Under 2023’s Senate Bill (SB) 1718, all Medicaid-accepting hospitals (i.e., most Florida hospitals) must ask admitted patients and emergency room (ER) visitors their immigration status. Hospitals must then share the aggregate responses with the Florida Agency for Health Care Administration (AHCA) each quarter so it can determine health care costs, especially related to uncompensated care.[1] The three options SB 1718 requires hospitals to include on their citizenship questionnaire are: Not lawfully present (i.e., undocumented), lawfully present (i.e., U.S. citizen or other documented status), or declined to answer.
AHCA released the first round of this data last month. The public dashboard intends to show that immigrants without a documented status are a strain on Florida’s health care system; however, its data does not support this. Inexplicably, AHCA sent a different report to the Legislature than what is publicly available on its dashboard. For ease of reading, Florida Policy Institute (FPI) refers to the original report as “the legislative report” and the current dashboard and its report as “the public dashboard” throughout.
Actual Cost of Care is Inflated
AHCA claims that the “approximate cost of care” for undocumented immigrants is more than $566 million, based on annual hospital operating expenses ($69.1 billion) and the share of respondents who claimed to be undocumented (0.82 percent of all respondents).[2]
Yet, this $566 million represents gross expenses before any revenue (i.e., insurance, self-pay, federal reimbursements) is taken into account. AHCA itself states that of the $69.1 billion in total operating expenses at Florida hospitals, only 3.76 percent ($2.6 billion) was uncompensated care, or care “not covered directly through Medicare, Medicaid, private insurance, or self-pay.”[3]
Matching AHCA’s methodology, then, a more measured estimate of care costs to serve Floridians who are undocumented is $21.3 million (0.82 percent of the uncompensated $2.6 billion), not $566 million. However, nowhere on the public dashboard does AHCA cite this figure.
It is unclear why AHCA chose to relay the cost of undocumented immigrant care as a share of all hospital expenses instead of just the uncompensated portion — especially since operating expenses include many fixed categories like rent that are not influenced by patients’ citizenship status. Even $21.3 million is likely an overestimate because AHCA does not know how much of undocumented immigrants’ care was truly uncompensated. While AHCA admits as much in its legislative report[4]; it fails to do so in its public dashboard.
Matching AHCA’s methodology, then, a more measured estimate of care costs to serve Floridians who are undocumented is $21.3 million (0.82 percent of the uncompensated $2.6 billion), not $566 million.
In reality, federal or private funding is likely covering some of this care, bringing uncompensated care down. Besides self-pay or private insurance, undocumented immigrants seeking emergency care may also have their care covered by Medicaid. The federal Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals to provide emergency care to all patients, regardless of citizenship or their ability to pay.
Notably, most Floridians who told hospitals they were undocumented were ER visitors (40,300 out of 54,444 total undocumented respondents, or 74 percent). As such, their care was more likely to be covered by emergency Medicaid.[5] Additionally, while not for immigrant care specifically, federal funding alleviates hospitals’ overall uncompensated care costs if they serve a “large number of Medicaid and uninsured individuals.” These are known as disproportionate share hospital (DSH) payments. Thus, while emergency Medicaid covers much of undocumented immigrants’ care, DSH steeply offsets hospitals’ uncompensated care costs overall.
Moreover, the Pew Research Center shows only 4 percent of Florida’s population is undocumented, and that over the past decade, this number has significantly declined — by over 240,000 people. With undocumented immigrants being 4 percent of the state population yet less than 1 percent of all hospital admissions and ER visitors (according to AHCA), that means these Floridians are underrepresented as health care seekers. In turn, this means that these Floridians are much smaller drivers of cost than other Floridians.
AHCA Omits Important Context Included in Original Legislative Report
In the legislative report, AHCA states that uncompensated care has declined almost every year since 2013. However, its public dashboard omits this information. Also, the legislative report claims there is no correlation between the share of undocumented immigrants served and the levels of uncompensated care in Florida. Again, the public dashboard neglects to include this caveat.
Furthermore, the legislative report points out that all new state arrivals (not just undocumented immigrants) contribute to higher health care costs over time.[6] Yet, AHCA’s public dashboard focuses only on how undocumented immigrants contribute to these costs. The dashboard does not make clear that undocumented immigrants — while a potential contributor to rising health care costs — are not the sole or even most significant contributor.
Finally, the legislative report includes the number of people who declined to answer hospitals’ citizenship question in its graphics and expounds on this data in the narrative. The public dashboard, however, excludes the decline to answer totals from its visual demonstrating counties’ immigrant care costs.
The dashboard’s detailed data tabs reveal that of the 6.63 million Floridians surveyed, most (6.1 million or 92 percent) were U.S. citizens or had a documented status, 486,000 (7 percent) declined to answer, and less than 1 percent were undocumented. AHCA’s choice to emphasize the 0.82 percent of survey respondents who were undocumented over the greater share of Floridians who declined to answer, have a documented status, or are U.S. citizens is misleading.
Public Dashboard Fails to Include Related Fiscal Impacts
As FPI noted during this year’s legislative session, the governor proposed allocating $558,000 and adding four positions that AHCA requested to collect SB 1718 data for the 2024-25 fiscal year. Although the Legislature seemingly followed suit, it is not as clear in delineating so. If costs are a concern to the state, the costs to collect and report on this data must be weighed. Moreover, health care costs are much greater if people in need of care delay or avoid it until it becomes chronic or dire — which lawmakers made all the more likely by targeting undocumented immigrants under SB 1718. This chilling effect puts Floridians’ health at risk and is expensive.
It is also important to consider the myriad contributions that immigrants — including those without a documented status — make to the Sunshine State. For example, despite not being granted legal status and many of the benefits that come with it, Florida’s undocumented immigrants contribute over $598 million annually in state and local taxes.
It is also important to consider the myriad contributions that immigrants — including those without a documented status — make to the Sunshine State.
All data has its limitations, and no estimates are perfect. However, data should always be provided alongside methodology and potential over- or under-estimates. This transparency is even more important for a taxpayer-funded authoritative body like AHCA to practice. Florida is poised to give the agency $558,000 to continue implementing SB 1718. Yet, there are serious concerns with AHCA’s approach thus far. For public transparency and accountability, AHCA should correct its dashboard’s major flaws and include the important context and limitations relayed in the version of the report that it did not release to the public.
Notes
[1] Agency for Health Care Administration, “Hospital Patient Immigration Status Report [public report],” p. 1, https://bit.ly/4b1pWmG.
[2] Public report, p. 2
[3] Public report, p. 2
[4] Agency for Health Care Administration, “Hospital Patient Immigration Status Report [legislative report],” pp. 2-3, https://bit.ly/3xBc7No.
[5] For the conditions under which emergency Medicaid applies in Florida, see Florida Agency for Health Care Administration, “Inpatient Hospital Services.”
[6] Legislative report, p. 3
