GAO reports on uncompensated care to undocumented immigrants

IMMIGRANTS & PUBLIC BENEFITS

Health Care

GAO reports on uncompensated care to undocumented immigrants
Immigrants' Rights Update, Vol. 18, No. 4, June 18, 2004

The General Accounting Office (GAO) has issued its response to a July 2002 congressional request for information on the cost to hospitals of providing uncompensated care to undocumented non–U.S. citizens. The report concludes that the cost cannot be accurately determined because the information gathered by the GAO’s survey of over 500 hospitals was insufficient to make accurate calculations possible and because hospitals do not routinely collect information on their patients’ immigration status. Among the 198 hospitals that did provide sufficient information for the GAO to make calculations, the median percentage of uncompensated care (measured as inpatient days) attributable to undocumented persons was below 5 percent.

The GAO’s study looked at the costs to hospitals of providing uncompensated care to undocumented persons, the availability of federal funding sources to offset those costs, and the Dept. of Homeland Security’s (DHS’s) responsibility for covering the medical costs of undocumented persons apprehended by the Border Patrol.

In an effort to determine hospital costs, the GAO surveyed hospitals in 10 states selected for their relatively high proportions of undocumented residents: Arizona, California, Florida, Georgia, Illinois, New Jersey, New Mexico, New York, North Carolina, and Texas. The survey asked hospitals to report their numbers of inpatient days for persons with and without Social Security numbers (SSNs) and used the comparison to estimate the share of uncompensated care costs attributable to undocumented persons. Inpatient days were used in lieu of emergency room admissions because hospitals are more likely to have complete information on those patients and because hospitals reported that the majority of uncompensated care costs are associated with inpatients.

While the survey response rate was 70 percent, only 39 percent of the surveyed hospitals provided enough information for the GAO to make accurate calculations. The GAO found that in those 198 hospitals the percentage of uncompensated care days attributable to undocumented persons ranged from 0 to 17 percent, with a median of 4.3 percent for hospitals in the bottom and middle thirds and 4.9 percent for hospitals in the top third.

The GAO used the absence of an SSN as a proxy for undocumented status, although the researchers acknowledged that this proxy would include persons who did not provide an SSN for privacy or other reasons and would exclude any undocumented patients who gave false SSNs. To test the accuracy of this proxy, the survey also asked hospitals if they had a method for identifying undocumented patients. The GAO reports that fewer than 5 percent of the hospitals replied that they had a method for identifying undocumented patients, and that these methods varied and led to results that were inconsistent with the results based on the lack of an SSN.

Regarding the DHS’s responsibility for covering the costs of medical care for undocumented persons, the GAO found that the DHS is responsible for providing medical care only for persons it has taken into custody, who are typically persons of special enforcement interest, such as drug smugglers. Border Patrol agents reported that they normally refer persons needing medical attention to hospitals without taking them into custody or attempting to determine their immigration status. Persons needing medical attention may also be admitted into the U.S. under humanitarian parole, but such cases do not occur often.

The report also looked at sources of federal funding for care to undocumented persons. The GAO identified emergency Medicaid and Medicaid disproportionate share hospital (DSH) grants to hospitals that serve a relatively large share of low-income persons as sources, noting that many undocumented persons are not eligible for emergency Medicaid. The report also pointed to the $25 million allocated to states to assist with the costs of providing care to undocumented persons under the 1997 Balanced Budget Act, but noted that this funding (which ended in 2001) was generally used by states for their Medicaid programs and was not distributed to providers. Finally, the GAO pointed to the funds authorized under the Medicare Prescription Drug, Improvement and Modernization Act of 2003 to reimburse hospitals and other providers for uncompensated emergency services to undocumented persons.

The GAO report recommends that the Dept. of Health and Human Services, in establishing a payment process for the funds, “develop appropriate internal controls” to ensure that payments are made only to undocumented immigrants or other persons specified by statute. The Centers for Medicare and Medicaid Services is working with provider organizations and others to develop a payment process. NILC has developed written comments that are posted here.