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should induce facilities to provide more

ed, if it is found that a particular type of regu-

uncompensated services to uninsured pa-

lation imposes undesirably high costs, or con-

tients than they might otherwise in a less level

versely appears to be markedly less costly, the

competitive market. At worst, such pools

question naturally arises whether there is a

arguably would be relatively benign, simply

logical substitute for it (or in the latter case,

transferring resources from one set of hospi-

whether it should logically displace other less

tals to another. However, at least 10 different

efficient forms of regulation aimed at the

studies have found conflicting evidence about

same purpose). Having in one location the

whether such pools actually increase the over-

results for a particular class of regulations

all provision of uncompensated care. More

facilitates these kinds of comparisons. The

worrisome, two different studies have found

findings regarding facilities regulation are

summarized in Table 2.20

that the existence of such pools was associated

with a dramatic increase in the risk of being

uninsured among those with low incomes

Access-Related Facilities Regulations

(e.g., 14.4 percentage points for those below

Under access related are included (1) the

poverty).23 Since being uninsured is associated

Emergency Medical Treatment and Active

Labor Act; (2) hospital community service

with a sizable increase in one's reliance on

Access-related

requirements (which include uncompensat-

publicly subsidized care (approximately $554

facilities

per capita uninsured in 2002)24 as well as an

ed care obligations imposed on facilities that

elevated risk of death,25 both result in signifi-

receive federal Hill-Burton grants or loans to

regulations cost

build or expand hospitals, state community

cant social costs attributable to this regula-

$11.8 billion

tion.26 Even if the uninsured receive care as a

service requirements, and state statutes man-

but provide

dating that county hospitals provide indi-

result of such programs, most of the adverse

gent care)21; (3) hospital uncompensated care

health effects of being uninsured stem from

benefits of only

delays in seeking primary and preventive care

pools that tax hospitals and redistribute the

$3.8 billion.

as well as a lack of continuity of care,27 which

revenues to facilities providing higher-than-

average uncompensated care loads;22 (4) hos-

are unlikely to be affected by uncompensated

care pools.28 In addition, the billions of dollars

pital conversion regulations that impose

state oversight on the process of converting

in uncompensated care provided through

public or nonprofit facilities to for-profit sta-

pools cannot be viewed as pure transfers.

tus; and (5) limited English proficiency

Evidence from the RAND Health Insurance

requirements that require hospitals and

Experiment, which measured changes in uti-

other health facilities to hire translators to

lization and expenditures of patients exposed

assist patients who cannot communicate in

to different levels of cost sharing in insurance

English. Although the mandatory provision

plans, shows that among patients given free

of transplant-related data by hospitals

care, 31 percent of the care they consume is

admittedly was intended to increase access to

wasted--that is, the value the patients attached

transplant services, it is included later under

to the care was 31 percent lower than its aver-

age cost.29 Hence even without any adverse

cost regulation as part of organ transplant

regulation and therefore excluded here to

effect of pools on the uninsured rate, the ben-

avoid double counting. All told, these access-

efits of such pools would be lower than their

related facilities regulations as a group cost

costs. EMTALA poses a similar problem in

$11.8 billion but provide benefits of only

terms of reducing the incentive to remain

$3.8 billion. Hospital uncompensated care

insured and of providing care that has a value

pools (net cost $5.2 billion) and EMTALA

that may be less than the cost of its provision.

(net cost $2.3 billion) account for the lion's

share of this net cost.

Cost-Related Facilities Regulations

In theory, uncompensated care pools

Under cost related, fraud and abuse regula-

should be beneficial on net; that is, they

tions are included--a large umbrella that

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