Abstract
BackgroundThe Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants. Our goal was to assess the effect of PRWORA on hospital uncompensated care in the United States.MethodsWe collected the following state-level data for the period from 1994 through 1999: foreign-born, noncitizen population and health uninsurance rates (US Census Current Population Survey); percentage of teaching hospitals (American Hospital Association Annual Survey of Hospitals); and each state's decision whether to implement the PRWORA Medicaid bar for legal permanent residents or to continue offering nonemergency Medicaid coverage using state-only funds (Urban Institute). We modeled uncompensated care expenditures by state (also from the Annual Survey of Hospitals) in both univariate and multivariable regression analyses.ResultsWhen measured at the state level, there was no significant relationship between uncompensated care expenditures and states' percentage of noncitizen immigrants. Uninsurance rates were the only significant factor in predicting uncompensated hospital care expenditures by state.ConclusionsReducing the number of uninsured patients would most surely reduce hospital expenditures for uncompensated care. However, data limitations hampered our efforts to obtain a monetary estimate of hospitals' financial losses due specifically to the immigrant eligibility changes in PRWORA. Quantifying the impact of these provisions on hospitals will require better data sources.
Highlights
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants
Data snapshots: state population and hospital characteristics Immigrant population Figure 1 displays the percentage of immigrants for each state, according to US Census data
Health insurance coverage The total number of medically uninsured persons living in the United States is estimated to be 42.5 million, or 16% of the population [22]
Summary
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants. Because uninsured immigrants affected by PRWORA are eligible only for emergency Medicaid, they lack coverage for any form of postdischarge medical care (eg, acute rehabilitation, medical equipment, follow-up outpatient or home health care, and transfer to long-term care facilities or nursing homes) [2]. Since these services often constitute the prevailing standard of care for chronic or disabling conditions, hospitals may incur substantial expenses by keeping Medicaid-ineligible patients in acutecare facilities longer than necessary due to lack of suitable long-term care or rehabilitation options [2]
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