Texas hospitals spent $1.05 billion treating patients illegally present in the United States during fiscal year 2025, representing more than 313,000 visits, according to a new report published by the Texas Public Policy Foundation in November 2026. The analysis, titled "Governing Blind," argues that Texas lacks the standardized data necessary to fully measure the fiscal and operational impacts of immigration on its public education, healthcare, and emergency services systems. While federal law requires the state to deliver services regardless of immigration status, the report finds that policymakers are forced to respond to visible strain without complete understanding of the scope, cost, or long-term consequences.
The healthcare figure comes from data collected under a 2024 executive order requiring Texas hospitals to ask patients about citizenship status during intake, though patients aren't required to answer and there's no verification mechanism to confirm responses. Between 2021 and 2024, U.S. Customs and Border Protection recorded more than 10.1 million encounters nationwide, with many months exceeding 100,000 encounters. During the same period, the Office of Refugee Resettlement released 67,271 unaccompanied minors into Texas, compared to 31,635 between 2015 and 2020. In education, the Federation for American Immigration Reform estimates that students with limited English proficiency cost Texas taxpayers $11.4 billion annually, while more than 10% of all U.S. public school students are designated as requiring English as a Second Language instruction. Cleveland Independent School District, serving the rapidly growing Colony Ridge development in Liberty County, saw enrollment jump 211% over a decade to nearly 10,000 students, with roughly 60% classified as emerging bilingual learners. The district now faces a 40% teacher turnover rate, nearly double the state average, and only 57% of students meet grade-level expectations, about 20 percentage points below the state average.
The report emphasizes that because no state agency tracks student immigration status, "no government entity currently measures the full scope of how many undocumented students are enrolled in Texas public schools, meaning policymakers cannot accurately assess the scale of the challenge they are managing, let alone design targeted solutions." In emergency services, the strain has been acute in border communities: El Paso spent $300,000 per day in 2022 responding to immigrant arrivals, while Eagle Pass declared a state of emergency after 4,000 people crossed in a single day in 2023. Eagle Pass Fire Chief Manuel Mello reported his department handled "up to 50 calls a day" during the surge, compared to a normal 27 to 30, with the increase entirely migrant-related. Kinney County, with a population of roughly 3,000, saw its emergency medical services calls more than double from an average of 235 annually to 486 in the first 10 months of 2022 alone.
The report argues that the central problem isn't simply cost but measurement, noting that "current data collection practices are fragmented, inconsistent, and often reliant on indirect indicators." This limits the ability of officials to move beyond assumptions toward evidence-based planning, particularly as immigration flows have become larger and more administratively complex than those contemplated when the Supreme Court ruled in 1982's Plyler v. Doe that states must provide free public education to all children regardless of status. The court's opinion at the time stated there was "no evidence in the record suggesting that illegal entrants impose any significant burden on the State's economy," a factual landscape the authors suggest has changed dramatically over four decades. Unpaid healthcare costs get passed to Texas taxpayers through higher insurance rates and public hospital funding, while school districts face growing demands for bilingual instruction, staffing, and infrastructure without precise accounting frameworks to measure impacts.
The report recommends three main actions: requiring school districts to collect and report citizenship status, immigration history, and English learner designation during enrollment; codifying the hospital citizenship data collection executive order into permanent statute with mandatory patient responses; and expanding emergency medical services reporting to capture immigration-related demand on local response systems. Author Selene Rodriguez writes that better data collection "will allow policymakers and local institutions to move from reactive decision-making to informed planning." The analysis stops short of calling for policy changes to immigration law itself, focusing instead on measurement as a prerequisite to any sustainable response. "Texas cannot effectively manage the impacts on public education, healthcare, and emergency services without a clearer understanding of the populations interacting with those systems," the report concludes, framing accurate tracking not as a solution to strain but as the foundation for responding with precision and accountability.