The Rio Grande Valley in South Texas has a number of the highest uninsured charges within the U.S. The variety of uninsured residents is anticipated to swell over the subsequent decade.
Sam Whitehead/KFF Well being Information
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Sam Whitehead/KFF Well being Information
RIO GRANDE CITY, Texas — Dr. Jake Margo Jr. stood within the triage room at Starr County Memorial Hospital explaining why an individual with persistent fever who might be handled with over-the-counter remedy did not must be admitted to the emergency room.
“We’ll deal with the sickest sufferers first,” Margo, a household drugs doctor, mentioned.
It is not like there was house on that June afternoon anyway. A small monitor on the wall pulsed with the vitals of present sufferers, who stuffed the ER. An ambulance idled exterior within the South Texas warmth with a affected person ready for a mattress to open up.
“Everyone reveals up right here,” Margo mentioned. “Whenever you’re overwhelmed and also you’re overrun, there’s solely a lot you are able to do.”
Trump voters and a brand new Trump legislation
Starr County, a largely rural, Hispanic group on the southern U.S. border, made headlines in 2024 when it voted Republican in a presidential election for the primary time in additional than a century. Immigration and the economic system drove the flip on this group, the place roughly a 3rd of the inhabitants falls beneath the poverty line.
Now, current actions by the Trump administration and the GOP-controlled Congress have triggered a brand new concern: the lack of docs, hospitals and different well being suppliers to proceed to look after uninsured sufferers. It is a worry not solely in Starr County, which has one of many highest uninsured charges within the nation. Communities throughout the U.S. with equally excessive proportions of uninsured individuals may battle as extra residents lose well being protection.
About 14 million fewer Individuals are anticipated to have medical health insurance in a decade resulting from President Trump’s new tax-and-spending legislation, which Republicans dubbed the One Massive, Stunning Invoice Act, or OBBBA, and the pending expiration of enhanced subsidies that slashed the worth of Reasonably priced Care Act plans for hundreds of thousands of individuals. The brand new legislation additionally limits applications that ship billions of {dollars} to assist those that look after uninsured individuals keep afloat.
The security internet might fail
“You’ll be able to’t disinsure this many individuals and never have, in lots of communities, only a collapse of the well being care system,” mentioned Sara Rosenbaum, founding chair of the Division of Well being Coverage and Administration at George Washington College’s Milken Institute College of Public Well being.
“The long run is South Texas,” she mentioned.
KFF Well being Information is inspecting the influence of nationwide well being care coverage modifications on uninsured individuals and their communities. Although the Trump administration informed KFF Well being Information it’s making “a historic funding in rural well being care,” individuals who deal with low-income sufferers, in addition to researchers and client advocates, say current coverage choices will make it more durable for individuals to remain wholesome. Docs, hospitals, and clinics that make up the well being care security internet may lose a lot cash they need to shut their doorways, a few of them warn.
“As a result of the affected person’s invoice isn’t going to receives a commission,” mentioned Dr. Joseph Alpert, editor-in-chief of The American Journal of Drugs and a professor of medication on the College of Arizona. “Uninsured sufferers stress the well being care system.”
Starr County reveals how this dynamic unfolds. Main care docs within the county serve a mean of just below 3,900 individuals every, practically 3 times the U.S. common.
Margo, the household doctor, mentioned as a result of so many individuals lack insurance coverage and there are so few locations to hunt care, many residents deal with the ER as their first cease after they’re sick.
In lots of circumstances, they’ve uncared for their well being, making them sicker and costlier to deal with. And federal legislation requires ERs at hospitals within the Medicare program to stabilize or switch sufferers, no matter their potential to pay.
That leaves Margo and his group to observe what he described as “catastrophe drugs.”
“They arrive in with chest ache or they cease respiration. They collapse. They’ve by no means seen a health care provider,” Margo mentioned. “They’re actually dying.”
Well being techniques in ‘survival mode’
When persons are uninsured or on Medicaid, they have an inclination to depend on a security internet of docs, hospitals, clinics, and group well being facilities, which supply providers freed from cost or take up getting reimbursed at decrease charges than they do treating sufferers on industrial insurance coverage.
These suppliers’ monetary conditions can usually be precarious, main them to depend on myriad federal helps. The Trump administration’s cuts to well being care and Medicaid within the identify of eliminating “waste, fraud and abuse” has many involved they will not climate the extra monetary pressure.
Trump’s new legislation funds his priorities, like extending tax cuts that primarily profit wealthier Individuals and increasing immigration enforcement. These prices are coated partially by a virtually $1 trillion discount in federal well being spending for Medicaid throughout the subsequent decade and modifications to the ACA, reminiscent of requiring extra paperwork and shortening the time for individuals to enroll.
Many Republicans have argued Medicaid has gotten too giant and strayed from the state-federal program’s core mission of overlaying these with low incomes and disabilities. And the GOP has fought to roll again the ACA since its passage.
Kush Desai, a spokesperson for the White Home, mentioned projections from the nonpartisan Congressional Funds Workplace about how many individuals may lose medical health insurance are an “overestimate.” He didn’t present an estimate the administration sees as extra correct.
Supporters of OBBBA say those that want well being protection can nonetheless get it in the event that they meet new necessities reminiscent of working in change for Medicaid protection.
And Michael Cannon, director of well being coverage research on the Cato Institute, a libertarian assume tank, mentioned even with the laws, Medicaid spending will develop, simply not as rapidly.
The finances legislation will not trigger “the sky to fall,” Cannon mentioned. “The inefficient suppliers needs to be shutting down.”
Layoffs beginning, extra anticipated
A current survey from AMGA, previously the American Medical Group Affiliation, which represents well being techniques throughout the nation, discovered practically half of rural amenities may shut or restructure resulting from Medicaid cuts. Practically three-quarters of respondents mentioned they anticipated layoffs or furloughs, together with of front-line clinicians.
Maria Salgado, a group well being employee, or promotora, for the nonprofit MHP Salud, meets with purchasers at a public library in Roma, Texas. One in all her jobs is to signal individuals up for well being protection.
Sam Whitehead/KFF Well being Information
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Public well being departments, which frequently fill gaps in care, additionally face federal funding cuts which have decreased their capability. In South Texas’ Cameron County, the well being division has eradicated practically a dozen positions, mentioned company head Esmer Guajardo. In neighboring Hidalgo County, the well being division has laid off greater than 30 individuals, mentioned Dr. Ivan Melendez, who helps oversee its operations.
In July, the Texas Division of State Well being Providers canceled Operation Border Well being, a large annual occasion that final 12 months offered free well being providers to almost 6,000 South Texas residents.
Gateway Neighborhood Well being Heart in Laredo, a border metropolis north of the Rio Grande Valley, is in “survival mode,” with a few third of sufferers already missing insurance coverage and much more who will battle to afford well being care if the ACA subsides aren’t renewed, mentioned David Vasquez, its director of communications and public affairs. The middle is in search of different types of funding to keep away from layoffs or cuts to providers, and its enlargement and hiring plans are on maintain, Vasquez mentioned.
That downsizing is going on as extra individuals lose medical health insurance and want free or reduced-cost care.
Esther Rodriguez, 39, of McAllen has been out of labor for 2 years and her husband makes $600 every week working in building. Neither of them has medical health insurance.
Medicaid coated the payments for the births of her 5 youngsters. Now, she relies on a cell well being clinic run by an area medical college, the place she will be able to pay out-of-pocket for routine checkups and medicines to manage her Sort 2 diabetes. If she wanted extra care, Rodriguez mentioned, she would go to the ER.
“It’s important to adapt,” she mentioned in Spanish.
“Demise by a thousand cuts”
Folks’s incapacity to pay leads to uncompensated care, or providers that hospitals, docs, and clinics do not receives a commission for, which, below an earlier model of the megabill, was projected to extend by $204 billion over the subsequent decade, in response to the City Institute, a nonprofit assume tank.
However the Trump administration can be chopping different help that helped offset the price of look after individuals who cannot pay. The brand new legislation caps federal applications that many well being suppliers for low-income individuals have come to rely on, particularly in rural areas, to shore up their budgets. These embrace taxes on hospitals, well being plans, and different suppliers that states use to assist fund their Medicaid applications. Such supplier taxes are a “monetary gimmick,” Desai mentioned.
Whereas the legislation creates a short lived $50 billion fund to help rural docs and hospitals, that is a little bit over a 3rd of estimated Medicaid funding losses in rural areas, in response to KFF, a well being info nonprofit that features KFF Well being Information. Desai referred to as the evaluation “flawed.”
Any loss in income may spell monetary break, particularly for small rural hospitals, mentioned Quang Ngo, president of the Texas Group of Rural & Neighborhood Hospitals Basis.
“It is form of like loss of life by a thousand cuts,” he mentioned. “Some will in all probability not make it.”
Further cuts to rural well being
And extra cuts may hold coming. The Trump administration’s finances request for the approaching fiscal 12 months requires cuts to a number of rural well being applications operated via the Well being Sources and Providers Administration. Desai mentioned the spending legislation’s funding in rural well being “dwarfs” the cuts.
In February, the Trump administration introduced funding cuts of 90% to the ACA navigator program, which helps individuals discover medical health insurance. That program has been “traditionally inefficient,” Desai mentioned.
In December 2023, practically 3 million of Texas’ uninsured have been eligible for ACA subsidies, Medicaid, or the Kids’s Well being Insurance coverage Program, in response to Texas 2036, a public coverage assume tank.
Maria Salgado spends her workdays tabling at group occasions, dropping off flyers at docs’ places of work, and holding one-on-one conferences with purchasers of MHP Salud, a nonprofit that connects residents to Medicaid and ACA protection.
She frightened funding cuts would actually set the group’s efforts again: “A variety of group members right here, they are going to be left behind,” mentioned Salgado, a group well being employee, or promotora.
Dr. Chris Casso, a major care doctor who grew up in McAllen and now practices there, held again tears as she described treating sufferers who’ve delay seeing a health care provider due to an incapacity to pay, solely to have their preventable situations deteriorate.
She worries about the way forward for her group as doctor shortages worsen, probably leaving few suppliers to deal with uninsured individuals.
Dr. Chris Casso grew up in McAllen, Texas, and now practices household drugs there. Her sister died at age 45 as a result of she could not afford medical health insurance to deal with her coronary heart illness and diabetes.
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“It is heartbreaking,” she mentioned, sitting in a small again room in her workplace in a suburban strip mall, wedged between a Kohl’s and a Shoe Carnival. “These are hardworking individuals,” she mentioned. “They fight their finest to deal with themselves.”
Casso mentioned her personal sister, who labored as a medical biller in a doctor’s workplace, could not afford medical health insurance. She delayed care and died at age 45 of problems from diabetes and coronary heart illness. Casso worries the longer term will discover extra individuals in comparable conditions.
“Our inhabitants goes to undergo,” she mentioned. “It is going to be devastating.”
KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working applications at KFF .
