State of Texas et al v. United States of America et al
Filing
64
REPLY in Support of 5 Opposed MOTION for Preliminary Injunction, filed by Phil Bryant, Paul R. LePage, Patrick L. McCrory, C.L. "Butch" Otter, Bill Schuette, State of Louisiana, State of Alabama, State of Arizona, State of Arkansas, State of Florida, State of Georgia, State of Idaho, State of Indiana, State of Kansas, State of Montana, State of Nebraska, State of North Dakota, State of Ohio, State of Oklahoma, State of South Carolina, State of South Dakota, State of Texas, State of Utah, State of West Virginia, State of Wisconsin. (Attachments: # 1 Exhibit Ex 1, # 2 Exhibit Ex. 2, # 3 Exhibit Ex. 3, # 4 Exhibit Ex. 4, # 5 Exhibit Ex. 5, # 6 Exhibit Ex. 6, # 7 Exhibit Ex. 7, # 8 Exhibit Ex. 8, # 9 Exhibit Ex. 9.a, # 10 Exhibit Ex. 9.b, # 11 Exhibit Ex. 10.a, # 12 Exhibit Ex. 10.b, # 13 Exhibit Ex. 10.c, # 14 Exhibit Ex. 10.d, # 15 Exhibit Ex. 10.e, # 16 Exhibit Ex. 10.f, # 17 Exhibit Ex. 10.g, # 18 Exhibit Ex. 10.h, # 19 Exhibit Ex. 10.i, # 20 Exhibit Ex. 10.j, # 21 Exhibit Ex. 10.k, # 22 Exhibit Ex. 10.l, # 23 Exhibit Ex. 10.m, # 24 Exhibit Ex. 10.n, # 25 Exhibit Ex. 10.0, # 26 Exhibit Ex. 10.p, # 27 Exhibit Ex. 10.q, # 28 Exhibit Ex. 10.r, # 29 Exhibit Ex. 10.s, # 30 Exhibit Ex. 11, # 31 Exhibit Ex. 12, # 32 Exhibit Ex. 13, # 33 Exhibit Ex. 14, # 34 Exhibit Ex. 15, # 35 Exhibit Ex. 16, # 36 Exhibit Ex. 17, # 37 Exhibit Ex. 18, # 38 Exhibit Ex. 19, # 39 Exhibit Ex. 20, # 40 Exhibit Ex. 21, # 41 Exhibit Ex. 22, # 42 Exhibit Ex. 23, # 43 Exhibit Ex. 24, # 44 Exhibit Ex. 25, # 45 Exhibit Ex. 26, # 46 Exhibit Ex. 27, # 47 Exhibit Ex. 28, # 48 Exhibit Ex. 29, # 49 Exhibit Ex. 30, # 50 Exhibit Ex. 31, # 51 Exhibit Ex. 32, # 52 Exhibit Ex. 33, # 53 Exhibit Ex. 34, # 54 Exhibit Ex. 35)(Oldham, Andrew)
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EXHIBIT 1
App. 0001
App. 0002
App. 0003
App. 0004
App. 0005
App. 0006
Exhibit 1 to
Declaration of Richard Allgeyer, Ph. D.
App. 0007
REPORT TO THE UNITED STATES CONGRESS ON SERVICES AND
BENEFITS PROVIDED TO UNDOCUMENTED IMMIGRANTS
Required Reporting for
Rider 59
House Bill 1
Eightieth Texas Legislature, Regular Session, 2007
EPIDEMIOLOGY TEAM
Strategic Decision Support
Financial Services Division
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
— November 2008 —
App. 0008
Table of Contents
I
Background ..........................................................................................................................1
II
Executive Data Summary ....................................................................................................2
III
Analytical Notes...................................................................................................................3
IV
Public Hospital District Facility Listing ..............................................................................6
V
References .........................................................................................................................11
-i-
App. 0009
I – Background
The 80th Texas Legislature, Regular Session, 2007, passed House Bill 1, General Appropriations Act, Article II,
Health and Human Services, Rider 59: “Report to the United States Congress on Services and Benefits
Provided to Undocumented Immigrants.”
This rider requires the Texas Health and Human Services Commission (HHSC) to report the cost of services
and benefits provided by HHSC to undocumented immigrants in the state. Rider 59 also requires HHSC to
compile these data for each Texas public hospital district facility. The text of Rider 59 is included below, with
the required data and supporting documentation on subsequent pages.
Rider 59 — Report to the United States Congress on
Services and Benefits Provided to Undocumented Immigrants
The Health and Human Services Commission shall compile a report of the cost of services and benefits provided to
undocumented immigrants, with the agency determining the extent to which undocumented immigrants are served by the
agency, by individual program. The agency may use a statistical method developed by the agency in cases where it is not
practical for the agency to directly determine whether recipients of a service or benefit are undocumented immigrants.
The Health and Human Services Commission shall also compile information on this subject from each public hospital
district within the state and include this information in the report and shall not enforce Title 8 of the United States Code
when compiling information on this subject.
The report must be produced using aggregated statistical data that does not contain personally identifiable information.
The purpose of compiling this information is to perform analysis to assist the United States Congress and this state in
making future health care and budgetary decisions. Information sought for the preparation of this report may not violate
any federal or state laws, including rules, regarding privacy.
This report shall be provided to the United States Congress by December 1, 2008, and may be used as supporting
materials by the State of Texas in requests for additional federal appropriations to assist with these costs.
The Health and Human Services Commission or a public hospital district may compile and report the information
required by this rider only in a manner the attorney general of this state certifies as consistent with federal law.
The Health and Human Services Commission again shall submit the required report to the Lieutenant Governor, Speaker
of the House of Representatives, and Members of the Legislature by December 1, 2008, and shall include the information
in the agency's annual report for 2008.
-1-
App. 0010
II – Executive Data Summary
A.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Estimated cost of services and benefits provided to undocumented immigrants (SFY 2007 )
$81.2 million
Texas Emergency Medicaid ($80 million) + Texas Family Violence Program ($1.2 million)
(Please see Analytical Notes on page 3 for subtotals and supporting documentation.)
B.
TEXAS PUBLIC HOSPITAL DISTRICTS
Estimated uncompensated care for undocumented immigrants (fiscal year 2006 )
$596.8 million
(Please see Analytical Notes on page 5 for subtotals and supporting documentation.)
Texas Health and Human Services Commission data are for state fiscal year 2007, the most recent data available. The Texas public
hospital districts data come from the Cooperative Annual Survey of Hospitals, which collects data for each facility's fiscal year. At
the time of this report's publication, the most recent survey data available were for fiscal year 2006.
-2-
App. 0011
III – Analytical Notes
A.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Estimated cost of services and benefits provided to undocumented immigrants (fiscal year 2007)
$81.2 million
Texas Emergency Medicaid ($80 million) + Texas Family Violence Program ($1.2 million)
1.
Texas Emergency Medicaid
Emergency Medicaid, Type Program 30 (TP 30), is a federal and state funded program that provides
Medicaid coverage, limited to emergency medical conditions including childbirth and labor, for non
citizens as well as undocumented immigrants living in the US. In fiscal year 2007, payments for
Emergency Medicaid, TP 30 totaled as follows:
A — Texas Emergency Medicaid, Type Program 30, Fiscal Year 2007
Inpatient hospital
Outpatient hospital
Professional and other services
Vendor drug
$252,300,000
$11,200,000
$53,700,000
$124,500
Total
$317,324,500
Since HHSC Medicaid claims data do not conclusively identify the legal residency status of immigrants,
the portion of the $317.3 million in Emergency Medicaid payments attributable to undocumented
immigrants must be estimated. According to the U.S. Census Bureau’s American Community Survey
(ACS) for Texas, approximately 2.6 million non citizens resided in Texas in 2006. The Department of
Homeland Security reports that 1.64 million, or 63 percent, of these residents were undocumented.
Therefore, this brings the estimated amount paid for Emergency Medicaid services to undocumented
immigrants residing in Texas to about $200 million:
B — Texas Emergency Medicaid ($317.3 million) x
Estimated Percent of Non-Citizens Who Are Undocumented Immigrants (63%)
= $200 million
The state shares the cost of the Medicaid program with the federal government, with Texas paying about
40 percent of Emergency Medicaid expenditures. Therefore, in fiscal year 2007 the total estimated state
cost for Medicaid services to undocumented immigrants was about $80 million.
C — Estimated Texas Emergency Medicaid for Undocumented Immigrants
Residing in Texas ($200 million) x Texas Share of Medicaid Cost (40%)
= $80 million
-3-
App. 0012
IV – Analytical Notes (Continued)
2.
Texas Family Violence Program
The Texas Family Violence Program (FVP) contracts with shelters and non-residential centers across
the state to provide essential services to victims of family violence. Core FVP services include shelter,
24-hour hotlines, emergency medical services, counseling, etc. In fiscal year 2007, the FVP funded
72 nonprofit family violence shelters, 8 non-residential centers, and 19 special non-residential projects
with a total budget of $23,199,451. State general revenue accounted for nearly $16.8 million
($16,759,995) of the program’s total spending for direct services.
The FVP does not ask victims of family violence about their residency status. Therefore, the portion of
the $16.8 million in FVP expenditures attributable to undocumented immigrants must be estimated.
According to the U.S. Census Bureau’s American Community Survey (ACS) for Texas, approximately
23.5 million individuals resided in Texas in 2006. The Department of Homeland Security reports that
1.64 million, or 7 percent, of these residents were undocumented. The total estimated state cost for direct
FVP services to undocumented immigrants in fiscal year 2007 was:
Texas Family Violence Program budget ($16.8 million) x
Estimated Number of Undocumented Texas Residents (7%)
= $1.2 million
B.
TEXAS PUBLIC HOSPITAL DISTRICTS
Estimated uncompensated care for undocumented immigrants (fiscal year 2006, 94 facilities)
$596.8 million
Limited information exists to estimate hospital-specific uncompensated care for undocumented
immigrants. As such, the method adopted for this report relies on regional estimates of undocumented
immigrants’ share of hospital uncompensated care, applying those estimates to each hospital in the
region.
The regional estimates are derived from a variety of sources. First, the software company Network
Sciences created a web-based eligibility screening tool called the “Community Health and Social
Services Information System” (CHASSIS™). The Indigent Care Collaboration (ICC), an alliance of
safety net providers in three Central Texas counties (Travis, Williamson and Hays), employed
CHASSIS™ to screen uninsured/under-insured patients for eligibility in government and local medical
assistance or payment programs. This system also tracked the percent of uninsured undocumented
immigrants served in these counties, and in 2005 found that nearly 14 percent of all patients screened in
hospital settings were undocumented immigrants. (Texas Comptroller of Public Accounts, 2006.) This
figure was used as a foundation for estimating uncompensated care for undocumented immigrants in the
remaining parts of Texas.
-4-
App. 0013
IV – Analytical Notes (Continued)
This 14 percent figure was then adjusted for each Public Health Region (PHR) based on information
from two additional sources. The first source, the 2006 American Hospital Association/Texas
Department of State Health Services/Texas Hospital Association (AHA/TDSHS/THA) Cooperative
Annual Survey of Hospitals, is required by state law. It is submitted annually by every Texas hospital
and lists each facility's reported uncompensated care (bad debt expenses plus charity care charges). The
second source, claims data from the state’s Emergency Medicaid, TP 30, is available for every hospital
stay for non citizens paid for by the state’s Medicaid program. In emergency cases, including childbirth
and labor, the federal government allows Medicaid via this program to pay for services rendered to
persons who would otherwise qualify for Medicaid regardless of their immigration status.
Based on the regional distribution of uncompensated care and Emergency Medicaid expenditures, the
Central Texas region’s share of the state’s uncompensated care appeared to be about 40 percent higher
than its share of Emergency Medicaid. Therefore, we estimate that approximately 20 percent of
uncompensated care statewide is accounted for by undocumented immigrants, compared to 14 percent in
the Central Texas region reported in the aforementioned ICC study. In order to account for this
difference statewide, the following formula was applied to each specific region:
Estimated Statewide Uncompensated Care Attributable To Undocumented Immigrants (20%) x
(Public Health Region’s Share of State Emergency Medicaid Expenditures /
Public Health Region’s Share of State Uncompensated Care) =
Estimated Percent of Uncompensated Care Attributed to
Undocumented Immigrants in a Public Health Region
As expected, results varied widely by a region's demographic composition and proximity to the border,
with the highest rate found in the Rio Grande Valley and the lowest rate in North Texas. The method
produced approximately the same rate statewide as for the state’s two largest population centers,
Houston and Dallas/Fort Worth.
These region-specific values were then applied to the reported uncompensated care for each public
hospital district facility to produce estimates of the uncompensated care for undocumented immigrants.
These facility totals were then added to generate the state total. Please see the facility-specific listing
below for more information.
-5-
App. 0014
IV – Public Hospital District Facility Listing
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A * B)
Public Hospital District Facility †
City
County
Permian Regional Medical Center
Andrews
ANDREWS
9
$1,426,975
5.79
$82,622
Bellville General Hospital
Bellville
AUSTIN
6
$1,888,004
21.20
$400,257
Muleshoe Area Medical Center
Muleshoe
BAILEY
1
$891,982
6.13
$54,678
Seymour Hospital
Seymour
BAYLOR
2
$1,314,921
2.35
$30,901
University Hospital
San Antonio
BEXAR
8
$329,954,339
7.79
$25,703,443
Angleton-Danbury Medical Center
Angleton
BRAZORIA
6
$9,151,361
21.20
$1,940,089
Sweeny Community Hospital
Sweeny
BRAZORIA
6
$1,798,967
21.20
$381,381
Burleson St. Joseph Health Center
Caldwell
BURLESON
7
$2,435,567
14.35
$349,504
Plains Memorial Hospital
Dimmitt
CASTRO
1
$2,069,565
6.13
$126,864
Bayside Community Hospital
Anahuac
CHAMBERS
6
$1,094,325
21.20
$231,997
Childress Regional Medical Center
Childress
CHILDRESS
1
$2,871,587
6.13
$176,028
Cochran Memorial Hospital
Morton
COCHRAN
1
$565,121
6.13
$34,642
Coleman County Medical Center
Coleman
COLEMAN
2
$1,867,080
2.35
$43,876
Rice Medical Center
Eagle Lake
COLORADO
6
$1,424,898
21.20
$302,078
Comanche County Medical Center
Comanche
COMANCHE
2
$2,508,293
2.35
$58,945
Concho County Hospital
Eden
CONCHO
9
$263,503
5.79
$15,257
North Texas Medical Center
Gainesville
COOKE
3
$8,802,166
21.50
$1,892,466
Muenster Memorial Hospital
Muenster
COOKE
3
$417,844
21.50
$89,836
Parkland Memorial Hospital
Dallas
DALLAS
3
$626,869,092
21.50
$134,776,855
Medical Arts Hospital
Lamesa
DAWSON
9
$2,717,784
5.79
$157,360
Cuero Community Hospital
Cuero
DE WITT
8
$3,678,475
7.79
$286,553
Hereford Regional Medical Center
Hereford
DEAF SMITH
1
$3,967,904
6.13
$243,233
-6-
App. 0015
IV – Public Hospital District Facility Listing, Continued
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A * B)
Public Hospital District Facility †
City
County
Eastland Memorial Hospital
Eastland
EASTLAND
2
$1,745,600
2.35
$41,022
Medical Center Hospital
Odessa
ECTOR
9
$67,643,877
5.79
$3,916,580
R. E. Thomason General Hospital
El Paso
EL PASO
10
$200,673,706
18.70
$37,525,983
Fisher County Hospital District
Rotan
FISHER
2
$540,185
2.35
$12,694
W.J. Mangold Memorial Hospital
Lockney
FLOYD
1
$555,669
6.13
$34,063
Frio Regional Hospital
Pearsall
FRIO
8
$1,988,980
7.79
$154,942
Memorial Hospital
Seminole
GAINES
9
$1,358,152
5.79
$78,637
Memorial Hospital
Gonzales
GONZALES
8
$4,198,738
7.79
$327,082
Hamilton General Hospital
Hamilton
HAMILTON
7
$2,955,437
14.35
$424,105
Hansford County Hospital
Spearman
HANSFORD
1
$627,299
6.13
$38,453
Chillicothe Hospital
Chillicothe
HARDEMAN
2
$149,096
2.35
$3,504
Hardeman County Memorial Hospital
Quanah
HARDEMAN
2
$431,416
2.35
$10,138
Ben Taub General Hospital
Houston
HARRIS
6
$960,155,000
21.20
$203,552,860
Northeast Medical Center Hospital
Humble
HARRIS
6
$56,336,561
21.20
$11,943,351
Coon Memorial Hospital and Home
Dalhart
HARTLEY
1
$2,711,061
6.13
$166,188
Haskell Memorial Hospital
Haskell
HASKELL
2
$177,793
2.35
$4,178
Hemphill County Hospital
Canadian
HEMPHILL
1
$316,312
6.13
$19,390
Hopkins County Memorial Hospital
Sulphur Springs
HOPKINS
4
$7,661,397
6.94
$531,701
Presbyterian Hospital of Commerce
Commerce
HUNT
3
$1,782,289
21.50
$383,192
Presbyterian Hospital of Greenville
Greenville
HUNT
3
$23,701,017
21.50
$5,095,719
Golden Plains Community Hospital
Borger
HUTCHINSON
1
$5,964,363
6.13
$365,615
Faith Community Hospital
Jacksboro
JACK
2
$619,741
2.35
$14,564
-7-
App. 0016
IV – Public Hospital District Facility Listing (Continued)
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A * B)
Public Hospital District Facility †
City
County
Jackson Healthcare Center
Edna
JACKSON
8
$1,688,113
7.79
$131,504
CHRISTUS Jasper Memorial Hospital
Jasper
JASPER
5
$5,814,021
4.54
$263,957
Hamlin Memorial Hospital
Hamlin
JONES
2
$216,321
2.35
$5,084
Stamford Memorial Hospital
Stamford
JONES
2
$835,599
2.35
$19,637
Otto Kaiser Memorial Hospital
Kenedy
KARNES
8
$1,488,269
7.79
$115,936
Kimble Hospital
Junction
KIMBLE
9
$862,799
5.79
$49,956
Knox County Hospital
Knox City
KNOX
2
$566,483
2.35
$13,312
Lavaca Medical Center
Hallettsville
LAVACA
8
$939,479
7.79
$73,185
Limestone Medical Center
Groesbeck
LIMESTONE
7
$1,720,727
14.35
$246,924
University Medical Center
Lubbock
LUBBOCK
1
$123,005,488
6.13
$7,540,236
Lynn County Hospital District
Tahoka
LYNN
1
$493,512
6.13
$30,252
Martin County Hospital District
Stanton
MARTIN
9
$735,801
5.79
$42,603
Matagorda General Hospital
Bay City
MATAGORDA
6
$10,756,443
21.20
$2,280,366
Heart of Texas Memorial Hospital
Brady
MCCULLOCH
9
$2,363,776
5.79
$136,863
Midland Memorial Hospital
Midland
MIDLAND
9
$40,088,376
5.79
$2,321,117
Richards Memorial Hospital
Rockdale
MILAM
7
$1,544,100
14.35
$221,578
Mitchell County Hospital
Colorado City
MITCHELL
2
$2,409,895
2.35
$56,633
Nocona General Hospital
Nocona
MONTAGUE
2
$1,058,607
2.35
$24,877
Memorial Hospital
Dumas
MOORE
1
$3,295,274
6.13
$202,000
Nacogdoches Memorial Hospital
Nacogdoches
NACOGDOCHES
5
$49,096,407
4.54
$2,228,977
Rolling Plains Memorial Hospital
Sweetwater
NOLAN
2
$3,283,504
2.35
$77,162
Ochiltree General Hospital
Perryton
OCHILTREE
1
$1,370,332
6.13
$84,001
-8-
App. 0017
IV – Public Hospital District Facility Listing (Continued)
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A * B)
Public Hospital District Facility †
City
County
Palo Pinto General Hospital
Mineral Wells
PALO PINTO
3
$7,608,018
21.50
$1,635,724
Campbell Health System
Weatherford
PARKER
3
$17,393,965
21.50
$3,739,702
Iraan General Hospital District
Iraan
PECOS
9
$110,920
5.79
$6,422
Reagan Memorial Hospital
Big Lake
REAGAN
9
$97,206
5.79
$5,628
Reeves County Hospital
Pecos
REEVES
9
$1,717,598
5.79
$99,449
Refugio County Memorial Hospital District
Refugio
REFUGIO
11
$1,935,402
60.56
$1,172,079
Ballinger Memorial Hospital District
Ballinger
RUNNELS
2
$1,087,906
2.35
$25,566
North Runnels Hospital
Winters
RUNNELS
2
$259,451
2.35
$6,097
Sabine County Hospital
Hemphill
SABINE
5
$765,265
4.54
$34,743
Starr County Memorial Hospital
Rio Grande City
STARR
11
$3,519,126
60.56
$2,131,183
Stonewall Memorial Hospital
Aspermont
STONEWALL
2
$141,622
2.35
$3,328
Lillian M. Hudspeth Memorial Hospital
Sonora
SUTTON
9
$1,352,108
5.79
$78,287
Swisher Memorial Hospital
Tulia
SWISHER
1
$935,352
6.13
$57,337
John Peter Smith Hospital
Fort Worth
TARRANT
3
$618,729,000
21.50
$133,026,735
Brownfield Regional Medical Center
Brownfield
TERRY
1
$2,117,936
6.13
$129,829
Titus Regional Medical Center
Mount Pleasant
TITUS
4
$13,783,587
6.94
$956,581
Tyler County Hospital
Woodville
TYLER
5
$2,801,493
4.54
$127,188
McCamey Hospital
McCamey
UPTON
9
$586,995
5.79
$33,987
Rankin County Hospital District
Rankin
UPTON
9
$134,422
5.79
$7,783
Val Verde Regional Medical Center
Del Rio
VAL VERDE
8
$8,965,303
7.79
$698,397
El Campo Memorial Hospital
El Campo
WHARTON
6
$3,854,197
21.20
$817,090
Shamrock General Hospital
Shamrock
WHEELER
1
$386,101
6.13
$23,668
-9-
App. 0018
IV – Public Hospital District Facility Listing (Continued)
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A * B)
Public Hospital District Facility †
City
County
Parkview Hospital
Wheeler
WHEELER
1
$577,427
6.13
$35,396
Electra Memorial Hospital
Electra
WICHITA
2
$1,300,014
2.35
$30,550
Wilbarger General Hospital
Vernon
WILBARGER
2
$2,687,964
2.35
$63,167
Connally Memorial Medical Center
Floresville
WILSON
8
$5,226,033
7.79
$407,108
Wise Regional Health System
Decatur
WISE
3
$15,033,103
21.50
$3,232,117
Hamilton Hospital
Olney
YOUNG
2
$3,184,195
2.35
$74,829
Total for the ninety-four Texas public hospital district facilities in FY 2006 — $596,848,958
Notes:
† The AHA/THA/TXDSHS Cooperative Annual Survey of Hospitals is administered to all Texas hospitals, and collects data for each facility's fiscal year. The 94 facilities listed here reported being either owned or
controlled by a public hospital district on the 2006 Cooperative Annual Survey of Hospitals. Data for FY 2007 were not available at the time of this report's publication.
*
Total facility uncompensated care is the sum of reported bad debt expenses and charity charges.
‡ Estimated percent of uncompensated care attributable to undocumented immigrants in a PHR was computed by using a formula designed for this report. Based on the regional distribution of uncompensated care and
Emergency Medicaid expenditures, the Central Texas region's share of the state's uncompensated care appeared to be about 40% higher than its share of Emergency Medicaid. Therefore, we estimate that approximately
20% of uncompensated care statewide is accounted for by undocumented immigrants, compared to 14% in the Central Texas region reported in the aforementioned ICC study. In order to account for this difference
statewide, the following formula was applied to each specific region. For more information, please see Analytical Notes on page 6.
Estimated Statewide Uncompensated Care Attributable To Undocumented Immigrants (20%) x
(Public Health Region’s Share of State Emergency Medicaid Expenditures /
Public Health Region’s Share of State Uncompensated Care) =
Estimated Percent of Uncompensated Care Attributed To Undocumented Immigrants in a Public Health Region
-10-
App. 0019
V – References
American Hospital Association/Texas Department of State Health Services/Texas Hospital Association, 2006.
Cooperative Annual Survey of Hospitals. Chicago/Austin.
House Bill 1, 80th Legislature, Regular Session, General Appropriations Act, Article II, Health and Human
Services, Rider 59: Report to the United States Congress on Services and Benefits Provided to Undocumented
Immigrants, pp. II-86-87.
Network Sciences, 2008. Community Health and Social Services Information System (CHASSIS Software™).
Retrieved October 17, 2008, from http://www.netsci.net/chassis.asp.
Texas Comptroller of Public Accounts, 2006. Special Report: Undocumented Immigrants in Texas, A
Financial Analysis of the Impact to the State Budget and Economy. Publication #96-1224. Retrieved
September 6, 2008, from http://www.window.state.tx.us/specialrpt/undocumented/undocumented.pdf.
Texas Health and Human Services Commission, Medicaid Administrative Data, Austin.
U.S. Department of Homeland Security, 2007. Estimates of the Unauthorized Immigrant Population Residing
in the United States: January 2006, Retrieved October 21, 2008, from
http://www.dhs.gov/xlibrary/assets/statistics/publications/ill_pe_2006.pdf.
U.S. Department of Commerce, 2007. American Community Survey (ACS): Public Use Microdata Sample
(PUMS), 2006. Washington, D.C.: U.S. Department of Commerce, Bureau of the Census.
-11-
App. 0020
Exhibit 2 to
Declaration of Richard Allgeyer, Ph. D.
App. 0021
REPORT ON SERVICES
AND BENEFITS PROVIDED TO
UNDOCUMENTED IMMIGRANTS
Updated report related to
Rider 59
House Bill 1
Eightieth Texas Legislature, Regular Session, 2007
— 2010 UPDATE —
Strategic Decision Support
Financial Services Division
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
App. 0022
Table of Contents
I
Background...........................................................................................................................................1
II
Executive Data Summary...................................................................................................................2
III
Analytical Notes ..................................................................................................................................3
IV
Public Hospital District Facility Listing ...........................................................................................8
V
References .........................................................................................................................................12
HHSC, Rider 59 Report — 2010 Update
-2-
App. 0023
I – Background
The 80th Texas Legislature, Regular Session, 2007, passed House Bill 1, General Appropriations Act, Article II,
Health and Human Services, Rider 59: “Report to the United States Congress on Services and Benefits
Provided to Undocumented Immigrants.”
This rider required the Texas Health and Human Services Commission (HHSC) to report the cost of services
and benefits provided by HHSC to undocumented immigrants in the state. Rider 59 also required HHSC to
compile these data for each Texas public hospital district facility. This report was originally completed in 2008.
Due to numerous requests for related current information, this document is the 2010 update of that original
report. The text of Rider 59 is included below, with the updated data and supporting documentation on
subsequent pages.
Rider 59 — Report to the United States Congress on
Services and Benefits Provided to Undocumented Immigrants
The Health and Human Services Commission shall compile a report of the cost of services and benefits provided to undocumented
immigrants, with the agency determining the extent to which undocumented immigrants are served by the agency, by individual
program. The agency may use a statistical method developed by the agency in cases where it is not practical for the agency to
directly determine whether recipients of a service or benefit are undocumented immigrants.
The Health and Human Services Commission shall also compile information on this subject from each public hospital district within
the state and include this information in the report and shall not enforce Title 8 of the United States Code when compiling
information on this subject.
The report must be produced using aggregated statistical data that does not contain personally identifiable information. The
purpose of compiling this information is to perform analysis to assist the United States Congress and this state in making future
health care and budgetary decisions. Information sought for the preparation of this report may not violate any federal or state
laws, including rules, regarding privacy.
This report shall be provided to the United States Congress by December 1, 2008, and may be used as supporting materials by
the State of Texas in requests for additional federal appropriations to assist with these costs.
The Health and Human Services Commission or a public hospital district may compile and report the information required by this
rider only in a manner the attorney general of this state certifies as consistent with federal law.
The Health and Human Services Commission again shall submit the required report to the Lieutenant Governor, Speaker of the
House of Representatives, and Members of the Legislature by December 1, 2008, and shall include the information in the
agency's annual report for 2008.
HHSC, Rider 59 Report — 2010 Update
-1-
App. 0024
II – Executive Data Summary
A.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Estimated cost of services and benefits provided to undocumented immigrants,
State Fiscal Year (SFY) 2009
$96 million
Note — in the original, 2008 version of this report, this figure was: $81 million.
(Please see Analytical Notes on page 3 for subtotals and supporting documentation.)
Texas Health and Human Services Commission data are for state fiscal year 2009, the most recent data available.
B.
TEXAS PUBLIC HOSPITAL DISTRICTS
Estimated uncompensated care for undocumented immigrants, facility fiscal year 2008
$717 million
Note — in the original, 2008 version of this report, this figure was: $597 million.
(Please see Analytical Notes on page 6 for subtotals and supporting documentation.)
The Texas public hospital districts data come from the Cooperative Annual Survey of Hospitals, which collects data for
each facility's fiscal year. At the time of this report's publication, the most recent survey data available were for fiscal year
2008.
HHSC, Rider 59 Report — 2010 Update
-2-
App. 0025
III – Analytical Notes
A.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Estimated cost of services and benefits provided to undocumented immigrants, SFY 2009
(1) Texas Emergency Medicaid — $62 million +
(2) Texas Family Violence Program — $1.3 million +
(3) Texas Children's Health Insurance Program (CHIP) Perinatal Coverage — $33 million
=
$96 million
1.
Texas Emergency Medicaid
Emergency Medicaid, Type Program 30 (TP 30), is a federal and state funded program that provides
Medicaid coverage, limited to emergency medical conditions including childbirth and labor, for non
citizens as well as undocumented immigrants living in the US. Emergency Medicaid is a federally
required program. In fiscal year 2009, payments for Emergency Medicaid, TP 30 totaled as follows:
—A—
Texas Emergency Medicaid, Type Program 30, Fiscal Year 2009
Inpatient hospital
Outpatient hospital
Professional and other services
Vendor drug
$275,010,314
$13,248,238
$20,778,110
$159,096
Total
$309,195,758
Since HHSC Medicaid claims data do not conclusively identify the legal residency status of immigrants,
the portion of the $309.2 million in Emergency Medicaid payments attributable to undocumented
immigrants must be estimated.
According to the U.S. Census Bureau’s American Community Survey (ACS) for Texas, approximately 2.6
million non citizens resided in Texas in 2006. The Department of Homeland Security reports that 1.64
million, or 63 percent, of these residents were undocumented. Therefore, the estimated amount paid
for Emergency Medicaid services to undocumented immigrants residing in Texas is about $194.8
million:
—B—
Texas Emergency Medicaid ($309.2 million)
x
Estimated Percent of Non-Citizens Who Are Undocumented Immigrants (63%)
=
$194.8 million
HHSC, Rider 59 Report — 2010 Update
-3-
App. 0026
III – Analytical Notes (Continued)
The state shares the cost of the Medicaid program with the federal government, with Texas typically
paying about 40 percent of Emergency Medicaid expenditures. However, in SFY 2009 due to provisions
of the American Recovery and Reinvestment Act of 2009 (ARRA), the federal government temporarily
increased its share of Medicaid expenditures to 68 percent, leaving the state with a 32 percent share.
Therefore, the total estimated state cost for Emergency Medicaid services to undocumented
immigrants residing in Texas in SFY 2009 was about $62 million.
—C—
Estimated Texas Emergency Medicaid for Undocumented
Immigrants Residing in Texas ($194.8 million)
x
Texas Share of Medicaid Cost under ARRA (32%)
=
$62 million
Note — in the original, 2008 version of this report, this figure was: $80 million.
2.
Texas Family Violence Program
The Texas Family Violence Program (FVP) contracts with non-profit agencies in three categories
(shelter centers, non-residential centers, and special non-residential projects (SNRP)) across the state
to provide essential services to victims of family violence. Core FVP services include shelter, 24-hour
hotlines, emergency medical services, counseling, etc. In SFY 2009, the FVP funded 72 nonprofit family
violence shelters, 8 non-residential centers, and 20 SNRPs, providing comprehensive family violence
services to victims, with a total budget of $24,028,440. State general revenue and Temporary
Assistance for Needy Families (TANF) converted to Title XX accounted for about $19 million
($19,235,988) of the program’s total spending for direct services. Services are provided without any
financial eligibility testing and free of charge.
The FVP does not ask victims of family violence about their residency status. Therefore, the portion of
the $19 million in FVP expenditures attributable to undocumented immigrants must be estimated.
According to the U.S. Census Bureau’s American Community Survey (ACS) for Texas, approximately 23.5
million individuals resided in Texas in 2006. The Department of Homeland Security reports that 1.64
million, or 7 percent, of these residents were undocumented. The total estimated state cost for direct
FVP services to undocumented immigrants in SFY 2009 was:
Texas Family Violence Program budget ($19 million)
x
Estimated Percent of Undocumented Immigrants in Texas (7%)
=
$1.3 million
Note — in the original, 2008 version of this report, this figure was: $1.2 million.
HHSC, Rider 59 Report — 2010 Update
-4-
App. 0027
III – Analytical Notes (Continued)
3.
Texas Children's Health Insurance Program (CHIP) Perinatal Coverage
Texas CHIP Perinatal Coverage provides prenatal care for the unborn children of low-income women.
Specifically, it provides prenatal care for women living at up to 200% Federal Poverty Level (FPL) who
do not otherwise qualify for Medicaid, typically due to their citizenship status. Nearly all participants of
CHIP Perinatal are either documented or non-documented non-citizens. Since this program does not
require citizenship documentation, there is no way to definitively report the number of undocumented
immigrants served. Therefore, the portion of the $188 million in CHIP Perinatal Coverage
expenditures (which represents prenatal services only) in SYF 2009 attributable to undocumented
immigrants must be estimated. Note: CHIP Perinate Coverage expenditures were not included in the
original Rider 59 report since, at the time its completion, a full year of program data was not available.
According to the U.S. Census Bureau’s American Community Survey (ACS) for Texas, approximately 2.6
million non citizens resided in Texas in 2006. The Department of Homeland Security reports that 1.64
million, or 63 percent, of these residents were undocumented. Therefore, this brings the estimated
amount paid for Texas CHIP Perinatal Coverage services to undocumented immigrants residing in
Texas for SFY 2009 to about $118 million:
Texas CHIP Perinatal Coverage budget ($188 million)
x
Estimated Percent of Non-Citizens Who Are Undocumented Immigrants (63%)
=
$118 million
The state shares the cost of the CHIP program with the federal government, with Texas typically
paying about 28 percent of expenditures. Therefore, the total estimated state cost for CHIP Perinatal
Coverage to undocumented immigrants residing in Texas in SFY 2009 was about $34 million.
Estimated CHIP Perinatal Coverage for Undocumented
Immigrants Residing in Texas ($118 million)
x
Texas Share of CHIP Expenditures (28%)
=
$33 million
Note — Expenditures for CHIP Perinate Coverage were not included in the original, 2008 version of the
Rider 59 report since, at the time its completion, a full year of program data was not available.
HHSC, Rider 59 Report — 2010 Update
-5-
App. 0028
III – Analytical Notes (Continued)
B.
TEXAS PUBLIC HOSPITAL DISTRICTS
Estimated uncompensated care for undocumented immigrants (fiscal year 2008; 99 facilities)
$717 million
Note — in the original, 2008 version of this report, this figure was: $597 million.
Limited information exists to estimate hospital-specific uncompensated care for undocumented
immigrants. As such, the method adopted for this report relies on regional estimates of undocumented
immigrants’ share of hospital uncompensated care, applying those estimates to each public hospital
district facility in the region.
The regional estimates (which have been rounded for this report’s update) are derived from a variety
of sources. First, a web-based eligibility screening tool called the “Community Health and Social
Services Information System” (CHASSIS™). The Indigent Care Collaboration (ICC), an alliance of
safety net providers in three Central Texas counties (Travis, Williamson and Hays), employed
CHASSIS™ to screen uninsured/under-insured patients for eligibility in government and local medical
assistance or payment programs (Network Sciences, 2008).
This system also tracked the percent of uninsured undocumented immigrants served in these counties,
and in 2005 found that nearly 14 percent of all patients screened in hospital settings were
undocumented immigrants. (Texas Comptroller of Public Accounts, 2006.) This figure was used as a
foundation for estimating uncompensated care for undocumented immigrants in the remaining parts of
Texas.
This 14 percent figure was adjusted for each Public Health Region (PHR) based on information from
two additional sources. The first source, the 2008 American Hospital Association/Texas Department
of State Health Services/Texas Hospital Association (AHA/TDSHS/THA) Cooperative Annual Survey of
Hospitals, is required by state law. It is submitted annually by every Texas hospital and lists each
facility's reported uncompensated care (bad debt expenses plus charity care charges).
The second source, claims data from the state’s Emergency Medicaid Type Program (TP) 30, is
available for every hospital stay for non citizens paid for by the state’s Emergency Medicaid program. In
emergency cases, including childbirth and labor, Medicaid pays for services rendered to persons who
would otherwise qualify for Medicaid regardless of their immigration status.
HHSC, Rider 59 Report — 2010 Update
-6-
App. 0029
III – Analytical Notes (Continued)
Based on the regional distribution of uncompensated care and Emergency Medicaid expenditures, the
Central Texas region’s share of the state’s uncompensated care appeared to be about 40 percent
higher than its share of Emergency Medicaid. Therefore, we estimate that approximately 20 percent of
uncompensated care statewide is accounted for by undocumented immigrants, compared to
14 percent in the Central Texas region reported in the aforementioned ICC study. In order to account
for this difference statewide, the following formula was applied to each specific region:
Estimated Statewide Uncompensated Care Attributable To Undocumented Immigrants (20%)
x
( Public Health Region’s Share of State Emergency Medicaid Expenditures /
Public Health Region’s Share of State Uncompensated Care )
=
Estimated Percent of Uncompensated Care Attributed to
Undocumented Immigrants in a Public Health Region
As expected, results varied widely by a region's demographic composition and proximity to the border,
with the highest rate found in the Rio Grande Valley and the lowest rate in North Texas. The method
produced approximately the same rate statewide as for the state’s two largest population centers,
Houston and Dallas/Fort Worth.
These region-specific values were then applied to the reported uncompensated care for each public
hospital district facility to produce estimates of the uncompensated care for undocumented
immigrants. These facility totals were then added to generate the state total. This computational logic
was revisited for the report's 2010 update, and it was determined that there was no justification to
change these formulas and values at this time. Please see the facility-specific listing below for more
information.
HHSC, Rider 59 Report — 2010 Update
-7-
App. 0030
IV – Public Hospital District Facility Listing
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated Facility
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A x B)
Public Hospital District Facility †
City
County
Permian Regional Medical Center
Andrews
ANDREWS
9
$3,872,258
0.06
$232,335
Bellville General Hospital
Bellville
AUSTIN
6
$2,177,652
0.21
$457,307
Muleshoe Area Medical Center
Muleshoe
BAILEY
1
$812,007
0.06
$48,720
Smithville Regional Hospital
Smithville
BASTROP
7
$5,629,736
0.14
$788,163
Seymour Hospital
Seymour
BAYLOR
2
$1,025,201
0.02
$20,504
University Hospital
San Antonio
BEXAR
8
$369,227,596
0.08
$29,538,208
Angleton-Danbury Medical Center
Angleton
BRAZORIA
6
$8,240,290
0.21
$1,730,461
Sweeny Community Hospital
Sweeny
BRAZORIA
6
$2,370,787
0.21
$497,865
Burleson St. Joseph Health Center
Caldwell
BURLESON
7
$3,864,113
0.14
$540,976
Atlanta Memorial Hospital
Atlanta
CASS
4
$5,787,215
0.07
$405,105
Plains Memorial Hospital
Dimmitt
CASTRO
1
$1,761,563
0.06
$105,694
Bayside Community Hospital
Anahuac
CHAMBERS
6
$1,627,946
0.21
$341,869
Childress Regional Medical Center
Childress
CHILDRESS
1
$3,187,285
0.06
$191,237
Cochran Memorial Hospital
Morton
COCHRAN
1
$202,007
0.06
$12,120
Coleman County Medical Center
Coleman
COLEMAN
2
$2,330,626
0.02
$46,613
Rice Medical Center
Eagle Lake
COLORADO
6
$1,536,586
0.21
$322,683
Comanche County Medical Center
Comanche
COMANCHE
2
$2,112,936
0.02
$42,259
Concho County Hospital
Eden
CONCHO
9
$291,931
0.06
$17,516
North Texas Medical Center
Gainesville
COOKE
3
$10,967,036
0.22
$2,412,748
Muenster Memorial Hospital
Muenster
COOKE
3
$392,877
0.22
$86,433
Coryell Memorial Hospital
Gatesville
CORYELL
7
$3,495,557
0.14
$489,378
Parkland Memorial Hospital
Dallas
DALLAS
3
$770,172,780
0.22
$169,438,012
HHSC, Rider 59 Report — 2010 Update
-8-
App. 0031
IV – Public Hospital District Facility Listing, Continued
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated Facility
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A x B)
Public Hospital District Facility †
City
County
Public
Health
Region
(PHR)
Richardson Regional Medical Center
Richardson
DALLAS
3
$28,107,007
0.22
$6,183,542
Medical Arts Hospital
Lamesa
DAWSON
9
$4,870,046
0.06
$292,203
Cuero Community Hospital
Cuero
DE WITT
8
$4,732,916
0.08
$378,633
Hereford Regional Medical Center
Hereford
DEAF SMITH
1
$5,343,007
0.06
$320,580
Eastland Memorial Hospital
Eastland
EASTLAND
2
$3,356,919
0.02
$67,138
Medical Center Hospital
Odessa
ECTOR
9
$74,028,538
0.06
$4,441,712
R. E. Thomason General Hospital
El Paso
EL PASO
10
$212,073,041
0.19
$40,293,878
Fisher County Hospital District
Rotan
FISHER
2
$537,418
0.02
$10,748
W.J. Mangold Memorial Hospital
Lockney
FLOYD
1
$903,277
0.06
$54,197
OakBend Medical Center
Richmond
FORT BEND
6
$26,351,512
0.21
$5,533,818
Frio Regional Hospital
Pearsall
FRIO
8
$2,063,071
0.08
$165,046
Memorial Hospital
Seminole
GAINES
9
$2,287,318
0.06
$137,239
Memorial Hospital
Gonzales
GONZALES
8
$4,260,810
0.08
$340,865
Hamilton General Hospital
Hamilton
HAMILTON
7
$4,433,680
0.14
$620,715
Hansford County Hospital
Spearman
HANSFORD
1
$718,184
0.06
$43,091
Hardeman County Memorial Hospital
Quanah
HARDEMAN
2
$512,530
0.02
$10,251
Chillicothe Hospital
Chillicothe
HARDEMAN
2
$190,958
0.02
$3,819
Ben Taub General Hospital
Houston
HARRIS
6
$1,107,257,370
0.21
$232,524,048
Tomball Regional Hospital
Tomball
HARRIS
6
$34,205,413
0.21
$7,183,137
Coon Memorial Hospital and Home
Dalhart
HARTLEY
1
$2,517,976
0.06
$151,079
Haskell Memorial Hospital
Haskell
HASKELL
2
$270,676
0.02
$5,414
Hemphill County Hospital
Canadian
HEMPHILL
1
$608,103
0.06
$36,486
HHSC, Rider 59 Report — 2010 Update
-9-
App. 0032
IV – Public Hospital District Facility Listing, Continued
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated Facility
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A x B)
Public Hospital District Facility †
City
County
Hopkins County Memorial Hospital
Sulphur Springs
HOPKINS
4
$8,855,915
0.07
$619,914
Hunt Regional Medical Center Greenville
Greenville
HUNT
3
$26,569,309
0.22
$5,845,248
Hunt Regional Community Hospital
Commerce
HUNT
3
$1,949,784
0.22
$428,952
Faith Community Hospital
Jacksboro
JACK
2
$1,336,009
0.02
$26,720
Jackson Healthcare Center
Edna
JACKSON
8
$1,511,280
0.08
$120,902
CHRISTUS Jasper Memorial Hospital
Jasper
JASPER
5
$8,386,654
0.05
$419,333
Stamford Memorial Hospital
Stamford
JONES
2
$1,263,715
0.02
$25,274
Hamlin Memorial Hospital
Hamlin
JONES
2
$118,858
0.02
$2,377
Otto Kaiser Memorial Hospital
Kenedy
KARNES
8
$1,956,818
0.08
$156,545
Knox County Hospital
Knox City
KNOX
2
$864,961
0.02
$17,299
Lavaca Medical Center
Hallettsville
LAVACA
8
$1,049,510
0.08
$83,961
Limestone Medical Center
Groesbeck
LIMESTONE
7
$2,966,202
0.14
$415,268
Llano Memorial Hospital
Llano
LLANO
7
$6,430,811
0.14
$900,314
University Medical Center
Lubbock
LUBBOCK
1
$116,021,682
0.06
$6,961,301
Lynn County Hospital District
Tahoka
LYNN
1
$485,660
0.06
$29,140
Martin County Hospital District
Stanton
MARTIN
9
$1,422,335
0.06
$85,340
Matagorda Medical Center
Bay City
MATAGORDA
6
$10,322,312
0.21
$2,167,686
Heart of Texas Memorial Hospital
Brady
MCCULLOCH
9
$2,354,023
0.06
$141,241
Medina Community Hospital
Hondo
MEDINA
8
$4,391,528
0.08
$351,322
Midland Memorial Hospital
Midland
MIDLAND
9
$48,655,866
0.06
$2,919,352
Mitchell County Hospital
Colorado City
MITCHELL
2
$3,674,336
0.02
$73,487
Bowie Memorial Hospital
Bowie
MONTAGUE
2
$3,216,286
0.02
$64,326
HHSC, Rider 59 Report — 2010 Update
- 10 -
App. 0033
IV – Public Hospital District Facility Listing, Continued
Public
Health
Region
(PHR)
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated Facility
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A x B)
Public Hospital District Facility †
City
County
Nocona General Hospital
Nocona
MONTAGUE
2
$1,531,908
0.02
$30,638
Memorial Hospital
Dumas
MOORE
1
$3,725,461
0.06
$223,528
Nacogdoches Memorial Hospital
Nacogdoches
NACOGDOCHES
5
$54,003,977
0.05
$2,700,199
Rolling Plains Memorial Hospital
Sweetwater
NOLAN
2
$4,232,138
0.02
$84,643
Ochiltree General Hospital
Perryton
OCHILTREE
1
$1,777,167
0.06
$106,630
Palo Pinto General Hospital
Mineral Wells
PALO PINTO
3
$6,269,909
0.22
$1,379,380
Iraan General Hospital
Iraan
PECOS
9
$373,544
0.06
$22,413
Reagan Memorial Hospital
Big Lake
REAGAN
9
$222,237
0.06
$13,334
Reeves County Hospital
Pecos
REEVES
9
$2,637,636
0.06
$158,258
Refugio County Memorial Hospital District
Refugio
REFUGIO
11
$1,866,730
0.61
$1,138,705
Ballinger Memorial Hospital District
Ballinger
RUNNELS
2
$750,577
0.02
$15,012
North Runnels Hospital
Winters
RUNNELS
2
$290,514
0.02
$5,810
Cogdell Memorial Hospital
Snyder
SCURRY
2
$7,086,091
0.02
$141,722
Starr County Memorial Hospital
Rio Grande City
STARR
11
$3,075,916
0.61
$1,876,309
Stonewall Memorial Hospital
Aspermont
STONEWALL
2
$108,093
0.02
$2,162
Lillian M. Hudspeth Memorial Hospital
Sonora
SUTTON
9
$1,838,340
0.06
$110,300
Swisher Memorial Hospital
Tulia
SWISHER
1
$1,036,407
0.06
$62,184
John Peter Smith Hospital
Fort Worth
TARRANT
3
$773,861,000
0.22
$170,249,420
Brownfield Regional Medical Center
Brownfield
TERRY
1
$2,479,007
0.06
$148,740
Titus Regional Medical Center
Mount Pleasant
TITUS
4
$18,528,136
0.07
$1,296,970
Tyler County Hospital
Woodville
TYLER
5
$3,472,921
0.05
$173,646
Rankin County Hospital District
Rankin
UPTON
9
$193,275
0.06
$11,597
HHSC, Rider 59 Report — 2010 Update
- 11 -
App. 0034
IV – Public Hospital District Facility Listing, Continued
Total
Facility
Uncompensated
Care *
(A)
Estimated Percent of
Uncompensated Care
Estimated Facility
Attributable to
Uncompensated Care
Undocumented Immigrants for Undocumented
Immigrants
in a PHR ‡
(B)
(A x B)
Public Hospital District Facility †
City
County
Public
Health
Region
(PHR)
McCamey Hospital
McCamey
UPTON
9
$55,186
0.06
$3,311
Uvalde Memorial Hospital
Uvalde
UVALDE
8
$8,347,207
0.08
$667,777
Val Verde Regional Medical Center
Del Rio
VAL VERDE
8
$10,632,139
0.08
$850,571
El Campo Memorial Hospital
El Campo
WHARTON
6
$3,507,501
0.21
$736,575
Shamrock General Hospital
Shamrock
WHEELER
1
$641,535
0.06
$38,492
Parkview Hospital
Wheeler
WHEELER
1
$450,335
0.06
$27,020
Electra Memorial Hospital
Electra
WICHITA
2
$1,366,414
0.02
$27,328
Wilbarger General Hospital
Vernon
WILBARGER
2
$3,562,302
0.02
$71,246
Connally Memorial Medical Center
Floresville
WILSON
8
$5,615,212
0.08
$449,217
Wise Regional Health System
Decatur
WISE
3
$25,177,926
0.22
$5,539,144
Hamilton Hospital
Olney
YOUNG
2
$2,004,045
0.02
$40,081
Total for the ninety-nine Texas public hospital district facilities in FY 2008 — $716,821,507
Notes:
† The AHA/THA/TDSHS Cooperative Annual Survey of Hospitals is administered to all Texas hospitals, and collects data for each facility's fiscal year. The 99 facilities listed here reported being either owned or controlled by
a public hospital district on the 2008 Cooperative Annual Survey of Hospitals. Data for FY 2009 were not available at the time of this report's publication.
*
Total facility uncompensated care is the sum of reported bad debt expenses and charity charges.
‡ Estimated percent of uncompensated care attributable to undocumented immigrants in a PHR was computed by using a formula designed for this report's original 2008 edition, and retained for this 2010 update. Based
on the regional distribution of uncompensated care and Emergency Medicaid expenditures, the Central Texas region's share of the state's uncompensated care appeared to be about 40% higher than its share of
Emergency Medicaid. Therefore, we estimate that approximately 20% of uncompensated care statewide is accounted for by undocumented immigrants, compared to 14% in the Central Texas region reported in the
aforementioned ICC study. In order to account for this difference statewide, the following formula was applied to each specific region. For more information, please see Analytical Notes on page 6.
Estimated Statewide Uncompensated Care Attributable To Undocumented Immigrants (20%) x
(Public Health Region’s Share of State Emergency Medicaid Expenditures /
Public Health Region’s Share of State Uncompensated Care) =
Estimated Percent of Uncompensated Care Attributed To Undocumented Immigrants in a Public Health Region
HHSC, Rider 59 Report — 2010 Update
- 12 -
App. 0035
V – References
American Hospital Association/Texas Department of State Health Services/Texas Hospital Association, 2008.
Cooperative Annual Survey of Hospitals. Chicago/Austin.
House Bill 1, 80th Legislature, Regular Session, General Appropriations Act, Article II, Health and Human
Services, Rider 59: Report to the United States Congress on Services and Benefits Provided to Undocumented
Immigrants, pp. II-86-87.
Network Sciences, 2008. Community Health and Social Services Information System (CHASSIS Software™).
Retrieved October 17, 2008, from http://www.netsci.net/chassis.asp.
Texas Comptroller of Public Accounts, 2006. Special Report: Undocumented Immigrants in Texas, A Financial
Analysis of the Impact to the State Budget and Economy. Publication #96-1224. Retrieved September 6, 2008,
from http://www.window.state.tx.us/specialrpt/undocumented/undocumented.pdf.
Texas Health and Human Services Commission, Medicaid Administrative Data, Austin.
U.S. Department of Homeland Security, 2007. Estimates of the Unauthorized Immigrant Population Residing in the
United States: January 2006, Retrieved October 21, 2008, from
http://www.dhs.gov/xlibrary/assets/statistics/publications/ill_pe_2006.pdf.
U.S. Department of Commerce, 2007. American Community Survey (ACS): Public Use Microdata Sample (PUMS),
2006. Washington, D.C.: U.S. Department of Commerce, Bureau of the Census.
HHSC, Rider 59 Report — 2010 Update
- 13 -
App. 0036
Exhibit 3 to
Declaration of Richard Allgeyer, Ph. D.
App. 0037
REPORT ON TEXAS
HEALTH AND HUMAN SERVICES
COMMISSION SERVICES
AND BENEFITS PROVIDED TO
UNDOCUMENTED IMMIGRANTS
Update to the Report Required by the
2008-09 General Appropriations Act,
H.B. 1, 80th Legislature, Regular Session, 2007
(Article II, Health and Human Services Commission, Rider 59)
FEBRUARY 2013 UPDATE
Strategic Decision Support
Financial Services Division
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
App. 0038
Table of Contents
I
Background ........................................................................................................................................... 3
II
Executive Data Summary................................................................................................................... 4
III
Analytical Notes .................................................................................................................................. 5
IV
References ........................................................................................................................................... 9
HHSC, Rider 59 Report — February 2013 Update
App. 0039
-2-
I – Background
The 2008-09 General Appropriations Act, H.B. 1, 80th Legislature, Regular Session, 2007 (Article II, Health and
Human Services Commission, Rider 59) required the Texas Health and Human Services Commission (HHSC)
to report the cost of services and benefits provided by HHSC to undocumented immigrants in the state. Rider
59 also required HHSC to compile these data for each Texas public hospital district facility. This report was
originally completed in 2008. Due to numerous requests for related current information, the report was
updated in 2010. This report is the second update to that original report. The text of Rider 59 is included
below, with the updated data and supporting documentation on subsequent pages.
Rider 59 — Report to the United States Congress on
Services and Benefits Provided to Undocumented Immigrants
The Health and Human Services Commission shall compile a report of the cost of services and benefits provided
to undocumented immigrants, with the agency determining the extent to which undocumented immigrants are
served by the agency, by individual program. The agency may use a statistical method developed by the agency in
cases where it is not practical for the agency to directly determine whether recipients of a service or benefit are
undocumented immigrants.
The Health and Human Services Commission shall also compile information on this subject from each public
hospital district within the state and include this information in the report and shall not enforce Title 8 of the
United States Code when compiling information on this subject.
The report must be produced using aggregated statistical data that does not contain personally identifiable
information. The purpose of compiling this information is to perform analysis to assist the United States Congress
and this state in making future health care and budgetary decisions. Information sought for the preparation of
this report may not violate any federal or state laws, including rules, regarding privacy.
This report shall be provided to the United States Congress by December 1, 2008, and may be used as
supporting materials by the State of Texas in requests for additional federal appropriations to assist with these
costs.
The Health and Human Services Commission or a public hospital district may compile and report the information
required by this rider only in a manner the attorney general of this state certifies as consistent with federal law.
The Health and Human Services Commission again shall submit the required report to the Lieutenant Governor,
Speaker of the House of Representatives, and Members of the Legislature by December 1, 2008, and shall
include the information in the agency's annual report for 2008.
HHSC, Rider 59 Report — February 2013 Update
App. 0040
-3-
II – Executive Data Summary
TEXAS HEALTH AND HUMAN SERVICES COMMISSION SERVICES
AND BENEFITS PROVIDED TO UNDOCUMENTED IMMIGRANTS
Estimated cost of services and benefits provided to undocumented immigrants in fiscal year (FY) 2011:
(1) Texas Emergency Medicaid — $71million
+
(2) Texas Family Violence Program (FVP) — $1.28 million
+
(3) Texas Children's Health Insurance Program (CHIP) Perinatal Coverage — $35 million
=
$107 million
Comparison of Estimates in Previous Reports and Current Estimate
FY 2007
(1) Texas Emergency Medicaid
(2) Texas Family Violence Program (FVP)
(3) Texas Children's Health Insurance Program (CHIP)
Perinatal Coverage
TOTAL TEXAS HEALTH AND HUMAN
SERVICES COMMISSION
FY 2009
FY 2011
$ 80 million
$1.2 million
$ 62 million
$1.3 million
$ 71 million
$1.28 million
N/A*
$ 33 million
$ 35 million
$ 81.2 million
$ 96 million
$ 107 million
* Expenditures for CHIP Perinatal Coverage were not included in the original 2008 Rider 59 report since, at the time of its completion,
a full year of program data was not available.
HHSC, Rider 59 Report — February 2013 Update
App. 0041
-4-
III – Analytical Notes
1.
Texas Emergency Medicaid
Emergency Medicaid, Type Program 30 (TP 30), is a federal and state funded program that provides Medicaid
coverage, limited to emergency medical conditions including childbirth and labor to non-citizens including
undocumented immigrants, living in the United States. Emergency Medicaid is a federally required program.
Three steps are necessary to estimate the cost of services and benefits that HHSC provided to undocumented
immigrants: A) Determine total Emergency Medicaid (TP 30) expenditures during fiscal year 2011; B) Estimate
the fraction of undocumented non-citizens during this timeframe and amounts expended on this population;
and C) Calculate the state share of TP 30 expenditures for the undocumented population.
During fiscal year 2011 payments for Emergency Medicaid, TP 30, were as follows:
—A—
Texas Emergency Medicaid, Type Program 30, Fiscal Year 2011
Inpatient hospital
Outpatient hospital
Professional and other services
Vendor drug
$299,203,323
$24,845,002
$16,591,397
$93,345
(A) Total
$340,733,067
Since HHSC Medicaid claims data do not conclusively identify the legal residency status of immigrants, the
portion of the $340.7 million in Emergency Medicaid payments attributable to undocumented immigrants must
be estimated.
According to the U.S. Census Bureau’s American Community Survey (ACS) for Texas, approximately 2.83 million
non-citizens resided in Texas in 2011. The Department of Homeland Security reports that 1.79 million, or 63
percent, of these residents were undocumented. Therefore, the estimated amount paid for Emergency
Medicaid services to undocumented immigrants residing in Texas is about $215 million:
HHSC, Rider 59 Report — February 2013 Update
App. 0042
-5-
III – Analytical Notes (Continued)
—B—
(A) Texas Emergency Medicaid ($341 million)
x
Estimated Percent of Non-Citizens Who Are Undocumented Immigrants (63%)
=
(B1) $215 million
The state shares the cost of the Medicaid program with the federal government, with Texas typically paying
about 40 percent of Emergency Medicaid expenditures. However, in fiscal year 2009, due to provisions of the
American Recovery and Reinvestment Act of 2009 (ARRA), the federal government temporarily increased its
share of Medicaid expenditures to 68 percent, leaving the state with a 32 percent share. In fiscal year 2011,
Texas’ share of Medicaid expenditures increased to 33 percent (B2). Therefore, the total estimated state cost
for Emergency Medicaid services provided to undocumented immigrants residing in Texas in fiscal year
2011was about $71 million.
—C—
(B1) Estimated Texas Emergency Medicaid for Undocumented
Immigrants Residing in Texas ($215 million)
x
(B2) Texas Share of Medicaid Cost under ARRA (33%)
=
$71 million
Comparison of Estimates in Previous Reports and Current Estimate
FY 2007
FY 2009
FY 2011
Inpatient hospital
Outpatient hospital
Professional and other services
Vendor Drug
(A) Sum of Expenditures
(B1) Estimated amount paid for services to
undocumented immigrants
(B2) Texas’ share of TP 30 expenditures
$252,300,000
$11,200,000
$53,700,000
$124,500
$317,324,500
$275,010,314
$13,248,238
$20,778,110
$159,096
$309,195,758
$299,203,323
$24,845,002
$16,591,396
$93,345
$340,733,067
$ 200 million
40%
$ 194.8 million
32%
$ 215 million
33%
(C) TEXAS' SHARE OF EXPENDITURES
$ 80 million
$ 62 million
$ 71 million
HHSC, Rider 59 Report — February 2013 Update
App. 0043
-6-
III – Analytical Notes (Continued)
2. Texas Family Violence Program
The Texas Family Violence Program (FVP) contracts with non-profit agencies in three categories (shelter
centers, non-residential centers, and special non-residential projects [SNRPs]) across the state to provide
essential services to victims of family violence. Core FVP services include shelter, 24-hour hotlines, emergency
medical services, counseling, etc. In fiscal year 2011, the FVP funded 70 non-profit family violence shelters, 10
non-residential centers, and 16 SNRPs, providing comprehensive family violence services to victims, with a
total budget of $23,682,177. State general revenue and Temporary Assistance for Needy Families (TANF)
converted to Title XX accounted for about $18 million ($18,281,411) of the program’s total spending for
direct services. Services are provided without any financial eligibility testing and are free of charge.
The FVP does not ask victims of family violence about their residency status. Therefore, the portion of the
$18 million in FVP expenditures attributable to undocumented immigrants must be estimated. According to
the U.S. Census Bureau’s American Community Survey (ACS) for Texas, approximately 25.7 million individuals
resided in Texas in 2011. The Department of Homeland Security reports that 1.79 million, or 7 percent, of
these residents were undocumented. The total estimated state cost for direct FVP services to undocumented
immigrants in fiscal year 2011 was:
Texas Family Violence Program budget ($18 million)
x
Estimated Percent of Undocumented Immigrants in Texas (7%)
=
$1.28 million
Comparison of Estimates in Previous Reports and Current Estimate
Texas Family Violence Program budget
ESTIMATED COSTS FOR DIRECT FVP SERVICES TO
UNDOCUMENTED IMMIGRANTS
HHSC, Rider 59 Report — February 2013 Update
SFY 2007 SFY 2009
$ 16.8 million $ 19 million
SFY 2011
$ 18 million
$1.2 million $1.3 million $1.28 million
App. 0044
-7-
III – Analytical Notes (Continued)
3. Texas Children's Health Insurance Program (CHIP) Perinatal Coverage
Texas CHIP Perinatal Coverage provides prenatal care to low-income women living at up to 200% of the
Federal Poverty Level (FPL) who do not otherwise qualify for Medicaid, typically due to their citizenship status.
Nearly all CHIP Perinatal Coverage enrollees are either documented or undocumented non-citizens. Since this
program does not require citizenship documentation, there is no way to definitively report the number of
undocumented immigrants served. Therefore, the portion of the $201 million in CHIP Perinatal Coverage
expenditures (which represents prenatal services only) in fiscal year 2011 attributable to undocumented
immigrants must be estimated. Note: CHIP Perinatal Coverage expenditures were not included in the original
Rider 59 report since, at the time of its completion, a full year of program data was not available.
According to the U.S. Census Bureau’s American Community Survey (ACS) for Texas, approximately 2.83 million
non-citizens resided in Texas in 2011. The Department of Homeland Security reports that 1.79 million, or 63
percent, of these residents were undocumented. Therefore, this brings the estimated amount paid for Texas
CHIP Perinatal Coverage services to undocumented immigrants residing in Texas for fiscal year 2011 to about
$127 million:
Texas CHIP Perinatal Coverage budget ($201 million)
x
Estimated Percent of Non-Citizens Who Are Undocumented Immigrants (63%)
=
$127 million
The state shares the cost of the CHIP program with the federal government. Texas typically pays about 28
percent of expenditures. Therefore, the total estimated state cost for CHIP Perinatal Coverage to
undocumented immigrants residing in Texas in fiscal year 2011 was about $35 million.
Estimated CHIP Perinatal Coverage for Undocumented
Immigrants Residing in Texas ($127 million)
x
Texas Share of CHIP Expenditures (28%)
=
$35 million
Comparison of Estimates in Previous Reports and Current Estimate
FY 2007
FY 2009
FY 2011
Texas CHIP Perinatal Coverage budget
Estimated amount paid for services to undocumented immigrants
*
*
$ 188 million
$ 118 million
$ 201 million
$ 127 million
Texas' share of the expenditures
*
$ 33 million
$ 35 million
* Expenditures for CHIP Perinatal Coverage were not included in the original 2008 Rider 59 report since, at the time of its completion,
a full year of program data was not available.
HHSC, Rider 59 Report — February 2013 Update
App. 0045
-8-
IV – References
The 2008-09 General Appropriations Act, H.B. 1, 80th Legislature, Regular Session, 2007 (Article II,
Health and Human Services Commission, Rider 59).
Texas Comptroller of Public Accounts, 2006. Special Report: Undocumented Immigrants in Texas, A
Financial Analysis of the Impact to the State Budget and Economy. Publication #96-1224. Retrieved
September 6, 2008, from http://www.window.state.tx.us/specialrpt/undocumented/undocumented.pdf.
Texas Health and Human Services Commission, Medicaid Administrative Data, Austin.
U.S. Department of Homeland Security. Estimates of the Unauthorized Immigrant Population Residing in the
United States: January 2011. Retrieved from:
http://www.dhs.gov/xlibrary/assets/statistics/publications/ois_ill_pe_2011.pdf
Date of publication: March 2012.
U.S. Department of Commerce. American Community Survey (ACS); Public Use Microdata Sample (PUMS)
for 2011. Washington, D.C.: U.S. Census Bureau. Date of publication: October 2012.
HHSC, Rider 59 Report — February 2013 Update
App. 0046
-9-
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