Effect of Undocumented Aliens on Hospitals’ Uncompensated Care Costs Is Uncertain

The impact of undocumented aliens on hospitals’ uncompensated care  costs remains uncertain. Determining the number of undocumented aliens  treated at a hospital is challenging because hospitals generally do not  collect information on patients’ immigration status and because  undocumented aliens are reluctant to identify themselves. Although about 70 percent of  hospitals responded to the survey, only 39 percent provided sufficient  information to evaluate the relationship between uncompensated care  levels and the proportion of care provided to patients without a Social  Security number. Some Federal Funding Has Been Available but Not for All Undocumented Aliens or Hospitals

Some federal funding has been available to assist with hospitals’ costs of  treating undocumented aliens, but this funding has not covered care of all  undocumented aliens or all hospital services, and not all hospitals receive  it. First,  Medicaid provides some coverage for eligible undocumented aliens, such  as low-income children and pregnant women. New Federal Funding Will Be Available Beginning in Fiscal Year 2005

The recently enacted Medicare Prescription Drug, Improvement, and  Modernization Act of 2003 appropriated additional funds, beginning in  fiscal year 2005, for payments to hospitals and other providers for  emergency medical services furnished to undocumented and certain other  aliens. By September 1, 2004, the Secretary is required to establish a  process for providers to request payments under the statute. Homeland Security Is Usually Not Responsible for Hospital Costs of Aliens Needing Emergency Medical Care Who Are Encountered by Border Patrol and Port-of-Entry Officials

Both Border Patrol agents and U.S. port-of-entry officials come into  contact with people needing emergency medical assistance whom they  refer or allow to enter for care, but in most situations, Homeland Security  is not responsible for the resulting costs of emergency medical assistance. Recommendation for Executive Action

To help ensure that funds appropriated by the Medicare Prescription Drug,  Improvement, and Modernization Act of 2003 are not improperly spent, we  recommend that the Secretary of Health and Human Services, in  establishing a payment process, develop appropriate internal controls to  ensure that payments are made to hospitals and other providers only for  unreimbursed emergency services for undocumented or certain other  aliens as designated in the statute. In all, the 10 states  comprised an estimated 78 percent of the population of undocumented  aliens in the United States in 2000. To determine the responsibility of the Department of Homeland Security  (Homeland Security) for covering the medical costs of sick or injured  aliens encountered by Border Patrol agents, we reviewed relevant laws,  regulations, and legal opinions and interviewed Border Patrol officials in  headquarters, in the nine sectors along the U.S.-Mexican border, and in the  Miami sector. We also interviewed Coast Guard officials about their  encounters with sick or injured aliens at sea.
Why GAO Did This Study

About 7 million undocumented aliens lived in the United States in 2000, according to Immigration and Naturalization Service estimates. Hospitals in states where many of them live report that treating them can be a financial burden. GAO was asked to examine the relationship between treating undocumented aliens and hospitals' costs not paid by patients or insurance. GAO was also asked to examine federal funding available to help hospitals offset costs of treating undocumented aliens and the responsibility of the Department of Homeland Security (Homeland Security) for covering medical expenses of sick or injured aliens encountered by Border Patrol and U.S. port-of-entry officials. To conduct this work, GAO surveyed 503 hospitals and interviewed Medicaid and hospital officials in 10 states. GAO also interviewed and obtained data from Homeland Security officials.

What GAO Found

Hospitals generally do not collect information on their patients' immigration status, and as a result, an accurate assessment of undocumented aliens' impact on hospitals' uncompensated care costs--those not paid by patients or by insurance--remains elusive. GAO attempted to examine the relationship between uncompensated care and undocumented aliens by surveying hospitals, but because of a low response rate to key survey questions and challenges in estimating the proportion of hospital care provided to undocumented aliens, GAO could not determine the effect of undocumented aliens on hospitals' uncompensated care costs. Federal funding has been available from several sources to help hospitals cover the costs of care for undocumented aliens. The sources include Medicaid coverage for emergency medical services for eligible undocumented aliens, supplemental Medicaid payments to hospitals treating a disproportionate share of low-income patients, and funds provided to 12 states by the Balanced Budget Act of 1997. In addition, the recently enacted Medicare Prescription Drug, Improvement, and Modernization Act of 2003 appropriated $1 billion over fiscal years 2005 through 2008 for payments to hospitals and other providers for emergency services provided to undocumented and certain other aliens. By September 1, 2004, the Secretary of Health and Human Services must establish a process for hospitals and other providers to request payments under the statute. Border Patrol and U.S. port-of-entry officials encounter aliens needing medical attention under different circumstances, but in most situations, Homeland Security is not responsible for aliens' hospital costs. The agency may cover medical expenses only for those people in its custody, but border officials reported that sick or injured people they encounter generally receive medical attention without being taken into custody.