Undocumented Aliens: Questions Persist about Their Impact on Hospitals' Uncompensated Care Costs
Published: 2004-05-21T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: An estimated 7 million undocumented aliens resided in the United States  in 2000, according to the Immigration and Naturalization Service (INS).  Concern has been raised that uncompensated care costs due to treating  undocumented aliens place financial strain on hospitals in many areas of  the United States, including along the U.S.-Mexican border. Some hospital  associations and hospital officials report that increasing numbers of  persons they believe to be undocumented aliens, including some whom  the U.S. Border Patrol has encountered and found in need of immediate  medical attention, are arriving at their hospitals. In addition, U.S. port-of- entry officials may grant aliens humanitarian parole, a means of allowing  temporary access into the United States, and these aliens may also arrive  at hospitals in need of medical care. Because federal law requires hospitals  participating in the federal Medicare health insurance program to  medically screen and, if necessary, treat to stabilize any person seeking  care for an emergency medical condition, regardless of immigration status,  some hospital officials have said they believe the federal government  should help pay for emergency and other medical care provided to  undocumented aliens.
Although hospital officials contend that they are left to absorb  uncompensated care costs for emergency treatment and other medical  services provided to undocumented aliens, questions remain about the  magnitude of the problem. No national data are available on the number of  undocumented aliens who receive medical care, the specific services they  receive, or the uncompensated care costs associated with their treatment.  At your request, we conducted a study to address this issue. We focused  our work on the following questions:    To what extent are hospitals’ uncompensated care costs related to treating  undocumented aliens?
What has been the availability of federal funding sources to help offset  hospitals’ costs of treating undocumented aliens?
What is the responsibility of the Department of Homeland Security  (Homeland Security) to cover the medical expenses of aliens needing  emergency medical care who are either encountered by Border Patrol  agents or granted humanitarian parole by U.S. port-of-entry officials?
To conduct this work, we focused our review on 10 states: Arizona,  California, Florida, Georgia, Illinois, New Jersey, New Mexico, New York,  North Carolina, and Texas. We selected the 4 Southwest states—Arizona,  California, New Mexico, and Texas—because uncompensated care costs  due to treating undocumented aliens has been a long-standing issue for  hospitals located in communities near the U.S.-Mexican border. We  selected the other 6 states because high estimated numbers of  undocumented aliens resided there in 2000, according to INS. In all, the 10  states comprised an estimated 78 percent of the population of  undocumented aliens in the United States in 2000. We mailed a  questionnaire to 503 hospitals located in the 10 states. We received survey  responses from 351 hospitals (70 percent), of which 198 (39 percent of  surveyed hospitals) provided the information necessary for us to calculate  their total uncompensated care costs and the proportion of care they  provided to patients without a Social Security number, a proxy we used  for undocumented aliens. To determine the availability of federal funding  sources to hospitals treating undocumented aliens, we obtained  documents and interviewed officials from state Medicaid offices and state  hospital associations in the 10 states, as well as from the Department of  Health and Human Services’ Centers for Medicare & Medicaid Services  (CMS). In addition, we reviewed provisions of the recently enacted  Medicare Prescription Drug, Improvement, and Modernization Act of 2003  pertaining to payments to providers for treating undocumented and other  aliens. Finally, to determine the policies and practices used by the U.S.  Border Patrol and U.S. port-of-entry officials when they encounter aliens  needing emergency medical care, we interviewed Homeland Security  officials, including officials from relevant Border Patrol jurisdictions and  U.S. ports of entry along the U.S.-Mexican border. We also interviewed  Coast Guard officials about their encounters with sick or injured aliens at  sea. For additional information on our scope and methodology and survey  results, see appendixes I and II. We conducted our work from September  2002 through April 2004 in accordance with generally accepted  government auditing standards.
subsections: section_title: Background
paragraphs: According to INS, the estimated population of undocumented aliens in the  United States increased from 3.5 million in 1990 to about 7 million in 2000.  Many states that had relatively few undocumented aliens in 1990  experienced rapid growth of this population during the decade. The  estimated number of undocumented aliens residing in Georgia, for  example, rose from 34,000 in 1990 to 228,000 in 2000. INS estimates  indicate that the vast majority of undocumented aliens were concentrated  in a few states, with nearly 70 percent from Mexico.
Undocumented aliens’ use of medical services has been a long-standing  issue for hospitals, particularly among those located along the U.S.- Mexican border. As required by the Emergency Medical Treatment and  Active Labor Act (EMTALA), hospitals participating in Medicare must  medically screen all persons seeking emergency care and provide the  treatment necessary to stabilize those determined to have an emergency  condition, regardless of income or immigration status. Two recent studies  have reported on hospitals’ provision of care to undocumented aliens, but  they were limited in scope. National data sources on health insurance  coverage do not report the extent to which undocumented aliens have  health insurance or are otherwise able to pay for their medical care.  Available data on the broader category of foreign-born noncitizens  suggests that a large proportion may be unable to pay for their medical  care. A U.S. Census Bureau report indicates that in 2002, more than 40  percent of foreign-born noncitizens residing in the United States, including  undocumented and some lawful permanent resident aliens, lacked health  insurance.
Homeland Security’s Bureau of Customs and Border Protection is  responsible for securing the nation’s borders. The bureau’s Border Patrol  is responsible for detecting and apprehending persons who attempt to  enter illegally between official ports of entry. The bureau’s Office of Field  Operations oversees U.S. port-of-entry officials who inspect and determine  the admissibility of all individuals seeking to enter the United States at  official ports of entry. Both Border Patrol agents and U.S. port-of-entry  officials may come into contact with persons needing emergency medical  care. For example, Border Patrol agents may encounter persons suffering  from severe dehydration or who have been injured in vehicle accidents,  and U.S. port-of-entry officials may encounter persons with urgent medical  needs, such as burn victims, seeking entry because the closest capable  medical facility is in the United States.
Border Patrol operations are divided into 21 sectors, but more than 95  percent of Border Patrol apprehensions in 2002 occurred in 9 sectors  bordering Mexico. Since the mid-1990s, the Border Patrol has been  implementing a strategy to strengthen security and disrupt traditional  pathways of illegal immigration along the border with Mexico. As we  reported in August 2001, however, one of the strategy’s major effects has  been a shift in illegal alien traffic from traditional urban crossing points  such as San Diego, California, to harsher, more remote areas of the  border. Rather than being deterred from illegal entry, many aliens have  instead risked injury and death trying to cross mountains, deserts, and  rivers. To reduce the number of undocumented aliens who die or are  injured trying to cross the border illegally, INS in 1998 created the Border  Safety Initiative, whose focus includes searching for and rescuing those  who may have become lost. One element of the initiative is tracking the  number of aliens whom Border Patrol agents rescue, a subset of all Border  Patrol encounters with sick or injured aliens.
U.S. port-of-entry officials inspect and determine the admissibility of  persons seeking entry at air, land, and sea ports of entry around the  country. Along the U.S.-Mexican border, officials at the 24 land ports of  entry, which cover 43 separate crossing points, conducted more than 250  million inspections in fiscal year 2003. The Secretary of Homeland  Security may parole—that is, allow temporary access into the United  States—an otherwise inadmissible alien for urgent humanitarian reasons,  such as treatment for an emergency medical condition.
section_title: Effect of Undocumented Aliens on Hospitals’ Uncompensated Care Costs Is Uncertain
paragraphs: 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. After speaking  with experts and hospital administrators, we determined that one  potentially feasible method for hospitals to estimate this population is to  identify patients without a Social Security number, recognizing that this  proxy can over- or underestimate undocumented aliens. We surveyed 503  hospitals in 10 states to collect information on patients without a Social  Security number and their effect on hospitals’ uncompensated care  levels—that is, uncompensated care costs as a percentage of total hospital  expenses. We also included a question in the survey to determine what  other methods, if any, hospitals were using to track undocumented aliens  to help assess how well patients without a Social Security number served  as a proxy for this population.
Despite a concerted follow-up effort, we did not receive a sufficient survey  response to assess the impact of undocumented aliens on hospitals’  uncompensated care levels or to evaluate the lack of a Social Security  number as a proxy for undocumented aliens. (Details on our survey  methods and analysis appear in app. I.) 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. Of all responding hospitals, fewer than 5 percent  reported having a method other than the lack of a Social Security number  alone to identify their undocumented alien patients, and the methods used  by these hospitals varied. For example, one hospital identified  undocumented aliens as those who were both Hispanic and lacked a  Social Security number; other hospitals identified undocumented alien  patients through foreign addresses or information from patient interviews.  Furthermore, the estimates produced by these other methods were  inconsistent with those produced by using lack of Social Security number  alone. Because we did not receive a sufficient survey response rate and  because we were unable to assess the accuracy of the proxy, we could not  determine the effect of undocumented aliens on hospital uncompensated  care levels. Until better information is available, assessing the relationship  between this population and hospitals’ uncompensated care levels will  continue to pose methodological challenges.
section_title: Some Federal Funding Has Been Available but Not for All Undocumented Aliens or Hospitals
paragraphs: 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. Two funding sources are available through the Medicaid program. First,  Medicaid provides some coverage for eligible undocumented aliens, such  as low-income children and pregnant women. Not all undocumented aliens  are eligible for or enrolled in Medicaid, however, and this coverage is  limited to emergency medical services, including emergency labor and  delivery. Second, Medicaid DSH adjustments are available to some  hospitals treating relatively large numbers of low-income patients,  including undocumented aliens. Finally, under the provisions of BBA,   $25 million was available annually, from fiscal years 1998 through 2001, to  assist certain states with their costs of providing emergency services to  undocumented aliens regardless of Medicaid eligibility. According to state  Medicaid officials in the states we reviewed, states used these funds to  help recover the state share of Medicaid expenditures for undocumented  aliens, and not to recover hospitals’ costs of care for undocumented aliens  not eligible for Medicaid. Recent legislation appropriated additional  federal funding—$250 million annually for fiscal years 2005 through  2008—for payments to hospitals and other eligible providers for  emergency medical services delivered to undocumented and certain other  aliens.
subsections: section_title: Medicaid Covers Emergency Medical Services for Eligible Undocumented Aliens
paragraphs: Undocumented aliens may qualify for Medicaid coverage for treatment of  an emergency condition if, except for their immigration status, they meet  Medicaid eligibility requirements. Medicaid coverage is also limited to care  and services necessary for treatment of emergency conditions for certain  legal aliens—including lawful permanent resident aliens who have resided  in the United States for less than 5 years and aliens admitted into the  United States for a limited time, such as some temporary workers. We  refer to Medicaid coverage for these groups of individuals—that is, those  whose coverage is limited to treatment of emergency conditions—as  emergency Medicaid. Because immigration status is a factor when states  determine an individual’s Medicaid coverage, people applying for Medicaid  are asked about their citizenship and immigration status as a part of the  Medicaid eligibility determination process.
State Medicaid officials in the 10 states that we reviewed reported  spending more than $2 billion in fiscal year 2002 for emergency Medicaid  expenditures (see table 1). Although states are not required to identify or  report to CMS their Medicaid expenditures specific to undocumented  aliens, several states provided data or otherwise suggested that most of  their emergency Medicaid expenditures were for services provided to  undocumented aliens. According to data provided by state Medicaid  officials in 5 of the 10 states, at least half of emergency Medicaid  expenditures in these states were for labor and delivery services for  pregnant women.
Emergency Medicaid expenditures in the 10 states have increased over the  past several years but remain a small portion of each state’s total Medicaid  expenditures. In 9 of the 10 states we reviewed, emergency Medicaid  expenditures grew faster than the states’ total Medicaid expenditures from  fiscal years 2000 to 2002. For example, while Georgia’s total Medicaid  expenditures increased by 44 percent during this period, the state’s  emergency Medicaid expenditures increased 349 percent—nearly eight  times as fast. Nevertheless, emergency Medicaid expenditures in these  states accounted for less than 3 percent of each state’s total Medicaid  expenditures.
Emergency Medicaid funding is limited in that not all undocumented  aliens treated at hospitals are eligible for Medicaid, not all eligible  undocumented aliens enroll in Medicaid, and not all hospital services  provided to enrolled undocumented aliens are covered by Medicaid.
Not all undocumented aliens are eligible for Medicaid.
Undocumented aliens are eligible for emergency Medicaid coverage only  if, except for immigration status, they meet Medicaid eligibility criteria  applicable to citizens. Many state hospital association officials we  interviewed commented that hospitals were concerned about  undocumented aliens who do not qualify for Medicaid. To qualify,  undocumented aliens must belong to a Medicaid-eligible category—such  as children under 19 years of age, parents with children under 19, or  pregnant women—and meet income and state residency requirements.  Arizona hospital and Medicaid officials said that many undocumented  aliens treated at their hospitals are only passing through the state and  cannot meet Medicaid state residency requirements. However,  comprehensive data are not available to determine the extent to which  undocumented aliens receiving care in hospitals are not eligible for  Medicaid coverage.
Not all eligible undocumented aliens enroll in Medicaid. Factors  besides eligibility may also influence the number of eligible undocumented  aliens who actually enroll in Medicaid and receive coverage. According to  officials in most state Medicaid offices and hospital associations we  interviewed, fear of being discovered by immigration authorities is one  factor that can deter undocumented aliens from enrolling. Enrollment in  Medicaid involves filling out an application; providing personal  information such as income and place of residency; and, in some states, an  interview. Also, because undocumented aliens are generally covered by  Medicaid only for the duration of an emergency event, they may have to  reenroll each time they receive emergency services.
Not all hospital services provided to undocumented aliens enrolled  in Medicaid are covered. Medicaid coverage for undocumented aliens is  limited to treatment of an emergency medical condition. Hospital  association officials in 7 of the 10 states we reviewed reported that a  concern of hospitals is the cost of treatment for undocumented aliens that  continues beyond emergency services and is not covered by Medicaid.  Aside from anecdotal information, however, data are not available to  determine the extent to which hospitals are treating undocumented aliens  for nonemergency conditions. Further, within federal guidelines, the  services covered under emergency Medicaid may vary from state to state.  According to an eligibility expert in CMS’s Center for Medicaid and State  Operations, the agency’s position is that each case needs to be evaluated  on its own merits, and the determination of what constitutes an emergency  medical service is left to the state Medicaid agency and its medical  advisors.
section_title: Medicaid Disproportionate Share Hospital Adjustments Aid Some Hospitals
paragraphs: Medicaid DSH payments are another source of funding available to some  hospitals that could help offset the costs of treating undocumented aliens.  Under the Medicaid program, states make additional payments, called  DSH adjustments, to qualified hospitals serving a disproportionate number  of Medicaid beneficiaries and other low-income people, which can include  undocumented aliens. As with other Medicaid expenditures, states receive  federal matching funds for DSH payments to hospitals. Medicaid DSH  allotments—the maximum federal contribution to DSH payments—totaled  $5 billion in fiscal year 2002 in the 10 states we reviewed. All hospitals,  however, do not receive these funds. In general, a hospital qualifies for  DSH payments on the basis of the relative amount of Medicaid service or  charity care it provides. Care provided to undocumented aliens could fall  into one of these categories. The extent to which hospitals benefit from  DSH payments depends on how states administer the DSH program.  Medicaid officials in some states we reviewed said that some hospitals  transfer money to the state to support the state’s share of the DSH  program; such transfers reduce the net financial benefit of DSH payments  to these hospitals.
section_title: Balanced Budget Act Funding for Undocumented Aliens Retained by States
paragraphs: Federal funding provided under BBA was made available to help states  recover their costs of emergency services furnished to undocumented  aliens regardless of Medicaid eligibility; the states we reviewed opted to  use this money to help recover the state share of emergency Medicaid  expenditures. BBA made $25 million available for each of fiscal years 1998  through 2001 for distribution among the 12 states with the highest  numbers of undocumented aliens. INS estimates of the undocumented  alien population in 1996 were used to identify the 12 states. Seven of the 10  states we reviewed were eligible for a portion of these allotments; 6 of the  7 states claimed these funds. BBA allotments for these 6 states accounted  for 91 percent of the $25 million available each year. States could use the  funds to help recover (1) the state share of emergency Medicaid  expenditures for undocumented aliens and/or (2) other state expenditures  or those of political subdivisions of the state, for emergency services  provided to those undocumented aliens not eligible for Medicaid. In each  of the 6 states, Medicaid officials reported using the state’s entire BBA  payment to recover a portion of what the state had already paid for  undocumented aliens under emergency Medicaid. These funds were not  used to cover hospitals’ costs for the care of undocumented aliens not  eligible for Medicaid.
In commenting on BBA funding, state hospital association officials in 5 of  the 7 states we interviewed that were eligible for this funding said that the  amount was too low. For example, in fiscal year 2001, BBA allotments for  undocumented aliens for the two states with the largest ($11,335,298) and  smallest ($651,780) allotments accounted for less than 2 percent of  reported emergency Medicaid expenditures in those states. Officials from  several state hospital associations, as well as from the American Hospital  Association, reported that their members would like any additional federal  funding for undocumented aliens to be distributed to hospitals more  directly. Some state hospital association and state Medicaid officials  nevertheless acknowledged matters that would need to be addressed in  order to distribute funds to hospitals for undocumented aliens not covered  by emergency Medicaid, including how hospitals would identify, define,  and document expenditures for emergency services provided to these  undocumented aliens. As mentioned above, fewer than 5 percent of  hospitals responding to our survey reported having a method for  identifying undocumented alien patients other than tracking patients  without a Social Security number.
section_title: New Federal Funding Will Be Available Beginning in Fiscal Year 2005
paragraphs: 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. Section 1011 of the act appropriated $250 million for each of fiscal  years 2005 through 2008 for this purpose. Two-thirds of the funds are to  be distributed according to the estimated proportion of undocumented  aliens residing in each state; the remaining one-third is designated for the  six states with the highest number of apprehensions of undocumented  aliens as reported by Homeland Security. These new funds are to be paid  directly to eligible providers, such as hospitals, physicians, and ambulance  services, for emergency medical services provided to undocumented and  certain other aliens that are not otherwise reimbursed. Payment amounts  will be the lesser of (1) the amount the provider demonstrates was  incurred for provision of emergency services or (2) amounts determined  under a methodology established by the Secretary of Health and Human  Services. By September 1, 2004, the Secretary is required to establish a  process for providers to request payments under the statute.
section_title: 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
paragraphs: 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.  Homeland Security may cover medical expenses only of people taken into  custody, but Border Patrol officials said that when they encounter people  with serious injuries or medical conditions, they generally refer the  individuals to local hospitals without first taking them into custody. The  agency does not track the number of aliens it refers to hospitals in this  fashion. Similarly, undocumented aliens arriving at U.S. ports of entry with  emergency medical conditions may be granted humanitarian parole for  urgent medical reasons, but they are not in custody, and Homeland  Security is not responsible for their medical costs.
subsections: section_title: The Border Patrol Generally Does Not Take Injured Aliens into Custody and Is Therefore Not Responsible for Subsequent Medical Costs
paragraphs: Although the Border Patrol does not have an agencywide formal written  policy regarding encounters with sick or injured persons, Border Patrol  officials and documents we obtained indicate that the Border Patrol’s first  priority in such encounters is to obtain medical assistance and, if  necessary, arrange transportation to a medical facility. According to  Border Patrol officials, agents generally do not take sick or injured  persons into custody on the scene, and because the individuals are not in  custody, Homeland Security is not responsible for their medical costs.  Under federal law, the U.S. Public Health Service, within the Department  of Health and Human Services, is authorized to pay the medical expenses  of persons in the custody of immigration authorities. Under an  interagency agreement, Homeland Security is responsible for reimbursing  the Department of Health and Human Services for hospital care provided  to such persons. The statute does not grant the Public Health Service the  authority to cover the medical expenses of aliens not in custody, and  therefore Homeland Security is not responsible for these medical costs.
Border Patrol officials provided a number of different reasons for not first  taking injured or sick persons they have encountered into custody. Several  officials said, for example, that Border Patrol agents assume a  humanitarian role when encountering persons needing emergency medical  care, and their first concern is obtaining medical assistance. In addition,  many officials said that an injured or sick person’s condition may affect his  or her ability to reliably answer questions about immigration status. Some  Border Patrol officials and documents indicated that taking all sick or  injured persons into custody would not be consistent with the agency’s  primary enforcement mission. They explained that the Border Patrol does  not have the resources to pursue a prosecution of every possible violation  of law, so agents exercise their prosecutorial discretion and concentrate  resources on those violations that will produce maximum results in  accomplishing their mission. Further, according to statute, an immigration  officer may not arrest an alien without a warrant unless the officer has  reason to believe that the person is in the United States in violation of  immigration law and is likely to escape before a warrant can be obtained.  Some officials maintained that when aliens encountered need medical  attention and are considered unlikely to escape, they are generally not  taken into custody.
Border Patrol officials reported that in certain instances, agents may take  particular persons into custody while they are in the hospital. For  example, if agents encounter an individual who is of particular law  enforcement interest—such as a suspected smuggler of drugs or aliens— they may take that individual into custody. Doing so may involve posting a  guard at the hospital. In these circumstances, Homeland Security would  assume responsibility for any costs of care once the individual is placed  into custody.
Border Patrol agents in the Miami sector encounter sick or injured aliens  under conditions slightly different from those in the Southwest, but their  practices in such encounters are generally consistent with those reported  by the nine Southwest sectors and with Border Patrol’s general unwritten  policy and practice. According to Miami sector officials, because the  sector has fewer than 100 agents to cover more than 1,600 coastal miles in  Florida, Georgia, South Carolina, and North Carolina, Miami sector agents  typically come into contact with aliens in response to calls from other law  enforcement agencies. If the other law enforcement agency called for local  emergency medical services before Miami Border Patrol sector agents  determined the person’s immigration status, Border Patrol agents would  not take that person into custody and Homeland Security would not be  responsible for his or her medical costs. According to Miami sector  officials, Homeland Security is responsible for medical costs only for those  people taken into custody after their immigration status has been  determined, and agents follow up at the hospital only with these patients.  If another law enforcement agency refers the person to the hospital,  Border Patrol agents said they do not follow up unless called by the  hospital upon the patient’s release, and then only if agents are available to  respond.
Undocumented aliens are also intercepted at sea by the U.S. Coast Guard.  Coast Guard cutters have trained medical personnel on board, and  according to officials in the agency’s Migrant Interdiction Division, when  Coast Guard personnel encounter sick or injured undocumented aliens,  their practice is to treat them at sea to the extent possible and return them  to their home countries once they are stabilized. On occasion, persons  encountered at sea with severe medical conditions may need to be  transported to shore or directly to a hospital, but this situation rarely  occurs. In fiscal year 2002, the Coast Guard brought 9 aliens to shore for  medical care and in fiscal year 2003, brought in 14. According to Coast  Guard officials, the agency has no responsibility to pay for care of those  aliens brought to shore for medical treatment.
section_title: The Border Patrol’s Total Encounters with Sick or Injured Aliens Is Unknown
paragraphs: It is unknown how often the Border Patrol refers sick or injured aliens not  taken into custody to hospitals. Border Patrol officials said the agency  does not track the total number of encounters with sick or injured  persons. What is known is how much the Department of Health and  Human Services pays for care, subject to reimbursement from Homeland  Security, for those already in Border Patrol custody. In fiscal year 2003,  the Department of Health and Human Services paid about $1.7 million in  medical claims for people in Border Patrol custody, of which about   $1.2 million was for hospital inpatient and outpatient expenses. Data are  also available on Border Patrol encounters with aliens that the agency  categorized as rescues—that is, incidents in which death or serious injury  would have occurred had Border Patrol agents not responded—but these  data do not include all encounters with aliens who were referred to  hospitals without first having been taken into custody. Our analysis of  Border Patrol rescue data for the nine sectors on the U.S.-Mexican border  shows that in fiscal year 2002 about 360 suspected undocumented aliens  were rescued and referred to hospitals for care. Rescued aliens were  referred to hospitals for a variety of medical reasons, including heat  exposure, possible heart attack, injuries, and complications from  pregnancy. Nearly half the referrals occurred in the Tucson Border Patrol  sector, which covers most of Arizona.
section_title: Homeland Security Is Not Responsible for Medical Costs of Aliens Granted Humanitarian Parole for Urgent Medical Reasons, but Few Such Paroles Are Granted
paragraphs: Homeland Security is not authorized to pay the medical costs of aliens  granted humanitarian parole at U.S. ports of entry for urgent medical  reasons because these individuals are not in custody. Humanitarian  paroles for urgent medical reasons are granted by port directors on a case- by-case basis and, according to most officials responsible for ports of  entry whom we interviewed, only when the alien is in medical distress or a  “life-or-death situation,” such as after a severe head trauma. Some port-of- entry officials cited instances when they turned aliens away because they  believed that the medical conditions were not urgent and medical facilities  in Mexico could provide treatment. When humanitarian paroles for urgent  medical reasons are granted, a formal record of arrival is completed to  document the aliens’ entry into the United States. Sometimes, port-of-entry  officials know in advance that an injured alien will be arriving, and the  form is completed beforehand. If medical urgency prevents completion of  this form at the port of entry, an official will go to the hospital to obtain  the necessary information. The length of time a paroled alien is allowed to  remain in the United States is determined case by case but cannot exceed  1 year. Like all other aliens who enter for a temporary period, a paroled  alien is expected to leave when his or her authorized stay ends.
Office of Field Operations data show that from June 1 through October 31,  2003, officials at 7 of the 24 ports of entry along the U.S.-Mexican border  granted a total of 54 humanitarian paroles for urgent medical reasons.  Almost two-thirds (35) of these paroles were granted at the Columbus port  of entry in New Mexico and brought to one local hospital. A Columbus  port-of-entry official stated that the limited capability of the nearby  medical facility in Mexico contributes to the high number of humanitarian  paroles granted for urgent medical reasons at the port. The hospital that  treated most of the paroled patients reported receiving no payment for any  of the 27 patients paroled from June through August 2003 and noted that 4  of these patients were later transferred to other hospitals for further care.  The other 19 paroles occurred at three ports of entry in Arizona and three  ports of entry in Texas, near small towns straddling the border.
Most (17 of 24) of the Southwest border ports of entry reported granting  no paroles for urgent medical reasons from June through October 2003.  Officials at three ports of entry we reviewed granted no humanitarian  paroles for urgent medical reasons during that time and are located near  large cities in Mexico. Officials at one of these ports of entry told us that  hospital care is available in the Mexican cities across the border, so that  Mexican residents need not be treated at U.S. hospitals. Hospital officials  in Arizona noted that several Arizona hospitals and the U.S. government  have provided funds and equipment to help improve the capabilities of  nearby Mexican medical facilities and that these measures helped reduce  their burden of cases from Mexico.
Finally, although aliens may be granted humanitarian parole for urgent  medical reasons, several port-of-entry officials told us that the majority of  persons seeking entry into the United States for emergency medical care  have proper entry documents. For example, some aliens arriving at U.S.  hospitals may be Mexican nationals with border crossing cards, which  allow entry into the United States within 25 miles of the border for  business or pleasure for up to 72 hours. Another port official reported that  many U.S. citizens live in Mexico and sometimes arrive in ambulances to  go to U.S. hospitals. According to some officials responsible for ports of  entry, hospitals may not be fully aware of the immigration status of  patients who have crossed the border to obtain emergency medical care;  this uncertainty may create the impression that ports are granting more  humanitarian paroles for urgent medical reasons than they are.
section_title: Conclusions
paragraphs: Despite hospitals’ long-standing concern about the costs of treating  undocumented aliens, the extent to which these patients affect hospitals’  uncompensated care costs remains unknown. The lack of reliable data on  this patient population and lack of proven methods to estimate their  numbers make it difficult to determine the extent to which hospitals treat  undocumented aliens and the costs of their care. Likewise, with respect to  undocumented aliens referred to hospitals but not first taken into custody  by the Border Patrol, neither the Border Patrol nor hospitals track their  numbers, making it difficult to estimate these patients’ financial impact on  hospitals. Until reliable information is available on undocumented aliens  and the costs of their care, accurate assessment of their financial effect on  hospitals will remain elusive, as will the ability to assess the extent to  which federal funding offsets their costs. The availability of new federal  funding under the Medicare Prescription Drug, Improvement, and  Modernization Act of 2003 may offer an incentive for hospitals serving  undocumented aliens to collect more reliable information on the numbers  of these patients and the costs of their care.
section_title: Recommendation for Executive Action
paragraphs: 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 doing so, the Secretary should  develop reporting criteria for providers to use in claiming these funds and  periodically test the validity of the data supporting the claims.
section_title: Agency Comments
paragraphs: We provided officials in CMS and Homeland Security an opportunity to  comment on a draft of this report. In its comments, CMS concurred with  our recommendation that the Secretary develop appropriate internal  controls and stated that the agency expects to develop appropriate  internal controls regarding funds appropriated by section 1011 of the  Medicare Prescription Drug, Improvement, and Modernization Act. The  agency said it is currently developing a process for providers to claim  these funds and indicated that it would be helpful for GAO to provide  insight into the specific internal controls that would be useful in ensuring  that claims are paid only for unreimbursed emergency services for  undocumented and certain other aliens. In response to CMS’s request, we  amended our recommendation to be more specific. CMS also agreed that  the new federal funding may offer an incentive for those hospitals  incurring significant costs for undocumented aliens to collect more  reliable information on the number of undocumented alien patients they  treat and the costs of their care, but it also noted that other providers,  especially those who do not regularly see undocumented aliens in  emergency department settings, may choose to continue to provide  uncompensated care to this population without ever trying to document  the costs. CMS also provided technical comments, which we incorporated  as appropriate. Homeland Security generally agreed with the report’s  findings and provided some technical comments regarding parole and the  numbers of ports of entry, which we incorporated as appropriate.
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section_title: Appendix I: Survey Methodology and Results
paragraphs: To collect information on the extent to which hospitals’ uncompensated  care costs are related to treating undocumented aliens, we mailed a  questionnaire to a sample of more than 500 hospitals in 10 states— Arizona, California, Florida, Georgia, Illinois, New Jersey, New Mexico,  New York, North Carolina, and Texas. We selected the 4 Southwest  states—Arizona, California, New Mexico, and Texas—because  uncompensated care costs due to treating undocumented aliens has been  a long-standing issue for hospitals located in communities near the U.S.- Mexican border. We selected the other 6 states because high estimated  numbers of undocumented aliens resided there in 2000, according to the  Immigration and Naturalization Service (INS). In all, the 10 states  comprised an estimated 78 percent of the population of undocumented  aliens in the United States in 2000. (See table 2.)
subsections: section_title: Survey Sample
paragraphs: We sent our survey to a randomly selected stratified sample of 503 of 1,637  short-term, nonfederal, general medical and surgical care hospitals that— according to either the American Hospital Association’s annual survey  database, fiscal year 2000, or the Centers for Medicare & Medicaid  Services Provider of Service File as of the end of 2000—had an emergency  department. Table 3 shows the characteristics of the universe from which  the hospitals were sampled.
From this universe of hospitals, we sampled 100 percent of the hospitals in  Arizona and New Mexico. In the other 8 states, we stratified the sample by  state, hospital ownership, and estimates of undocumented aliens by  county.
section_title: Survey Questions
paragraphs: Our survey included questions about the hospital, such as (1) whether it  had an emergency department in fiscal year 2002; (2) the number of  staffed beds on the last day of fiscal year 2002; (3) financial information on  bad debt and charity care charges, total expenses, gross patient revenue,  and other operating revenue; (4) whether the hospital routinely collected  Social Security numbers and, for fiscal year 2002, total inpatient days and  the number of inpatient days for people without a Social Security number,  our proxy for undocumented aliens; and (5) as a means of evaluating the  accuracy of the proxy, whether the hospital used a method other than lack  of a Social Security number alone to identify undocumented aliens.
section_title: Lack of Social Security Number as a Proxy for Undocumented Aliens
paragraphs: After speaking with hospital officials, we concluded that although lack of a  Social Security number could potentially over- or underestimate the actual  population of undocumented aliens treated by a hospital, it might be the  least burdensome way for hospitals to provide us with information for our  survey that would allow us to attempt to identify care given to  undocumented aliens. We included a question on the survey asking  hospitals to report the number of inpatient days for patients without a  Social Security number. We used this information, along with total  inpatient days reported, to calculate the proportion of inpatient days for  patients without a Social Security number in order to approximate the  proportion of inpatient care provided to undocumented aliens. Although  undocumented aliens may first seek care through hospital emergency  departments, we focused on inpatient care because hospital officials  reported that patient data, including Social Security numbers, are  generally more complete for persons admitted as inpatients; persons  treated in the emergency department are often released before such  information can be collected. Further, although a large number of patients  may be seen in emergency departments, hospital officials reported that the  majority of uncompensated care cost is incurred in inpatient settings.
We could not establish the accuracy of our proxy before carrying out the  survey, so to assess our proxy, we included a survey question on hospitals’  methods for estimating undocumented aliens. We were, however, unable  to determine our proxy’s accuracy. Fewer than 5 percent of hospitals  responding to the survey reported that they had methods of estimating  undocumented aliens other than lack of Social Security number alone.  These methods varied among the hospitals and led to estimates  inconsistent with those based on lack of a Social Security number.
section_title: Survey Pretesting and Response
paragraphs: We also pretested our questionnaire in person with officials at six  hospitals to determine if it was understandable and if the information was  feasible to collect, and we refined the questionnaire as appropriate. We  conducted follow-up mailings and telephone calls to nonrespondents. We  obtained responses from 351 hospitals, for an overall response rate of  about 70 percent. Of the hospitals that returned surveys, 300 provided  financial information to calculate uncompensated care levels—defined as  uncompensated care as a percentage of total expenses—but only 198 (39  percent of all hospitals surveyed) provided sufficient information to allow  us to examine the relationship between hospitals’ uncompensated care  levels and the percentage of inpatient days for patients without a Social  Security number. We performed checks for obvious errors and  inconsistent data but did not independently verify the information  hospitals provided in the survey.
section_title: Data from Responding Hospitals
paragraphs: Three hundred hospitals provided sufficient information to calculate  uncompensated care levels. Table 4 shows financial information for these  hospitals; this information is not generalizable to the overall population.
For the 198 hospitals that provided sufficient information, we examined  the variation in uncompensated care levels by percentage of inpatient days  attributable to patients without a Social Security number after dividing the  distribution of the latter into thirds. Table 5 shows this information for  these 198 hospitals; this information is not generalizable to the overall  population.
Factors other than the percentage of inpatient days attributable to patients  without a Social Security number, such as the extent to which hospitals  treat uninsured patients (including uninsured patients with a Social  Security number), could affect the variation in uncompensated care levels  among hospitals.
Since a high proportion of hospitals we surveyed did not provide us with  information to calculate the percentage of inpatient days attributable to  patients without a Social Security number, and we could not validate the  accuracy of this proxy, we cannot evaluate either the relationship between  the percentage of inpatient days attributable to patients without a Social  Security number and hospitals’ uncompensated care levels, or to what  extent hospitals’ uncompensated care costs are related to treating  undocumented aliens.
section_title: Appendix II: Methodology for Determining Federal Funding Sources and Homeland Security’s Responsibility for Medical Costs
paragraphs: To determine the availability of federal funding sources to assist hospitals  with the costs of treating undocumented aliens, we reviewed relevant  literature and legal documents, spoke with officials at the Centers for  Medicare & Medicaid Services (CMS), and interviewed state Medicaid and  hospital association officials in the same 10 states in which we surveyed  hospitals—Arizona, California, Florida, Georgia, Illinois, New Jersey, New  Mexico, New York, North Carolina, and Texas. Specifically, to assess the  availability of Medicaid to cover hospitals’ costs of treating undocumented  aliens, we reviewed Medicaid eligibility and Medicaid disproportionate  share hospital (DSH) laws and regulations and interviewed state Medicaid  officials about Medicaid coverage, eligibility requirements, and DSH  programs in their states. We collected data on total state Medicaid  expenditures and DSH allotments from CMS and on emergency Medicaid  expenditures from state Medicaid officials. We assessed the reliability of  the above data by interviewing agency individuals knowledgeable about  the data. After reviewing state expenditure and DSH allotment figures for  logic and following up where necessary, we determined that these data  sources were sufficiently reliable for the purposes of this report. We also  reviewed published reports and spoke with state hospital association  officials about impediments to obtaining Medicaid coverage for  undocumented aliens treated at hospitals. To determine the availability of  federal funds allotted to states through the Balanced Budget Act of 1997  (BBA) for emergency services furnished to undocumented aliens, we  obtained information on BBA allotments to states and interviewed state  Medicaid officials in the seven states in our review that were eligible to  receive these funds about how they used the funds. We also reviewed CMS  guidance relevant to BBA’s section on emergency medical services for  undocumented aliens and interviewed hospital association officials. In  addition, we reviewed the provisions in the Medicare Prescription Drug,  Improvement, and Modernization Act of 2003 pertaining to payments to  providers for treating undocumented and other aliens, and we interviewed  CMS officials about their plans to implement these provisions.
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. We obtained data from the  Department of Health and Human Services’ Division of Immigration Health  Services on payments for medical claims for aliens in Border Patrol  custody. We also obtained and analyzed data from the Border Patrol’s  Border Safety Initiative database to determine how many of the suspected  undocumented aliens counted as rescues by the Border Patrol were  transported to local hospitals. We assessed the reliability of these data by  interviewing agency officials knowledgeable about the data, reviewing the  data for logic and internal consistency, and following up with officials  where necessary. We determined that the data on payments for medical  claims for aliens in Border Patrol custody and on suspected  undocumented aliens rescued by the Border Patrol were sufficiently  reliable for the purposes of this report.
To determine the responsibility of Homeland Security for covering the  medical costs of aliens seeking humanitarian parole for urgent medical  reasons at ports of entry, we interviewed officials in the four Field  Operations offices responsible for ports of entry along the U.S.-Mexican  border and at five of the ports of entry: Brownsville, Texas; Columbus,  New Mexico; Douglas, Arizona; El Paso, Texas; and San Ysidro, California.  At the El Paso port of entry, we interviewed officials at the port’s busiest  crossing point, Paso Del Norte. We selected these five ports of entry for  geographic diversity or because they had granted a large number of  paroles. We reviewed relevant laws, regulations, and procedures regarding  parole authority. Because Homeland Security did not normally collect data  on the number of paroles granted specifically for urgent medical  treatment, we requested that the Office of Field Operations record the  number of such paroles granted at ports of entry along the U.S.-Mexican  border.
section_title: Appendix III: Comments from the Centers for Medicare & Medicaid Services
section_title: Appendix IV: Comments from the Department of Homeland Security
section_title: Appendix V: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: In addition to those named above, Carla D. Brown, Ellen W. Chu, Jennifer  Cohen, Michael P. Dino, Jennifer Major, Kevin Milne, Dae Park, Karlin  Richardson, Sandra Sokol, Adrienne Spahr, Leslie Spangler, and Marie C.  Stetser made key contributions to this report.