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.

In a state where the death penalty is as ingrained as cowboy boots and conservative politics, news of Robert Roberson’s death sentence broke through in Texas after the rarest of phenoms: a noisy, bipartisan effort that bypassed the governor’s office to save a man from lethal injection.

For years, the appeals of Roberson’s capital murder conviction for the 2002 death of his chronically ill, 2-year-old daughter had lumbered through the courts, tracing a byzantine process that often fails to register with residents of the nation’s execution capital, where 591 inmates have been put to death in the state since capital punishment was reinstated in 1976.

But while lawmakers were making historic interventions, many Texans took note of the silence by the person traditionally empowered to step in at the last minute: Gov. Greg Abbott.

“Abbott’s silence is deafening,” said Brandon Rottinghaus, a professor of political science at the University of Houston.

After all, Abbott had at his disposal the power to grant a 30-day reprieve for Roberson, whose lawyers claim was wrongfully convicted based on junk science. A U.S. Supreme Court Justice urged him to take that step. If Abbott had, there would have been no frantic and unprecedented rush by lawmakers to issue a subpoena of Roberson and then go to court to block the execution — first to a Travis County judge, then to Texas’ two high courts before Roberson’s execution was finally called off.

There’s been no public statement from Abbott about Roberson’s case before or since. If the execution had gone forward, Roberson would have been the first person in the nation to be put to death in a shaken baby syndrome case, a diagnosis that has come into question in recent years. Multiple requests for comment to the governor’s office by The Texas Tribune went unanswered.

The silence “certainly signals his willingness to go his own way against the Legislature and also reflects that, like Gov. Perry before him, the realization that being tough on crime is an essential element of muscularity for national Republicans,” Rottinghaus said.

Silence on executions, not unusual

Unlike the Hollywood image of a governor making a frantic phone call to stop an execution, the reality, especially in Texas, is far less dramatic. Texas governors can only act on a recommendation of clemency from their own appointees to the Texas Board of Pardons and Paroles. Or they can opt for the 30-day reprieve.

According to the Associated Press, the Texas parole board has recommended clemency in a death row case only six times since the state resumed executions in 1982. In three of those cases, death row inmates had their sentences commuted to life in prison. In two of the cases, Perry rejected the parole board's recommendation to commute a death sentence to life in prison, and the two prisoners were executed.

But despite that limited power, Abbott may have inadvertently raised the Texas public’s expectations of intervention last year. That’s when he was quick to jump in publicly after a jury convicted an Austin man of fatally shooting a Black Lives Matter protester. Abbott posted on social media that he would quickly seek a pardon. The parole board did recommend a pardon a year later, and Abbott made good on his promise.

But veteran court watchers say Abbott’s silence on even a high profile death penalty case is not out of the ordinary.

“It’s typical,” said Elsa Alcala, who served for seven years as a judge on the Texas Court of Criminal Appeals, the state’s highest criminal court, before stepping down in 2018. “Usually, the governor doesn’t get involved.”

So far, more than 60 executions have been carried out while Abbott has been governor, a fraction of the more than 200 that occurred when former Gov. Rick Perry was in office. That’s the result of increased judicial scrutiny on death row cases and more prosecutors seeking life in prison instead of the death penalty.

Abbott has only commuted one death sentence. In 2018, he spared the life of Thomas “Bart” Whitaker, who masterminded a murder-for-hire scheme that resulted in the death of his mother and younger brother and injured his construction company executive father, who ultimately forgave his son. Whitaker’s case was reduced to a life sentence.

“Even going back to Ann Richards, I don’t think there’s a history of Texas governors in capital cases giving reprieves,” said Kenneth Williams, the Fred Gray Endowed Chair for Civil Rights and Constitutional Law at Texas Tech University. “They rarely do in capital cases.”

Longtime Texas political observer Cal Jillson agreed.

“Governors at least going back to George W. Bush, in the case of a mentally challenged inmate named Oliver Cruz, and Rick Perry, in the case of Cameron Todd Willingham, have been reluctant to intervene in death penalty cases for fear of appearing ‘soft on crime,’” said Jillson, a political science professor at Southern Methodist University.

The added fact that Abbott, before he was first elected governor in 2014, was the state’s longest-serving attorney general, whose office is charged with ensuring a trial court’s death sentence is carried out, could help explain why Texans don’t hear much from him regarding an individual’s case.

“He defended these cases, so that may weigh on him as governor,” said Williams, the Texas Tech University law professor, adding that Abbott’s lack of intervention in this or any other case is not out of step with governors in other states.

“Most governors are reluctant to grant any kind of clemency after there’s been conviction,” he said. “I don’t think they want the blowback in that.”.

How the case unfolded

Roberson, 57, of Palestine, was convicted of his daughter’s death in 2003 after an autopsy determined his daughter, Nikki, who had been ill with a fever, had died of shaking and blows. Investigators believed that Roberson’s emotionless demeanor was further evidence of his guilt. Roberson has since been diagnosed as having autism, which could explain Roberson’s behavior at the time. A police detective whose investigation sent the East Texas man to death row, now supports Roberson’s claims of innocence.

On Wednesday, as both the Texas parole board and the Texas Court of Criminal Appeals rejected Roberson’s last-minute appeals, the House committee members issued their subpoena, arguing that only Roberson could provide unique testimony on Texas’ pioneering 2013 junk science law — which Roberson had tried, and failed, to use to prove his innocence. Last month, 80 Texas lawmakers, including supporters of the death penalty, wrote Texas parole board members in support of Roberson’s request for clemency.

The law is designed to allow defendants an avenue to prove their innocence if they were convicted based on science that is later shown to be faulty. In fact, no Texas death row inmate has successfully used the law to obtain a new trial, leading the Texas Defender Service to conclude that the statute “is not operating as the Texas Legislature intended.”

The steps legislators took to halt the execution were unprecedented, and drew some complaints of overstepping their authority.

“I will absolutely defend what we did,” state Rep. Brian Harrison, R-Midlothian, a member of the House jurisprudence committee who began looking into Roberson’s cases a few months ago on the recommendation of a colleague. “We have to protect the integrity of the criminal justice system.”

Harrison confirmed that lawmakers contacted Abbott after their subpoena was issued but did not want to discuss specifics of those conversations, describing them only as “professional and productive.”

Many of those who tracked the Roberson saga this week were struck more by the actions of the Legislature than the inaction of Abbott.

“What is unusual in the case of Robert Roberson is not so much Abbott’s silence, as the bipartisan effort to slow this execution at least long enough to take a closer look,” Jillson said.

But Amanda Marzullo, the former executive director of the Texas Defender Service, said it was necessary for the Legislature to step in, given that the use of clemency by American governors has waned.

“We have seen a massive atrophy in the clemency power,” she said. “It was something governors did all the time.”

She pointed to how more than 200 years ago, a governor’s pardon power was used more often because death was often the punishment for far lesser crimes.

"This is how this system was designed,” Marzullo said. “So no one branch is doing all of the work in a particular sector.”

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2024/10/19/greg-abbott-robert-roberson-death-penalty/.

The Texas Tribune is a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy. Learn more at texastribune.org.

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