It's a token amount but still a good first step. That's the evaluation hospital industry executives gave to last week's announcement that $1 billion will be finally disbursed to providers of emergency care for illegal immigrants, more than a year after the Medicare Modernization Act of 2003 allocated the funding.
The CMS issued guidelines for the allocation of $1 billion over four years to hospitals and other providers, marking the first time that the federal government is targeting funds specifically for the healthcare of illegal immigrants. But with an estimated $1.45 billion already spent each year on care for such patients, hospital leaders, while happy about the additional funding, said it is but a drop in the bucket.
"In some way it's a token amount, but it's acknowledgement that hospitals have been burdened by" the cost of caring for illegal aliens, said Chris Van Gorder, president and chief executive officer of Scripps Health, a five-hospital system in San Diego.
Under the regulations, hospitals in all 50 states plus Washington D.C., will receive $250 million each year from fiscal 2005 to fiscal 2008. This year, California will receive the largest share of the pot, $70.8 million, followed by Texas, which will receive $46 million, and Arizona, which will get $45 million.
How much each state receives is based on the its share of the country's illegal immigrants. The six states that apprehend the largest number of illegal immigrants -- another way to gauge the level of care being provided to them -- also will receive extra payments. The money given to providers will be paid quarterly and adjusted proportionately if the costs exceed the state's allocation. Hospitals expect to receive their first payment later this year or early next year.
The funding addresses a major issue for hospitals. Because of the federal Emergency Medical Treatment and Active Labor Act, hospitals cannot turn away patients who arrive in their emergency rooms asking for care. And even if they could, hospital executives said, they wouldn't. But as a result, hospitals -- especially those along Mexico's border -- say they provide millions of dollars of uncompensated care each year for illegal immigrants.
Scripps estimates it spends more than $4 million each year providing uncompensated care for such patients, Van Gorder said. Statewide, California hospitals provided an estimated $500 million in uncompensated care for illegal immigrants in 2003, or more than seven times the $70.8 million it will receive in funding under the new program, said Jan Emerson, a spokeswoman for the California Hospital Association.
"We'd love to see a long-term dedicated source of funding and more money" as the next step in federal involvement in uncompensated care for illegal immigrants, Emerson said.
David Lopez, president and CEO of Harris County Hospital District, a three-hospital system in Houston, estimated it spends about $40 million on illegal immigrant patients. "Some of them come to us with chronic illnesses. Some come with renal failure and we have to dialyze them and some come to us two or three times a week," he said. He estimated his system would receive $9 million under the new program.
Legislation to give hospitals additional funding to offset costs associated with caring for such patients was proposed more than two years ago. When the funding was included in the Medicare Modernization Act, hospitals believed they had finally won a victory, but the road to attaining the money has been slippery.
A year ago, Rep. Dana Rohrabacher (R-Calif.) introduced legislation that would have required hospital workers to document the immigration status of patients and report illegal immigrants to federal authorities in order to receive the funding. The hospital community fought the proposal, saying it would make them de facto border patrol agents.
The House defeated the proposal 331-88 (May 24, 2004, p. 9).
Soon after, though, the CMS came out with its own proposal that would have required hospitals to ask patients their immigration status without requiring the hospitals to report illegal immigrants to authorities. Hospitals, however, said the plan was still unacceptable. Even without the reporting requirement, immigrant patients would be wary about being turned in for deportation and, as a result, would bypass necessary care. In the fall, the CMS relented and dropped its proposal (Oct. 11, 2004, p. 14).
While hospitals will not be required to ask patients directly about their immigration status under the regulations released last week, they will have to ask questions that allow a patient's status to be revealed. Such questions include where the person was born, whether the person is eligible for Medicaid and whether the person has a foreign passport or other form of foreign identification.
CMS Administrator Mark McClellan last week told reporters the patient's information would not be used for deportation purposes but in rare circumstances could be used for criminal cases. Some, however, expressed concerns that even an indirect attempt to determine someone's immigration status poses risks.
"Who are you going to ask? Are you going to ask everyone or will it be based on someone's appearance?" said Lopez of Harris County Hospital District. "If you ask about a foreign birth certificate, it may make a patient skittish ... so some people may not seek care."
Don May, vice president of policy at the American Hospital Association, said most of the questions hospitals will have to ask are already part of the information-gathering process at hospitals and should not present problems. But he said the process would need to be watched.
"We're going to monitor this carefully to ensure it doesn't deter access to care," he said.