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Press Release: New Documentation Rule Threatens Medicaid Coverage For Many

African American Beneficiaries at Particular Risk

A bill nearing final passage in Congress that would cut programs such as Medicaid, student loans, and child support enforcement contains a little-noticed provision that would require all citizens applying for Medicaid to produce a passport or a birth certificate to prove they are U.S. citizens. The new rule also would apply to all citizens currently receiving Medicaid when they seek to renew their Medicaid eligibility, which in most cases must be done every six months. The requirement will take effect July 1 if the House approves the bill, which is scheduled for a vote on the House floor on February 1.

Roughly 49 million low-income Americans, including 12 million African Americans — and 800,000 elderly African Americans — would be subject to the new requirement between July 2006 and June 2007. Many of these people lack passports and do not have birth certificates in their possession. Medicaid applicants who have neither of these documents could find that their Medicaid coverage is denied or seriously delayed; current Medicaid beneficiaries who have neither of these documents could lose their Medicaid coverage.

African Americans are at special risk. Many elderly African Americans have no birth certificate: they were born in a time when racial discrimination in hospital admissions kept their mothers from giving birth at a hospital, so their birth often was not officially registered. One study estimated that about one in five African Americans born in the 1939-40 period lack a birth certificate.

“This ill-conceived requirement would exacerbate a historical legacy of discrimination and could cause many elderly African Americans to lose access to health care,” stated Leighton Ku, a senior fellow at the Center and co-author of the report.

Also at special risk are:

  • people whose personal documents have been destroyed by disasters like Hurricane Katrina (many of whom are African American);
  • people who have a sudden medical emergency but cannot get their documents quickly (some states take a month or longer to provide a duplicate birth certificate when one is requested); and
  • people who are homeless, mentally ill, severely disabled, or in nursing homes.

The new rule provides no exceptions, even for people who are extremely old or have severe impairments, such as Alzheimer’s disease.

HHS Study Finds No Substantial Evidence of Fraud

Supporters of the new rule say it is needed to prevent illegal immigrants from obtaining Medicaid by falsely claiming to be citizens. Yet a comprehensive investigation last year by the Department of Health and Human Services’ Office of the Inspector General found no substantial evidence that this problem exists. Legal immigrants are already required to provide proof of their legal immigrant status, and most states allow citizen applicants to attest, under penalty of perjury, that they are citizens; these states ask for documentation from citizen applicants if they have reason to question the applicant’s truthfulness. The HHS report found no problems with this approach.

States Would Face New Headaches as Well

The new rule would create problems for state and local officials as well as beneficiaries. Officials would have to notify applicants of the new requirements, check the documents, and keep records that these documents were submitted. Connecticut’s Medicaid director stated that requiring documentation “would be an enormous administrative burden,” and Wisconsin’s Medicaid director stated that it “would have a material and significant effect on enrollment.”

New Opportunity for House to Give Budget Agreement Needed Scrutiny

The new Medicaid citizenship documentation requirement is part of a budget agreement between the House and Senate that cuts about $40 billion over five years from domestic programs. The House approved an earlier version of the budget agreement in late December, but since the Senate subsequently modified the agreement slightly, the House must vote on the Senate-approved measure when it returns at the end of January.

The citizenship documentation requirement — and many other provisions tucked into the 774-page bill — received little scrutiny from House Members when they voted on the budget agreement shortly before Christmas. Members did not receive a copy of the agreement until 1 a.m. on December 19 and were required to vote on it between 5 a.m. and 6 a.m. that same day.

“Few if any House Members can have understood the impact of the many provisions of the budget agreement when they voted on it in December,” stated Center Executive Director Robert Greenstein. “Now, however, the House has a chance to look the bill over carefully and decide whether provisions like this harmful and unnecessary Medicaid citizenship requirement truly reflect the right priorities for this country.”

The Center has issued two reports on the new rule: New Medicaid Requirement Is Unnecessary and Could Impede Citizens’ Coverage, which provides an overview of the issue, and New Requirement for Birth Certificates or Passports Could Threaten Medicaid Coverage for Vulnerable Beneficiaries: A State-by-State Analysis, which provides state-specific data on the number of people who could be affected by the new rule. Both reports are available on the Center’s website (