Early Monday morning the House narrowly passed the Conference Report of the Deficit Reduction Act of 2005 – in other words, the budget bill. If approved by the Senate, the Medicaid program would now require U.S. citizens who apply for Medicaid to provide proof of their citizenship status – generally by producing a birth certificate or passport. This requirement would not only increase the administrative burden of the Medicaid enrollment process, but also hinder or delay coverage for a significant number of eligible, low-income Americans who do not have birth certificates or passports in their possession.
Since 1986, verification of U.S. citizenship for purposes of Medicaid eligibility has been governed by section 1137(d) of the Social Security Act, which allows applicants to declare – under penalty of perjury – their citizenship status without needing to provide back-up documentation. The Center for Medicare & Medicaid Services (CMS) has encouraged self-declaration in an effort to expedite and simplify the Medicaid application process.
Some observers may think that self-declaration allows ineligible, especially undocumented, immigrants to falsely obtain Medicaid coverage. However, in a recent report the Department of Health and Human Services’ Office of Inspector General (OIG) found no substantial evidence that immigrants unlawfully obtain Medicaid by falsely claiming citizenship. According to the OIG, 47 states allow self-declaration of citizenship for Medicaid and 44 states require further documentation when there is reason to question an applicant’s status. In fact, state Medicaid administrators reported that they had not seen a problem with self-declaration of citizenship from their quality control review systems. Therefore, this provision would create little to no savings from eliminating ineligible immigrants who have falsely claimed citizenship status to obtain Medicaid coverage.
The provision does, however, increase procedural barriers for citizens. Many people, especially low-income people, do not possess copies of their birth certificates and do not have passports – and even people who may have obtained birth certificate copies at one point may not have them when they apply for Medicaid coverage. For example, Hurricane Katrina evacuees may have lost their birth certificates during the relocation process. Currently, Louisiana’s Vital Records registry is backlogged and not functioning at normal capacity due to Hurricane Katrina. If this provision is implemented, Louisiana natives without birth certificates, who would otherwise be eligible for Medicaid, will have delayed access to health coverage.
Moreover, the need to obtain a birth certificate or passport would impose a new, out-of-pocket cost on the Medicaid application process and delay potential enrollees’ ability to complete their application. These costs and time delays may deter potential enrollees from entering the program and cause them to remain uninsured. New York residents, for example, must pay $30.00 and wait up to four weeks if they apply for a birth certificate through regular mail. However, if a potential Medicaid enrollee needs to complete the Medicaid application process as soon as possible, he or she must pay $45 for an expedited birth certificate. Alternatively, a new passport costs $82 for children under age 16 and $97 for everyone else. These costs would certainly cause financial difficulties for low-income individuals and families and could prevent or delay an individual from getting needed health care. It will also impose new costs on individuals who are already enrolled in the Medicaid program, but must reapply for benefits on a regular basis – and in some cases, individuals who have coverage now may become uninsured if they cannot manage to comply with this requirement.
Two groups of citizens that would be particularly hard hit by this provision are elderly African-Americans and other elderly individuals from rural areas. Many older Americans born in the South or in rural areas of the country may not have been born in hospitals or attended by physicians at birth – instead, they were often born at home – and therefore may lack birth certificates. Historic racial discrimination also prevented many African-Americans from having birth certificates because they were not allowed access to local hospitals. One study estimated that one-fifth of African-Americans born in the 1939-40 period lacked a birth certificate. Ironically, this new documentation requirement will most likely be easier for documented immigrants to meet than certain natural born citizens.
The Congressional Budget Office estimates that this provision would save $220 million in Medicaid costs over five years. These savings would not come from preventing ineligible immigrants from wrongly obtaining Medicaid coverage, but from reducing or delaying Medicaid enrollment for individuals who are U.S. citizens. In addition, this provision would actually increase Medicaid administrative costs. States are already burdened by the amount of paperwork and documentation needed to enroll an individual in Medicaid, and this new requirement not only increases the amount of time states must spend verifying information on each application and eligibility renewal, but it also increases the likelihood that state eligibility workers will need to scrutinize repeat applications – for example, individuals who are denied coverage because they fail to provide documentation may later reapply.
The government’s goal should be to help individuals attain a better quality of life – which includes health care coverage – not to create cumbersome and ineffectual processes that impede a U.S. citizen from attaining needed health care coverage. This new requirement – if passed – will contribute to the burdensome Medicaid application process and contribute to the growing number of Americans without health insurance.
Meredith L. King is the Health Policy Research Analyst at the Center for American Progress.