To test Hypothesis 1, the proposed research project will use an experimental survey design to gather information from patients and/or their family members who will be found in emergency rooms in the Los Angeles area. In the experimental design, the independent variable will be the ratio of patients who are illegal immigrants to patients that are not illegal immigrants. The dependent variable for Hypothesis 1 will be the cost to the hospital for treating patients after individual payments for services and/or third-party reimbursements other than Medicaid and Medi-Cal.
If Hypothesis 1 is correct, then hospitals with higher numbers of patients who are illegal immigrants will have higher numbers of uninsured patients and will be less likely to receive payment for treating its patients. Hypothesis 2 will be tested by a review of health care facilities within the same region from which the sample for Hypothesis 1 was drawn. The focus of this review will be to determine whether the increase in the illegal population that has occurred since 1995 has coincided with an increase in the use of local hospitals.
This review will also seek to learn how many hospitals have been closed during this period and whether those closures coincided with an increase in the number of uninsured patients who were illegal immigrants. Finally, the survey will seek to determine whether the overall quality of health care services as measured by emergency room wait times increased during this period. Sample The research sample will consist of 100 patients and/or family members who visit the selected emergency rooms on the night of the survey.
In the event that the responses from 100 patients or family members cannot be gathered in a single night, another survey will be conducted in the same emergency rooms on the following night. While a visit to the emergency room is often traumatic for the patient and the family, it is also provides an opportunity to talk with patients and family members while they are waiting to see a doctor.
After determining the potential respondent’s linguistic preferences, the surveyor will introduce himself or herself and tell the potential respondent that they are conducting research on the level of health care services that are available for guest workers. The term “illegal immigrant” will not be used in the survey. Instead, the term “guest worker” will be used. Surveyors will ask questions in the preferred language of the respondent, English or Spanish.
The survey instrument will only ask for general demographic information, such as the gender and age of the patient and the nature of the emergency or condition that brought him or her to the emergency room. Respondents will not be asked their name, address, or any other personal information. To help encourage responses and to establish trust and credibility with respondents, each respondent will receive an information packet with information about health services that are available in the community.
Even with this procedure, there is still a possibility that illegal immigrants will not acknowledge their illegal status. The results of the survey questions about immigration status will be compared to other information about illegal immigrant population to help to check for accuracy. Other ethical concerns for this research include privacy concerns and respecting the wishes of individuals to be left alone during what can be an emotionally trying event.
Critical case patients, i. e., patients with gunshot wounds, domestic violence cases, and other cases that are life threatening or that appear to be highly emotional for the people who are involved, will not be approached to complete a survey. The elimination of critical care cases from the sample should have an interesting effect on the results of the survey. This limited sample will give some indication of the number of patients who use the ER for non-emergency cases because they cannot afford a regular office visit to the doctor.
The practice of using the ER in cases in which most people would use a regular family physician is one example of how the health care system becomes clogged when resources are used in a manner in which they were not intended. Research instrument To help to ensure a higher response rate, the survey instrument will be brief. Surveys will be completed by the interviewers. In addition to gathering non-specific demographic information about the sample population, the surveys will also ask the following questions (questions will be asked in the preferred language of the respondent):
1. Does your employer provide health insurance? 2. If your employer does not provide insurance, then are you receiving health benefits through Medicaid or some other program? 3. How often do you or members of your family visit the emergency room? 4. Do you or your family use doctors other than those who are in the emergency room? 5. When you come to the emergency room, how long do you usually have to wait to see a doctor? 6. Was there another emergency room that you went to before you started coming to this one?
If so, then where was it and why did you choose to come here today instead of going there? This survey instrument should have high validity but the reliability of the responses may be suspect. Reliability refers to the integrity of the research sample and the likelihood that respondents will be truthful in their responses. One of the potential weaknesses of this survey design is the understandable reluctance of illegal immigrants to identify themselves as being in the country illegally. This reluctance could affect the reliability of the survey questions and of the proposed research project.
To reduce this anxiety and to overcome language barriers, bilingual Spanish-speaking interviewers will be hired to ask the survey questions. Validity refers to whether the survey questions are aligned with the research questions in the objective of the research study. In this study, the research questions pertain to whether hospitals that treat illegal immigrants are being compensated for their services and how the treatment of illegal immigrants affects the treatment of citizens and legal immigrants.
Not having employer-provided health insurance and not being enrolled in Medicaid (see Survey Question 1) are strong predictors of the inability of patients to pay for services rendered. Frequent visits to the emergency room (see Survey Question 3) is an indicator of inappropriate use of emergency room services, i. e. , using the emergency room as a primary care provider. Frequent use of the emergency room is also an indicator of an uneven distribution of medical resources between illegal immigrants and citizens and legal immigrants. This overuse would be consistent with Hypothesis 2.
This indicator would be further supported by the response to Survey Question 4, which asks the illegal immigrant whether he or she uses doctors other than those in the emergency room. Survey Question 5 refers to the quality of care that is received by all patients. Assuming that there is no bias for or against illegal immigrants in the waiting room, this question should provide an indication of the quality of care that all patients receive. Finally, Survey Question 6 seeks to learn whether the respondent is aware of any emergency room closures or other changes in service.