Sam Whitehead and Renuka Rayasam
RIO GRANDE CITY, Texas — 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 medicine didn’t have to be admitted to the emergency room.
“We’re going to take care of the sickest patients first,” Margo, a household drugs doctor, mentioned.
It’s not 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 exterior within the South Texas warmth with a affected person ready for a mattress to open up.
“Everybody shows up here,” Margo mentioned. “When you’re overwhelmed and you’re overrun, there’s only so much you can do.”
Starr County, a largely rural, Hispanic neighborhood 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 neighborhood, 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 shortcoming of medical doctors, hospitals, and different well being suppliers to proceed to look after uninsured sufferers. It’s a concern 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 might battle as extra residents lose well being protection.
About 14 million fewer Americans are anticipated to have medical health insurance in a decade on account of President Donald Trump’s new tax-and-spending legislation, which Republicans dubbed the One Big Beautiful Bill Act, and the pending expiration of enhanced subsidies that slashed the worth of Affordable Care Act plans for hundreds of thousands of individuals. The new legislation additionally limits programs that ship billions of {dollars} to assist those that look after uninsured individuals keep afloat.
“You can’t disinsure this many people and not have, in many communities, just a collapse of the health care system,” mentioned Sara Rosenbaum, founding chair of the Department of Health Policy and Management at George Washington University’s Milken Institute School of Public Health.
“The future is South Texas,” she mentioned.
KFF Health News is inspecting the impression of nationwide well being care coverage adjustments on uninsured individuals and their communities. Though the Trump administration advised KFF Health News it’s making “a historic investment in rural health care,” individuals who deal with low-income sufferers, in addition to researchers and client advocates, say current coverage selections will make it tougher for individuals to remain wholesome. Doctors, hospitals, and clinics that make up the well being care security web might lose a lot cash they need to shut their doorways, a few of them warn.
“Because the patient’s bill is not going to get paid,” mentioned Joseph Alpert, editor-in-chief of The American Journal of Medicine and a professor of drugs on the University of Arizona. “Uninsured patients stress the health care system.”
Starr County exhibits how this dynamic unfolds.
Primary care medical doctors within the county serve a median of just under 3,900 people every, almost thrice 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 many instances, they’ve uncared for their well being, making them sicker and costlier to deal with. And federal law requires ERs at hospitals within the Medicare program to stabilize or switch sufferers, no matter their skill to pay.
That leaves Margo and his group to apply what he described as “disaster medicine.”
“They come in with chest pain or they stop breathing. They collapse. They’ve never seen a doctor,” Margo mentioned. “They’re literally dying.”
Health Systems in ‘Survival Mode’
When persons are uninsured or on Medicaid, they have an inclination to depend on a security web of medical doctors, hospitals, clinics, and neighborhood well being facilities, which provide providers freed from cost or take in getting reimbursed at decrease charges than they do treating sufferers on business insurance coverage.
Those 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” have many involved they received’t climate the extra monetary pressure.
Trump’s new legislation funds his priorities, like extending tax cuts that primarily profit wealthier Americans and increasing immigration enforcement. Those prices are lined partly by an almost $1 trillion discount in federal well being spending for Medicaid inside the subsequent decade and adjustments to the ACA, equivalent to 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 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 House, mentioned projections from the nonpartisan Congressional Budget Office about how many individuals might lose medical health insurance are an “overestimate.” He didn’t present an estimate the administration sees as extra correct.
Supporters of the “One Big Beautiful Bill” say those that want well being protection can nonetheless get it in the event that they meet new necessities equivalent 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 legislation received’t trigger “the sky to fall,” Cannon mentioned. “The inefficient providers should be shutting down.”
A recent survey from AMGA, previously the American Medical Group Association, which represents well being methods throughout the nation, discovered almost half of rural amenities might shut or restructure on account of Medicaid cuts. Nearly three-quarters of respondents mentioned they anticipated layoffs or furloughs, together with of front-line clinicians.
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 almost a dozen positions, mentioned company head Esmer Guajardo. In neighboring Hidalgo County, the well being division has laid off greater than 30 individuals, mentioned Ivan Melendez, who helps oversee its operations.
In July, the Texas Department of State Health Services canceled Operation Border Health, an enormous annual occasion that final yr supplied free well being providers to almost 6,000 South Texas residents.
Gateway Community Health Center in Laredo, a border metropolis north of the Rio Grande Valley, is in “survival mode,” with a couple of 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 heart is on the lookout for 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 occurring as extra individuals lose medical health insurance and wish 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 development. Neither of them has medical health insurance.
Medicaid lined the payments for the births of her 5 youngsters. Now, she is determined by a cellular well being clinic run by a neighborhood medical college, the place she will be able to pay out-of-pocket for routine checkups and medicines to manage her Type 2 diabetes. If she wanted extra care, Rodriguez mentioned, she would go to the ER.
“You have to adapt,” she mentioned in Spanish.
‘Death by a Thousand Cuts’
People’s incapability to pay leads to uncompensated care, or providers that hospitals, medical doctors, and clinics don’t receives a commission for, which, beneath an earlier model of the megabill, was projected to extend by $204 billion over the subsequent decade, according to the Urban Institute, a nonprofit assume tank.
But the Trump administration can be reducing different assist that helped offset the price of look after individuals who can’t pay. The new legislation caps federal programs that many well being suppliers for low-income individuals have come to rely upon, particularly in rural areas, to shore up their budgets. These include taxes on hospitals, well being plans, and different suppliers that states use to assist fund their Medicaid applications. Such supplier taxes are a “financial gimmick,” Desai mentioned.
While the legislation creates a short lived $50 billion fund to assist rural medical doctors and hospitals, that’s slightly over a 3rd of estimated Medicaid funding losses in rural areas, according to KFF, a well being info nonprofit that features KFF Health News. Desai known as the evaluation “flawed.”
Any loss in income might spell monetary damage, particularly for small rural hospitals, mentioned Quang Ngo, president of the Texas Organization of Rural & Community Hospitals Foundation.
“It’s kind of like death by a thousand cuts,” he mentioned. “Some will probably not make it.”
And the hits might preserve coming. The Trump administration’s price range request for the approaching fiscal yr requires cuts to a number of rural well being applications operated via the Health Resources and Services 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 “historically inefficient,” Desai mentioned.
In December 2023, almost 3 million of Texas’ uninsured had been eligible for ACA subsidies, Medicaid, or the Children’s Health Insurance Program, according to Texas 2036, a public coverage assume tank.
Maria Salgado spends her workdays tabling at neighborhood occasions, dropping off flyers at medical doctors’ places of work, and holding one-on-one conferences with shoppers of MHP Salud, a nonprofit that connects residents to Medicaid and ACA protection.
She nervous funding cuts would actually set the group’s efforts again: “A lot of community members here, they’re going to be left behind,” mentioned Salgado, a neighborhood well being employee, or promotora.
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 incapability to pay, solely to have their preventable situations deteriorate.
She worries about the way forward for her neighborhood as physician shortages worsen, probably leaving few suppliers to deal with uninsured individuals.
“It’s 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 people,” she mentioned. “They try their best to take care of themselves.”
Casso mentioned her personal sister, who labored as a medical biller in a doctor’s workplace, couldn’t 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 related conditions.
“Our population is going to suffer,” she mentioned. “It’s going to be devastating.”
KFF Health News is a nationwide newsroom that produces in-depth journalism about well being points and is among the core working applications at KFF—an impartial supply of well being coverage analysis, polling, and journalism. Learn extra about KFF.
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