The Rio Grande Valley in South Texas has a few 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 may very well be handled with over-the-counter treatment did not should be admitted to the emergency room.
“We’ll maintain the sickest sufferers first,” Margo, a household drugs doctor, mentioned.
It isn’t like there was house on that June afternoon anyway. A small monitor on the wall pulsed with the vitals of present sufferers, who crammed the ER. An ambulance idled outdoors 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 regulation
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 financial system drove the flip on this group, the place roughly a 3rd of the inhabitants falls beneath the poverty line.
Now, latest actions by the Trump administration and the GOP-controlled Congress have triggered a brand new concern: the lack of medical doctors, hospitals and different well being suppliers to proceed to take care of 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 folks might wrestle as extra residents lose well being protection.
About 14 million fewer Individuals are anticipated to have medical insurance in a decade resulting from President Trump’s new tax-and-spending regulation, which Republicans dubbed the One Huge, Stunning Invoice Act, or OBBBA, and the pending expiration of enhanced subsidies that slashed the worth of Reasonably priced Care Act plans for tens of millions of individuals. The brand new regulation additionally limits applications that ship billions of {dollars} to assist those that take care of uninsured folks keep afloat.
The protection web might fail
“You possibly can’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 analyzing the influence of nationwide well being care coverage modifications on uninsured folks and their communities. Although the Trump administration advised 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 latest coverage choices will make it tougher for folks to remain wholesome. Medical doctors, hospitals, and clinics that make up the well being care security web might lose a lot cash they have to shut their doorways, a few of them warn.
“As a result of the affected person’s invoice just isn’t going to receives a commission,” mentioned Dr. Joseph Alpert, editor-in-chief of The American Journal of Drugs and a professor of drugs on the College of Arizona. “Uninsured sufferers stress the well being care system.”
Starr County reveals how this dynamic unfolds. Main care medical doctors within the county serve a median of slightly below 3,900 folks 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 once they’re sick.
In lots of circumstances, they’ve uncared for their well being, making them sicker and dearer to deal with. And federal regulation requires ERs at hospitals within the Medicare program to stabilize or switch sufferers, no matter their capability to pay.
That leaves Margo and his group to follow what he described as “catastrophe drugs.”
“They arrive in with chest ache or they cease respiratory. They collapse. They’ve by no means seen a health care provider,” Margo mentioned. “They’re actually dying.”
Well being methods in ‘survival mode’
When individuals are uninsured or on Medicaid, they have an inclination to depend on a security web of medical doctors, hospitals, clinics, and group well being facilities, which supply companies freed from cost or take in getting reimbursed at decrease charges than they do treating sufferers on industrial insurance coverage.
These suppliers’ monetary conditions can typically 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 regulation funds his priorities, like extending tax cuts that primarily profit wealthier Individuals and increasing immigration enforcement. These prices are coated partly by an almost $1 trillion discount in federal well being spending for Medicaid inside the subsequent decade and modifications to the ACA, similar to requiring extra paperwork and shortening the time for folks to enroll.
Many Republicans have argued Medicaid has gotten too massive and strayed from the state-federal program’s core mission of masking 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 might lose medical 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 similar to 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 shortly.
The price range regulation will not trigger “the sky to fall,” Cannon mentioned. “The inefficient suppliers must be shutting down.”
Layoffs beginning, extra anticipated
A latest survey from AMGA, previously the American Medical Group Affiliation, which represents well being methods throughout the nation, discovered practically half of rural services might 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 folks up for well being protection.
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Public well being departments, which regularly 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 folks, mentioned Dr. Ivan Melendez, who helps oversee its operations.
In July, the Texas Division of State Well being Companies canceled Operation Border Well being, a large annual occasion that final 12 months offered free well being companies to just about 6,000 South Texas residents.
Gateway Group 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 wrestle 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 companies, and its enlargement and hiring plans are on maintain, Vasquez mentioned.
That downsizing is occurring as extra folks lose medical 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 per week working in development. Neither of them has medical insurance.
Medicaid coated the payments for the births of her 5 kids. Now, she is determined by a cell well being clinic run by an area medical faculty, 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.
“You need to adapt,” she mentioned in Spanish.
“Dying by a thousand cuts”
Individuals’s incapacity to pay ends in uncompensated care, or companies that hospitals, medical doctors, 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 keeping with the City Institute, a nonprofit assume tank.
However the Trump administration can also be chopping different assist that helped offset the price of take care of individuals who cannot pay. The brand new regulation caps federal applications that many well being suppliers for low-income folks have come to rely on, particularly in rural areas, to shore up their budgets. These embody 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 regulation creates a short lived $50 billion fund to assist rural medical doctors and hospitals, that is slightly over a 3rd of estimated Medicaid funding losses in rural areas, in keeping with KFF, a well being info nonprofit that features KFF Well being Information. Desai known as the evaluation “flawed.”
Any loss in income might spell monetary destroy, particularly for small rural hospitals, mentioned Quang Ngo, president of the Texas Group of Rural & Group Hospitals Basis.
“It is type of like demise by a thousand cuts,” he mentioned. “Some will in all probability not make it.”
Extra cuts to rural well being
And extra cuts might preserve coming. The Trump administration’s price range request for the approaching fiscal 12 months requires cuts to a number of rural well being applications operated by way of the Well being Sources and Companies Administration. Desai mentioned the spending regulation’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 folks discover medical 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 keeping with Texas 2036, a public coverage assume tank.
Maria Salgado spends her workdays tabling at group occasions, dropping off flyers at medical doctors’ workplaces, 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: “Quite a lot 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 main 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 folks.
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 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 folks,” she mentioned. “They struggle their finest to maintain themselves.”
Casso mentioned her personal sister, who labored as a medical biller in a doctor’s workplace, could not afford medical insurance. She delayed care and died at age 45 of issues from diabetes and coronary heart illness. Casso worries the long run will discover extra folks in comparable conditions.
“Our inhabitants goes to endure,” 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 without doubt one of the core working applications at KFF .
