Doctors React to Texas Rule Requiring Them to Ask About Immigration Status

A new Texas rule that requires hospitals to ask patients about immigration status has raised concern about further straining trust between physicians and their patients, according to experts who spoke with MedPage Today.

“As a doctor who has chosen to work in safety net hospitals, which are designed to care for those who have nowhere else to go, it’s a concerning rule for me,” Brian Williams, MD, a trauma surgeon in Dallas who has run as a Democratic congressional candidate in the state, told MedPage Today. “It may erode trust between the healthcare establishment and many of the patients in the state of Texas.”

The rule, which went into effect on Nov. 1, requires hospitals in Texas that receive Medicaid or Children’s Health Insurance Program funding to ask patients whether they are in the U.S. legally. It also requires those hospitals to track the cost of treating patients who do not have legal status.

However, patients can decline to provide information on their legal status, and hospital employees must tell patients that their response will not affect the care they receive, which is a federal requirement.

“As a doctor, any patient’s immigration status is irrelevant to me,” Williams said. “If they come to me and they’re sick and they need care, I’m going to provide that care.”

Republican Gov. Greg Abbott announced the executive order in August, which appears to be modeled on a law implemented in Florida last year, according to the Associated Press.

Since the Florida law went into effect in May 2023, limited data have been made publicly available. According to a KFF Health News report, the self-reported data suggested undocumented immigrants made up less than 1% of emergency department visits and admissions in Florida from June to December 2023. Notably, the report also showed that approximately 7% of patients declined to provide their immigration status.

In Texas, hospitals must begin reporting immigration status and healthcare costs to the state by March 2025, according to the AP.

Cedric Dark, MD, MPH, an emergency medicine physician and associate professor at Baylor College of Medicine in Houston, said he has not been informed about how it will be integrated into hospital protocols yet.

Even though the implementation of this practice is uncertain at his center as well, Williams said he believes it still could deter patients from coming to the hospital. “They should see us as a safe place, safe people to care for them in times of need, not someone who may ask to report immigration status that can affect their ability to stay in the country,” Williams added. “My role as a healer is suddenly being blurred to be an enforcer of immigration status.”

If the rule does require physicians to ask their patients directly, Dark said it would be “very clunky.” Emergency medicine physicians do not have the time amid their myriad duties to question each patient about their immigration status, he said.

Another fear is that the rule might expose physicians to violating the Emergency Medical Treatment and Labor Act (EMTALA). This federal law requires hospitals to provide stabilizing treatment “regardless of the patient’s insurance status or ability to pay” when they present to an emergency department with a medical condition, according to HHS.

“Am I personally as a physician going to be liable for an EMTALA violation?” Dark posited. “A lot goes into the implementation of that rule and how hospitals actually put it into effect so that they don’t violate the EMTALA obligation.”

Despite all the concerns raised by enacting this new rule, Dark emphasized that it might not even accomplish its goal, since “the way that the governor is asking those questions is not designed to actually get to that answer.”

“When you look at the facts, research will show you time and again that immigrants, in general, spend less on healthcare than U.S. citizens, and I’d be willing to bet that the amount of money spent on uncompensated care is going to be far outpaced by U.S. citizens than undocumented people,” Dark said.

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