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Sustainable Society:  A society that balances the environment, other life forms, and human interactions over an indefinite time period.







Medical Emergency: Who Pays the Price for Uncompensated Emergency Medical Care Along the Southwest Border?

Executive Summary

U.S./Mexico Border Coalition*
September 2002



Report on Uncompensated Emergency Health Care

On September 26, 2002, Senator Jon Kyl of Arizona announced the release of the Coalition's report entitled "Medical Emergency: Who Pays the Price for Uncompensated Emergency Medical Care Along the Southwest Border?"  The report, which was prepared by MGT of America for the Coalition, was funded through an HHS appropriation secured by Senator Kyl.

The study reports that, in 2000, border hospitals spent more than $200 million to provide emergency health care to undocumented immigrants - $79 million in California; $74 million in Texas; $31 million in Arizona; and $6 million in New Mexico.  Emergency transportation providers spent more than $13 million in 2000.

The Coalition's report makes several policy recommendations (see Executive Summary).  The bottom line is Congress should reimburse local governments and ambulance services for providing emergency medical care to undocumented immigrants.

Southwest border counties —the 24 counties adjoining the Mexican border— are facing a medical emergency.  A score of federal and state policies, such as declining federal Medicaid reimbursements and rising professional liability insurance costs, are contributing to an imminent health care crisis.  The disproportionate burden placed on southwest border counties for providing emergency healthcare services to undocumented immigrants is compounding an already alarming state of affairs.

In 2000, the Immigration and Naturalization Service (INS) apprehended over 1.5 million undocumented immigrants—a fraction of the individuals that either entered the United States without detection or over-stayed their entry visas.  They come for various reasons, but many end up needing emergency medical care they cannot afford.

Uncompensated care is the unreimbursed or uncollectible costs incurred by any medical provider for providing healthcare services. The federal government defines a medical emergency as a condition with a sudden onset that could expect to result in a person’s serious bodily harm or death if not immediately treated.  Every state and county along the southwest border has approached the issue of uncompensated emergency health care services differently. However, as the number of undocumented immigrants in the country has escalated, state and local governments have increasingly stepped up to the plate to cover the cost of uncompensated care.

A poll conducted in November 2000 by Fingerhut Granados Opinion Research established that Americans believe, by a margin of almost six to one, that the federal government rather than local government should pay for emergency medical services provided to undocumented immigrants.  While the majority of Americans feel the federal government should pay for this care, to date, researchers have had little success defining the size of the problem.  In fiscal year 2001, Senator Jon Kyl of Arizona secured funds for the U.S./Mexico Border Counties Coalition (USMBCC) to:

“determine the unreimbursed costs incurred to treat undocumented aliens for medical emergencies in southwest border States, their border counties, and hospitals within the jurisdiction of these States and counties.”

The USMBCC hired MGT of America, Inc. (MGT) in the fall of 2001 to conduct the analysis.

Estimating the Cost of Uncompensated Care

According to the American Hospital Association annual survey, southwest border county hospitals reported uncompensated care totaling nearly $832 million in 2000.[1] Using an advanced statistical modeling approach, MGT determined that almost $190 million or about 25 percent of the uncompensated costs these hospitals incurred resulted from emergency medical treatment provided to undocumented immigrants.

To develop our cost estimate, we compared reported levels of uncompensated hospital care and socio-economic factors such as poverty rates, median age, and net domestic migration in non-border counties to border counties.  We found a statistically significant difference between the amount of uncompensated care delivered in border counties versus non-border counties.  We attribute this difference to undocumented immigrants who seek emergency medical care in southwest border counties.

Using a separate methodology, MGT estimated that emergency medical services (EMS) providers incurred another $13 million in uncompensated costs in 2000. Here we used the County Business Patterns data set and the average percent of uncompensated care reported on our survey of border EMS providers to estimate the cost.

Together the costs of emergency hospital and transportation services exceeded $200 million.  Yet, this figure does not represent the total costs borne by southwest border counties and local medical providers. In Figure 1 the boxes in gray represent the costs we were not able to estimate. Costs incurred for preventive, acute, extended or rehabilitative healthcare, and non-emergency medical transportation are not included in our estimate since these services fall outside the federal definition of an “emergency” and were therefore beyond the scope of our analysis.  Furthermore, services delivered by a physician in a hospital’s emergency department that are not paid by or through the hospital are billed separately and cannot be captured by examining uncompensated hospital costs. As such, costs incurred by physicians attending an undocumented immigrant in a medical emergency also are not included in our cost estimate.

Figure 1

Source:  MGT of America, Inc

The problem of uncompensated emergency services has far reaching implications beyond loss of hospital revenues.  Health care costs and insurance premiums are rising, due in part to burgeoning levels of uncompensated care.  Rising health insurance premiums are threatening business’ ability, particularly small business, to offer employees affordable health care benefits.  High liability costs and low levels of compensation are threatening the viability of emergency rooms and emergency transportation providers along the border.  Some counties with high rates of uncompensated care can no longer afford to provide “charity” care for local needy residents. In some instances, high levels of unpaid medical bills related to undocumented immigrants have forced local healthcare providers to reduce staffing, increase rates, and cut back services.


  • Our findings are based on an extensive literature review, policy analysis, field research, statistical modeling exercise, and written surveys of southwest border hospitals and emergency transportation providers. Our study found:

  • State and local governments and local healthcare providers absorb a large portion of the costs of providing uncompensated emergency medical care to undocumented immigrants.  These costs impose a significant financial burden on southwest border hospitals’ and emergency medical services (EMS) providers, and account for an estimated 25 percent of hospitals uncompensated costs.

  • No standard method to track the amount of uncompensated care provided to undocumented immigrants currently exists. The absence of Social Security Numbers (SSN), in combination with other factors, may provide the federal government with an adequate proxy to enable tracking of aggregate amounts of uncompensated emergency care delivered to undocumented immigrants.

  • The Emergency Medical and Treatment and Active Labor Act (EMTALA) requires hospitals and emergency personnel to screen, treat and stabilize anyone who seeks emergency medical care regardless of income or immigration status. Under Emergency Medicaid, the federal government pays for some emergency medical care delivered to undocumented immigrants who, except for their immigration status, would be eligible for Medicaid.  EMTALA mandates conflict with Emergency Medicaid reimbursement policies to the extent that EMTALA requires screening and treatment beyond those covered under the Medicaid “emergency condition” definition.

  • Our survey and field research suggest that the Immigration and Naturalization Service (INS) continues to bring injured and ill undocumented immigrants to hospital emergency rooms without taking financial responsibility for their medical care.


Some members of Congress are addressing the issue of uncompensated emergency medical services and have filed legislation to address the lack of adequate federal reimbursement for emergency medical treatment provided to undocumented immigrants.  In light of our study’s findings, we propose the following recommendations:

  • Congress should provide additional federal funding to reimburse hospitals, emergency transportation providers, and other health providers for care provided to undocumented immigrants.

  • Congress should take into account the additional losses incurred by southwest border counties related to the treatment and transport of undocumented immigrants when developing federal funding proposals designed to offset relevant losses.

  • Congress should require hospitals and emergency medical providers seeking federal funds to pay for uncompensated emergency medical services, to approximate the number of undocumented immigrants provided uncompensated emergency care using the absence of a Social Security Number as the principal proxy.

  • Congress should direct the Centers for Medicare and Medicaid Services (CMS) to extend Medicaid reimbursement for post-stabilization treatment for otherwise eligible individuals whose treatment results from a qualified emergency as defined by the U.S. Department of Health and Human Services.

  • Congress should appropriate funds for the INS to pay for emergency medical services that result from search and rescue or apprehension activities the INS initiates.

  • Congress should direct the U.S. Department of Health and Human Services (DHHS) to work with the states and the INS to develop a formal process that would allow hospitals and emergency transportation providers to determine an individual’s immigration status and submit federal reimbursement requests without violating EMTALA’s provision against asking a patient’s status prior to delivering treatment.

Areas for Additional Research

Our examination of the costs associated with uncompensated emergency medical care provided in southwest border counties suggests areas needing additional study.  In particular, the following areas merit further research and analysis:

  • Cost of emergency medical services provided by physicians.
  • Cost of medical care such as rehabilitation and other extended care that is not included in the current federal definition of an emergency medical condition.
  • Changes to Medicaid that could make it easier for hospitals and other medical providers to receive reimbursement for treating certain categories of patients who meet Medicaid categorical eligibility.

The need for federal action is clear. The growing medical emergency on the southwest border has far reaching implications, not only for the southwest border, but for the nation as a whole.

[1] The complete results by county, including 95 percent confidence interval calculations, are included in Appendix F.

MFS note: Also see on the MFS Website, "Illegal Aliens and American Medicine".
* Border Counties Coalition.
"Medical Emergency: Who Pays the Price for Uncompensated Emergency Medical Care Along the Southwest Border?"
MGT of America, September 26, 2002.
See original at < http://www.bordercounties.org/index.asp?Type=B_BASIC&SEC={C90385BE-27F1-4E75-98F1-450DD3608069} >.


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