Undocumented Aliens
Questions Persist about Their Impact on Hospitals' Uncompensated Care Costs Gao ID: GAO-04-472 May 21, 2004About 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.
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.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-04-472, Undocumented Aliens: Questions Persist about Their Impact on Hospitals' Uncompensated Care Costs
This is the accessible text file for GAO report number GAO-04-472
entitled 'Undocumented Aliens: Questions Persist about Their Impact on
Hospitals' Uncompensated Care Costs' which was released on May 28,
2004.
This text file was formatted by the U.S. General Accounting Office
(GAO) to be accessible to users with visual impairments, as part of a
longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Requesters:
United States General Accounting Office:
GAO:
May 2004:
Undocumented Aliens:
Questions Persist about Their Impact on Hospitals' Uncompensated Care
Costs:
GAO-04-472:
GAO Highlights:
Highlights of GAO-04-472, a report to congressional requesters
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 (see table).
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.
Federal Funding Sources That Have Been Available to Help Cover Costs of
Treating Undocumented Aliens:
[See PDF for image]
[End of table]
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.
What GAO Recommends:
GAO recommends that the Secretary of Health and Human Services, in
establishing a payment process under recently enacted legislation,
develop appropriate internal controls to ensure payments are made only
for unreimbursed emergency services for undocumented or certain other
aliens. The Centers for Medicare & Medicaid Services concurred with
GAO‘s recommendation. Homeland Security also agreed with the report‘s
findings.
www.gao.gov/cgi-bin/getrpt?GAO-04-472.
To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Janet Heinrich at (202) 512-7119.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Effect of Undocumented Aliens on Hospitals' Uncompensated Care Costs Is
Uncertain:
Some Federal Funding Has Been Available but Not for All Undocumented
Aliens or Hospitals:
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:
Conclusions:
Recommendation for Executive Action:
Agency Comments:
Appendix I: Survey Methodology and Results:
Survey Sample:
Survey Questions:
Lack of Social Security Number as a Proxy for Undocumented Aliens:
Survey Pretesting and Response:
Data from Responding Hospitals:
Appendix II: Methodology for Determining Federal Funding Sources and
Homeland Security's Responsibility for Medical Costs:
Appendix III: Comments from the Centers for Medicare & Medicaid
Services:
Appendix IV: Comments from the Department of Homeland Security:
Appendix V: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Acknowledgments:
Tables:
Table 1: Federal and State Emergency Medicaid Expenditures for 10
States, Fiscal Year 2002:
Table 2: Estimated Undocumented Aliens Residing in 10 States, 2000:
Table 3: Characteristics of Universe from Which Hospitals Were Sampled:
Table 4: Financial Information for Responding Hospitals:
Table 5: Uncompensated Care Levels by Tertile of Percentage of
Inpatient Days Attributable to Patients without a Social Security
Number:
Abbreviations:
BBA: Balanced Budget Act of 1997:
CMS: Centers for Medicare & Medicaid Services:
DSHdisproportionate share hospital
EMTALA: Emergency Medical Treatment and Active Labor Act:
INS: Immigration and Naturalization Service:
United States General Accounting Office:
Washington, DC 20548:
May 21, 2004:
Congressional Requesters:
An estimated 7 million undocumented aliens[Footnote 1] resided in the
United States in 2000, according to the Immigration and Naturalization
Service (INS).[Footnote 2] 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.[Footnote 3] 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.
Results in Brief:
The impact of undocumented aliens on hospitals' uncompensated care
costs remains uncertain. Hospitals generally do not collect information
on patients' immigration status, thereby making it difficult to
identify patients who are undocumented aliens and the costs associated
with treating them. We determined that a potentially feasible method
for hospitals to collect information for our survey that would allow us
to estimate the amount of care given to undocumented aliens would be to
identify patients without a Social Security number. We used this proxy,
with the understanding that it could possibly over-or underestimate the
number of undocumented aliens, in our survey of hospitals to assess the
effect of undocumented aliens on hospitals' total uncompensated care
costs. Thirty-nine percent of surveyed hospitals provided information
to evaluate this relationship. Because of the low response rate to key
questions and because we were unable to assess the accuracy of the
proxy, we could not determine the effect of undocumented aliens on
hospitals' levels of uncompensated care.
Federal funding to help offset hospitals' costs for treating
undocumented aliens has been available from several sources, but this
funding has not covered care of all undocumented aliens or all medical
services and has not been available to all hospitals. Two of these
sources are available through the Medicaid program, the joint federal-
state program that finances health care for low-income people. First,
Medicaid provides health care coverage for some undocumented aliens.
Like citizens, however, some undocumented aliens are not eligible for
or may choose not to enroll in Medicaid. In addition, coverage for
undocumented aliens under Medicaid is limited to services for treatment
of emergency medical conditions. Second, Medicaid disproportionate
share hospital (DSH) adjustments provide supplemental payments to
hospitals serving relatively large numbers of low-income patients,
which can include undocumented aliens. Not all hospitals receive these
payments, however. A third source of federal funding was provided in
the Balanced Budget Act of 1997 (BBA), which made $25 million available
annually, from fiscal years 1998 through 2001, to selected states for
emergency services provided to undocumented aliens. States could use
these funds to recover the state share of Medicaid expenditures for
undocumented aliens and other state expenditures for undocumented
aliens not eligible for Medicaid. The states we reviewed all opted to
use these funds to help recover their state Medicaid expenditures, and
no new funding was available to hospitals to help cover costs of
undocumented aliens not eligible for Medicaid. The recently enacted
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
appropriated additional federal funding--$1 billion over fiscal years
2005 through 2008--for payments to hospitals and other eligible
providers of emergency medical services delivered to undocumented and
certain other aliens. According to the statute, the Secretary of Health
and Human Services must establish by September 1, 2004, a process for
hospitals and other providers to request these payments.
Border Patrol agents and U.S. port-of-entry officials encounter aliens
needing emergency medical care under different circumstances, but in
most cases Homeland Security is not responsible for these aliens'
hospital costs. Homeland Security may cover medical expenses only of
people in its custody, and persons needing emergency medical assistance
encountered by the Border Patrol and U.S. port-of-entry officials
generally receive hospital care without being taken into custody.
Border Patrol officials reported that their first priority when they
encounter sick or injured people is to seek medical assistance,
generally without first determining immigration status or taking them
into custody. In some circumstances, such as when a sick or injured
person is of particular law enforcement interest--for example, a
suspected drug smuggler--Border Patrol agents may take a person into
custody at the hospital; in this case, Homeland Security is responsible
for the costs of care once the alien is in custody. Although the Border
Patrol tracks aliens in its custody, it does not track the number of
aliens not in custody whom it refers to hospitals. At U.S. ports of
entry, officials may encounter aliens seeking entry to obtain emergency
medical care from a U.S. hospital. Under certain circumstances, U.S.
port-of-entry officials may grant these aliens humanitarian parole, a
means of allowing temporary access into the United States, for urgent
medical reasons. According to officials, these types of paroles do not
occur often, and when they do, the aliens are not placed in custody and
Homeland Security is not responsible for medical expenses. Data
collected by Homeland Security's Bureau of Customs and Border
Protection's Office of Field Operations show that from June through
October 2003, 54 such paroles were authorized at ports along the U.S.-
Mexican border.
We are making a recommendation that as part of establishing a process
for paying hospitals' and other providers' claims under the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003, the
Secretary of Health and Human Services develop appropriate internal
controls to ensure that claims are paid only for unreimbursed emergency
services for undocumented or certain other aliens as designated in the
statute. In commenting on a draft of this report, CMS concurred with
our recommendation and stated that the agency expects to include proper
internal controls in its payment process before distributing any funds
to providers. CMS also 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. We
also provided officials in Homeland Security an opportunity to comment
on a draft of this report. In its comments, Homeland Security generally
agreed with the report's findings. Both agencies also provided
technical comments, which we incorporated as appropriate. The agencies'
comment letters are reprinted in appendixes III and IV.
Background:
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.[Footnote 4]
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.[Footnote 5] Two
recent studies have reported on hospitals' provision of care to
undocumented aliens, but they were limited in scope.[Footnote 6]
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.[Footnote 7]
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.[Footnote 8] 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.[Footnote 9]
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.[Footnote 10] 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.[Footnote 11]
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. 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.[Footnote 12] 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.
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. 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.
Medicaid Covers Emergency Medical Services for Eligible Undocumented
Aliens:
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.[Footnote 13]
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.
Table 1: Federal and State Emergency Medicaid Expenditures for 10
States, Fiscal Year 2002:
State: Arizona;
Expenditures: 84.
State: California[A];
Expenditures: 776.
State: Florida;
Expenditures: 223.
State: Georgia;
Expenditures: 62.
State: Illinois;
Expenditures: 75.
State: New Jersey;
Expenditures: 27.
State: New Mexico[B];
Expenditures: 4.
State: New York;
Expenditures: 474.
State: North Carolina;
Expenditures: 43.
State: Texas;
Expenditures: 265.
Total;
Expenditures: 2,034[C].
Source: State Medicaid officials.
[A] California emergency Medicaid expenditures do not include
expenditures for lawful permanent resident aliens.
[B] Data for New Mexico are for state fiscal year 2002.
[C] Numbers do not add to total shown because of rounding.
[End of table]
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.[Footnote 14] 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.[Footnote 15] 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.[Footnote 16] 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.
Medicaid Disproportionate Share Hospital Adjustments Aid Some
Hospitals:
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.[Footnote 17] 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.
Balanced Budget Act Funding for Undocumented Aliens Retained by States:
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.[Footnote 18] 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.[Footnote
19] 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.
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. Section 1011 of the act appropriated $250 million for each of
fiscal years 2005 through 2008 for this purpose.[Footnote 20] 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.[Footnote 21] 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.[Footnote 22]
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.
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. 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.
The Border Patrol Generally Does Not Take Injured Aliens into Custody
and Is Therefore Not Responsible for Subsequent Medical Costs:
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.[Footnote 23] 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.[Footnote 24]
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.[Footnote 25] 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.[Footnote 26] 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.
The Border Patrol's Total Encounters with Sick or Injured Aliens Is
Unknown:
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.[Footnote 27] 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.
Homeland Security Is Not Responsible for Medical Costs of Aliens
Granted Humanitarian Parole for Urgent Medical Reasons, but Few Such
Paroles Are Granted:
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.[Footnote 28] 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.
Conclusions:
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.
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 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.
Agency Comments:
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.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from its date. We will then make copies available to other interested
parties upon request. In addition, this report will be available at no
charge on the GAO Web site at http://www.gao.gov.
If you have any questions, please contact me at (202) 512-7119.
Additional GAO contacts and the names of other staff members who made
major contributions to this report are listed in appendix V.
Signed by:
Janet Heinrich:
Director, Health Care--Public Health Issues:
List of Requesters:
The Honorable W. Todd Akin
The Honorable Joe Baca
The Honorable Cass Ballenger
The Honorable Nathan Deal
The Honorable Mark Foley
The Honorable Charles A. Gonzalez
The Honorable Luis V. Gutierrez
The Honorable Rubén Hinojosa
The Honorable John L. Mica
The Honorable Grace F. Napolitano
The Honorable Solomon P. Ortiz
The Honorable Ed Pastor
The Honorable Silvestre Reyes
The Honorable Lucille Roybal-Allard
The Honorable José E. Serrano
House of Representatives:
[End of section]
Appendix I: Survey Methodology and Results:
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.):
Table 2: Estimated Undocumented Aliens Residing in 10 States, 2000:
State: All States;
Estimated number: 7,000,000;
Percentage of total estimated undocumented aliens residing in the
United States: 100.0%.
State: California;
Estimated number: 2,209,000;
Percentage of total estimated undocumented aliens residing in the
United States: 31.6%.
State: Texas;
Estimated number: 1,041,000;
Percentage of total estimated undocumented aliens residing in the
United States: 14.9%.
State: New York;
Estimated number: 489,000;
Percentage of total estimated undocumented aliens residing in the
United States: 7.0%.
State: Illinois;
Estimated number: 432,000;
Percentage of total estimated undocumented aliens residing in the
United States: 6.2%.
State: Florida;
Estimated number: 337,000;
Percentage of total estimated undocumented aliens residing in the
United States: 4.8%.
State: Arizona;
Estimated number: 283,000;
Percentage of total estimated undocumented aliens residing in the
United States: 4.0%.
State: Georgia;
Estimated number: 228,000;
Percentage of total estimated undocumented aliens residing in the
United States: 3.3%.
State: New Jersey;
Estimated number: 221,000;
Percentage of total estimated undocumented aliens residing in the
United States: 3.2%.
State: North Carolina;
Estimated number: 206,000;
Percentage of total estimated undocumented aliens residing in the
United States: 2.9%.
State: New Mexico;
Estimated number: 39,000;
Percentage of total estimated undocumented aliens residing in the
United States: 0.6%.
Source: U.S. Immigration and Naturalization Service.
[End of table]
Survey Sample:
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.
Table 3: Characteristics of Universe from Which Hospitals Were Sampled:
Characteristic: All hospitals;
Number of hospitals: 1,637;
Percentage of hospitals: 100%.
Characteristic: Ownership: Not-for-profit;
Number of hospitals: 967;
Percentage of hospitals: 59%.
Characteristic: Ownership: Investor owned;
Number of hospitals: 317;
Percentage of hospitals: 19%.
Characteristic: Ownership: Government owned;
Number of hospitals: 353;
Percentage of hospitals: 22%.
Characteristic: Number of staffed beds: Less than or equal to 73;
Number of hospitals: 415;
Percentage of hospitals: 25%.
Characteristic: Number of staffed beds: More than 73 and less than or
equal to 279;
Number of hospitals: 814;
Percentage of hospitals: 50%.
Characteristic: Number of staffed beds: More than 279;
Number of hospitals: 408;
Percentage of hospitals: 25%.
Characteristic: County poverty level: Less than or equal to 11%;
Number of hospitals: 448;
Percentage of hospitals: 27%.
Characteristic: County poverty level: More than 11 percent and less
than or equal to 19 percent;
Number of hospitals: 943;
Percentage of hospitals: 58%.
Characteristic: County poverty level: More than 19%;
Number of hospitals: 246;
Percentage of hospitals: 15%.
Characteristic: State: Arizona;
Number of hospitals: 53;
Percentage of hospitals: 3%.
Characteristic: State: California;
Number of hospitals: 335;
Percentage of hospitals: 20%.
Characteristic: State: Florida;
Number of hospitals: 175;
Percentage of hospitals: 11%.
Characteristic: State: Georgia;
Number of hospitals: 141;
Percentage of hospitals: 9%.
Characteristic: State: Illinois;
Number of hospitals: 186;
Percentage of hospitals: 11%.
Characteristic: State: New Jersey;
Number of hospitals: 71;
Percentage of hospitals: 4%.
Characteristic: State: New Mexico;
Number of hospitals: 31;
Percentage of hospitals: 2%.
Characteristic: State: New York;
Number of hospitals: 187;
Percentage of hospitals: 11%.
Characteristic: State: North Carolina;
Number of hospitals: 107;
Percentage of hospitals: 7%.
Characteristic: State: Texas;
Number of hospitals: 351;
Percentage of hospitals: 21%.
Source: GAO analysis of American Hospital Association and U.S. Census
Bureau data.
Notes: Because of rounding, percentages may not add to 100. Data from
the American Hospital Association's Annual Survey Database, Fiscal Year
2000, and the U.S. Census Bureau's Census 2000 Demographic Profiles.
[End of table]
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.[Footnote 29]
Survey Questions:
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.
Lack of Social Security Number as a Proxy for Undocumented Aliens:
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.
Survey Pretesting and Response:
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.
Data from Responding Hospitals:
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.
Table 4: Financial Information for Responding Hospitals:
Financial information: Total uncompensated care costs (dollars);
Median: $2.6 million.
Financial information: Total expenses (dollars);
Median: $58.0 million.
Financial information: Uncompensated care levels (percentage);
Median: 5.0%.
Source: GAO.
Notes: Based on GAO's 2003 survey of hospitals. Results are limited to
the 300 respondents that provided sufficient information and are not
generalizable to the overall population.
[End of table]
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.
Table 5: Uncompensated Care Levels by Tertile of Percentage of
Inpatient Days Attributable to Patients without a Social Security
Number:
Tertile (percentage range ): Bottom third (0-0.24);
Median uncompensated care level (percent): 4.3%;
Minimum uncompensated care level (percent): 0.0%;
Maximum uncompensated care level (percent): 17.5%.
Tertile (percentage range ): Middle third (> 0.24-1.66);
Median uncompensated care level (percent): 4.3%;
Minimum uncompensated care level (percent): 1.3%;
Maximum uncompensated care level (percent): 14.6%.
Tertile (percentage range ): Top third (> 1.66-19.71);
Median uncompensated care level (percent): 4.9%;
Minimum uncompensated care level (percent): 1.4%;
Maximum uncompensated care level (percent): 17.0%.
Source: GAO.
Notes: Based on GAO's 2003 survey of hospitals. Results are limited to
the 198 respondents that provided sufficient information and are not
generalizable to the overall population.
[End of table]
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.
[End of section]
Appendix II: Methodology for Determining Federal Funding Sources and
Homeland Security's Responsibility for Medical Costs:
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.
[End of section]
Appendix III: Comments from the Centers for Medicare & Medicaid
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services:
Administrator
Washington, DC 20201:
DATE:
APR 13 2004:
TO: Janet Heinrich:
Director, Heath Care-Public Health Issues
General Accounting Office:
FROM: Mark B. McClellan, M.D., Ph.D.
Administrator:
Centers for Medicare & Medicaid Services:
SUBJECT: General Accounting Office Draft Report, "Undocumented Aliens:
Questions Persist about Their impact on Hospitals' Uncompensated Care
Costs" (GAO-04-472):
Thank you for the opportunity to review and comment on the General
Accounting Office's (GAO) draft report entitled, "Undocumented Aliens:
Questions Persist about Their Impact on Hospitals' Uncompensated Care
Costs."
This report examines the relationship between treating undocumented
aliens and hospitals' cost not paid by patients or insurance. In
addition, the 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 cost remains elusive. The GAO attempted to examine the
relationship between uncompensated care and undocumented aliens by
survey. However, due to the low response rate from hospitals, GAO could
not determine the effect of undocumented aliens on hospital
uncompensated care costs.
Section 1011 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) distributes $250 million per year
during fiscal years 2005 - 2008 to eligible providers (i.e., hospitals,
physicians, providers of ambulance services) for emergency services
provided to undocumented aliens. Two-thirds of these funds will be
divided among all 50 states and the District of Columbia based on their
relative percentages of undocumented aliens. One-third will be divided
among the six states with the largest number of undocumented alien
apprehensions.
The GAO states that the availability of new Federal funding, under the
MMA, may offer an incentive for hospitals serving undocumented aliens
to collect more reliable information on the number of these patients
and the costs of their care. While this may be true for those hospitals
incurring significant cost related to undocumented aliens, some
hospitals and other providers, especially those who do not see
undocumented aliens in an emergency department setting on a regular
basis, may chose to continue to provide uncompensated care without ever
trying to document the number or costs associated with providing care
to this population. In addition, given the pro rata reduction provision
contained in section 1011 and the limitation on Federal funding, some
providers may choose not to document or bill for emergency services
provided to undocumented aliens.
The GAO recommends that, "the Secretary of HHS, 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 other eligible
aliens."
We concur with the recommendation. In fact, we are currently developing
the process to implement section 1011 of the MMA and expect to
establish appropriate internal controls prior to making payments to
hospitals and other providers. To this end, it would be useful if the
GAO provided its insight into the specific internal controls it
believes would be useful in ensuring that claims are paid only for
unreimbursed emergency services for undocumented or certain other
aliens.
[End of section]
Appendix IV: Comments from the Department of Homeland Security:
U.S. CUSTOMS AND BORDER PROTECTION
Department of Homeland Security:
Memorandum:
DATE: April 14, 2004:
FILE: AUD-1-OP SM:
MEMORANDUM FOR JANET HEINRICH
DIRECTOR, HEALTH CARE-PUBLIC HEALTH ISSUES:
FROM: Seth M. M. Stodder:
Director, Office of Policy and Planning:
SUBJECT: Draft Audit Report of Undocumented Aliens Hospital Care Costs:
Thank you for providing us with a copy of your draft report entitled,
"Undocumented Aliens: Questions Persist about Their Impact on
Hospitals' Uncompensated Care Costs" and the opportunity to discuss the
issues in this report.
CBP generally agrees with the report and has provided the attached
general/technical comments to be included in the final report.
We have determined that the information contained in the draft report
does not warrant protection under the Freedom of Information Act.
If you have any questions regarding the attached comments, please have
a member of your staff contact Ms. Sandy Manuel at (202) 927-2096.
Attachment:
[End of section]
Appendix V: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Kim Yamane, (206) 287-4772 Linda Y. A. McIver, (206) 287-4821:
Acknowledgments:
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.
FOOTNOTES
[1] Federal law does not define the term "undocumented alien." For
purposes of this report, the term "undocumented alien" refers to a
person who enters the United States without legal permission or who
fails to leave when his or her permission to remain in the United
States expires.
[2] INS was abolished and its functions, including those of the Border
Patrol and immigration inspection at ports of entry, were transferred
to the Department of Homeland Security, effective March 1, 2003. Pub.
L. No. 107-296, § 441, 116 Stat. 2135, 2192 (2002).
[3] Hospital uncompensated care is care for which the hospital receives
no payment from either the patient or an insurer. Uncompensated care
costs include (1) costs of providing charity care, that is, care for
which the hospital never expected to receive payment because of the
patient's inability to pay, and (2) bad debt incurred for services for
which the hospital expected but did not receive payment because
patients were unable or unwilling to pay.
[4] U.S. Immigration and Naturalization Service, Estimates of the
Unauthorized Immigrant Population Residing in the United States: 1990
to 2000 (Washington, D.C.: 2003).
[5] EMTALA applies to hospitals participating in Medicare, the federal
health insurance program for seniors age 65 and over, and some disabled
persons. See 42 U.S.C. § 1395dd (2000). According to federal
regulations implementing EMTALA, a hospital that provides emergency
services must medically screen all persons who come to the hospital
seeking emergency care to determine whether an emergency medical
condition exists. If the hospital determines that a person has an
emergency medical condition, the hospital must provide treatment
necessary to stabilize that person or arrange for an appropriate
transfer to another facility. See 42 C.F.R. pt. 489 (2003).
[6] One study, conducted for the United States-Mexico Border Counties
Coalition, focused on the 24 counties located along the U.S.-Mexican
border [MGT of America, Medical Emergency: Costs of Uncompensated Care
in Southwest Border Counties (Austin, Tex.: 2002)]. The study estimated
that uncompensated care due to emergency medical treatment provided to
undocumented aliens was approximately $190 million, but the 95 percent
confidence interval around this estimate ranged from about $7 million
to about $373 million. Another study, conducted by the Florida Hospital
Association in 2002, examined hospital charges for uninsured
noncitizens in 56 Florida hospitals, or 26 percent of the acute care
hospitals in that state.
[7] U.S. Department of Commerce, Economics and Statistics
Administration, U.S. Census Bureau, Health Insurance Coverage in the
United States: 2002 (Washington, D.C.: 2003).
[8] U.S. General Accounting Office, INS' Southwest Border Strategy:
Resource and Impact Issues Remain after Seven Years, GAO-01-842
(Washington, D.C.: Aug. 2, 2001).
[9] The Border Patrol defines a "rescue" as a situation in which the
lack of intervention by the Border Patrol could result in death or
serious bodily injury to those suspected of attempting to enter
illegally.
[10] Previously under the INS, each of the 43 crossing points was
considered a distinct port of entry for most purposes.
[11] Under the Immigration and Nationality Act, the Attorney General
was authorized to parole aliens into the United States for humanitarian
reasons. See 8 U.S.C. § 1182(d)(5)(A) (2000). This authority was
transferred to the Secretary of Homeland Security and responsibility
for this authority was delegated to the level of port director.
Humanitarian paroles may also be granted for other reasons, such as to
allow an individual to attend the funeral of a close relative or to
accompany seriously ill family members.
[12] For example, U.S. citizens might not provide their Social Security
number, or undocumented aliens might provide a false or stolen Social
Security number.
[13] In general, most aliens applying for Medicaid, including lawful
permanent resident aliens, must provide documentation of immigration
status and sign a declaration stating that they are in satisfactory
immigration status for Medicaid. Undocumented aliens and some other
aliens who are eligible only for emergency Medicaid are not required to
provide documentation of immigration status or sign a declaration of
immigration status.
[14] In Arizona, emergency Medicaid expenditures increased from fiscal
year 2000 to fiscal year 2002, but the percentage increase was not more
than that for total Medicaid expenditures. California's data on
emergency Medicaid expenditures excluded those for lawful permanent
resident aliens.
[15] At the same time, pre-enrollment policies in some states may
facilitate enrollment. In 2 of the 10 states we reviewed, Medicaid
officials said that undocumented aliens in their states may enroll in
Medicaid before an emergency condition arises; a third state allows
undocumented women to enroll during their third trimester of pregnancy.
Medicaid officials in 2 of these states reported believing that such
policies can increase enrollment of undocumented aliens.
[16] Two court cases have provided slightly different interpretations
of the scope of coverage under emergency Medicaid. See Greenery
Rehabilitation Group, Inc. v. Hammon, 150 F.3d 226 (2nd Cir. 1998)
(stabilization after initial injury ends Medicaid coverage unless
another emergency develops) and Scottsdale Healthcare, Inc. v. Arizona
Health Care Cost Containment System Admin., 75 P.3d 91 (Az. Sup. Ct.
2003) (stabilization after initial injury does not determine whether
Medicaid coverage ends). See also Luna v. Division of Social Services,
589 S.E.2d 917 (N.C. Ct. App. 2004) (adopting the reasoning of the
Arizona Supreme Court).
[17] Hospitals that meet federally set criteria must be designated as
DSH hospitals. Under 42 U.S.C. § 1396r-4(b) (2000), a hospital is
deemed to be a DSH hospital if its Medicaid inpatient utilization rate
is at least one standard deviation above the mean rate for hospitals
receiving Medicaid payments in the state or if the hospital's low-
income utilization rate exceeds 25 percent. The Medicaid inpatient
utilization rate is the number of Medicaid inpatient days as a
percentage of total inpatient days. The low-income utilization rate is
calculated using total hospital revenue for patient services that are
paid by Medicaid, the amount of state and local government cash
subsides for patient services, and total hospital charges for inpatient
hospital services attributable to charity care.
[18] Pub. L. No. 105-33, § 4723, 111 Stat. 251, 515.
[19] The seven states in our review that qualified for BBA allotments
are Arizona, California, Florida, Illinois, New Jersey, New York, and
Texas. Of these, New Jersey did not claim any BBA funds.
[20] Pub. L. No. 108-173, § 1011, 117 Stat. 2066, 2432.
[21] The law specifies that the proportion of undocumented aliens in
each state is as determined by INS as of January 2003 on the basis of
the 2000 census.
[22] In addition to undocumented aliens, the statute pertains to
certain Mexican citizens permitted to enter the country for 72 hours or
less and aliens paroled into the United States for eligible services.
Eligible services include health care services required by EMTALA and
related hospital and ambulance services as defined by the Secretary of
Health and Human Services.
[23] 42 U.S.C. § 249 (2000).
[24] Under 42 U.S.C. § 249, the Public Health Service is authorized to
provide medical care for persons who are "detained by" INS. (INS's
functions were transferred to Homeland Security effective Mar. 1,
2003.) The term "detained" is not defined in the statute or in the
agency's regulations, but its meaning was addressed in City of El
Centro v. United States, 922 F.2d 816 (Fed. Cir. 1990). In this case,
the court determined the meaning of "detained" by applying principles
derived from analogous situations, such as those involving seizures of
persons under the Fourth Amendment. According to the court, a seizure
occurs when the government acts intentionally to deprive a person of
freedom of movement.
[25] 8 U.S.C. § 1357(a)(2) (2000).
[26] Executive Order 12807 directs the Coast Guard to interdict
migrants at sea beyond U.S. territorial limits and return them to their
countries of origin.
[27] Not all persons rescued by the Border Patrol require a referral
for hospital care.
[28] In response to our request, Homeland Security's Bureau of Customs
and Border Protection's Office of Field Operations collected data
starting in June 2003 on the number of humanitarian paroles granted for
urgent medical reasons at ports of entry located along the U.S.-Mexican
border.
[29] For sampling purposes, we developed estimates of undocumented
aliens as a percentage of the population by county by (1) dividing INS
estimates of the number of undocumented aliens in each state by Census
Bureau estimates of the number of foreign-born noncitizens in the state
and (2) applying this ratio to Census Bureau estimates of the number of
foreign-born noncitizens in each county.
GAO's Mission:
The General Accounting Office, the investigative arm of Congress,
exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as "Today's Reports," on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order
GAO Products" heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. General Accounting Office
441 G Street NW,
Room LM Washington,
D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director, NelliganJ@gao.gov (202) 512-4800 U.S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D.C.
20548:
