On August 8, 2024, Greg Abbott, Governor of Texas, issued an executive order directing the Texas Health and Human Services Commission “to assess costs to the Texas public hospital system imposed by the federal government’s open-border policies.”¹ The order directed hospitals to collect information on patients not lawfully present in the United States beginning November 1, 2024. The initial data submission was due to the Health and Human Services Commission no later than March 1. The data will then be reported to the Governor, the Lieutenant Governor, and the Speaker of the House on January 1, 2026, and annually thereafter.

Data Collection

“The executive order is really just trying to collect data,” explained David Wampler, PhD, LP, FAEMS, San Antonio. He noted that undocumented immigrants have always passed through the area, and the federal Emergency Medical Treatment and Labor Act (EMTALA) compels Centers for Medicare & Medicaid Services (CMS) hospitals to care for all acutely ill or injured patients. However, this is the first time that hospitals have been explicitly directed to gather data on the number of patient discharges, emergency visits, and the cost of care provided to the patients. Dr. Wampler explained that this information is meant to help evaluate the financial burden on hospitals in the state.

Andrea Green, MD, FACEP, Past President of the Texas College of Emergency Physicians (TCEP) and an emergency physician in El Paso, Texas, explains that at registration, patients are given a form that has the patient’s name, but no address or phone number. The form asks if the patient is a citizen or lawfully present in the United States. The patient can answer yes, answer that he or she is unlawfully present, or decline to answer. “I suspect most of the patients we are seeing are lawfully present or citizens,” said Dr. Green. “We rarely get any decline to answer.” She agrees that the process is primarily about data collection.

To the best of Dr. Wampler’s knowledge, the hospitals report data that are not explicitly linkable to any individual patient but rather are surveillance in nature and address five main questions: 1) What is the cost of providing health care services, particularly to uninsured and Medicaid patients? 2) How many individuals are utilizing the public hospital system without corresponding payment? 3) How much reimbursement from Medicaid, the federal government, and other sources are public hospitals receiving compared with the total costs? 4) How much care is provided without reimbursement? 5) What are the overall operational expenditures of public hospitals?