摘要：Objectives. We examined the association between the size and growth of Latino populations and hospitals’ uncompensated care in California. Methods. Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models. Results. We found a significant association between the growth of California’s Latino population and hospitals’ uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant. Conclusions. Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals’ uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures. Uncompensated hospital care for the uninsured and underinsured imposes a significant financial burden on the US health care system. The American Hospital Association reported that uncompensated care rose to $45.9 billion in 2012, which accounted for 6.1% of total hospital expenses that year. 1 This problem affects hospitals’ financial stability and ability to recoup losses from reduced payments, which in turn can hurt their ability to care for the local population, operate emergency department and specialty services to meet patient needs, and maintain optimal nurse staffing ratios. 2–4 Hospitals have typically responded to increased uncompensated care by increasing prices for paying patients 5 ; however, Medicaid and Medicare payments have been reduced, and it has become more difficult to shift costs to private payers. Uncompensated care also affects all levels of government, which provide subsidies to offset these losses through other programs. 6 The largest source of federal funding for uncompensated care—Medicaid Disproportionate Share Hospital (DSH) payments—totaled $11.4 billion in 2012. 7 Despite these mechanisms that indirectly subsidize hospitals’ provision of uncompensated care, hospital closures have been linked to uncompensated care. 8 Hospital administrators, policymakers, and advocates for the uninsured hoped that the Patient Protection and Affordable Care Act (ACA) would provide health insurance to many of the almost 50 million previously uninsured Americans and thereby significantly reduce uncompensated care. The Supreme Court’s decision on the ACA allows states to opt out of the mostly federally funded Medicaid expansion, which will likely lower the projected numbers of Americans who obtain coverage and potentially undermine the predicted decreases in future uncompensated care by hospitals. 9 Existing policy efforts focus on decreasing hospital payments to reduce health care spending, 10 and DSH payments are being reduced in anticipation of increases in insurance coverage in all states. 11 These recent health policy developments have brought the problem of uncompensated hospital care into a new focus, generating increasing interest in understanding what factors affect hospitals’ financial stress. Some have suggested that immigrants use large amounts of uncompensated care, 12 potentially implicating the Latino population—the nation’s largest immigrant group 13 —in rising uncompensated care. However, hospital uncompensated care may also decrease because of Latinos’ low health care utilization 14–21 and expenditures, 22–25 which have been described in the context of the healthy immigrant effect (i.e., Latino immigrants are usually younger and healthier than Latinos born in the United States) 26 and other factors (e.g., fewer available health care resources, lack of linguistically appropriate care, discrimination in health care settings, and fear of deportation among undocumented Latinos). 27,28 Empirical evidence for the potential impact of changing Latino demographics on hospitals’ uncompensated care is limited at best. A study of Oregon state data found weak evidence of an association between the size of the Latino population and hospital uncompensated care. 27 A nonsignificant relationship might have reflected Latinos’ immigrant status, limited health care access, and unwillingness or inability to seek health care. California’s hospitals account for more than 10% of uncompensated care nationally. 29 California has the largest Latino population of any state, as well as the largest growth rate in its Latino population. 29 In 2012, 44.5% of California's uninsured population was Latino. 30 Among the uninsured Latino population in the state, more than 1 million will remain uninsured, even after the ACA’s coverage expansions. 31,32 Although some are able to temporarily access emergency Medicaid services for significant, emergent health issues, the majority are uninsured and require help from local indigent care programs, hospital charity care, federally qualified health centers, or other safety net providers. Hence, California, because of its high number (7 million) and percentage (20%) of uninsured residents prior to the ACA, 33 offers an excellent setting to study the impact of the Latino population on the uninsured rate, uncompensated care need, and local safety net providers. We examined the association between Latino population growth rates and hospitals’ uncompensated care in California between 2000 and 2010. These growth rates not only reflected the marginal increases in uncompensated care and Latino population estimates, but also took into account baseline levels of these variables. Because growth rates are considered to be better than the level measures for predicting future population growth trends, 34 our findings could have important policy implications regarding the allocation of health care resources.
