Citizens Who Lack Papers Lose Medicaid
By ROBERT PEAR
Published: March 12, 2007
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
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
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
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
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
“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.