Revised March 13,
2007
NEW MEDICAID CITIZENSHIP DOCUMENTATION REQUIREMENT IS TAKING A TOLL: States Report Enrollment Is Down and Administrative Costs Are Up
By Donna Cohen Ross
Introduction
A new federal law that
states were required to implement July 1 is creating a barrier to health-care
coverage for U.S. citizens — especially children — who are eligible for health
insurance through Medicaid. The new law, a provision of the Deficit Reduction
Act of 2005, requires U.S. citizens to present proof of their citizenship and
identity when they apply for, or seek to renew, their Medicaid coverage. Prior
to enactment of the law, U.S. citizens applying for Medicaid were permitted to
attest to their citizenship, under penalty of perjury.
In the eight months
following implementation of the new requirement, an increasing number of states
are reporting marked declines in Medicaid enrollment, particularly among
low-income children. States also are reporting significant increases in
administrative costs as a consequence of the requirement.
This analysis presents
the data available so far on this matter. The available evidence strongly
suggests that those being adversely affected are primarily U.S. citizens
otherwise eligible for Medicaid who are encountering difficulty in promptly
securing documents such as birth certificates and who are remaining uninsured
for longer periods of time as a result.
The new requirement also appears to be reversing
part of the progress that states made over the past decade in streamlining
access to Medicaid for individuals who qualify, and especially for children.
For example, to improve access to Medicaid and reduce administrative costs, most
states implemented mail-in application procedures, and many states reduced
burdensome documentation requirements. The new Medicaid citizenship
documentation requirement now appears to be pushing states in the opposite
direction, by impeding access to Medicaid. Families must furnish more
documentation and may be required to visit a Medicaid office in person to apply
or renew their coverage, bypassing simpler mail-in and on-line enrollment
opportunities, because they must present original documents such as birth
certificates that can take time and money to obtain. This is likely to
cause the most difficulty for working-poor families that cannot afford to take
time off from work to visit the Medicaid office and for low-income families
residing in rural areas.
What State Officials Are
Saying About
the Citizenship Documentation Requirement
“The largest adverse effect of this policy
has been on people who are American citizens … we have not turned up many
undocumented immigrants receiving Medicaid in Waterloo, Dubuque or
anywhere else in Iowa.”
Kevin W. Concannon, Director,
Iowa Dept. of Human Services
New York Times,
March 12, 2007
“[Kansas] Gov. Kathleen Sebelius … recently
said the state's enrollment has declined by 18,000 people since the
citizenship documentation requirement took effect. Many of those people
are likely citizens who simply lack documents, she said, who may
experience a harmful gap in health insurance coverage.”
United Press International
(UPI)
Friday December 1, 2006
"While we understand that the new law
targets illegal immigrants, we must point out that the impact of the law
in our state is mostly falling on eligible citizens."
Andrew Allison, Deputy
Director, Kansas Health Policy Authority
Lawrence Journal World,
Friday January 19, 2007
“These numbers [the Medicaid enrollment
decline] are not driven primarily by the loss of population from New
Orleans and other parishes affected by Hurricane Katrina…We are quite
confident that the overwhelming majority of these children are citizens —
born right here in Louisiana — and not ineligible alien children.”
J. Ruth Kennedy, Deputy
Medicaid Director
Louisiana Department of Health and Hospitals
November 13, 2006
“Congress wanted to crack down on illegal
immigrants who got Medicaid benefits by pretending to be U.S. citizens
…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.”
James D. Jones, Director,
Bureau of Eligibility Management
Wisconsin Department of Health and Family Services
New York Times,
March 12, 2007 |
The new citizenship documentation requirement — which the Bush Administration
did not request and the Senate initially did not adopt, but which the House of
Representatives insisted upon in conference — was presented by its proponents as
being necessary to stem a problem of undocumented immigrants securing Medicaid
by falsely declaring themselves to be U.S. citizens. The new requirement was
adopted despite the lack of evidence that such a problem existed. In response
to a report in 2005 by the Inspector General of the Department of Health and
Human Services, Mark McClellan, then the Administrator of the Centers for
Medicare and Medicaid Services at HHS, noted: “The [Inspector General’s] report
does not find particular problems regarding false allegations of citizenship,
nor are we aware of any.”
Impact of the
Citizen Documentation Requirement on Medicaid Applicants and Beneficiaries: The
Early Evidence
Medicaid enrollment
figures for all states for the period since the new requirement was implemented
on July 1 are not yet available. By contacting several individual states that
do have such data, however, we were able to secure enrollment information from
Wisconsin, Kansas, Iowa, Louisiana, Virginia, New Hampshire and Ohio. The data
show the following:
- All seven states report a significant
drop in enrollment since implementation of the requirement began.
- Medicaid officials in these states attribute
the downward trend primarily or entirely to the citizenship documentation
requirement.
Two types of problems
are surfacing:
- Medicaid is being denied or terminated
because some beneficiaries and applicants cannot produce the specified documents
despite, from all appearances, being U.S. citizens; and
- Medicaid eligibility determinations
are being delayed, resulting in large backlogs of applications, either because
it is taking time for applicants to obtain the required documents or because
eligibility workers are overloaded with the new tasks and paperwork associated
with administering the new requirement.
Some states have
designed mechanisms specifically to track enrollment changes resulting from the
new procedures. Wisconsin, for example, has established computer codes to
distinguish when Medicaid eligibility is denied or discontinued due to a lack of
citizenship or identity documents. In other states, a comparison of current and
past enrollment trends strongly suggests that the new requirement is largely
responsible for the enrollment decline. For example, in many states aggressive
“back to school” outreach activities conducted in August and September usually
result in increased child enrollment in September and October. In 2006,
however, states such as Virginia and Louisiana reported that child enrollment
declined despite vigorous promotional campaigns, indicating that the new
requirement undermined the value of the outreach efforts.
The Medicaid
enrollment declines identified in this paper do not appear to be driven by
broader economic trends or a change in the employment of low-income families.
If that were the case, parallel enrollment decline trends would appear in the
Food Stamp Program, which is the means-tested program whose enrollment levels
are most responsive to such developments. Instead, Food Stamp caseloads have
been increasing slightly in recent months. Moreover, each of the states
identified in this paper as having sustained a drop in Medicaid enrollment saw
its food stamp caseload rise since implementing the citizenship documentation
requirement. (Figure 1).
An example comparing Food Stamp and Medicaid enrollment in Wisconsin is shown
(Figure 2).
Both Medicaid and the Food Stamp Program serve similar populations of low-income
families and are often administered by the same agencies and caseworkers. A key
difference is that the citizenship documentation rules were applied to Medicaid
but there were no such changes in the Food Stamp Program.
It thus appears that the changes in Medicaid enrollment are a result of
changes in Medicaid policies — particularly citizenship documentation — that do
not affect eligibility for food stamps.
The following states
have documented declines in Medicaid enrollment since the implementation of the
Medicaid citizenship documentation requirement:
- Wisconsin: In seven months — between
July 31, 2006 and March 1, 2007— a total of 19,413 Medicaid-eligible individuals
were either denied Medicaid or lost coverage as a result of the documentation
requirement. The loss of Medicaid coverage occurred despite Wisconsin’s efforts
to minimize the impact of the requirement by obtaining birth records
electronically from the state’s Vital Records agency. Obtaining proof of
identify, rather than proof of citizenship, was the major problem for people in
Wisconsin who were otherwise eligible during this period: two-thirds (66.5
percent) of those who were denied Medicaid or who lost Medicaid coverage due to
the new requirement did not have a required identity document, as compared to
19.9 percent who did not provide the required citizenship documents and 12.3
percent who were missing both a citizenship and identity document.
This indicates that most of those who were denied were, in fact, U.S. citizens.
“We recently saw a toddler in
our pediatrics clinic. Her grandmother, who has custody, brought her in.
She was worried that her granddaughter was behind in her immunizations,
and since the little girl has no health insurance, the grandmother turned
to us for help. We then discovered that the child, who had been born
prematurely, suffers from chronic lung disease and her development is
considerably delayed. She needs a nebulizer to deliver the medication to
help her breathe and she also needs speech and other therapy. This child
is eligible for Medicaid, but because her grandmother does not have the
required birth certificate, she could not be enrolled. The child will get
Medicaid coverage when we obtain her birth certificate, most likely at
least a month from now. But in the meantime, necessary treatment has been
delayed because her grandmother cannot afford to pay the bills during the
wait for an eligibility determination. For a child with developmental
delays, every day without the necessary therapy and treatment makes it
more difficult for her to catch up with her peers… It has gotten so
complex that we’ve added a lawyer to our clinic to help sort things out.”
Dr. Pam Shaw
Chief of the Division of Ambulatory Pediatrics
KU Medical Center
January 31, 2007 |
- Kansas: The Kansas Health Policy
Authority (KHPA) reports that between 18,000 and 20,000 applicants and previous
beneficiaries, mostly children and parents, have been left without health
insurance since the citizenship documentation requirement was implemented.
About 16,000 of these individuals are “waiting to enroll” or “waiting to be
re-enrolled;” the state says these eligibility determinations are being delayed
because of a large backlog of applications related to the difficulties
confronting individuals and eligibility workers alike who are attempting to
comply with the new rule. Documents on the KHPA website state that the
“majority of
of families with pending applications will qualify for coverage under the new
requirements when we are able to complete processing.”
In the meantime, these children and parents are barred from getting the health
coverage for which they qualify and are, in most cases, uninsured.
- Iowa: Iowa has identified an
unprecedented decline in Medicaid enrollment that state officials attribute to
the Medicaid citizenship documentation requirement. Prior to July 1,
2006, overall Medicaid enrollment had steadily increased for the past several
years. While sporadic declines occurred in rural counties, no county in
the state’s larger population centers experienced a decline in the months
leading up to the implementation of the new requirement. However,
between July and September 2006, Medicaid enrollment sustained the largest
decrease in the past five years; this also was the first time in five years
that the state has experienced an enrollment decline for three consecutive
months.
Although other factors
may contribute to the recent decrease in enrollment, state officials point out
the state is now experiencing a more severe effect on enrollment than it has
following any of the Medicaid changes that have occurred over the past several
years. The state’s conclusion that the citizenship documentation requirement is
driving the decline is supported by the fact that enrollment has dropped among
the populations subject to the requirement (children and families) but has
remained steady among groups not affected by the requirement (individuals
receiving Medicare and SSI).
- Louisiana: Between July 1 and
December 31, 2006 Louisiana experienced a net loss of more than 14,880 children
in its Medicaid program. According to state officials, this decline represents
the enrollment changes outside the Katrina evacuation area, indicating that the
loss in enrollment has not been driven by factors related to the hurricanes,
such as population changes. The reason for the drop-off is two-fold, according
to the state: for some people, Medicaid is being denied or terminated because
they have not presented the required citizenship or identity documents. In
addition, the additional workload generated by the new requirement is diverting
the time and effort eligibility workers normally would spend on activities to
ensure that Medicaid beneficiaries do not lose coverage at renewal. According
to state officials, the enrollment decline would be even greater were it not for
the ability of eligibility workers to conduct “real time” on-line inquiries with
the state’s Vital Records agency to obtain birth records for individuals born in
Louisiana. Eligibility workers have been conducting more than 60,000 such
inquiries each month.
- Virginia: Between July 1, 2006
and March 1, 2007, enrollment in the state’s Medicaid program has declined by
13,279 children. Virginia also reported a substantial backlog in
application processing at its central processing site, with 3,500 cases
pending approval for Medicaid at the end of February 2007, when normally no
more than 50 such cases are pending at the end of a month.
After the plunge in
children’s Medicaid enrollment over several months, a small increase occurred in
December 2006 (although Medicaid enrollment for children then began dropping
again in January). State officials say the December “up-tick” suggests that some
families are finally “getting over the hurdles” imposed by the new law and
children (who were eligible at the time they applied but lacked the required
documentation) are getting health coverage after a significant delay during
which they were without coverage. After December enrollment dropped again, but
according to state officials, this represents a routine seasonal trend seen in
both Medicaid and SCHIP. However, while Medicaid lost about 2,000 children
during February lat year, February 2007 decline was 3,900 children — almost
double — suggesting that the ongoing effects of citizenship documentation
exacerbated the usual post-holiday trend. During the same period in which
children’s Medicaid declined, enrollment of children in the state’s separate
SCHIP program, not subject to the citizenship documentation requirement,
increased except for the usual seasonal drop after the holidays explained
above. (See Figure 3).
- New Hampshire: Data from the New
Hampshire Healthy Kids Program, a private organization that processes mail-in
applications for the state’s Medicaid and SCHIP programs, indicate that the
percentage of applications submitted with all necessary documents in September
of this year dropped by almost half compared to the percentage of complete
applications submitted in September 2005. If applicants do not supply missing
documentation within 28 days, New Hampshire closes the application. The
percentage of applications closed due to missing documents has also increased
significantly: from around 10 percent of applications before the new
requirement to 20 percent in August 2006. In addition, New Hampshire Healthy
Kids reports that between June 2006 and September 2006, enrollment of children
in Medicaid dropped by 1,275.
- Ohio: According to data from the Ohio
Department of Job and Family Services, Medicaid enrollment in the “Covered
Families and Children” category dipped by 39,000 between September 2006 and
February 2007, the period during which the state has been implementing the
citizenship documentation requirement. In the months prior to this policy
change, enrollment for this population, which is the group most affected by
the citizenship documentation requirement, had increased steadily. In addition
to the enrollment decline, beginning in September 2006, the proportion of
applications processed in accordance with the state’s 30-day “timeliness”
standard also dropped, from between 72 and 74 percent to 65 percent. This
suggests that it is taking longer for families to complete their applications
because it is taking a long time to secure the required documents.
Impact on State
Administrative Costs
Data on state Medicaid administrative costs for
the months since July 1 are not available from CMS or any other national
source. Several states, however, have examined the impact of the new Medicaid
citizenship documentation requirement on their administrative expenditures. The
costs they expect to incur are below.
- Illinois: Illinois is projecting $16
million to $19 million in increased staffing costs in the first year of
implementation of the requirement.
- Arizona: The Arizona legislature has
allocated $10 million to implement the citizenship documentation requirement.
This included the costs associated with staffing, training and payments for
obtaining birth records.
- Colorado: The FY07-08 budget request
for the Colorado Department of Health Care Policy and Financing includes a
request for an additional $2.8 million for county administration costs. This
request is based on an assumption by the Centers for Medicare and Medicaid
Services (CMS) that it will take an additional 5 minutes per application for a
caseworker to process citizenship and identity documents. The Department stated
in a Joint Budget Committee Hearing that this amount “may not be sufficient for
Colorado counties and special record storage needs.”
- Washington: Washington State is
projecting additional costs associated with hiring 19 additional FTEs in FY07
due to the new requirement, and retaining seven of them in FY08 and FY09. The
state estimates that the costs will be $2.7 million on FY07 and $450,000 in each
of the succeeding two years.
- Wisconsin: Wisconsin is expecting
increased costs of $1.8 million to cover the increased workload associated with
administering the requirement in FY07 and $600,000 to $700,000 per year for the
two years after that.
- Louisiana: The Louisiana legislature
allocated an additional $1.58 million to the state budget to help cover the
costs of administering the citizenship documentation requirement. This increase
includes the cost of adding 20 new staff positions.
- Minnesota: Minnesota is estimating
that it will spend $1.3 million in FY07 for new staff, birth record fees and
other administrative expenses.
Conclusion
Based on these
findings and reports, and strong anecdotal evidence, it seems increasingly clear
that the new Medicaid citizenship documentation requirement is having a negative
impact on Medicaid enrollment, especially among children. Insufficient
information is available to determine the precise extent to which individuals
whose Medicaid eligibility has been delayed, denied or terminated are U.S.
citizens, eligible legal immigrants, or ineligible immigrants. However, the
fact that significant numbers of individuals are being approved for Medicaid
after delays of many months, during which they were uninsured, demonstrates that
the requirement is adversely affecting substantial numbers of U.S. citizens,
especially children who are citizens. Moreover, a large body of research
conducted over a number of years has conclusively shown that increasing
documentation and other administrative burdens generally results in eligible
individuals failing to obtain coverage as a result of the enrollment and renewal
processes having become more complicated to understand and more difficult to
navigate.
Regarding the Medicaid enrollment declines, Anita Smith, Chief of the Bureau of
Medical Supports for the Iowa Department of Human Services has stated: “There is
no evidence that the [enrollment] decline is due to undocumented aliens leaving
the program. Rather, we believe that these new requirements are keeping
otherwise eligible citizens from receiving Medicaid because they cannot provide
the documents required to prove their citizenship or identity.”
A number of governors
across the nation are announcing their intentions to push new initiatives to
cover the uninsured, particularly children. These proposals are being designed
to build upon existing public coverage programs, of which Medicaid is the
largest, and invariably these proposals call for the enrollment of individuals
who are currently eligible for existing programs but remain uninsured. Success
will depend, in large measure, on policies and procedures that facilitate rather
than frustrate such efforts so that eligible individuals can obtain the benefits
for which they qualify. The Medicaid citizenship documentation requirement,
which appears to be an extremely blunt instrument, stands to undercut such
efforts by placing a daunting administrative obstacle in the way of many
low-income U.S. citizens who otherwise have shown that they qualify or by
discouraging potentially eligible citizens from applying because the process
appears too complex or intimidating. The requirement also appears to be
deflecting state human and financial resources away from activities designed to
reach eligible children and families and to enroll them in the most efficient
and effective manner.
Laura Cox, Leighton Ku and Melanie Nathanson contributed to this paper.
End Notes:
U.S. Department of Health and Human
Services, Office of Inspector General, "Self-declaration of U.S. Citizenship
for Medicaid," July 2005.
Data from Food and Nutrition Service, USDA,
June 2006 through October 2006.
Wisconsin
Department of Health and Family Services
Data from Iowa,
Louisiana, Virginia and New Hampshire first published in:
Resuming the
Path to
Health Coverage for Children and Parents: A
50 State Update on Eligibility Rules, Enrollment and Renewal Procedures, and
Cost-Sharing Practices in Medicaid and SCHIP in 2006 by
Donna Cohen Ross, Laura Cox and Caryn Marks, Kaiser Commission on Medicaid
and the Uninsured, January 2007.
Wisconsin
Department of Health and Family Services
Kansas Health Policy Authority, Factsheet,
www.khpa.ks.gov , December 4, 2006.
Communication with Anita Smith, Bureau Chief, Bureau of Medical Supports,
Iowa Department of Human Services, December 8, 2006.
Communication
with J. Ruth Kennedy, Deputy Medicaid Director Louisiana Department of
Health and Hospitals, November 13, 2006 and March 9, 2007.
Communication with Linda Nablo, Director, Division of Maternal and Child
Health, Virginia Department of Medical Assistance services, November 13,
2006, January 16, 2007 and March 12, 2007.
Communication with Tricia Brooks, President and CEO, New Hampshire Healthy
Kids, November 14, 2006.
Ohio
Department of Job and Family Services
Illinois Department of Healthcare and Family Services
Communication with Tom Betlach, Deputy
Director, Arizona AHCCCS,
October 23, 2006.
Colorado
Center on Law and Social and Social Policy,
December 14, 2006.
Communication
with Mary Wood, Office Chief, Washington Health and Recovery Services
Administration, December 21, 2006.
Communication with James Jones, Director, Bureau of Eligibility Management,
WI Department of Health and Family Services, December 21, 2006.
Communications
with J. Ruth Kennedy, Deputy Medicaid Director Louisiana Department of
Health and Hospitals, March 9, 2007.
Communication with Pat Callaghan, Minnesota Department of Human Services,
December 21, 2006.
Michael Perry, Susan Kannel, R. Burciaga Valdez and Christina Chang,
"Medicaid and Children Overcoming Barriers to Enrollment: Findings from a
National Survey," Kaiser Commission on Medicaid and the Uninsured, January
2000; Zoë Neuberger, "Reducing Paperwork and Connecting Low-Income Children
With School Meals: Opportunities Under the New Child Nutrition
Reauthorization Law," Center on Budget and Policy Priorities, November 2004.
Communication with Anita Smith, Bureau Chief, Bureau of Medical Supports,
Iowa Department of Human Services, December 8, 2006.
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