expected to affect Medicaid in the near future, there are pieces of the One Big Beautiful Bill Act that have yet to be fully rolled out.

Eligibility for non U.S. citizens will narrow in October, cutting humanitarian immigrants such as asylum seekers and human trafficking survivors from the list of people who are eligible. And funding overall will continue to slow over the next decade.

And these entitlement programs are just the beginning of major changes to the country’s social safety net.

Head Start, which provides education to low-income preschoolers, is facing one of the biggest overhauls since it was created in 1965. The changes could tighten eligibility requirements as well as change quality standards.

Ballek, the night nurse and mom of two who lost SNAP coverage, is facing a triple whammy.

She hopes to finish the Medicaid applications for her children soon. The process is complicated. She’s grateful her husband, who is disabled and on his own Medicaid plan, is taken care of.

Her son’s 10-year-old well child visit may get delayed if she doesn’t learn quickly whether his coverage is approved.

And she doesn’t know how she’ll pay for the specialist her 4-year-old daughter was seeing without help from Medicaid.

She’s grateful for the support from teachers and nurses at the Head Start program her daughter attends. They have been able to manage her care and resolve some regression issues she’s had. But one major change the feds want to make to the program is to increase the student teacher ratio.

Ballek said there are 19 kids for two teachers in their program. She’d hate to see teachers reduced to one.

“I fear, depending on how they overhaul the program, it is going to impact the students that are looking at coming into Head Start next school year and possibly change the way it is this year,” Ballek said.

Disclosure: Episcopal Health Foundation and Texas Hospital Association have been major financial supporters of The Texas Tribune. T.L.L. Temple Foundation and Texans Care for Children have been financial supporters within the past five years. The Texas Tribune is a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in our journalism. Find a complete list of them and more information about our financial and disclosure policies here.

This article first appeared on The Texas Tribune.

In a state once considered one of the most affordable places in the country, candidates have popped up at barbershops and in voters’ homes vowing to tackle a new problem for Texas: its cost-of-living woes.

In ads, they’re holding bags of groceries as they bemoan how expensive food, healthcare and gas have become. On the campaign trail, they promise to cut taxes and give away money to help people thrive in Texas.

The word “affordability” is everywhere.

“Affordability has become the defining issue of this cycle and the voters want candidates to speak on it,” said Michael Adams, a professor and director of the Master of Public Affairs Graduate Program at Texas Southern University.

From housing to groceries and gas, Texans’ regular expenses have risen considerably in the past several years. As those costs have grown, Texans have increasingly said the higher cost of living is one of the biggest problems facing the state.

As Texans feel the pinch from the rising cost of living, candidates in this year's midterms up and down the ballot and across party lines are desperate to convince voters they have the bona fides to tackle the affordability crisis.

In the state’s marquee Senate race, Republican Ken Paxton has floated tax breaks for families to help pay for health care and housing costs, and more ideas. Among the proposals from state Rep. James Talarico, his Democratic foe from Austin: abolishing the gas tax to help Texans’ transportation costs and expanding tax benefits for parents with kids.

Gov. Greg Abbott, seeking a fourth term, wants to abolish school property taxes and make it easier to build homes. State Rep. Gina Hinojosa, the Austin Democrat running to unseat him, wants to send $1,500 to every Texas household and stop Wall Street from buying single-family homes.

For decades, Texas was considered a bastion of affordability, with its relatively low cost of living used to lure residents and employers from other, more expensive states. But Texas hasn’t proven immune from the national cost-of-living crisis that’s center stage in this year’s midterm elections. Signs abound that the state’s affordability has eroded.

Among major spending categories, energy prices saw the biggest leap in the last decade — a 65% jump — driven by gas prices, surging demand, natural disaster recovery and hardening costs and expanding transmission infrastructure. Housing grew by 44% and food rose by 41%, outpacing the state's overall inflation of 35%. Healthcare costs rose 25% from 10 years ago.

While the statewide median household income rose more than $25,000 between 2014 and 2024, it represented a 14% increase after inflation. Poverty has fallen in Texas and across the country in the past decade, but Texas still had the second-highest number of households living below the poverty line in 2024. While those higher up the income ladder are feeling the pinch from higher prices, lower income Texans have long faced difficulties making ends meet.

What’s more is higher tariffs and stricter immigration policies under the Trump administration have hit Texas harder than other states, said Ray Perryman, a longtime Texas economist, owing to the state’s bounty of international trade and reliance on immigration to fuel job growth. Those effects have been at least somewhat offset by the state’s lower cost of living and gas prices relative to the rest of the country, Perryman said.

“The whole thing is something of a perfect storm,” Perryman said.

Those higher costs have fueled unease among Texas voters. Texans’ top concern used to be immigration. But amid rising costs and slowing immigration, a plurality of Texans now view inflation and higher prices as the most important issue facing the state, according to an August poll of registered voters by the Texas Politics Project at the University of Texas at Austin. Higher prices came in as the top issue for Republicans and independents and the second most important issue for Democrats behind political corruption, the poll found.

“When you ask Texans what they think the most important problem is, a large chunk, and a large chunk across the political spectrum, say that first of all rising prices and more generally the economy are big problems facing the state and big problems for them,” said James Henson, director of the Texas Politics Project.

And while candidates in the marquee races have floated proposals to address key pain points for Texans’ budgets, some ideas might be more partisan signaling than serious proposals that would make a real difference, experts said. Some ideas, if enacted, could wind up making life more expensive, they said.

Even as voters want candidates to tackle the problem, there’s some doubt any can rein in costs.

Santiago Quinonez, a 25-year-old data analyst in Austin, said he’s had to cut back on eating out as costs rise. His younger sister now lives with him to save money on rent.

Affordability will be top of mind for Quinonez when he heads to the ballot box in November, he said, a sentiment he said was common among his family members and friends. But he’s skeptical any candidate could solve the issue.

“Instead of just telling me that they’re going to do something, have a decent, concrete plan and details about how they’re going to do it, which I don’t think anyone really has,” Quinonez said.

Santiago Quinonez, 25, refuels his car at a gas station in Austin on Aug. 26, 2026.

What’s at stake politically

Amid a national midterm environment already slated to be a difficult one for the GOP, Republicans find themselves playing defense amid a slower economy even as Texas has largely done better than the rest of the country. That poses potential peril for Republicans just as it did Democrats two years ago, when they faced bruising losses as voters felt the squeeze from inflation.

Making matters difficult: President Donald Trump’s trade war and the Iran war have driven up costs, adding hundreds of dollars in additional expenses to the average American family’s budget each year.

Texas Republicans have long touted the state’s robust economic growth, but those declarations might fall short if voters don’t see themselves benefitting from that growth, Henson said.

“I just think it's made it harder for Republican incumbents to make those arguments, and even harder for Republican incumbents to talk about ‘the Texas miracle,’ because in several different dimensions, it's not feeling as miraculous anymore,” Henson said.

Texas Democrats see an opportunity to paint Republicans as having presided over the state as it got more expensive while doing little if anything to stop it.

“Texas Republicans have been in office for three decades, and they got us here,” said Manny Garcia, former executive director of the Texas Democratic Party. “They've been paying attention to their billionaire, millionaire donors, lining up their pockets instead of making sure that regular Texans can have opportunities.”

That sentiment can be found among voters. Cydney Murry-Berry, a 33-year-old human resources director and mother of two, grew up in a poorer neighborhood in East Austin, she said, but has worked her way to a comfortable life in South Austin and a job in Westlake Hills. Even so, Murry-Berry said she feels limited in her ability to continue moving up the financial ladder amid higher costs. Child care in particular has strained her family’s budget, and they’ve had to sacrifice family vacations and nights out.

Growing up in a poorer neighborhood, Murry-Berry said, has made her acutely aware of income inequality around the city and the state, something she said will factor heavily into her vote in November.

“I’ve been able to see all levels of that,” Murry-Berry said. “It’s really unfortunate that we have had the same governor for this long and there hasn’t been changes, it’s only gotten worse. You can see there’s a lack of understanding for those that do not look like they look and make what they make.”

Still, Democrats face a damaged brand after stinging losses in 2024. Republicans argue that Texas is in a better position to weather tough economic times than bluer states — and that Democrats wouldn’t make it better.

“Democrats have never proposed any initiative to lower the cost of living; it has always been more taxes and more spending,” said Eduardo Leal, press secretary for the Abbott campaign. “Governor Abbott’s answer is to lower costs and cut taxes.”

Republicans haven’t completely abandoned culture war issues like immigration and abortion. While urban and suburban voters were most concerned about inflation and higher prices, immigration barely edged out higher costs as rural voters’ top concern, according to the UT poll. Nonetheless, social issues have taken a back seat to the cost-of-living crisis on the campaign trail, said Vinny Minchillo, a Plano-based Republican strategist.

“No one can worry about social issues if they're worrying about where their next meal is coming from,” Minchillo said. “So in some ways, social issues are a little bit of a luxury.”

‘Fuel to the fire?’

Candidates in the marquee races have thrown out a litany of ideas to tackle high costs in a number of areas, including housing, healthcare, child care, property insurance and higher education.

Some of those ideas could move the needle, policy experts said. Others wouldn’t — and potentially could drive up costs instead.

State Rep. Gina Hinojosa, Democratic candidate for governor, speaks during her campaign launch event in Brownsville on Oct. 15, 2025.

Gov. Greg Abbott answers questions from the media during a press conference in Austin on Aug. 10, 2026.

Hinojosa wants to tap the state’s rainy day fund — essentially Texas’ savings account, which sat at a record $24.8 billion toward the end of last year — to send each Texas household a $1,500 check as a source of one-time financial relief. Hinojosa’s campaign estimates doing so would cost the state $17 billion.

That carries the possibility of driving inflation, said John Diamond, senior director of the Center for Tax and Budget Policy at the Baker Institute for Public Policy at Rice University. That’s what happened when the federal government sent $1,400 checks to U.S. families in the wake of the COVID-19 pandemic to provide financial relief and stimulate the economy, which experienced a growth in demand while the global economy was still dealing with supply chain problems.

Given that Texas is near full employment and inflation is above 2%, injecting $17 billion into the state’s economy could fuel demand and drive up prices, Diamond said.

“You really don't want to add any fuel to the fire,” Diamond said, adding that, “$17 billion is not a massive amount, but it's still enough to create some pricing pressures.”

Abbott’s property tax plan has drawn skepticism from tax policy experts across the political spectrum — particularly a proposal to cap how fast property values can rise, which wouldn’t guarantee lower tax bills while creating other side effects like higher housing costs.

Texas Attorney General Ken Paxton, the Republican nominee for U.S. Senate, speaks at a campaign event in Amarillo on May 7, 2026.

State Rep. James Talarico, the Democratic nominee for U.S. Senate, speaks at a campaign stop in Sanderson on July 13, 2026.

Paxton’s proposed income-tax deductions to help with homebuying and healthcare costs would flow to those making higher incomes and would provide little or nothing for lower-income families, who already have little tax liability to deduct from, said Andrew Lautz, senior director of federal policy at the conservative Tax Foundation’s Center for Federal Tax Policy.

Talarico has proposed expanding the federal Child Tax Credit and reinstating the Affordable Care Act’s enhanced premium tax credits to lower health insurance premiums, among other tax benefits.

There’s potential for tax breaks proposed by Paxton and Talarico to backfire, Lautz said. The ideas might ease pressure on household budgets in the short-term, he said, but if the federal government ultimately has to borrow money to pay for those breaks, that can also drive up inflation, Lautz said.

“The more our debt increases, the higher interest rates go throughout the economy, and the harder it is for folks to afford to borrow, to buy a home, or to buy a car, or go to college, or for a business to finance new investments,” Lautz said.

Hinojosa disputed the idea that her plan, which would need approval from the Texas Legislature, would drive inflation. Economists who vetted the plan, she said, believe a state-level payment wouldn’t have the same effects as the federal stimulus checks because it’s at a smaller scale.

But part of campaigning is about signaling what a candidate’s values are to voters, even if the policy proposals themselves aren’t completely solid, said Garcia, the former TDP executive director.

“It starts getting people an understanding of, ‘how would you approach the next problem?’” he said. “‘Are you going to side with the corporation? Are you going to side with me?’”

Beyond the financial relief, Hinojosa sees the checks idea as a way to rebuild trust in government at a time when distrust is high.

“We have to demonstrate to people that government can do something for the people of Texas. I mean, we pay for it,” she said.

Traffic moves around a CITGO gas station in Austin on Aug. 26, 2026.

Staff writer Kayla Guo contributed to this report.

This article first appeared on The Texas Tribune.

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.