Eliminating the Proposed Reduction in Disproportionate Share Hospital Funding under the Patient Protection and Affordable Care Act

Hewett Chiu

While the Patient Protection and Affordable Care Act provides for expanded health coverage options for many American citizens, there are still a large number of vulnerable populations left without affordable health access. The intended reduction in federal Disproportionate Share Hospital payments to healthcare providers to subsidize charity care for these populations should be reassessed and discontinued. In doing so, individual consideration must be given to the regulatory, industry, independent, and consumer interests surrounding the regulation to prohibit this required statutory reduction.

1. Introduction

Healthcare is an ever-evolving industry, and the landscape by which it is regulated has changed dramatically in the past few years. In March 2010, the United States Congress passed the Patient Protection and Affordable Care Act ("PPACA"), and it was signed into law on March 23, 2010 by President Barak Obama. As an attempt to increase access to and improve quality of health services, the major provisions of the statute center on requiring eligible citizens of the United States to maintain health insurance coverage ("individual mandate"), either individually or through their employer, or pay a penalty; expanding the eligibility of Medicaid¹ to a broader spectrum of low income individuals within each state or otherwise lose pre-existing federal Medicaid funding to that state; and providing a means to enroll in qualified health plans² through the federal and state health insurance exchanges^3,4.

To help low income individuals afford the premiums, the PPACA calls for the exchanges to help offset costs in the form of tax subsidies⁵. Under the assumption that most individuals would receive coverage with the individual mandate and that each state would expand Medicaid and operate their own exchanges, the Obama Administration designed the PPACA to also reduce the funding for charity care of low income patients. This decrease in Disproportionate Share Hospital ("DSH") funding, originally beginning in Fiscal Year ("FY") 2014 and lasting until FY 2020, effectively reduces hospitals' funding by a total of approximately $17.1 billion for seeing patients who have no ability to pay for their healthcare (Kaiser Family Foundation, 2013). Due to strong outcries from leading interest groups and professional associations such as the American Hospitals Association, America's Essential Hospitals, and America's Hospital and Health Systems, Congress passed the Continuing Appropriations Resolution in 2013 to delay the DSH reductions until FY 2016, followed by the Protecting Access to Medicare Act in 2014 to further delay the DSH reductions until FY 2017, but double the reduction to $35.1 billion. In 2015, the Medicare Access and CHIP Reauthorization Act was passed which further delayed the reductions until FY 2018 and lasting until FY 2025.

2. Ongoing Barriers to Healthcare Access

Despite the number of provisions in the PPACA designed to increase enrollment in health insurance plans, there are still major statutory and judicial impediments to ensuring equitable and affordable health access for all members within society. In fact, an estimated 30 million individuals will still be left without insurance after the full enactment of the PPACA (Cole et. al., 2014). These obstacles continue to fuel funding challenges for healthcare providers to treat the vulnerable populations who need medical care the most.

Statutorily, the PPACA itself includes language that does not allow everyone to obtain coverage through the exchange marketplaces. Chief among those who are barred from participation are immigrants who are not deemed "lawfully present"⁶ in the United States. In certain states, even if these immigrants are undocumented, they may still receive care with Persons Residing Under Color of Law (“PRUCOL”) status⁷, in which services covered by Medicaid are available given they are lawfully present under the knowledge of the government. However, those who are not PRUCOL eligible continue to be barred from health coverage. Given no other options, more often than not, they would be forced to rely on life-saving charity care by clinics offering sliding fee scales predicated on family size and household income, but are blind to documentation.

The 2012 landmark decision by the Supreme Court of the United States in National Federation of Independent Business v. Sebelius also posed a significant judicial barrier to increased healthcare access for vulnerable populations. The Court ruled that while the penalty levied for not satisfying the individual mandate is within Congress's taxing power and thus can be upheld as a tax, Congress does not have the power to coerce states to expand Medicaid to cover individuals and families with income levels up to 138% of the Federal Poverty Level or discontinue a state's current Medicaid funding if they choose not to do so. By ruling that universal Medicaid expansion across all states is unconstitutional, the Court effectively continued to bar the expected 3.6 million or more individuals who otherwise would be newly eligible for Medicaid from gaining coverage, leaving most of them without truly affordable ongoing primary care options (Price and Eibner, 2013).

3. Impact of Reduced DSH Funding as a General Interest Matter

DSH funding provided approximately $44.6 billion in compensation to hospitals that see a considerable number of charity care cases – cases in which the patients normally are not able to afford care and the hospital would otherwise not be compensated (Coughlin et. al., 2014). These hospitals act as the "safety net" providers for the community. Hospitals who partake in the federal Medicare⁸ program and operate an active Emergency Department are obligated to provide a full medical screening and stabilize acute life-threatening conditions or make the appropriate transfer to another facility that has the ability to do so for all patients who enter its doors regardless of their ability to pay under the Emergency Medical Treatment and Active Labor Act (“EMTALA”) of 1986. For those who are not lawfully present and those who still face financial difficulties in purchasing health insurance by not being eligible for Medicaid, this type of emergency care is the only medical care available without cost. However, this would also cause healthcare costs to rise, as common ailments experienced by these populations are now treated in the more resource intensive and expensive emergency room, while they could have been easily prevented more effectively in a less costly primary care environment. To help defray the cost burden on the hospitals, the federal government allocates DSH funding to each state, and the funding is then subsequently disbursed to each facility (Mitchell, 2013). Believing that each state would be required to expand Medicaid while designing the PPACA, the Obama Administration did not see as much a need to continue DSH funding. The DSH reductions are therefore a result of the need for a means to fund the expansion of Medicaid.

Statutes providing for the distribution of DSH funding, however, are also a means by the government to protect the public health of individual communities as a matter of general interest. A policy for the general interest would be approved by the constituents to which the matter relates on the basis of the ideology underlying the collective decision-making process of the overall constituency, given no barriers to fully understand, implement, and monitor the policy (Levine and Forrence, 1990). From an economic framework, healthcare is an imperfect market plagued with principal agent problems and asymmetric information. The physician-patient relationship is often paternalistic in character. This approach, in which the physician acting as the agent makes decisions for the patient acting as the principal, occurs when the physician bases his/her decisions on what he/she believes "is 'best' for the misguided citizenry [patient] rather than what the citizenry [patient] might prefer" (Croley, 2008). Because of this physician-patient relationship, the patient frequently does not have all the background information necessary to make an informed decision for him/herself, or have the underlying knowledge to understand and interpret the information properly. Further, when a patient is ill, he/she is often not in a position to make critical, fully-informed decisions. Thus, the paternalistic approach allows healthcare providers to protect the general interest of those who otherwise are not able to care for themselves.

In a climate where many hospitals and health systems are already under significant financial strain (American College of Healthcare Executives, 2013), a reduction in DSH funding would only mean that many “safety net” providers would no longer be able to continue caring for vulnerable populations in a similar manner as they have in the past. While this may indeed lead to cost reductions, this may also cause further issues in public health and bioethics. If a patient is sick and is not able to access care in a timely manner, the medical condition may worsen over time fairly quickly. Aggregated over an entire population of individuals who are barred from participating in health coverage under the PPACA, this may lead to public health concerns of certain jurisdictions exhibiting higher prevalence of more severe chronic or acute diseases over time.

In addition, some conditions may be infectious and without treatment, other individuals within the community may be susceptible to the disease. Influenza, tuberculosis, and sexually transmitted diseases are just some examples. Moreover, healthcare can arguably be identified as a basic human right. It can thus be seen as a major ethical concern if the government the citizenry elects and entrusts to protect it is not able to provide healthcare to all its constituents and maintain a safe baseline of health and wellbeing for its communities. Therefore, despite imperfect market conditions, considering the clear and positive benefits of reducing public health disparities and communicable diseases, it is difficult to believe that the general public would not approve of ensuring continual access of healthcare to all individuals within their community. Even if certain individuals are not public-interest oriented for the citizens at large but rather self-interested and do not believe their tax dollars should be spent providing indigent care, the public health argument prevails. By being a general interest matter, DSH funding reductions need to be ceased to continue maintaining a baseline positive level of public health and safety for each community in the United States.

4. Understanding Individual Interests

While Congress has delayed the DSH reductions to FY 2017, the total reductions are still scheduled to double and healthcare providers will still suffer the consequences of an even more dramatic decrease in funding for uncompensated care. To prohibit this intended decrease, the major regulatory, industry, and consumer interests must first be understood.

To analyze these interests, a framework based on public choice theory, special interest theory, and public interest theory will be used. In applying the economic concept of public choice theory to legislators and regulators, economist George Stigler maintains that those who are elected act for selfish reasons, pursuing their own private interests and furthering personal gains. This involves being principally interested in securing their job positions (Croley, 2008). Their jobs require them to make policies and decisions on how to spend the public's resources, but it would be expensive for the public to monitor this decision-making and policy development process in order to cast a fully informed vote for candidates. The lack of monitoring allows for a certain amount of slack⁹ from the general public, but not necessarily with specific interest groups who share a specific regulatory goal and are willing to expend the resources necessary to reach that goal. Without being in the public eye, legislators and regulators can become "captured" by these interest groups holding special interests and not necessarily general interests. Once captured, these individuals would seek to advance these special interests in exchange for the incentives offered to them personally; essentially, exhibiting self-interested behavior by making decisions that would not be approved by the general public if the public were fully aware of the situation (Levine, 1998).

Under public interest theory¹⁰, those selected to represent the general citizenry seek to make decisions to benefit the welfare of the citizenry. These individuals are "other-regarding"; in the social context, they seek to maximize the welfare of individuals with respect to the preferences of others. However, such a welfare state is typically difficult to analyze in the traditional context of Pareto efficiency (Levine and Forrence, 1990), which dictates that it would not be possible to make an individual better off without causing another individual to be worse off from the decisions made. When a market is not able to make efficient decisions, market failure exists¹¹. In such cases, government intervention through regulations exists to correct inefficiencies and failures in the market, and while there may not be a clear justification for the regulations that exist and these regulations may not always deliver the intended results, such regulations do prevent both positive and negative externalities¹² that result from an inefficient market (Posner, 2012). This effectively provides a public interest argument for government actions, where the government is taking action on behalf of the general public to correct for the externalities that may occur from the select few, in tandem with the paternalistic notion that the government understands what's best for the people (Breyer, 1982). In healthcare, individual welfare can be viewed as a function of the allocation of health services from market decisions. It is already established that healthcare is not a perfect market, and thus, government intervention in the public interest is required.

Regulatory Interests. The Secretary of Health & Human Services ("HHS") and the Centers for Medicare and Medicaid Services ("CMS") are primarily responsible for implementing, enforcing, and regulating the provisions of the PPACA. In the matter of DSH funding, regulators in CMS determine the method to decide how much DSH funding to distribute to each state, and the actual amount of funding to be distributed. Therefore, CMS regulators are targets to be captured. It is difficult to narrow down specific regulators in CMS who are responsible for the DSH program to analyze their motives and intentions in performing their duty to understand the true potential for capture. These regulators derive their utility from knowing they perform their jobs in an honorable manner for the betterment of the American public. If the regulators in question are serving in CMS as a means to further their own careers or to secure a more lucrative post-regulatory position with a large health system using their specialized knowledge from serving in CMS, then they have the potential to become captured. This potential is multiplied when they are serving in their current capacity for a limited term.

If they could be captured, the regulators would be incentivized to adjust the DSH payment reduction algorithm to favor those particular hospitals and health systems leading the capture. For example, if a certain metric that is currently not used in determining DSH payments is more prevalent, easier to collect data for, and leads to the hospitals receiving more DSH funding or an increase in other federal funding (such as Medicare) to offset the DSH payment shortfall, then the regulators might consider utilizing this metric in the DSH reduction plan when captured.

However, hospitals are fairly localized to their geographic areas, and DSH funding is distributed from CMS to the states, who then distribute the funding to the hospitals. Therefore, the states act as an intermediary that further decide the methodology for allocating the received federal DSH payments to each facility. If a specific hospital or health system would like to improve its particular position over those of the overall hospital industry, it would need to consider capturing state regulators rather than CMS regulators.

Industry Interests. The key industry interests are the healthcare providers and the associations that are created to represent them. Organizations that have been involved in the DSH funding matter include the American Hospital Association ("AHA"), America's Essential Hospitals ("AEH"), and America's Hospital and Health Systems ("AHHS"). They have released fact sheets and statements commenting on the detrimental effects of DSH payment cuts to their member hospitals.

Collectively, these industry interests hold considerable bargaining and lobbying power. In 2014, for example, the AHA alone spent $15 million in lobbying (Center for Responsive Politics, 2014). They are in a position to be able to capture elected officials while pursuing their special interests, and likely view their current monitoring, lobbying and contribution costs well worth the loss of tens of billions of dollars in the upcoming decade. In advancing their own interests, they also make a public interest argument mentioning how DSH cuts would lead to further reduction of jobs and critical health services available to everyone in a community, not just vulnerable populations.

Consumer Interests. The consumers themselves - the patients - arguably have the greatest intrinsic interest in ensuring DSH funding remains. They are the ones with the medical conditions to be treated and the general public the DSH funding was designed to serve. Therefore, consumers demonstrate self-interest in worrying about where and how they are able to seek care when they need it if they do not have coverage. Some also speak out in the public interest, calling attention to how their communities as a whole have been neglected and face significant health disparities. An example of consumers representing the needs of their communities are patients who serve on the governing board of their local Federally Qualified Health Center ("FQHC")¹³. As a statutory requirement, FQHCs are required to have a governing board composed of a majority who are served by the center, and the remaining "non-consumers" of the board being representative of the community which the center serves (Grants for Operating Community Health Centers, 42 C.F.R. Part 51c.304). Those consumers who are on the board of FQHCs likely oppose DSH reductions, as these payments can serve as the key funding source for the health centers.

Most of the time, however, this particular consumer group of vulnerable populations and immigrants do not have the resources and capabilities to represent themselves. The public choice, special interest, and public interest theories may not hold in analyzing their interests since these theories are predicated upon the assumption that the general public are voting for the officials who are representing them and are designing the policies in question. However, those who are not documented or are of low socioeconomic status are either not eligible to, or historically do not participate in the democratic process. Therefore, for most of these individuals, their intentions would mainly center on self-interest.

5. Aligning Action with Interests

To eliminate the DSH payment reductions, coordinated action must be developed which aligns with the individual interests of each interest group. This involves (1) ensuring the issue is represented significantly on the public agenda; and (2) targeting the clear message of the detriments of reduced DSH funding backed by academic research.

Public Agenda. The issue must first be made more prevalent on the public agenda. There currently is enough slack on the matter to accord the potential for the few well-funded industry interest groups such as the AHA to capture regulators and other officials for their special interests centering around increased revenues. However, the current industry interest groups have already put forth a considerable effort to persuade for the termination of the funding reductions, resulting only in CMS postponing but doubling the reductions. This shows that there needs to be a more comprehensive and integrated effort to achieve the ultimate goal of eradicating the DSH reductions.

If a larger proportion of the public knew and understood the issue, there could be more interest groups representing a wider variety of special interests such as those held by the independent grassroots organizations synchronizing their efforts. It is more difficult to coordinate a larger group of smaller players, especially if the players are not entirely invested in the issue, leading to a free-rider problem where these players put forth little effort and try to benefit from those who are performing the work. However, DSH reductions are related to many other interests in other industries, and a stronger spotlight on these other interests in addition to the current efforts by the hospital industry would strengthen the public interest argument and lead to a more serious scrutiny on this matter. Showing how the current CMS regulations for doubling the reductions with the delay only makes matters twice as worse later on would allow mainstream America to reduce the slack given to the Administration, and CMS on this matter, and would force them to reconsider the reduction.

Targeted Communication. In designing targeted messaging for Congress and the Administration to effectively end the DSH reductions, academic research should be integrated. The AHHS letter posited that there is no justification for payment reductions from any reduction in levels of uncompensated care. Academic research should be undertaken to prove this statement, showing no statistically significant correlation between the payment cuts and the amount of uninsured and uncompensated care cases in the United States. By incorporating this research, Congress, the Administration, and regulators would be forced to take more caution in responding to the payment reduction elimination requests. If they respond unfavorably, they are effectively decrying the work of academics and the merits of free information and statistically proven data (Croley, 2008). It would be harmful to their public image for the citizenry to see that their officials and representatives are acting at odds with clear conclusions backed by the rigor of academic research, especially in a society that embraces evidence-based medicine and evidence-based management.

6. Conclusion

Disproportionate Share Hospital payments are a staple for many providers to ensure indigent vulnerable populations are able to receive the medical care they need. These are the groups that need healthcare the most, and require relatively greater allocation of resources. The PPACA provision that reduces DSH funding to healthcare providers, and the subsequent acts that delay but double DSH funding, do not provide an adequate level of resources for healthcare providers to properly care for their communities.

As a matter of public health in the general interest, there are many further specific interests and groups involved. From CMS and state regulators to the powerful hospital industry groups, grassroots independent social service organizations, and even the consumers themselves, there are many special and public interests to balance. By analyzing these interests and the potential for capturing the key decision-makers, it becomes evident that a coordinated effort speaking to these interests is required to achieve the prohibition of further DSH funding reductions. Highlighting the issue more on the public agenda, and providing research and information to legislators and regulators would provide the concrete steps necessary to ensure a strong safety net system to care for all individuals, regardless of their socioeconomic and legal status.

Footnotes

¹As the key social health program for those with low income and limited resources, Medicaid is a jointly federal and state funded program that is operated by each state. The PPACA expanded both the eligibility criteria to qualify for Medicaid and federal Medicaid funding to the states.

²42 U.S.C. § 18021 defines a "qualified health plan" as a plan that has been certified and approved by the marketplace on which it is offered, provides the essential health benefits package as defined in Section 18022(a), and is offered by a qualified health insurance carrier agreeing to the stipulations set forth in Sections 18021 and 18031(d).

³Section 1311 of the PPACA provides for states to establish American Health Benefit Exchanges ("exchanges"), which are governmental or not-for-profit entities as decided by the state, and serves as a competitive online marketplace to allow consumers to browse and enroll in eligible plans in that particular state.

⁴Section 1321(c) of the PPACA calls for the Secretary of Health and Human Services to establish and operate the exchanges should a state decide not to establish and/or operate one itself. These exchanges are known as the "federal" exchanges.

⁵The subsidy is in the form of a tax credit for the monthly premium for the selected health plan. The credit is determined based on Modified Adjusted Gross Income ("MAGI") of the enrollee and where the MAGI falls within the Federal Poverty Level (https://www.healthcare.gov/lower-costs/save-on-monthly-premiums/). The credit is not available for catastrophic coverage plans, which already have a low monthly premium (https://www.healthcare.gov/choose-a-plan/catastrophic-plans/).

⁶45 C.F.R. Part 152.2 provides a definition of "lawfully present" to include immigrants who have permission to live and/or be employed in the United States in determining eligibility for the Pre-Existing Condition Insurance Plans under the PPACA, and the U.S. Department of Health and Human Services and the U.S. Department of Treasury adopted this definition for eligibility to participate in the exchanges (National Immigration Law Center, 2012).

⁷PRUCOL is an eligibility classification recognized by certain states, but not by the U.S. Citizenship and Immigration Services, for specific public benefits (U.S. Social Security Administration, 2012).

⁸Medicare is administered by the U.S. federal government and provides health coverage to individuals over 65 years of age who have paid their share of payroll taxes while they worked, and covers those with certain chronic and long term disabilities.

⁹The term "slack" was used by Kalt and Zupan in 1984 to describe a situation where monitoring costs are burdensome so as to cause a principal agent problem in which a representative elected by a voter does not conform to the wishes of the voter.

¹⁰Public interest theory is often seen as opposing public choice theory and special interest theory. Despite this contrast, ideologies from these theories still allow them to be used in conjunction for analyzing motivations in the context of this discussion.

¹¹In the traditional economic context, the decisions made within markets center on the allocation of resources by the market. This allocation of resources is extended to tangible and intangible goods and services, such as welfare states from the health status and wellbeing of individuals due to their ability to receive health services.

¹²Externalities, or "spillover effects" are secondary effects as a result of a decision made in doing business. Examples include pollution or second-hand smoke. United States Supreme Court Associate Justice Stephen Breyer argues that classical regulation is not effective in dealing with externalities; but rather, taxes, marketable rights, or bargaining are better tactics (Breyer, 1982).

¹³FQHCs are not-for-profit healthcare organizations that comply with specific Medicare and Medicaid requirements under Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act and receive funding under the Health Center Program under Section 330 of the Public Health Service Act.

References

American College of Healthcare Executives (2013). Top Issues Confronting Hospitals: 2013. http://www.ache.org/pubs/research/ceoissues.cfm.

America's Hospital and Health Systems (December 2, 2013). Letter to Max Baucus, Fred Upton, Orrin Hatch, and Henry Waxman. http://strategichealthcare.net/wp-content/uploads/2013/12/120213-Hospital-Letter-to-Stop-DSH-Cuts.pdf

Breyer, S. (1982). Regulation and Its Reform. Harvard University Press.

Cole, Evan S., Walker, Daniel, Mora, Arthur, and Diana, Mark L. (2014). "Identifying Hospitals That May Be At Most Financial Risk From Medicaid Disproportionate-Share Hospital Payment Cuts." Health Affairs, 33, no.11 (2014):2025-2033.

Continuing Appropriations Resolution, 2014 (H.J.RES.59 § 1204).

Coughlin T.A., Holahan J., Caswell K., McGrath M. (2014). "An estimated $84.9 billion in uncompensated care was provided in 2013; ACA payment cuts could challenge providers." Health Aff (Millwood). 2014;33(5):807–14.

Croley, S.P. (2008). Regulation and Public Interests: The Possibility of Good Regulatory Government. Princeton University Press.

Doctors for America (2013). Medicaid Expansion: States and Medicaid Expansion. http://www.drsforamerica.org/take-action/medicaid-expansion.

Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395dd).

Grants for Operating Community Health Centers (42 C.F.R. Part 51c.304)

Jacobson, B. (January 12, 2010). "Obama Received $20 Million from Healthcare Industry in 2008 Campaign." CommonDreams. http://www.commondreams.org/news/2010/01/12/obama-received-20-million-healthcare-industry-2008-campaign.

Kaiser Family Foundation (October 27, 2014). Explaining Health Care Reform: Questions About Health Insurance Subsidies. http://kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health/.

Kaiser Family Foundation (November 2013). How Do Disproportionate Share Hospital Payments Change Under the ACA? http://kaiserfamilyfoundation.files.wordpress.com/2013/11/8513-how-do-medicaid-dsh-payments-change-under-the-aca.pdf.

Kalt, Joseph, and Mark Zupan (1984). "Capture and Ideology in the Economic Theory of Politics," 74 American Economic Review 279-300.

Levine, Michael E. (1998). “Regulatory Capture” The New Palgrave Dictionary of Economics and the Law, 267-271.

Levine, Michael E. and Forrence, Jennifer L. (1990). “Regulatory Capture, Public Interest, and the Public Agenda: Toward a Synthesis”, Journal of Law, Economics, & Organization, Vol. 6, Special Issue: [Papers from the Organization of Political Institutions Conference, April 1990, pp. 167-198.

Mitchell, A. (2013). Medicaid Disproportionate Share Hospital Payments. http://www.fas.org/sgp/crs/misc/R42865.pdf.

National Immigration Law Center (September 2012). "Lawfully Present" Individuals Eligible under the Affordable Care Act. http://www.nilc.org/document.html?id=809.

Ohlheiser, A. (2013). Obama Will Nominate Vivek Hallegere Murthy for Surgeon General. The Wire. http://www.thewire.com/national/2013/11/obama-will-nominate-vivek-hallegere-murthy-surgeon-general/71628/#disqus_thread.

Center for Responsive Politics (2014). Influence & Lobbying: American Hospital Association. OpenSecrets.org. https://www.opensecrets.org/orgs/summary.php?id=D000000116

Patient Protection and Affordable Care Act (Pub. L. No. 111-148).

Posner, R.H. (April 15, 2012). “The Nirvana Fallacy Revisited.” Becker-Posner Blog. http://www3.nd.edu/~ndlaw/prog-law-economics/Posner-The-Nirvana-Fallacy-Revisited.pdf.

Price C.C., Eibner C. (2013). "For states that opt out of Medicaid expansion: 3.6 million fewer insured and $8.4 billion less in federal payments." Health Aff (Millwood). 2013;32(6):1030–6.

Protecting Access to Medicare Act of 2014 (H.R.4302 § 221).

Stigler, George (1971). "The Theory of Economic Regulation," 2 Bell Journal of Economics and Management Science 3-21.

The White House (2014). FACT SHEET: Immigration Accountability Executive Action. http://www.whitehouse.gov/the-press-office/2014/11/20/fact-sheet-immigration-accountability-executive-action

U.S. Social Security Administration (2012). Persons Residing Under Color of Law. https://secure.ssa.gov/poms.nsf/lnx/0500501420.

Vicini, James and Stempel, Jonathan (June 28, 2012). "US Top Court Upholds Healthcare Law in Obama Triumph." Reuters. http://www.reuters.com/article/2012/06/28/usa-healthcare-court-idUSL2E8HS4WG20120628.