Little-noticed documentation rule could threaten coverage for many
Little-noticed documentation rule could threaten coverage for many
The budget reconciliation bill considered in Congress at the beginning of this year contained a little-noticed provision to require all citizens applying for Medicaid to produce a passport or birth certificate to prove they are U.S. citizens. The rule also would apply to citizens currently receiving Medicaid when they renew their Medicaid eligibility, which comes every six months in many states.
A report from the Center on Budget and Policy Priorities estimates 49 million low-income Americans, including 12 million African Americans, with 800,000 elderly African Americans, would be subject to the new requirement between July 2006 and June 2007.
"Many of these people lack passports and don't have birth certificates in their possession," the report said. "Medicaid applicants who have neither of these documents could find that their Medicaid coverage is denied or seriously delayed; current Medicaid beneficiaries who have neither of these documents could lose their Medicaid coverage."
"This ill-conceived requirement would exacerbate a historical legacy of discrimination and could cause many elderly African Americans to lose access to health care," says Center on Budget and Policy Priorities senior fellow Leighton Ku, lead author of the report.
The report says others at special risk would be: 1) people whose documents have been destroyed by disasters such as Hurricane Katrina (many of whom are African American); 2) people with a sudden medical emergency but cannot get their documents quickly (some states take a month or longer to provide a duplicate birth certificate when one is requested; and 3) people who are homeless, mentally ill, severely disabled, or in nursing homes. The new regulation would not make any exceptions, even for those who are extremely old or have severe impairments, such as Alzheimer's disease.
While the regulation's supporters say it is needed to prevent illegal immigrants from falsely claiming to be citizens, Mr. Ku referenced a 2005 investigation by the Department of Health and Human Services' Office of Inspector General (OIG) that found no substantial evidence that such a concern is valid. Immigrants already are required to provide proof of their legal immigrant status, and most states allow applicants to attest, under penalty of perjury, that they are citizens, requiring documentation from applicants whose truthfulness they question. CMS agreed with the OIG and reported it has no evidence of a problem in this area.
Savings from denying coverage
Since government agencies have said there is no problem, Mr. Ku says, the provision would generate little or no savings from rooting out ineligible immigrants who have applied for Medicaid. Thus the savings, estimated by the Congressional Budget Office at $220 million over five years, would come primarily from reducing or delaying enrollment among applicants who are, in fact, U.S. citizens.
Mr. Ku also says the requirement would be a significant new administrative burden for state and local agencies. In 16 states, the number of Medicaid beneficiaries who would be required to submit the new paperwork would exceed 1 million. If as little as 2% of Medicaid beneficiaries could not readily produce a birth certificate or passport, 1 million low-income Americans could lose Medicaid coverage and become uninsured or be delayed in obtaining coverage.
"The percentage of U.S. citizen beneficiaries who are unable to produce readily a birth certificate or passport may well be much larger than that," Mr. Ku says.
Citizens who have already demonstrated their citizenship for other federal programs such as Supplemental Security Income or Medicare still would be required to produce documentation for Medicaid or lose coverage.
But in some cases, according to Mr. Ku, people may never have been issued a birth certificate because they were born at home and their birth was not officially registered. He says a particular problem exists for large numbers of elderly African Americans because they were born in a time when racial discrimination in hospital admissions, especially in the South, as well as poverty, kept their mothers from giving birth at a hospital. He says one study estimated that about 20% of African Americans born in 1939 and 1940 lack a birth certificate because of these problems.
In addition, many people, particularly low-income people, don't have birth certificates in their possession and don't have passports. While many may have had a birth certificate in their possession at one time, after moving various times over the course of their lives, many may no longer have a birth certificate handy. This could be a problem, Mr. Ku says, for those who are elderly or have physical or mental disabilities and are in need of immediate medical care.
Under the requirement, a mother whose child is injured may find her child will not get timely medical coverage because she does not have a valid copy of a birth certificate readily available. Adding to the problem is the fact that obtaining the documents can take substantial time and money. For example, in California, it generally takes 10-12 weeks to get a birth certificate from the county office in the county where the birth occurred, and it can take six to eight months if the information submitted is not complete.
Because of heightened homeland security procedures, Mr. Ku says, the process for obtaining birth certificates has become more cumbersome in recent years. And in some areas it may be particularly problematic for people to secure birth certificates on a timely basis for stepchildren, foster children, or individuals whose names have changed as a result of marriage or for other valid reasons.
Moreover, it can cost $5 to $23 to get a birth certificate and $87 to $97 to get a passport, effectively adding an application fee to Medicaid for many people, which would deter at least some from entering the program.
How many would be affected?
Using the Census Bureau's March 2003, 2004, and 2005 Current Population Surveys, the researchers estimated the percentage of Medicaid beneficiaries in each state who are native or naturalized citizens and those who are noncitizen beneficiaries. Those estimates were applied to HHS administrative data on the number of people enrolled in Medicaid in each state at any point during fiscal year 2003 to estimate the number of people in each state who would be required to produce the documentation (see chart below).
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"We do not know what percentage of Medicaid beneficiaries would be unable to locate a birth certificate or passport on a timely basis and would be denied Medicaid coverage," Mr. Ku says. "At this point, it is hard to say how many individuals would be harmed, but the number is likely to be substantial."
The administrative burden on agencies would come because they would be required to notify applicants of the new requirement, check their documents, keep records that the documents were submitted, delay enrollment if people cannot locate the documents and, in some cases, try to help people locate the documents. Mr. Ku quotes Connecticut's Medicaid director as saying that requiring documentation "would be an enormous administrative burden," and cites the Wisconsin Medicaid director as saying the proposal "would have a material and substantial effect on enrollment."
'Tremendous problem' in Georgia
The proposal was added to the reconciliation bill by two Georgia Republican House members, including Rep. Charlie Norwood, who claims there is a "tremendous problem" with illegal immigrants obtaining Medicaid care, costing Georgia $100 million to $700 million annually.
Ohio Medicaid director Barbara Edwards said her state stopped requiring birth certificates and saw a decided improvement in coverage and re-enrollment for children.
"We saw an improvement in continuity of care when we simplified the application process," she told reporters at the National Association of State Medicaid Directors' annual conference last November.
A spokesperson for Mr. Norwood rejected suggestions his proposal would deter U.S. citizens from gaining Medicaid since the provision gives the Secretary of Health and Human Services power to authorize alternative methods of proving citizenship status if needed.
The OIG report said that in recent years HHS has encouraged the practice of self-declaration of citizenship in an attempt to simplify Medicaid application procedures, but also has encouraged states to verify the accuracy of citizenship statements with other sources and conduct post-eligibility reviews.
OIG noted last July that 27 states don't check the accuracy of any U.S. citizenship statements as part of their post-eligibility control methods. It recommended the CMS strengthen post-eligibility quality controls in states that allow self-attestation and spell out which documents states can accept when determining Medicaid eligibility and CMS agreed with that recommendation.
Mr. Ku tells State Health Watch while staff members working for those in Congress who support the proposal have defended the requirement, "the things they're saying just aren't right." While some congressional staffers have said people would be allowed to sign up for Medicaid and provide the documentation later, he said, the truth is there is no provision for that in the proposal and it would be against current law.
"Many congressional staff members just don't understand the provisions of this proposal," he says.
While there are some potential swing votes, Mr. Ku said the provision might stay in the conference report but perhaps could be changed when technical corrections are made to the budget reconciliation bill.
As part of the CBPP effort to lobby against the proposal, the group commissioned a survey that found a "significant number" of people who don't have a birth certificate or passport at home, Mr. Ku told SHW.
"It's surprising how few people in our offices know where their birth certificate is," he says.
[Download materials on the issue at www.cbpp.org. Contact Mr. Ku at (202) 408-1080. Download the OIG report at oig.hhs.gov/oei/reports/oei-02-03-00190.pdf.]
The budget reconciliation bill considered in Congress at the beginning of this year contained a little-noticed provision to require all citizens applying for Medicaid ...Subscribe Now for Access
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