Spending on undocumented immigrants

Florida Medicaid spending on undocumented immigrants plummets after new law

A POLITICO analysis found that Medicaid expenditures for undocumented immigrants in Florida has dropped dramatically since Gov. Ron DeSantis signed a law directing hospitals to ask patients about their immigration status.

By Arek Sarkissian

The amount of money that Florida’s Medicaid program spends to provide emergency health care to undocumented migrants has dropped significantly after Republican Gov. Ron DeSantis launched a multi-pronged crackdown on illegal immigration amid his unsuccessful primary bid for president.

DeSantis signed a law last year directing hospitals that accept Medicaid to ask patients about their immigration status when they seek treatment. While the law does not force patients to provide hospitals with an answer, immigrant rights groups feared the mandate would scare migrants away from seeking urgent medical attention. The DeSantis administration and other Florida Republicans say any marked decreases in spending are signs his immigration crackdown is working.

Florida’s Emergency Medical Assistance program for undocumented immigrants has seen a 54 percent drop in expenditures billed to Medicaid this year — with less than two months remaining in the fiscal year — since the state immigration law took effect, according to a POLITICO analysis. Thomas Kennedy of the Florida Immigrant Coalition said while there is no concrete evidence that the drop in Medicaid spending is a result of the law, which took effect in July 2023. there have been other signs of fallout.

“Obviously, there’s been somewhat of an exodus of migrants in Florida,” Kennedy said. “When this was all going through — we had warned about the exacerbated work[force] shortages and the distressed industries — we said this would be a bad idea.”

Federal law bars undocumented immigrants from Medicaid eligibility, even if they meet other requirements. But federal law also requires that states authorize limited Medicaid coverage for migrants facing a medical emergency, including dialysis, a pregnant woman delivering a baby or trauma.

Data provided to POLITICO by the Florida Agency for Health Care Administration and the U.S. Department of Health and Human Services show $148.4 million in state and federal Medicaid dollars went toward emergency coverage for immigrants in Florida in the year before the state’s new immigration law took effect. As of May 3, $67 million has gone toward emergency coverage this year. With two months left in the fiscal year that number will rise, but the state is still on track for a dramatic decrease in spending.

The spending drop represents a dramatic spike in the rate of decline. The AHCA data also shows Medicaid expenditures in the 12 months before the law took effect dropped a little more than 13 percent. Medicaid expenditures went from $171.4 million in 2022 to the $148.4 million from last year.

About half of the Emergency Medical Assistance spending goes toward pregnant women who were in labor, according to Leonardo Cuello, a research professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families — and he said a consequence of the state immigration law is that women may avoid the hospital when it’s time to give birth.

“Do we want the mothers of U.S. citizen babies avoiding the hospital when they unexpectedly go into labor?” Cuello wrote in an email. “This will have terrible long-term consequences for Florida.” When asked for comment, the governor’s office sent a statement from Alecia Collins, a spokesperson for AHCA. “While the state’s health care system is designed to serve and prioritize legal United States citizens, those with medical necessities will still be treated by a hospital,” she said.

The DeSantis administration has devoted millions of state budget dollars and other resources toward combating illegal immigration as part of an ongoing feud with the Biden administration over federal policy on the Mexican border. And next year’s $116.5 billion state budget includes a $557,882 line item for AHCA to expand a program created by the immigration law that monitors health care costs associated with undocumented immigrants.

In a separate statement, Collins wrote that Medicaid expenditures are only part of the financial burden that illegal immigration places on the state’s hospital system. AHCA’s budget surveillance program published a report in March that determined hospitals were left to cover more than $566 million in medical bills in the last six months of 2023 that patients who were undocumented did not pay.

“By shedding light on the true cost burden of illegal immigration we hope to bring awareness to the citizens of Florida and the United States as a whole,” Collins wrote. “The current state of inaction in Washington DC is unacceptable, and this crisis must be addressed.”

Hospitals can request emergency Medicaid funding on behalf of a migrant from the Florida Department of Children and Families. If approved, DCF will grant emergency medical assistance for a limited number of days. Most recipients are pregnant women who have gone into labor or chronically ill patients who require life-saving treatments such as dialysis, but some include people who showed up with a serious medical emergency.

Data provided by DCF shows the agency granted more than 147,000 emergency authorizations in Florida’s fiscal 2022, which ended June 30 of that calendar year, and then 116,000 in fiscal 2023. DCF has made 99,000 authorizations as of April 30, two months before the end of fiscal 2024.

Medicaid expenditures are the first look at medical bills generated by undocumented immigrants that are covered by taxpayers. Medicaid is funded by state and federal tax revenue, usually leaving states responsible for about 40 percent of the spending. For instance, of the $67 million spent so far this year, $28 million came from state dollars, according to AHCA data.

The impact of the immigration law on health care first emerged in February, after the Mexican Consulate in Orlando noticed a drop in participation in a free health screening program for women. At the time, Republicans said the drop in participation was a sign that the law was a success since it was intended to drive migrants away from the state. The law directs hospitals to ask patients about their immigration status, and AHCA analyzes any answers. The agency sent a report to the legislature in March that compared the percentage of patients who told hospital officials they were in the U.S. illegally against the overall costs incurred by hospitals in the previous year to extrapolate how much care for undocumented people was costing.

The AHCA report received plenty of criticism from experts, who said it failed to provide details on the data used to determine that migrants were responsible for $566 million in unpaid hospital bills. Leighton Ku, director of the Center for Health Policy Research at The George Washington University, suspected the AHCA report had overestimated costs and the comparatively low Medicaid spending bolstered his suspicions.

“This is so very far below what the state estimated in its March report,” Ku said. “I still think the March report is overestimating things, but I’m not completely sure about where they got their data.”

Ku said hospitals definitely take a hit from migrants who aren’t eligible for emergency Medicaid, but still fail to pay their hospital bills. But Medicaid also provides hospitals with millions of dollars in additional funding for treating a disproportionate number of Medicaid recipients, and that money is meant to make up for uncompensated care.

Cuello, the Georgetown professor, said the AHCA report finds no correlation between caring for undocumented immigrants and hospital losses or uncompensated care. In fact, the report actually reveals a connection between rural counties and uncompensated care, he said.

“The best way for Florida to address uncompensated care, protect rural hospitals, and most importantly, help rural Floridians, is to accept the incredibly generous federal funding available to expand Medicaid and provide coverage to rural Floridians,” Cuello wrote. (Florida is one of 10 states that has not opted in to Medicaid expansion under the Affordable Care Act.)

Some Republicans were afraid the immigration law would hurt the state’s agriculture industry, which relies heavily on migrants for labor during spring and fall harvest seasons. In June 2023, one month before the law took effect, state Rep. Rick Roth (R-West Palm Beach) told an audience, with the help of a Spanish interpreter, at an event in Hialeah that some employees were leaving the state for Georgia due to the law. He asked for help in getting them to stay.

“It’s urgent you talk to all of your people and convince them that you have resources, state representatives and other people that can explain the bill to you,” Roth told the audience, before he quickly switched to praise for former President Donald Trump and DeSantis.

“I’m still supporting Donald Trump and I love my governor,” Roth said.

Roth did not respond to requests for comment via email and text message this month. But Kennedy — the Florida Immigrant Coalition activist — said Republicans had called him a conspiracy theorist for warning that migrants would leave the state due to the law requiring hospitals to ask about patients’ immigration status.

“We were accused of being conspiracy theorists,” Kennedy said. “Obviously, there’s something there — it’s undeniable.”