ER Overcrowding: Strategies to Prioritize Care

RIO GRANDE CITY, Texas — Dr. Jake Margo Jr. stood in the triage room at Starr County Memorial Hospital explaining why a person with persistent fever who could be treated with over-the-counter medication didn't need to be admitted to the emergency room.

"We're going to take care of the sickest patients first," Margo, a family medicine physician, said.

It's not like there was space on that June afternoon anyway. A small monitor on the wall pulsed with the vitals of current patients, who filled the ER. An ambulance idled outside in the South Texas heat with a patient waiting for a bed to open up.

"Everybody shows up here," Margo said. "When you're overwhelmed and you're overrun, there's only so much you can do."

Trump voters and a new Trump law

Starr County, a largely rural, Hispanic community on the southern U.S. border, made headlines in 2024 when it voted Republican in a presidential election for the first time in more than a century. Immigration and the economy drove the flip in this community, where roughly a third of the population falls below the poverty line.

Now, recent actions by the Trump administration and the GOP-controlled Congress have triggered a new concern: the inability of doctors, hospitals and other health providers to continue to care for uninsured patients. It's a fear not only in Starr County, which has one of the highest uninsured rates in the nation. Communities across the U.S. with similarly high proportions of uninsured people could struggle as additional residents lose health coverage.

About 14 million fewer Americans are expected to have health insurance in a decade due to President Trump's new tax-and-spending law, which Republicans dubbed the One Big, Beautiful Bill Act, or OBBBA, and the pending expiration of enhanced subsidies that slashed the price of Affordable Care Act plans for millions of people. The new law also limits programs that send billions of dollars to help those who care for uninsured people stay afloat.

The safety net may fail

"You can't disinsure this many people and not have, in many communities, just a collapse of the health care system," said 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 said.

KFF Health News is examining the impact of national health care policy changes on uninsured people and their communities. Though the Trump administration told KFF Health News it is making "a historic investment in rural health care," people who treat low-income patients, as well as researchers and consumer advocates, say recent policy decisions will make it harder for people to stay healthy. Doctors, hospitals, and clinics that make up the health care safety net could lose so much money they must close their doors, some of them warn.

"Because the patient's bill is not going to get paid," said Dr. Joseph Alpert, editor-in-chief of The American Journal of Medicine and a professor of medicine at the University of Arizona. "Uninsured patients stress the health care system."

Starr County shows how this dynamic unfolds. Primary care doctors in the county serve an average of just under 3,900 people each, nearly three times the U.S. average.

Margo, the family physician, said because so many people lack insurance and there are so few places to seek care, many residents treat the ER as their first stop when they're sick.

In many cases, they have neglected their health, making them sicker and more expensive to treat. And federal law requires ERs at hospitals in the Medicare program to stabilize or transfer patients, regardless of their ability to pay.

That leaves Margo and his team to practice 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 said. "They're literally dying."

Health systems in 'survival mode'

When people are uninsured or on Medicaid, they tend to rely on a safety net of doctors, hospitals, clinics, and community health centers, which offer services free of charge or absorb getting reimbursed at lower rates than they do treating patients on commercial insurance.