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State Sen. Victor Torres represents predominantly Hispanic Osceola County in central Florida. At Sunday Mass at his local church, immigrants often tell him they are scared to seek health care.

“They say, ‘My mother is ill, or my kid is sick, but I don’t have insurance,’’’ the Democrat said in an interview. “And I tell them, ‘You cannot be turned away. Go to the hospital. Don’t wait until the last minute when it’s too late.’”

Under the federal Emergency Medical Treatment & Labor Act (EMTALA), hospitals that have emergency departments and participate in Medicare — about 98% of hospitals in the United States — must provide emergency care to all patients, regardless of their ability to pay.

Florida and Texas, however, recently have required hospitals to ask patients about their immigration status. Supporters say the new policies will illuminate the costs of caring for people living in the country illegally, but critics say they are designed to dissuade immigrants from seeking care.

Florida Republican Gov. Ron DeSantis in May 2023 signed a sweeping immigration law that includes a provision requiring hospitals that accept Medicaid (which includes state funding) to collect data on patients’ immigration status. In August, Texas Republican Gov. Greg Abbott followed suit, by signing an executive order that requires Texas public hospitals to collect data on the costs they incur to provide emergency and inpatient care for people lacking permanent legal status.

“Texans should not have to shoulder the burden of financially supporting medical care for illegal immigrants,” Abbott said in issuing the order.

Data from Texas aren’t available yet. In Florida, however, a March report by the state Agency for Health Care Administration suggests patients lacking legal status account for a relatively narrow slice of overall health care spending.

In the second half of 2023, the agency found, immigrants without legal status accounted for 0.82% of hospital visits and 0.83% of emergency department visits. Florida hospitals spent a total of $69 billion in 2022, so based on those percentages, they spent about $566 million on care for immigrants lacking legal status.

The agency acknowledged that it did not know how much of that $566 million was so-called uncompensated care — that is, care not paid for by insurance or by the patient. It also did not find any correlation between a hospital’s level of uncompensated care and its percentage of patients living in the country illegally, nor was there an obvious connection between a hospital’s profitability and the percentage of its patients who were such immigrants.

In fact, the agency found that high levels of spending on uncompensated care were more associated with a county being rural than having a lot of immigrants lacking legal status.

“Research overwhelmingly suggests that immigrants don’t use as much health care and don’t use higher benefits than U.S.-born people,” said Drishti Pillai, associate director of the racial equity and health policy program at KFF, a health policy research organization. Pillai recently coauthored a KFF issue brief on the potential effects of the Florida and Texas measures.

KFF has found that immigrants spend less on health care than U.S.-born residents, and some research suggests that they end up subsidizing the health care of other U.S. residents through their payment of insurance premiums and taxes.

In both states, hospitals must inform patients that no matter how they respond to immigration-related questions, they will receive care. In Florida, hospitals also must tell patients that their answers won’t be reported to immigration authorities. Nevertheless, data from Florida suggests that the patients are being scared away by the prospect of being asked about their immigration status.

DeSantis has boasted that the policy has resulted in a decrease in Medicaid spending.

“We knew we’d get no support from the federal government, so we’ve had to do all these things at the state level,” DeSantis told Fox Newsin a June interview. “We made sure when you have people show up at the hospital that we’re asking about immigration status, and that’s caused the Medicaid expenditures to plummet by 50% in the state of Florida.”

A recent analysis of federal and state data backs up that assertion. In 2022, the year before the Florida law was enacted, state and federal Medicaid spending on emergency services for immigrants without legal status totaled $148.4 million. Between July 1, 2023, when the law took effect, and May 3, 2024, the total declined to $67 million, according to a Politico analysis of data from the Florida Agency for Health Care Administration and the U.S. Department of Health and Human Services. Medicaid, which provides health insurance to people with low incomes, is jointly funded by the federal government and states.

Florida Republican state Rep. Rick Roth, who runs a farm and employs hundreds of migrant laborers, voted for the measure. “I believe that the bill was mostly political, not punitive. It doesn’t prevent them from getting health care. It [creates] a perception that it’s going to be more difficult.”

Other supporters of the Florida law and Texas order say it makes sense to figure out how much money states are spending on care for immigrants here illegally — and if possible, to reduce it.

“Today, our health care system is overrun by illegals who came into our country, and the cost is borne by people like you and me, who are regular citizens, regular immigrants, who came here the right way,” Abraham George, the chairman of the Texas Republican Party — and an immigrant from India — said an interview.

‘A scare tactic’

Torres, the Florida lawmaker, pointed out that most immigrants and their families take on difficult work, contribute to the economy and pay taxes — without getting benefits such as Social Security, Medicaid, or Medicare.

“This is a scare tactic by the Republicans on immigrants who are working every day and not asking for any handouts,” Torres said. “They’re working their tail off and just protecting themselves and their families.”

Illegal immigration is a central issue in the presidential campaign, and former President Donald Trump and other Republicans often talk about migrants draining public coffers by using benefits. Generally speaking, immigrants without permanent legal status cannot enroll in federally funded health care coverage under Medicaid, Medicare or CHIP (Children’s Health Insurance Program), and they can’t purchase plans under the Affordable Care Act.

However, hospitals cannot turn them away in an emergency, and six states (California, Colorado, Illinois, New York, Oregon and Washington) plus the District of Columbia use state money to provide coverage to some adults regardless of their immigration status.

In Texas, even some Democrats worry about what hospitals and the state spend to care for immigrants without legal status who don’t have insurance and can’t pay out of pocket.

“These individuals are our fellow neighbors — they should never be denied treatment or demonized by extremists. But this can’t go unfunded in any way,” Texas Democratic state Rep. Eddie Morales told Stateline.

Morales said it’s legitimate for Texas to examine what it is spending on care for immigrants without legal status, and that it should help hospitals pay for uncompensated care. But he blamed Republicans in Washington for torpedoing a bipartisan bill that aimed to address the challenges at the border.

Long-term costs

Pillai, of KFF, said the Florida and Texas efforts might end up increasing those states’ health care costs if people lacking legal status avoid care but have to eventually visit the hospital in a worsened condition.

“This can cause routine situations to become more complex and expensive to treat later on, and it can lead to greater health care costs if an individual ends up presenting to the emergency room,” Pillai said.

In the issue brief, Pillai and her colleagues also note that immigrants without legal status play an outsize role in the Florida and Texas workforces, particularly in fields such as construction, farming, and transportation.

That’s why Mike Oldham, president of the Texas Farmers Union, said he doesn’t support Abbott’s executive order. Oldham said that such measures create a climate of fear, such that migrant workers and their families who come to Texas to work “won’t even be seen out in the daytime.”

“We have to have migrant labor. If you want milk and cheese and eggs and all the vegetables, you’ve got to have migrant labor,” Oldham said. “I can’t go pick up any white people that will do those jobs. They just won’t do them.”

Oldham said requiring hospitals to ask more questions on intake forms and hire interpreters to inquire about patients’ immigration status just creates unnecessary burdens for them.

Hospitals in Texas and Florida are too scared to discuss these policies, because they don’t want to be cast under a spotlight, especially if they serve people lacking legal status, said Deliana Garcia, a chief program officer at the Migrant Clinicians Network, a national nonprofit that focuses on health solutions for migrant populations and works with clinicians.

Garcia said the health care system can either support a person when they are relatively healthy, or provide more expensive care later on when their condition is more severe.

Besides, she said, “you don’t want someone who is ill circulating where they might then sicken you.”

This story first appeared in Stateline, part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and X.

NEW YORK — As temperatures soared into the 90s, the heat and humidity hit the concrete in Astoria, Queens, and bounced into the air. People moved along the scorched sidewalk slowly, their clothes drenched with sweat.

Elianne Alvarado, 44, who was raised in New York City and has lived here for most of her life, ascended the steps to the elevated Astoria Boulevard subway station, fanning herself with a sheet of paper. She was looking forward to escaping the heat in an air-conditioned train.

“I don’t ever remember it being this hot,” Alvarado told Stateline. “I remember other summers being nice, not that hot. But this week has been crazy.”

The heat wave that pummeled New York state and much of the East Coast and Midwest last week and into the weekend broke daily records in several cities. On June 19, Boston (98 degrees); Hartford, Connecticut (97); and Providence, Rhode Island (91), all set new highs for that date. In New York City, temperatures reached the low 90s — not a record, but plenty hot enough to cause misery, especially with humidity and the radiant heat from concrete and asphalt.

The Northeast is not the hottest part of the country, but several states in the region are among those where average temperatures have increased the most over the past two decades. In recent years, climate change has forced states such as Connecticut, Massachusetts, New Jersey and New York to take extreme heat more seriously. In preparing for a hotter future, some of them are copying the policies of states that are used to sizzling temperatures, such as Arizona, Florida and Louisiana.

Some states act to protect residents from extreme heat — with a new focus on young people

Public health officials in Connecticut and New York, for example, are partnering with the federal Centers for Disease Control and Prevention to ensure that their most vulnerable residents — older and lower-income people — are better prepared for extreme heat and other aspects of climate change. And in April, New Jersey published a draft Extreme Heat Resilience Action Plan, recognizing that, “while the state remains committed to reducing emissions, New Jersey is past the point of avoiding all climate change impacts and needs to enact measures to adapt.”

“New Jersey is a northern state, and it is not necessarily the folks that are hardest hit by this phenomenon of extreme heat compared to, for example, the desert Southwest,” said Nathaly Agosto Filión, deputy chief climate resilience officer for the New Jersey Department of Environmental Protection.

“But for that reason, much of our built environment is maybe not as well designed to withstand the impacts, and much of our population sort of undervalues the extent to which it is a problem for our communities.”

New Jersey’s draft plan includes 133 action items, but the first priority is helping New Jerseyans cope with the heat. The state aims to do that by beefing up emergency preparedness and response; providing public cooling centers; planting more trees; and adopting workplace safety rules, among many other steps. It also plans a public information campaign to make people — especially vulnerable populations such as older and homeless people — aware of the risks of extreme heat.

“We’re also talking about outdoor workers, we’re also talking about athletes, we’re also talking about folks that are pregnant or breastfeeding — these are all subpopulations that are really important to engage,” Agosto Filión said.

‘Hot box’ apartments

Extreme heat is the leading cause of weather-related deaths in the United States — and those deaths are increasing as average temperatures rise, according to the U.S. Department of Health and Human Services. Approximately 2,302 people died from heat-related causes last year, up from 1,722 in 2022 and 1,602 in 2021.

Those totals are likely an underestimate, because heat waves make death more likely from other causes as well. A New York City analysis in 2022, for example, found an annual average of 360 heat-exacerbated deaths in the city compared with 10 caused directly by heat.

Last week on 31st Street in Astoria, Hassan Johnson was standing outside a bank with a water bottle and a towel, which he used to wipe the multiplying beads of sweat on his forehead. The 48-year-old truck driver blasts his three air conditioners when he’s at home, but the one in his truck is broken and it’s “hot as hell” as he makes deliveries. Driving in such conditions can be dangerous: In July 2022, paramedics had to cover a New York UPS driver in ice packs and take him to the hospital after he nearly collapsed at the end of his Long Island route.

Not far away, Meg Johansson was braving treeless Broadway to get an iced coffee.

“It’s a bad one,” said Johansson, 38, who has lived in the city for 15 years. “There have been a few summers where I remember really hot days, but I don’t remember one this early that was so prolonged. So it’s just been like torture trying to leave the house.”

Back at the Astoria Boulevard subway station, Alvarado said she was coping by staying hydrated, walking in the shade and taking cold showers. She’s fortunate to have air conditioning in her home, but she said she’s nervous about what the future will bring.

“You feel like you’re burning,” she said. “It’s like we are in a walking sauna.”

Ladd Keith, an associate professor of planning at the University of Arizona who focuses on climate change, said cities and states should have different plans to cope with extreme heat, because housing and development differ so dramatically among communities.

One challenge, Keith explained, is that many homes were designed for climates that have changed dramatically. Many “hot box” apartments in New York don’t have air conditioning because decades ago it was rarely needed. In the Pacific Northwest, many homes have large windows to let in light, but they let in too much heat during the now-warmer summers. Homes designed to rely on air conditioning, like those in Arizona, quickly become miserable if the power goes out.

Keith said that for the most part, the rising temperatures haven’t been enough to convince most Americans that heat is a serious threat — yet.

“Even though the awareness is growing, we really haven’t had this watershed moment, or what I call a ‘heatshed’ moment, where we’ve said, ‘We really need to take this seriously as a climate risk,’” Keith told Stateline.

Southern experience

But public officials in some states are focused on the threat.

The New York State Department of Health is one of 13 recipients, mostly state and local agencies across the country, of a CDC climate resilience grant. Neil Muscatiello, who heads the department’s bureau of environmental health, said the goal is “to identify how we think climate change is going to be impacting New Yorkers, particularly vulnerable populations, and then work on adaptations or interventions to help reduce those risks.”

The agency, noting that people can fall ill at lower temperatures, recently changed New York’s heat alert threshold from 100 degrees to 95 degrees. Last week, it was tracking emergency room visits and coordinating with other state and local agencies on getting vulnerable people to cooling centers.

Muscatiello said the department is also learning from other jurisdictions that have dealt with heat for years.

“It is a really collaborative process, not only with CDC, but also with other state partners. We’re always interested to hear what they’re doing.”

Meg Johansson, 38, has lived in New York for 15 years and can’t remember it being so hot so early in the summer. Shalina Chatlani/Stateline

Southern cities and states have long integrated heat resilience into their public health programs and have lessons to share.

In 2021, Miami-Dade County, Florida, became the first jurisdiction in the world with a chief heat officer. Since then, Phoenix and other cities have followed suit.

One policy change Jane Gilbert, Miami-Dade’s heat officer, made was to lower the thresholds for heat advisories and warnings. The county now issues advisories when the heat index — what the temperature feels like to the human body when relative humidity is combined with the air temperature — reaches 105 degrees, down from the previous 108 degrees. The new standard for a heat warning is a heat index of 110 degrees, down from 113 degrees. She made the changes because heat-related illness can happen at the lower temperatures.

Gilbert also created an outreach strategy to help homeless people cope with extreme heat, including placing cooling centers in areas where there are many people living on the streets.

Many states decline to require water breaks for outdoor workers in extreme heat

“We are doing a lot of great services to people who are unsheltered. That doesn’t mean we don’t miss people. We are doing a lot of messaging to employers with employees doing work, but that doesn’t mean we won’t miss people,” Gilbert said. “We know there are gaps. There is definitely more work to be done. That’s what we are focused on.”

Like Florida, Louisiana has long experience with extreme heat. But the state’s public health response still has to evolve with the warming planet, said Michelle Lackovic, who is the project lead for Louisiana’s Occupational Heat-Related Illness Prevention Program at the Louisiana Department of Health. Last year, she said, the state had more heat-related emergency department visits and fatalities than ever before.

Last summer the Louisiana Department of Health created a public, online dashboard for heat-related illness and daily counts of emergency room visits that it updates weekly during the hot months. The data is also broken down by sex, age, race and geography, so that the public can be aware of who may be most susceptible to the rising temperatures.

The state experienced over three weeks of temperatures above 95 degrees last year, Sundee Winder, an executive director at the health department, told Stateline.

“Drought, wildfires, saltwater intrusion, all of those things were a result of that extensive heat last year that was unprecedented for our state,” Winder told Stateline. “So, we continue to improve our dashboard, make it more user-friendly, and share the times of day that we see [people should] avoid.”

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and X.