Breakthrough 2019 – A Sustainable Vision For Helping The Poor

Breakthrough 2019 – A Sustainable Vision For Helping The Poor

Breakthrough 2019 – A Sustainable Vision For Helping The Poor

Is there a solution to poverty? That’s the question GCO president and CEO Randy Hicks discussed with AEI president Robert Doar as a keynote at Breakthrough 2019.

One powerful step forward in the anti-poverty fight is the Success Sequence: Helping as many people as possible attach to employment, stable family lives, and education. And solutions come locally.

“We don’t really succeed in helping people move up unless we have a really great and strong civil society and faith-based institutions helping people on a one-to-one basis,” Robert Doar shared. “Government can write a check. Government can fund a program. But it can’t help a person get a job or help a child learn to read. That happens at a local level in an individual experience.”

Recommendations for Expanding Access to Quality Healthcare

This is the sixth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, the third explained the impact of uninsurance, the fourth focused on Medicaid and the Affordable Care Act, and the fifth highlighted challenges to expanding access to healthcare.

While there are significant challenges to providing low-income uninsured Georgians with quality healthcare, there are cost-efficient, state-based solutions Georgia can implement in the short-term that can positively impact health outcomes for Georgians in the coverage gap.

Provide State Government Support for Georgia’s Charity Clinics

The state’s 96 clinics served more than 183,000 unique patients and saved the state over $200 million in 2012 while not receiving any state funding. However, other state governments do financially support their charity clinics. Virginia provides $3.5 million to its 53 clinics; Ohio gives $435,000 for 46 clinics; West Virginia provides $4.3 million to 11 clinics; and South Carolina recently approved $2 million for 51 clinics.[i]

The state’s existing charity clinics have the capacity to serve more patients, but funding and unnecessary state restrictions limit their ability to meet their full potential. The Georgia Charitable Care Network requested a $2 million appropriation from the Georgia legislature in 2014.[ii] Since clinics’ can provide $7 worth of services for every $1 spent, this relatively small amount of government funding would allow clinics to be open more hours and serve an estimated 100,000 additional patients.[iii] With the increase in funds, the expansion in capacity could take place at many clinics with little delay, providing much needed care to Georgia’s most vulnerable citizens. However, funding for Georgia’s charity clinics was not included in the state’s FY 2015 budget.

While a $2 million appropriation would allow Georgia’s current clinics to serve more patients, over 40 percent of counties do not have a charity clinic. A larger appropriation would allow for the Georgia Charitable Care Network to help underserved communities open new clinics. Since many rural areas have limited access to care, new clinics could have a significant impact on communities across the state.

In 2015, the state should provide $10 million in funding to support the dramatic expansion of current clinics and the creation of new ones in underserved communities. Compared to the $2.1 billion cost of Medicaid expansion over ten years, this appropriation is affordable for the state and sustainable in the long-term while still expanding access to quality healthcare to a significant portion of the state’s low-income uninsured population.

Expand Telemedicine into Charity Clinics

Telemedicine is the provision of care through real-time interactive communication between the patient and provider from one site to another via electronic communications. The electronic communication – which usually includes at least video and audio – allows a provider to care for a patient at a different location. Telemedicine can be used to provide primary and specialty care, remote patient monitoring, and medical education. Care through telemedicine can take place at hospitals, clinics, community health centers, nursing homes, and schools.[iv]

Telemedicine has improved access to care for many individuals – especially those in rural areas that have a physician shortage – because instead of traveling across the state to see a provider, a patient can go to a local clinic or hospital and be connected with a provider located anywhere in the state. Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better management of chronic diseases, reduced travel times, shared health professional staffing, and fewer or shorter hospital stays.[v]

Georgia has one of the most robust and developed telemedicine networks in the country, but Georgia’s charity clinics are not currently using telemedicine. Utilizing telemedicine in the clinics would enhance their ability to deliver services. Setting up telemedicine presentation sites in charity clinics would allow providers to volunteer their time at clinics across the state without leaving their office. This would be especially beneficial to individuals who live in rural areas and often do not have access to specialty care.

Charity clinics currently do not have the capital to purchase the technology and infrastructure required for telemedicine, which is relatively inexpensive given the benefit it provides.[vi] The Georgia legislature should include funding to pilot the use of telemedicine in its charity clinic appropriation.

Modernize Nurse Practitioner Laws and Regulations

Many nurse practitioners and other mid-level providers deliver care to patients at charity clinics as employees or volunteers. However, the ability of NPs to provide care is limited by Georgia’s restrictive laws and regulations.

Georgia should join the one-third of states that provide full practice authority to NPs. By implementing the licensing model recommended by the National Council of State Boards of Nursing and the Institute of Medicine, NPs will be able to provide the high level of care that they are educated and prepared to provide at charity clinics and other healthcare facilities across the state.[vii]

While many physician associations have opposed these reforms, a 2012 study found no evidence of differences in primary care physician earnings between states that provide NPs with full practice authority and those that maintain practice barriers.[viii] Since the literature on NPs finds no reason to be concerned with the quality of care provided by NPs and it should not impact Georgia’s physicians’ earnings, there is little to no reason for the state to continue to limit the care NPs can provide.

Reinstate Sales Tax Exemption for Charity Clinics

Many healthcare providers are exempt from the payment of Georgia’s sales and use tax, including licensed nonprofit in-patient general hospitals, mental hospitals, nursing homes, and hospices.[ix] From 2008 to 2010, Georgia’s volunteer health clinics were also exempt from Georgia sales tax on medical and office supplies and other purchases.[x]

Given the amount and quality of care charity clinics deliver and the savings this care provides to the state, Georgia should reinstate the sales tax exemption to provide the clinics with more resources to serve individuals in need of care.

Replace the Lost Federal DSH Funds with State Dollars

Many hospitals have expressed concern about the upcoming loss of DSH funds. In 2016, Georgia hospitals will lose an estimated $26 million in federal funds for uncompensated care. The federal funding loss increases to $40 million in 2017 and $111 million in 2018.[xi]

DSH funds are an important source of revenue for many of the state’s hospitals, and the federal reduction could cause some of the hospitals to cut services or completely close. To support this essential component of the state’s safety-net, the state should replace the lost federal funding. Since implementing the above recommendations to support the state’s charity clinics and other state and federal health policies could reduce the amount of uncompensated care provided by hospitals, the state may not need to replace the full amount of lost federal funding. Thus, the state should work with hospitals to identify the amount of uncompensated care they provide and to calculate the amount of state funding needed for hospitals to maintain services.


[i] Georgia Charitable Care Network, “Partners in Georgia’s Safety Net.”

 

[ii] John Sparks, “Stabilizing the Healthcare Safety Net: A Partnership with Free and Charitable Clinics,” Georgia Charitable Care Network, Presentation to Georgia General Assembly Joint Study Committee on Medicaid Reform, November 18, 2013, video of testimony found at http://www.house.ga.gov/Committees/en-US/MedicaidReform.aspx.

 

[iii] GCO interview with Donna Lopper, Georgia Charitable Care Network, December 9, 2013.

 

[iv] American Telemedicine Association, “What is Telemedicine?” accessed March 5, 2014, http://www.americantelemed.org/about-telemedicine/what-is-telemedicine.

 

[v] Ibid.

 

[vi] GCO interview with Jeffrey Kesler, Georgia Partnership for Telehealth, March 13, 2014.

 

[vii] James F. Lawrence, “These are our 2014 state policy priorities!!” United Advanced Practice Registered Nurses of Georgia, accessed February 27, 2014, https://uaprn.enpnetwork.com/nurse-practitioner-news/39141-these-are-our-2014-state-policy-priorities-.

 

[viii] Patricia Pittman and Benjamin Williams, “Physician Wages in States with Expanded APRN Scope of Practice,” Nursing Research and Practice (2012): 4, http://www.hindawi.com/journals/nrp/2012/671974/.

 

[ix] Georgia Department of Revenue, “Tax Exempt Nonprofit Organizations,” accessed April 9, 2014, https://etax.dor.ga.gov/TaxLawandPolicy/nonprofit_orgs.aspx.

 

[x] Wesley Tharpe, Adding Up the Fiscal Notes: Crossover Day 2014, Georgia Budget and Policy Institute, March 2014, 4, http://gbpi.org/wp-content/uploads/2014/03/Grab-bag-of-Tax-Measures-on-the-Table.pdf.

 

[xi] Georgia Hospital Association, Hospitals 101, 28.

Challenges to Expanding Access to Quality Healthcare

This is the fifth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, the third explained the impact of uninsurance, and the fourth focused on Medicaid and the Affordable Care Act.

Georgia faces many challenges and barriers to expanding access to quality healthcare for low-income uninsured individuals, particularly for those in the Medicaid expansion coverage gap.

State Fiscal Constraints

Preliminary estimates projected that providing Medicaid to newly eligible adults through the expansion would cost the state approximately $2.1 billion from 2014 to 2023. Since the federal government covers 100 percent of the cost for the first three years and then slowly reduces its contribution until it is set at 90 percent in 2020, expansion is projected to first cost the state about $120 million in 2017. In 2023, the final year of the projection, state costs will have risen to almost $406 million.[i]

Governor Deal and other state leaders maintain that the state cannot afford Medicaid expansion and have expressed serious concerns that the federal government will be unable to live up to its obligations under Medicaid expansion. Therefore, any policy or program that would improve access to healthcare for low-income uninsured Georgians must cost significantly less than Medicaid expansion and must rely upon state-based sources of funding.

Physician Shortage

Georgia ranked 41st in the country in active physicians and 44th in primary care physicians per capita in 2010.[ii] According to the U.S. Department of Health & Human Services, almost 2 million Georgians live in a “Primary Care Health Professional Shortage Area,” meaning there are a low number of primary health professionals relative to the population.[iii] In 2010, 31 of Georgia’s 159 counties did not have an internal medicine physician; 63 did not have a pediatrician; 79 did not have an OB/GYN; and 66 did not have a general surgeon.[iv]

Georgia’s Fiscal Year 2015 budget allocates $2 million in additional funds to develop new graduate medical education programs to train residents.[v] While an important step, the state must continue to pursue efforts to address its shortage of primary care providers. Without more providers, many Georgians may not have access to primary care, even if they have health insurance coverage.

Limits to Nurse Practitioner Scope of Practice

Nurse practitioners (NPs) are an important provider of primary care across the country. In many states, NPs evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments. A literature review by the National Governor’s Association found that most studies show that NPs provide comparable care to physicians and achieve equal or higher satisfaction rates among their patients. The review did not find any studies that raised concerns about the quality of care offered by NPs.[vi]

Georgia’s laws and regulations for NPs are more restrictive than almost any other state. A 2007 study ranked Georgia’s NP regulations 48th in the country because the state’s NP limitations affect patients’ freedom to choose providers and NPs ability to provide primary care.[vii] Georgia’s restrictions include requiring NPs to be supervised by a physician and to have a collaborative agreement with a physician or a physician’s supervisor/delegation in order to prescribe drugs. These limitations do not exist in over one-third of states.[viii]

Fiscal Challenges of Safety-net Hospitals

Hospitals that serve a large number of Medicaid and low-income uninsured patients receive state and federally funded supplemental payments from state Medicaid programs. Called disproportionate share hospital (DSH) payments, the funding offsets the disadvantaged financial situation of hospitals that provide large amounts of uncompensated care to uninsured individuals and serve a substantial number of patients in the relatively low-paying Medicaid program.[ix]

The ACA was expected to reduce the number of uninsured individuals and, therefore, reduce hospital uncompensated care costs. This would create less need for DSH payments. Thus, the ACA required annual aggregate reductions in federal DSH funding from FY 2014 through FY 2020.

In 2011, almost 40 percent of Georgia hospitals lost money. Rural hospitals are in an even worse financial situation as 55 percent had negative total margins.[x] Given their financial struggles, Georgia hospitals have expressed concern regarding the DSH reduction. Since Georgia does not plan to expand Medicaid, the reduction in DSH payments would not be offset by an increase in revenue through having more patients being covered by Medicaid. Thus, the hospitals are likely to receive less funding, while the demand for uncompensated care is expected to persist.


 [i] Georgia Department of Community Health, “Preliminary Estimate on the Impact of Federal Health Care Reform on the Georgia’s Medicaid and PeachCare Program,” Handout, April 2012.

 

[ii] Center for Workforce Studies, 2011 State Physician Workforce Data Book, Association of American Medical Colleges, November 2011, 8-11, https://www.aamc.org/download/263512/data.

 

[iii] Bureau of Clinician Recruitment and Service, “Designated Health Professional Shortage Areas Statistics,” U.S. Department of Health & Human Services, Health Resources and Services Administration (HRSA), as of May 30, 2014, accessed May 30, 2014, 2, http://ersrs.hrsa.gov/reportserver/Pages/ReportViewer.aspx?/HGDW_Reports/BCD_HPSA/BCD_HPSA_SCR50_Smry_HTML&rs:Format=HTML4.0.

 

[iv] Georgia Board for Physician Workforce, Georgia Physician and Physician Assistant Professions Data Book 2010/2011, December 2013, i, https://gbpw.georgia.gov/sites/gbpw.georgia.gov/files/related_files/document/2010-2011%20Physician%20and%20Physician%20Assistant%20Data%20Book.pdf.

 

[v] Governor Nathan Deal, Office of the Governor, “Deal: Budget includes half a billion dollars in k-12 education,” Press Release, April 28, 2014, accessed May 23, 2014, https://gov.georgia.gov/press-releases/2014-04-28/deal-budget-includes-half-billion-dollars-k-12-education.

 

[vi] National Governors Association, The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care, December 20, 2012, 5, http://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.html.

 

[vii] Nancy Rudner Lugo et al., “Ranking State NP Regulation: Practice Environment and Consumer Healthcare Choice,” The American Journal for Nurse Practitioners 11 (2007): 16, http://www.eileenogrady.net/upload/Ranking%20of%20states%20AJNP_April_07_%5Bfinal%5D.pdf.

 

[viii] Barton Associates, “Interactive Nurse Practitioner (NP) Score of Practice Law Guide,” accessed February 27, 2014, http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/.

 

[ix] Georgia Department of Community Health, “Georgia Medicaid: SFY 2013 Medicaid DSH Allocation,” http://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/document/Preliminary_SFY2013_Allocation_of_DSH_Allotment.pdf.

 

[x] Ibid., 14.

Medicaid and the Affordable Care Act

This is the fourth entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report, the second looked at Georgia’s healthcare safety net, and the third explained the impact of uninsurance. 

Medicaid is the country’s main public health insurance program for low-income families and individuals, including children, parents, pregnant women, seniors, and people with disabilities. A joint federal/state program, the federal government sets mandatory eligibility groups and general guidelines for benefits, while states establish individual eligibility criteria within federal standards.

The Georgia Department of Community Health projects that over 1.8 million Georgians will enroll in Medicaid and PeachCare in 2014 – 18.56 percent of the state population. The Department estimates that the state will spend $2.85 billion on these programs – 15.57 percent of state revenue. The federal government will cover the remaining $6.65 billion for a total expenditure of $9.5 billion. [i]

In 2010, Congress passed and President Obama signed into law the Patient Protection and Affordable Care Act (Affordable Care Act or ACA). The expansion of Medicaid eligibility to all nonelderly adults who make up to 138 percent of FPL is a major component of the law. In 2012, the Supreme Court found the ACA’s Medicaid expansion to be unconstitutionally coercive of states. As a result of the ruling, expanding Medicaid is now optional for states.

Georgia Governor Nathan Deal and the General Assembly have chosen not to expand Medicaid because of the cost to the state and unsustainability of the federal contribution.

An estimated 534,000 uninsured adults in Georgia making less than 100 percent of the federal poverty level fall in the expansion “coverage gap.” These uninsured individuals would be newly eligible for Medicaid under the expansion but will likely continue to have limited access to affordable health coverage without a change in the state’s expansion decision or other health policy changes. [ii]

GCO’s new healthcare access report focuses on identifying sustainable solutions to improve healthcare for these individuals.


[i] Clyde L. Reese III and Jerry Dubberly, “Georgia Medicaid and PeachCare for Kids,” Georgia Department of Community Health, Presentation to Georgia General Assembly Joint Study Committee on Medicaid Reform, August 28, 2013, 11, 33, http://www.house.ga.gov/Documents/CommitteeDocuments/2013/MedicaidReform/DCH%20PP%20Presentation_Medicaid%20Reform%20Study%20Committee_082813.pdf.

 

[ii] Genevieve M. Kenney et al., “Opting in to the Medicaid Expansion under the ACA: Who Are the Uninsured Adults Who Could Gain Health Insurance Coverage?,” Timely Analysis of Immediate Health Policy Issues, Robert Wood Johnson Foundation and Urban Institute, August 2012, 18, http://www.urban.org/UploadedPDF/412630-opting-in-medicaid.pdf.

The Impact of Uninsurance

This is the third entry in a series of posts highlighting GCO’s new report – Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report and the second entry looked at Georgia’s healthcare safety net.

The lack of access to affordable care contributes to many individuals going without important services. Uninsured individuals in Georgia are nearly four times less likely than the insured to have had a routine check-up in the past two years[i] and are more likely to experience avoidable hospitalizations for conditions such as pneumonia, diabetes, and asthma.[ii] In 2011, 36 percent of low-income adults in Georgia reported that they went without care because of cost in the past year. Only two states had a higher percentage of individuals going without care.[iii]

Uninsured individuals are financially costly for taxpayers and the insured as well. In 2013, uninsured individuals across the country spent an estimated $25.8 billion out-of-pocket on medical care and received between $74.9 billion and $84.9 billion in uncompensated care. About 60 percent of the uncompensated care spending was provided by hospitals, 26.4 percent by publicly supported community providers, and 14 percent by office-based physicians who provided in-kind services or charity care.[iv]

Providers also attempt to recover their losses from providing uncompensated care to uninsured patients and those covered by government programs that pay below cost, such as Medicare and Medicaid, by increasing charges for those with private insurance. The higher prices charged to private insurance are passed on to families and business through higher premiums.

Estimates vary on how much cost shifting occurs. One study estimates that cost shifting through increased premiums and other similar strategies accounts for about 2.4 percent of private health insurance costs,[v] while another study estimates that uncompensated care cost shifting makes up 7.7 percent of private insurance costs.[vi] If the higher estimates are accurate, the uninsured population is costing the average Georgia individual $330 and the average family $900 per year in higher premiums.[vii]


 [i] Patricia Ketsche et al., The Uninsured in Georgia, Georgia Health Policy Center, Issue Brief, November 2008, http://www.issuelab.org/resource/uninsured_in_georgia_2008.

 

[ii] John O’Looney, Louis Kudon, interand Glenn M. Landers, Avoidable Hospitalizations in Georgia: An Analysis of the Potential for Strategic Action, Georgia Health Policy Center, January 2005, http://ghpc.gsu.edu/sites/default/files/documents/ghpc/community_public_health/Avoidable_Hospitalizations_11-29-07_FINAL.pdf.

 

[iii] Health System Data Center, “Georgia: Low-Income Population Scorecard,” The Commonwealth Fund, accessed February 26, 2014, http://datacenter.commonwealthfund.org/scorecard/low-income/12/georgia/.

 

[iv] Teresa A. Coughlin et al., “An Estimated $84.9 Billion In Uncompensated Care Was Provided In 2013; ACA Payment Cuts Could Challenge Providers,” Health Affairs 33 (2014): 810, http://content.healthaffairs.org/content/33/5/807.abstract?=right.

 

[v] Coughlin et al., “An Estimated $84.9 Billion In Uncompensated Care,” 812.

 

[vi] Families USA, Hidden Health Tax: Americans Pay a Premium, May 2009, 26, http://familiesusa.org/sites/default/files/product_documents/hidden-health-tax.pdf.

 

[vii] Ben Furnas and Peter Harbage, The Cost Shift from the Uninsured, Center for American Progress Action Fund, March 24, 2009, 2, http://www.americanprogressaction.org/wp-content/uploads/issues/2009/03/pdf/cost_shift.pdf.

Georgia’s Uninsured and the Healthcare Safety-Net

This is the second entry in a series of posts highlighting GCO’s new report, Increasing Access to Quality Healthcare for Low-Income Uninsured Georgians. The first entry provided an overview of the report .

Unfortunately, 19 percent of Georgians lack health insurance, the sixth highest percentage in the country in 2012.[i] Of the nonelderly uninsured, 56 percent live in households that make less than 139 percent of the federal poverty level (FPL), which is $16,221 for an individual and $33,151 for a family of four.[ii]

While it can be difficult for uninsured individuals to find care – particularly those with low-incomes – some uninsured individuals access care through Georgia’s healthcare safety-net. These providers include community health centers, charity clinics, public hospitals, local health departments, and private office-based physicians who provide limited free care.[iii]

Community Health Centers

The state’s community health centers provide primary and preventive care to many uninsured individuals on a sliding fee scale based on patient or family income. In 2011, Georgia’s Federal Qualified Health Centers (FQHCs) – local, non-profit, community-owned healthcare providers – served more than 317,000 patients at 152 delivery sites across the state. Of the FQHC patients, 51 percent were uninsured. The National Association of Community Health Centers estimates that 13 percent of Georgia’s low-income uninsured population was served by an FQHC in 2011.[iv]

Charity Clinics

Uninsured individuals in 90 of Georgia’s 159 counties have access to a charity clinic as another option to help meet their primary care needs. In 2012, the state’s 96 nonprofit, independent charity clinics served 183,625 unique patients, and 62 percent of these patients were below the poverty level.[v] Due to their volunteer nature, clinics are able to provide an average of $7 worth of services for every $1 invested, and the average cost per patient visit is $29.[vi]The total value of the services provided by Georgia’s charity clinics in 2012 was over $200 million.[vii]

Public Hospitals

In addition to community health centers and charity clinics, many uninsured patients seek care in hospital emergency rooms. Since many low-income uninsured individuals can only afford a small portion of the care they receive and hospitals are required to provide emergency healthcare to anyone needing it, providers are often uncompensated for the services they provide. In 2012, Georgia hospitals provided $1.6 billion in uncompensated care, including $936 million in free, indigent, and charity care and $671 million in care for which the patient did not pay his or her bill and was not qualified for the hospital’s indigent or charity care programs.[1],[viii]


[1] Uncompensated care is an overall measure of hospital care provided for which no payment was received from the patient or insurer. It is the sum of care for which the hospital never expected to be reimbursed and care for which it is unable to obtain reimbursement for the care provided, called “bad debt.” Uncompensated care excludes other unfunded costs of care, such as underpayment from Medicaid and Medicare.

[i] The Henry J. Kaiser Family Foundation, “Health Insurance Coverage of the Total Population,” accessed March 12, 2014, http://kff.org/other/state-indicator/total-population/.

 [ii] The Henry J. Kaiser Family Foundation, “Distribution of the Nonelderly Uninsured by Federal Poverty Level,” accessed March 12, 2014, http://kff.org/uninsured/state-indicator/distribution-by-fpl-2/?state=GA.

 [iii] Mark A. Hall, “Health Care Safety Net Resources by State,” Robert Wood Johnson Foundation, February 2012, http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/02/health-care-safety-net-resources-by-state.html.

 [iv] National Association of Community Health Centers, “Georgia Health Center Fact Sheet,” http://www.nachc.com/client/documents/research/GA12.pdf.

 [vi] Georgia Charitable Care Network, “Georgia Charitable Care Network – Partners in Georgia’s Safety Net,” Handout provided by the Georgia Charitable Care Network.

 [vii] Ibid.

 [viii] Georgia Hospital Association, Hospitals 101: A Resource Guide for Elected Officials, Fourth Edition, February 2014, 3, https://publications.gha.org/Portals/4/Hospital101UpdatedApril2014.pdf; American Hospital Association, “American Hospital Association: Uncompensated Hospital Care Cost Fact Sheet,” January 2013, http://www.aha.org/content/13/1-2013-uncompensated-care-fs.pdf.