Revised January 4, 2006

Leighton Ku and Donna Cohen Ross

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Health Policy

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The conference version of the budget reconciliation bill, which has passed the Senate and which the House plans to vote on in early February, would impose a new requirement on states that all U.S. citizens who apply for Medicaid must provide documentation of their citizenship status, generally by producing a passport or a birth certificate and a driver’s license.[1]  This requirement would have the effect of impeding or delaying coverage for significant numbers of eligible, low-income U.S. citizens, since many low-income people do not have birth certificates or passports in their possession.

Sponsors of this provision may think this new procedure would prevent ineligible immigrants from falsely obtaining Medicaid coverage.  Yet the provision’s principal impact would be on citizens, for whom it would erect a new procedural barrier.  Moreover, an examination of this issue by the HHS’ Office of Inspector General (OIG) indicates that the provision is unnecessary. [2]  OIG found no substantial evidence that immigrants are obtaining Medicaid by falsely claiming citizenship.

Federal law already requires immigrants who apply for Medicaid to provide proof of their legal immigration status.[3]  States demand such documents on their Medicaid applications and take other steps as well to verify immigrants’ legal status.  When people apply as citizens, they normally attest, under penalty of perjury, that they are citizens, and states usually do not require documentation of citizenship on a routine basis.  However, if there is any question about the citizenship of an applicant, almost all states have policies to require documentation of citizenship, as the OIG findings show.  In addition, state Medicaid directors have noted that routinely asking for documentation would substantially increase administrative burdens.

The Office of Inspector General Study

OIG conducted a comprehensive review of state Medicaid policies in this area and issued a report on this matter in July 2005.  After studying the evidence, OIG did not recommend a new requirement for documentation of citizenship.  Although most states permit self-attestation of citizenship, OIG found that almost all states require further documentation when there is reason to question an applicant’s status.  Moreover, state Medicaid administrators reported that, based on the results of their quality control review systems, “they have not seen a problem with self-declaration of citizenship.”

The Centers for Medicare and Medicaid Services at the U.S. Department of Health and Human Services, which oversees the Medicaid program, concurred with OIG.  CMS reported it has no evidence that there is a problem in this area.

This indicates that the provision would generate little or no savings from rooting out ineligible immigrants who have applied for Medicaid and falsely claimed to be citizens.  The savings from this provision, which the Congressional Budget Office estimates to be $220 million over five years, would instead come primarily from reducing or delaying enrollment among applicants who are, in fact, U.S. citizens. 

Consequences for Citizens

Many people, particularly low-income people, do not have birth certificates in their possession and do not have passports.  (Most poor individuals cannot afford to travel abroad, or are not physically well enough to do so.)  While these people may have had a birth certificate in their possession at one time, after moving various times over the course of their lives, many may no longer have a birth certificate handy.  This could be a particular problem for people who are elderly or have physical or mental disabilities and are in need of immediate medical care.

Under the new requirement, a mother whose child is injured may find her child will not get timely medical coverage because she does not have a valid copy of a birth certificate readily available.  Citizens who are homeless or who have experienced a disaster such as Hurricane Katrina or a fire may be unable to enroll in Medicaid because they do not have the required documents in their possession.  Significant numbers of other low-income patients would be similarly affected.

Adding to these problems is the fact that obtaining these documents can take substantial time and cost money.  For example, in California, it generally takes 10 to 12 weeks to get a birth certificate from the county office in the county where the birth occurred, and it can take six to eight months if the information submitted is not complete.  Because of heightened homeland security procedures, the process for obtaining birth certificates has become more cumbersome in recent years.  And in some areas, it may be particularly problematic for people to secure birth certificates on a timely basis for step-children, foster children, or individuals whose names have changed (e.g., because of marriage).

Moreover, the cost of getting duplicate birth certificates or passports would effectively add an application fee to Medicaid for many people, which could deter some from entering the program and cause them to remain uninsured.  It can cost $5 to $23 to get a birth certificate.  A passport costs $87 to $97.

Particular Problems for Elderly African-Americans

A number of native-born citizens, particularly older African-Americans and other disadvantaged individuals, may lack birth certificates and consequently may find access to Medicaid delayed or barred.  Many older Americans born in the South or in rural areas in other parts of the country were not born in hospitals or attended by physicians and thus may lack birth certificates.  They often were born at home because their families were too poor to afford, or too isolated to obtain, a hospital or physician-attended birth, or because the racial discrimination that was prevalent in that period prevented them from going to the local hospital.  One study estimated that one-fifth of African-Americans born in the 1939-40 period lacked a birth certificate.  Lack of birth certificates also is a problem among some Native American citizens. [4]

Complicating Program Administration for the States

Finally, in the OIG study referred to above, state administrators informed OIG that requiring birth certificates or passports would increase state administrative burdens and slow eligibility processing, by making the application process more cumbersome.  A new requirement of this nature also would make enrollment by mail — a common procedure used to simplify applications for children and families — more complicated, as states would need to process birth certificates and passports and then mail them back to applicants.

In November, the Medicaid director for Connecticut, David Parella, observed that requiring documentation “would be an enormous administrative burden.” Wisconsin’s Medicaid director, Mark Moody, added that the proposal “would have a material and significant effect on enrollment.”[5]

End Notes:

[1] Some other documents, such as citizenship naturalization papers, are allowed, but birth certificates and passports are the main documents that would be used by native-born citizens.  If a birth certificate is submitted, it must be accompanied by a driver’s license or other document that proves identity.  HHS may specify other permissible documents.

[2] Office of the Inspector General, “Self-Declaration of U.S. Citizenship Requirements for Medicaid,” July 2005.

[3] Undocumented immigrants are eligible only for coverage of emergency medical care, not full Medicaid coverage.

[4] S. Shapiro, “Development of Birth Registration and Birth Certificates in the United States,” Population Studies, 4:86-111, 1950.  Cited by I. Rosenwaike and M. Hill, “The Accuracy of Age Reporting Among Elderly African-Americans: Evidence of a Birth Registration Effect,” Population Aging Research Center, Univ. of Pennsylvania, Working Paper, July 1995. T. Vanderpool, “Rites of Passage,” Tucson Weekly, Feb. 27, 2003.

[5] John Reichard, “Critics Say New Documentation Rules for Medicaid Would Reduce Enrollment,” CQ HealthBeat, Nov. 8, 2005.