The New York Times
Citizens Who Lack Papers Lose Medicaid
By ROBERT PEAR
WASHINGTON, March 11 — A new federal rule intended to keep illegal immigrants from receiving Medicaid has instead shut out tens of thousands of United States citizens who have had difficulty complying with requirements to show birth certificates and other documents proving their citizenship, state officials say.
Florida, Iowa, Kansas, Louisiana, New Mexico, Ohio and Virginia have all reported declines in enrollment and traced them to the new federal requirement, which comes just as state officials around the country are striving to expand coverage through Medicaid and other means.
Under a 2006 federal law, the Deficit Reduction Act, most people who say they are United States citizens and want Medicaid must provide “satisfactory documentary evidence of citizenship,” which could include a passport or the combination of a birth certificate and a driver’s license.
Some state officials say the Bush administration went beyond the law in some ways, for example, by requiring people to submit original documents or copies certified by the issuing agency.
“The largest adverse effect of this policy has been on people who are American citizens,” said Kevin W. Concannon, director of the Department of Human Services in Iowa, where the number of Medicaid recipients dropped by 5,700 in the second half of 2006, to 92,880, after rising for five years. “We have not turned up many undocumented immigrants receiving Medicaid in Waterloo, Dubuque or anywhere else in Iowa,” Mr. Concannon said.
Jeff Nelligan, a spokesman for the federal Centers for Medicare and Medicaid Services, said the new rule was “intended to ensure that Medicaid beneficiaries are citizens without imposing undue burdens on them” or on states. “We are not aware of any data that shows there are significant barriers to enrollment,” he said. “But if states are experiencing difficulties, they should bring them to our attention.”
In Florida, the number of children on Medicaid declined by 63,000, to 1.2 million, from July 2006 to January of this year.
“We’ve seen an increase in the number of people who don’t qualify for Medicaid because they cannot produce proof of citizenship,” said Albert A. Zimmerman, a spokesman for the Florida Department of Children and Families. “Nearly all of these people are American citizens.”
Since Ohio began enforcing the document requirement in September, the number of children and parents on Medicaid has declined by 39,000, to 1.3 million, and state officials attribute most of the decline to the new requirement. Jon Allen, a spokesman for the Ohio Department of Job and Family Services, said the state had not seen a drop of that magnitude in 10 years.
The numbers alone do not prove that the decline in enrollment was caused by the new federal policy. But state officials see a cause-and-effect relationship. They say the decline began soon after they started enforcing the new rule. Moreover, they say, they have not seen a decline in enrollment among people who are exempt from the documentation requirement — for example, people who have qualified for Medicare and are also eligible for Medicaid.
Wisconsin keeps detailed records listing reasons for the denial or termination of benefits. “From August 2006 to February of this year, we terminated benefits for an average of 868 people a month for failure to document citizenship or identity,” said James D. Jones, the eligibility director of the Medicaid program in Wisconsin. “More than 600 of those actions were for failure to prove identity.” In the same period, Mr. Jones said, the state denied an average of 1,758 applications a month for failure to document citizenship or identity. In 1,100 of those cases, applicants did not provide acceptable proof of identity.
“Congress wanted to crack down on illegal immigrants who got Medicaid benefits by pretending to be U.S. citizens,” Mr. Jones said. “But the law is hurting U.S. citizens, throwing up roadblocks to people who need care, at a time when we in Wisconsin are trying to increase access to health care.”
Medicaid officials across the country report that some pregnant women are going without prenatal care and some parents are postponing checkups for their children while they hunt down birth certificates and other documents.
Rhiannon M. Noth, 28, of Cincinnati applied for Medicaid in early December. When her 3-year-old son, Landen, had heart surgery on Feb. 22, she said, “he did not have any insurance” because she had been unable to obtain the necessary documents. For the same reason, she said, she paid out of pocket for his medications, and eye surgery was delayed for her 2-year-old daughter, Adrianna.
The children eventually got Medicaid, but the process took 78 days, rather than the 30 specified in Ohio Medicaid rules.
Dr. Martin C. Michaels, a pediatrician in Dalton, Ga., who has been monitoring effects of the federal rule, said: “Georgia now has 100,000 newly uninsured U.S. citizen children of low-income families. Many of these children have missed immunizations and preventive health visits. And they have been admitted to hospitals and intensive care units for conditions that normally would have been treated in a doctor’s office.”
Dr. Michaels, who is president of the Georgia chapter of the American Academy of Pediatrics, said that some children with asthma had lost their Medicaid coverage and could not afford the medications they had been taking daily to prevent wheezing. “Some of these children had asthma attacks and had to be admitted to hospitals,” he said.
In Kansas, R. Andrew Allison, the state Medicaid director, said: “The federal requirement has had a tremendous impact. Many kids have lost coverage or have not been able to obtain coverage.” Since the new rule took effect in July, enrollment in Kansas has declined by 20,000 people, to 245,000, and three-fourths of the people dropped from the rolls were children.
Megan J. Ingmire, a spokeswoman for the Kansas Health Policy Authority, which runs the state Medicaid program, said the waiting time for applicants had increased because of a “huge backlog” of applications. “Applicants need more time to collect the necessary documents, and it takes us longer to review the applications,” Ms. Ingmire said.
The principal authors of the 2006 law were Representatives Charlie Norwood and Nathan Deal, both Georgia Republicans. Mr. Norwood died last month.
Chris Riley, the chief of staff for Mr. Deal, said the new requirement did encounter “some bumps in the road” last year. But, he said, Mr. Deal believes that the requirement “has saved taxpayers money.” The congressman “will vigorously fight repeal of that provision” and will, in fact, try to extend it to the Children’s Health Insurance Program, Mr. Riley said. He added that the rule could be applied flexibly so it did not cause hardship for citizens.
In general, Medicaid is available only to United States citizens and certain “qualified aliens.” Until 2006, states had some discretion in deciding how to verify citizenship. Applicants had to declare in writing, under penalty of perjury, whether they were citizens. Most states required documents, like birth certificates, only if other evidence suggested that a person was falsely claiming to be a United States citizen.
In Virginia, health insurance for children has been a top priority for state officials, and the number of children on Medicaid increased steadily for several years. But since July, the number has declined by 13,300, to 373,800, according to Cindi B. Jones, chief deputy director of the Virginia Medicaid program.
“The federal rule closed the door on our ability to enroll people over the telephone and the Internet, wiping out a full year of progress in covering kids,” Ms. Jones said.
State and local agencies have adopted new procedures to handle and copy valuable documents. J. Ruth Kennedy, deputy director of the Medicaid program in Louisiana, said her agency had received hundreds of original driver’s licenses and passports in the mail.
Barry E. Nangle, the state registrar of vital statistics in Utah, said, “The new federal requirement has created a big demand for birth certificates by a group of people who are not exactly well placed to pay our fees.” States typically charge $10 to $30 for a certificate.