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Medicaid ID Law Backfires

A controversial federal law designed to keep illegal immigrants out of Medicaid is still ensnaring U.S. citizens 18 months after it took effect. It has

Jul 31, 2020
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A controversial federal law designed to keep illegal immigrants out of Medicaid is still ensnaring U.S. citizens 18 months after it took effect. It has prevented tens of thousands of eligible U.S. citizens from enrolling in the program, according to Medicaid officials representing at least a dozen states.
The law, passed in 2005 as part of a sweeping effort to reduce budget deficits, requires that Americans wishing to enroll in Medicaid must provide original-copy citizenship and identification documents. Previous rules allowed applicants to self-declare their citizenship status, under penalty of perjury. The legislation was the brainchild of Georgia GOP Reps. Nathan Deal and the late Charlie Norwood, who pushed the stricter guidelines to target the illegal immigrants who they said were infiltrating the program at the taxpayers’ expense.
Illustration by: Matt Mahurin
But the new law, which took hold in July 2006, drew immediate criticism from many state health officials, who said the tighter rules prevented participation by thousands of eligible beneficiaries who had trouble gathering their documents. A year and a half later, many officials say, this effect remains largely unchanged.
In Virginia, for example, Medicaid enrollment among children alone fell by roughly 14,000 in the eight months after the installation of the new guidelines. Rebecca Mendoza, the director of the Division of Maternal and Child Health for Virginia’s Dept. of Medical Assistance Services, said enrollment is creeping back up, but remains below what it was when the federal rules took effect. On July 1, 2006, total participation was 352,133, she said, while today the figure stands at 347,503.
Michigan officials tell a similar tale. Paul Reinhart, Michigan’s Medicaid director, said his program saw “straight linear growth” for most of the past seven years. Enrollment climbed steadily over that time, he said, from about 1 million to more than 1.5 million. But that growth stopped in the wake of the new documentation rules, he said, and enrollment has hovered at roughly 1.5 million for nearly 16 months.
“Up here in Michigan,” Reinhart said, “the Canadians aren’t exactly banging down our door. What’s probably happened is that people have had a tough time getting their paperwork together.”
Michigan’s economy, Reinhart added, has been suffering for years as foreign car makers have proven successful competitors for Detroit’s one-time powerhouse market. For that reason, health officials expected Medicaid rolls to continue growing. The plateau effect, Reinhart said, can be attributable only to the citizenship guidelines. “There certainly hasn’t been an economic turnaround,” he said.
Michigan and Virginia are not alone. Medicaid enrollment in Colorado had hovered around 400,000 in 2005 and early 2006, according to state documents. In the wake of the new guidelines, however, participation figures fell fairly steadily for 12 months, bottoming out at around 380,000. Last month, enrollment remained under 381,000.
“Medicaid enrollment has stayed flat,” said Joanne Lindsay, a spokesperson for Colorado’s Dept. of Health Care Policy and Financing, “and we know anecdotally that parents who are not citizens are much less likely to get their kids signed up, even if the kids are citizens. They’re very apprehensive.”
In response to that trend, Lindsay said, Colorado is in the process of deputizing schools, non-profits and other community-based groups with the power to verify citizenship documents for purposes of Medicaid enrollment. That process, she said, should eliminate any apprehension by allowing individuals hoping to get benefits to submit their papers without having to visit a government office.
Supporters of the new law argue that the the restrictions will save the Medicaid program millions of dollars by weeding illegal immigrants from the rolls. Chris Riley, Deal’s spokesman, said late last week that that objective has never changed. Riley said the law allows for plenty of state flexibility in managing the new rules. For example, he said, state attorneys general have the right to determine which applicant documents are acceptable. If some states are having trouble enrolling eligible citizens, he added, it’s only because they have failed to exercise this flexibility.
But in June 2006, the Centers for Medicare and Medicaid Services sent states restrictive guidelines detailing which documents the agency would accept. Jeff Brenn, chief of eligibility and payment for Nevada’s Division of Welfare and Supportive Services, said there is little flexibility in that regard. “CMS has been very specific about documentation,” he said.
Other state officials were even terser in reaction to Riley’s documentation claims.
“That’s patently false,” said Andrew Allison, deputy director of the Kansas Health Policy Authority, “and it illustrates that this law was crafted by those with no understanding whatsoever of the Medicaid program. It’s a one-size fits all approach to a problem that was never documented.”
Indeed, before the law was passed, Bush administration officials questioned the extent of the problem. In 2005, Mark McClellan, then head of the Centers for Medicare and Medicaid Services, responded to an internal inspector general report with the following: “While there are vulnerabilities in states’ accepting self-declaration of citizenship, states have little evidence that many non-eligible, non-citizens are receiving Medicaid as a result.”
In a further curious trend, there is evidence that the proof-of-citizenship rules are keeping more African-American and white beneficiaries out of Medicaid than Latinos. An analysis performed last spring by Virginia Medicaid officials, for example, found that enrollment among black and white kids fell by thousands in the wake of the new guidelines, while participation among Latinos continued to climb.
More recently, Kansas health officials conducted a similar ethnic study, with similar results. According to state figures, overall Medicaid enrollment between June 2006 and February 2007 fell 5.9 percent for all populations. Yet, for Latinos, participation dropped just 2.6 percent, while for whites, it dropped 6.2 percent. African-Americans fared worst of all, with enrollment dropping 8 percent.
Allison attributed much of the overall drop to the sudden increase in paperwork his office was forced to manage as a result of the new documentation requirements. “If you want to reduce enrollment, just add administrative burden,” he said.
But as for the discrepancies among the different ethnicities, Allison had a different theory, originated by Virginia officials. Latinos, he said, are accustomed to requests for their citizenship documents, and therefore have them ready. Low-income African-Americans and whites, on the other hand, may have rarely been asked for those documents, and, as a result, have difficulty producing them. In no case does that mean that these people are not eligible citizens, he added.
“You can only imagine,” Allison said, “that this policy didn’t hit its target.”
This program is denying service to many more citizens who should be eligible than it is denying illegal immigrants
Iowa health officials echoed Allison’s criticisms. “,” said Roger Munns, a spokesman for Iowa’s Dept. of Human Services. “It’s quite clear that we’ve got people coming to our door who are, in fact, citizens. But they simply can’t locate their documents.”
But not all states have seen drops in Medicaid enrollment as a result of the new guidelines. Health officials in Minnesota, for example, said that when the rules were installed they took aggressive steps, like retrieving birth records from other states. As a result, there has been no tangible effect on participation, they said.
Several other states already had proof-of-citizenship requirements in place before the federal law arrived. Arizona was one. As a result, “the transition was much easier for us,” according to Rainey Daye Holloway, spokeswoman for the Arizona Health Care Cost Containment System. “We haven’t experienced the drop that other people have.”
Still other states have yet to install the new guidelines. California, which has far and away more Medicaid participants than any other state, is still in the process of taking the rules statewide. But health officials there said they hope to use the experiences of other programs to ease the process. “We do expect that it will affect different populations differently,” said Toby Douglas, deputy director of health care policy at California’s Dept. of Health Care Services.
Of the 3.2 million beneficiaries who will be affected by the citizenship guidelines, Douglas said, state officials have already determined that about half were born in California. For those individuals, he said, identification documents will be required, but proof-of-citizenship papers will not.
Meanwhile, health officials in states that have experienced problems are hoping time will allow eligible citizens to locate their documents and sign on to the program — a process some say has taken longer than they expected.
“I thought that was going to happen,” said Michigan’s Reinhart, “but it hasn’t happened yet.”
Dexter Cooke

Dexter Cooke

Dexter Cooke is an economist, marketing strategist, and orthopedic surgeon with over 20 years of experience crafting compelling narratives that resonate worldwide. He holds a Journalism degree from Columbia University, an Economics background from Yale University, and a medical degree with a postdoctoral fellowship in orthopedic medicine from the Medical University of South Carolina. Dexter’s insights into media, economics, and marketing shine through his prolific contributions to respected publications and advisory roles for influential organizations. As an orthopedic surgeon specializing in minimally invasive knee replacement surgery and laparoscopic procedures, Dexter prioritizes patient care above all. Outside his professional pursuits, Dexter enjoys collecting vintage watches, studying ancient civilizations, learning about astronomy, and participating in charity runs.
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