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IV. Health Care

State and federal-funded health benefits for undocumented immigrants are limited in Texas (see Exhibit 1). Costs for services are far more likely to fall on local governments, non-profit and private health care facilities.

State Costs

Health-related benefits available for undocumented immigrants in Texas generally fall into three categories: emergency Medicaid; state-local programs such as mental health services and school-based health centers; and public health programs.

Emergency Medicaid

Medicaid is a federal/state funded program that provides healthcare to low income families, pregnant women, elderly people and those with disabilities and dependent children and related caretakers. Eligible persons must meet asset requirements.[15]

Emergency Medicaid payments represent the majority of state costs for medical care provided to undocumented immigrants. In the case of a medical emergency, such as childbirth and labor or other conditions that may threaten an individual’s life, the federal government allows Medicaid to pay for services rendered to persons who would otherwise qualify for Medicaid regardless of their immigration status. Not all undocumented immigrants seeking medical care qualify for emergency Medicaid.

Medicaid expenditures for all immigrants, regardless of legal status, more than doubled (114 percent) from 2000 to 2005. When adjusted for inflation, spending rose by 98.4 percent. The average number of recipients per month increased by 81 percent during the same time period.

Because the Texas Health and Human Services Commission makes no distinction between legal immigrants, undocumented immigrants, refugees and those awarded asylum, costs attributed to undocumented immigrants must be estimated. The Pew Hispanic Center estimates that undocumented immigrants account for 30 percent of all immigrants. Based on that estimate, Exhibit 6 details both state and federal estimated costs to emergency Medicaid.

EXHIBIT 6
Estimated State and Federal Medicaid Expenditures for Undocumented Immigrants, 2000 and 2005

  2000 2005 Difference
Medicaid Expenditures $45,206,381 $96,864,943 114.3%
Medicaid Expenditures (constant 2000 dollars) $45,206,381 $89,698,067 98.4%
Average Number Recipient Months per Month 1,528 2,762 80.8%
Medicaid Expenditures per Recipient Month $2,466 $2,923 18.5%
Medicaid Expenditures per Recipient Month (constant 2000 dollars) $2,466 $2,678 8.6%

Note: Amounts may not add due to rounding.
Note: Recipient month equals one month’s coverage for an eligible individual.
Sources: Texas Health and Human Services Commission and Carole Keeton Strayhorn, Texas Comptroller of Public Accounts.

The state shares the costs of Medicaid with the federal government. Texas pays approximately 40 percent of Medicaid costs; therefore, the total estimated state cost for Medicaid services for undocumented immigrants was $38.7 million in fiscal 2005 (Exhibit 7).

EXHIBIT 7
Estimated State Medicaid Expenditures for Undocumented Immigrants, 2000 and 2005

  2000 2005 Difference
Medicaid Expenditures $18,082,552 $38,745,977 114.3%
Medicaid Expenditures (constant 2000 dollars) $18,082,552 $35,879,227 98.4%

Sources: Texas Health and Human Services Commission and Carole Keeton Strayhorn, Texas Comptroller of Public Accounts.

Children with Special Health Care Needs

The U.S. Department of Health and Human Services defines children with special health care needs (CSHCN),

...as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.[16]

Funding for this program is split between the states and federal Title V, Maternal Child Health Services Block Grants. State and federal CSHCN expenditures in Texas totaled $20.2 million in fiscal 2005 (Exhibit 8).

EXHIBIT 8
Children with Special Health Care Needs Treated in Texas, All Funds 2005

  Clients Served Percent Expenditures Percent
Citizens/Legal Residents 633 30.0% $4,177,280 20.7%
Non-Citizens 1,452 68.8% $15,960,962 78.9%
Unknown 25 1.2% $89,921 0.4%
Hepatitis B 2,110 100.0% $20,228,163 100.0%

Source: Texas Department of State Health Services.

CSHCN assistance is available for Texas residents, as defined by the Texas Administrative Code, regardless of their citizenship status in the U.S. In Exhibit 8, the “Non-Citizens” category accounts for foreign-born Texas residents who have reported to the Texas Department of State Health Services or another state entity that they are neither U.S. citizens nor legal residents. “Non-citizens” thus are likely to be undocumented immigrants.

The federal government requires states to expend at least 30 percent of their Title V funds on CSHCN. The fiscal 2005 block grant amount for Texas totaled $37 million, with a minimum of 30 percent ($11.1 million) dedicated to CSHCN. About 55 percent of the funds expended on CSHCN in fiscal 2005 were federal, with the state supplying the remaining 45 percent.

Applying the state share of 45 percent to the “Non-Citizens” category in Exhibit 8 indicates that the estimated state cost for CSHCN services provided to undocumented immigrants was $7.2 million in fiscal 2005.

Substance Abuse Services

The Texas Department of State Health Services (DSHS) spent about $17.3 million in state funding—or 16 percent of all funding—for substance abuse intervention and treatment in fiscal 2005. As with mental health services, substance abuse services base eligibility on diagnosis rather than income or citizenship. The vast majority of people receiving publicly funded treatment have an order issued by a court of law requiring that they participate in treatment as a part of their sentencing.

DSHS collects data on substance abusers receiving treatment in Texas. The information collected includes age at first drug use, gender, ethnicity, marital status, educational level, homelessness and criminal justice involvement. In 2005, DSHS began collecting citizenship information on individuals receiving publicly-funded substance abuse treatment. About 5.5 percent or 8,446 of the 152,441 persons who received treatment reported that they were not U.S. citizens.[17]

While DSHS now collects data on citizenship, this information is not linked to the number or types of services individuals receive.

Such factors make it difficult to estimate the state’s cost for providing substance abuse services to undocumented immigrants. The Comptroller estimates that the number of undocumented immigrants receiving services is 30 percent of the non-citizens identified above (again based on Pew estimate of percent undocumented), and therefore that 1.66 percent of all individuals receiving state-funded substance abuse services were undocumented immigrants in fiscal 2005. Applying that percentage to state expenditures for substance abuse results in a cost of about $287,700.

Mental Health Services

Texas pays for state mental hospital services almost entirely with state general revenue. In fiscal 2005, the state spent $225.7 million on state mental hospitals.[18]

Unlike Medicaid, eligibility for mental health services is not means-based, but instead is based on a patient’s diagnosis, the severity of his or her illness and the availability of funds. To qualify for state-funded mental health services, an individual must be a member of the “priority population”—those who are significantly functionally impaired and have a diagnosis of schizophrenia, bipolar disease (manic depression) or major clinical depression.[19]

State mental hospitals also are subject to the federal Emergency Treatment and Active Labor Act (EMTALA). EMTALA requires all hospitals receiving payments from Medicaid or Medicare—virtually all hospitals—to screen anyone presenting at an emergency department to determine if an emergency condition exists and, if so, to provide appropriate care regardless of ability to pay.

Therefore, persons entering a state mental hospital with an emergency medical condition cannot be turned away based on citizenship or for any other reason. If the event is an emergency, but a state mental hospital does not have capacity or is not found by staff assessing the person’s condition to be the “least restrictive environment,” the person is referred to a local mental health authority for care.

Under EMTALA, community mental health centers and state mental hospitals cannot inquire about a person’s citizenship status unless the person is likely to qualify for Medicaid-reimbursed mental health services. As discussed earlier, only undocumented immigrants that would otherwise qualify for Medicaid could qualify for such funding, and then only in an outpatient setting, since Medicaid does not cover inpatient mental hospital stays for adults between 19 and 65. For this reason, the need to ask about citizenship would not arise often.

To obtain the most accurate number of undocumented immigrants receiving services in the public mental health system, it would be necessary to conduct primary research through interviews and surveys of local mental health authorities and state mental hospital directors. Using the same methodology used for substance abuse, the Comptroller estimates a state cost for mental health services of $3.8 million in fiscal 2005. This estimate assumes 1.66 percent of state expenditures were associated with undocumented immigrants.

Immunizations

To attend public school, parents must provide proof that their children have been immunized before enrollment. Immunizations may be obtained from numerous outlets that are convenient for undocumented immigrants, including school-based health centers, local public health departments (LPHDs) and federally qualified health centers (FQHCs).

Texas spent about $46.9 million for adult and child immunizations in fiscal 2005, of which 57.3 percent or $26.9 million was state general revenue. In all, 17 immunization doses are required for a child to enter school. Exhibit 9 summarizes the number and type of vaccinations required for Texas public schools.

EXHIBIT 9
Vaccinations Required for Public School Admission

Vaccine Number of Doses
Diphtheria, Tetanus Toxoid, and Pertussis Vaccine (DTaP) 5
Polio Vaccine (IPV) 4
Measles, Mumps, Rubella (MMR) 2
Hepatitis B 3
Varicella 1
Hepatitis A (only required in 40 counties in Texas) 2
Total Vaccinations 17

Source: Texas Department of State Health Services.

In 2002 (most recent year for which data is available) DSHS administered about 6 million doses of vaccine to persons under the age of 20. As noted in the Education section of this report, the Comptroller estimates 135,000 undocumented immigrants are enrolled in Texas schools. All of these children must have current vaccination records to attend school. Many undocumented children living in Texas, however, receive some or all required immunizations before they arrive in the U.S.

In Mexico, the largest country of origin of undocumented immigrants, almost 96 percent of children under the age of five have received all their vaccinations, compared to 79 percent of U.S. children under age three.[20] As a result, many undocumented school-aged children who arrive in Texas will have all their age-appropriate vaccinations. Students who do not have proof of their vaccinations must either provide documentation or receive another series of vaccinations. While many have documentation, the Comptroller is unable to determine the percent of those who do not.[21]

This makes estimating the state cost of providing immunizations to undocumented children attending Texas public schools difficult to calculate, because there is no way to determine when undocumented children currently enrolled in Texas schools arrived in the U.S., or the percent who had some or all their immunizations before immigrating. Costs associated with undocumented children are miniscule, with the Comptroller’s estimate being about $33,000 in fiscal 2005. This is based on four percent of undocumented children in public schools, or 5,400, receiving immunizations. These 5,400 children account for .12 percent of total school enrollment. This figure was applied to the $26.0 million in state funds.

Women and Children’s Health Services/School-based Programs

Undocumented immigrant children enrolled in day care, preschools and primary schools may be eligible for state School-Based Health Center Services. These children as well as undocumented women also may receive health care through Women and Children’s Health Services.

Texas has more than 100 school-based health centers that deliver services to about 200,000 children annually. DSHS funds four of these health centers. Schools may receive state funding for startup costs of up to $125,000 per year from DSHS.[22] School-based centers may provide comprehensive primary and preventive physical health, dental health, mental health and health education services to children and adolescents.[23]

The state funds school-based health centers to provide a “medical home” for children that otherwise have limited access to healthcare because they are uninsured or have disabilities requiring care during the school day. The centers make no distinction between citizen and non-citizen students.

Most visits to the school-based health center are for services such as diagnosis and treatment of a simple illness or minor injury; immunizations; physical examinations, including sports physicals; preventive health visits, including Early Periodic Screening, Diagnosis, and Treatment; and mental health and psychosocial counseling.[24]

Another avenue to medical care for undocumented immigrants is the state Women’s and Children’s Health Services. Women and Children’s Health Services provide community-based maternal and child health services for low-income persons not eligible for Medicaid or the Children’s Health Insurance Program (CHIP). These services include preventive, primary and dental care for children and cancer screening for women.

Texas spent $21.9 million in state funds for these programs in fiscal 2005. The Comptroller estimates that slightly more than 3 percent of all students enrolled in public education were undocumented immigrants in fiscal 2005. The number of undocumented immigrant women receiving services is unknown. Therefore, a conservative estimate to the state for both services in fiscal 2005 is slightly more than 3 percent of state expenditures, or about $674,000.

Public Health

State and local public health agencies provide all Texas residents with public health services regardless of citizenship status, because public health services are intended to protect all Texans’ health. For example, care and treatment of infectious diseases are provided to anyone requiring them regardless of their ability to pay or citizenship status because such care protects the state’s residents against the spread of those diseases.

DSHS funds 65 local public health departments (LPHD) that provide for the control and treatment of infectious diseases, as do some state-funded facilities such as the Texas Center for Infectious Disease and South Texas Health Care (formerly the South Texas Hospital). These two facilities spent $7.8 million and $5.4 million respectively in general revenue funds in fiscal 2005. The state also provided LPHDs and other health and education organizations with $38.1 million in 2005 state general revenue funding for HIV identification, prevention and treatment, while DSHS received about $13 million in state general revenue funds to combat tuberculosis (TB) and Hansen’s disease (leprosy).[25]

The federal government also provides DSHS with funding for “Refugee Health Services,” which primarily involve treating refugees who may be infected with TB and other infectious diseases.

In 2005, DSHS reported 1,535 cases of TB. Of these, 48.1 percent were foreign-born. Using the 30 percent share used earlier in this report to estimate the percent of foreign-born here without authorization results in an estimated 221 of those infected with TB being undocumented immigrants. The cost per TB case to the state is unknown.

Other high-incidence infectious diseases include HIV/AIDS, sexually transmitted diseases and meningitis. Data on country of origin for these individuals are not available. Assuming slightly more than 6 percent of the state’s residents were undocumented immigrants, the Comptroller’s estimated costs for fiscal 2005 were $3.9 million.

Emergency Medical Services

In fiscal 2005, Texas spent about $55.2 million in state funds for emergency medical services (EMS), primarily ambulance and other emergency transportation and trauma facilities.

Little centralized demographic information exists for EMS. The U.S./Mexico Border Counties Coalition (U.S./MBCC) surveyed border counties in 2001 and found that about 7 percent of the costs these private and public ambulance service providers incurred was attributable to undocumented immigrants. The method used to identify these costs for the border region could be applied to the entire state with some modification. However, the Comptroller’s office would need to know the total revenue for all ambulance providers in Texas to calculate a cost related to undocumented immigrants and that information is not available. Therefore in estimating costs, the Comptroller applies the percent of undocumented immigrants in Texas to total state expenditures. This results in a cost to the state in fiscal 2005 of $3.4 million.

The Comptroller estimates the total cost for state funded healthcare services for undocumented immigrants was $58 million in fiscal 2005. Exhibit 10 details the state cost associated with undocumented immigrants and the percent of state funds estimated.

EXHIBIT 10
State Healthcare Costs Associated with Undocumented Immigrants
Fiscal 2005

Service Area General Revenue Percent of Expenditures on Undocumented Immigrants Undocumented Immigrant Costs
Emergency Medicaid* $129,153,257 30.0% $38,745,977
CSHCN $9,111,352 78.9% $7,189,280
Substance Abuse $17,305,929 1.7% $287,651
Mental Health $225,650,365 1.7% $3,750,650
Immunizations $26,906,780 0.1% $33,143
Women/School $21,901,933 3.1% $674,463
Public Health $64,300,000 6.1% $3,937,888
EMS $55,156,810 6.1% $3,377,937
Total $549,486,426 10.6% $57,996,990

* Program Type 30 (Foreign-Born: 30 % undocumented)
Sources: Texas Health and Human Services Commission and Carole Keeton Strayhorn, Texas Comptroller of Public Accounts.

Local Government and the Private Sector

Local government and private businesses incur the largest share of health-related costs for undocumented immigrants in Texas. The state Indigent Healthcare and Treatment Act requires Texas counties to provide “safety net” services for indigent persons and others not covered by private health insurance or public health insurance programs such as Medicare, Medicaid and CHIP.[26]

Texas law gives counties three basic options for delivering indigent healthcare, including hospital districts, public hospitals and county indigent health care programs (CIHCPs). All of these entities have a statutory obligation to cover a set of basic health care services including primary and preventative services designed to meet the needs of the community as well as inpatient and outpatient and nursing facility services.

Hospital districts are special taxing entities that may levy a tax not to exceed 75 cents per $100 in property valuation to fund indigent health care. Texas law requires hospital districts to provide services to persons with incomes below 21 percent of the federal poverty line. Hospital districts can, however, set higher income thresholds. Hospital districts also may receive financing from the state’s unclaimed lottery revenue, the federal Disproportionate Share Hospital Program and supplemental Medicaid and Medicare payments to teaching hospitals through the Graduate Medical Education Program. These districts cover 144 of Texas’ 254 counties.[27]

Public hospitals are funded in Texas by sales and use taxes and are eligible for the same types of funding as hospital districts. Texas law defines a public hospital as a hospital owned, operated, or leased by a county or municipality.[28] Texas public hospitals serve residents in all or parts of 29 Texas counties.[29]

County indigent health care programs (CIHCP) use both local and state funds to pay health care providers for services for eligible patients. Counties cover residents whose incomes place them below 21 percent of the federal poverty line, but they may adopt a less restrictive income standard. County CIHCPs’ eligibility criteria also may impose resource limits (e.g. bank account balance limits, number/value of vehicles, etc.) and residency requirements. While county residency may be a requirement for CIHCP eligibility, citizenship is not. The level of state funding is tied to the level of local funding provided. In fiscal 2005, the state set aside $5.2 million to reimburse 21 counties through the CIHCP State Assistance Fund. Counties must spend more than 8 percent of their general revenue tax levy on qualified healthcare expenditures to qualify for state funding. All or some parts of 150 Texas counties operate CIHCPs.[30]

Local indigent health care entities have always been legally responsible for providing emergency medical services to those who met the responsible entity’s eligibility criteria. The issue of providing preventive health care for undocumented immigrants was addressed in 2003 with the passage of H.B. 2292, which granted local indigent health care entities explicit permission to provide preventive and acute care services to area residents without regard to their immigration status. This legislation eliminated any need to ask a patient about citizenship status for primary and preventive care, and most counties do not ask about citizenship status other than to determine eligibility for a federal or state payment program.

The Harris County Hospital District, the nation’s third-busiest public hospital system, estimated about one-in-five of patients seen by the county’s healthcare system were undocumented immigrants. Medical care for these patients, both emergency and non-emergency related, accounted for $97.3 million or approximately 14 percent of the system’s total operating costs in 2005.[31]

In 2001, the U.S./Mexico Border Counties Coalition (U.S./MBCC) interviewed border hospital chief executive officers and chief financial officers to obtain an estimate of the share of their hospitals’ uncompensated care attributable to undocumented immigrants. Based on their responses, the coalition estimated that about 25 percent of these hospitals’ uncompensated care costs resulted from uninsured, undocumented immigrants.

Since then, the Indigent Care Collaboration (ICC), an alliance of “safety net” providers in three Central Texas counties (Travis, Williamson and Hays), has begun tracking the percent of uninsured undocumented immigrants they serve using a web-based eligibility screening tool called the Community Health And Social Services Information System (CHASSIS™).

CHASSIS™ is used to screen uninsured/under-insured patients for eligibility in federal, state, and local medical assistance or payment programs (e.g. Medicaid, CHIP, CIHCP, Primary Health Care (PHC), SSI, local charity programs, etc.) In 2005, about 14 percent of all patients screened using CHASSIS™ in hospital settings were found to be undocumented. If only the patients screened through the hospitals’ emergency departments are examined, however, the percent of undocumented immigrants increases to 25 percent. This finding regarding the percent of emergency room patients who are undocumented is in keeping with the conclusions of U.S./MBCC’s 2001 study on emergency medical services provided to undocumented immigrants in Texas border counties.

Texas hospitals reported $9.2 billion in uncompensated care in 2004.[32] An estimate of 2005 costs was unavailable. Uncompensated care generally encompasses care provided to uninsured and underinsured individuals who cannot pay for the services they receive. Applying the ICC’s estimate of 14 percent of patients to total uncompensated care provided by Texas hospitals produces a statewide estimate of uncompensated healthcare costs attributable to undocumented immigrants of $1.3 billion.

Federally Qualified Health Centers

Federally qualified health centers (FQHC) include community health centers, migrant health centers, programs that provide health care for the homeless, public housing primary care programs and urban Indian and tribal health centers. FQHCs are supported by federal grants, Medicaid, Medicare, private insurance payments and state and local contributions.[33] Although anyone may seek services at an FQHC, nearly 71 percent of health center patients have family incomes at or below poverty. In addition, about 40 percent of health centers’ patients are uninsured and another 36 percent depend on Medicaid.[34]

According to the Texas Association of Community Health Centers, Texas FQHCs receive about 40 percent of their funding from sources such as Medicaid (27 percent) and state and local funds (13 percent). Grants and contracts -- federal and non-federal -- account for another 41 percent of revenues. Their remaining funds come from a variety of sources including Medicare, Children’s Health Insurance Program (CHIP), private insurance, self-pay patients and other miscellaneous sources.[35]

In 2005, Texas FQHC patients were covered by Medicaid/CHIP (25 percent), Medicare (7 percent), private insurance (7 percent) and other public programs (2 percent). The remaining 59 percent had no insurance.[36] Texas FQHCs served about 6 percent of the state’s uninsured in 2004. More than half of the 562,000 patients seen preferred to be served in a language other than English. More than 14,000 were seasonal or migrant farm workers.

Texas FQHCs are not required to and do not collect data on their patients’ citizenship status or place of birth. Therefore, it is impossible to estimate the percent of state or local funds spent by FQHCs that are attributable to undocumented immigrants.

Clinics

Other sources of healthcare for Texas’ undocumented immigrants include primary care and free clinics. ICC’s member clinics screened about 84,000 patients in 2005.[37] Of those screened, slightly more than 50 percent were found to be undocumented immigrants. An average clinic visit costs about $230. No data are available on the number of clinic visits made by this population, and as a result the Comptroller cannot estimate the cost of clinic services provided to undocumented immigrants.

The Robert Wood Johnson and Annie E. Casey Foundations created the Access Project to assist local communities develop and sustain efforts that improve healthcare and promote universal coverage with a focus on the uninsured. The Access Project reported that Texas counties spent an estimated $870 million on all indigent health care in 1999.[38] The Access Project, however, was examining indigent health care in its entirety and did not distinguish between citizens and noncitizens. U.S./MBCC examined emergency medical care only—that is, care required by federal law. As a result, there are no studies that estimate Texas costs for non-emergency or primary care provided to undocumented immigrants at the county or municipal level.

Section 1011

As mentioned above, Texas hospitals may be reimbursed for emergency healthcare provided to qualified undocumented immigrants by the Health and Human Services Commission, through the federal Emergency Medicaid program. More recently, the federal government has authorized payment for emergency medical care provided to undocumented immigrants under Section 1011 of the Medicare Modernization Act.

Section 1011 reimburses hospitals, physicians and ambulance providers based on Medicare reimbursement for services rendered to undocumented immigrants. Beginning in federal fiscal 2005, the federal government will pay about $250 million per year directly to providers that submit qualified claims. Texas’ allotment under Section 1011 was $56 million per year for four years. At this time, however, eligible Texas providers, including hospitals, physicians and ambulance services, have not submitted claims for all of the $56 million available.

The difficulty in estimating the cost to LPHDs, physicians or EMS services of care provided to uninsured undocumented immigrants varies depending on the availability of data and the existence of previous primary research.

As a rule, none of these entities maintain data on the citizenship of the patients they treat. This lack of data makes it virtually impossible to place a dollar figure on the cost to these providers related to undocumented immigrants. While no data are available to estimate the magnitude of the cost, it is clear that, other than Emergency Medicaid, Section 1011 and the limited state funds available, local tax dollars or private donations must cover most of the cost of providing care to undocumented immigrants.

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