August 1, 2007
NEW CHARGES ABOUT HOW HOUSE CHILDREN'S HEALTH BILL
AFFECTS UNDOCUMENTED IMMIGRANTS ARE FALSE
By Robert Greenstein
Rep. Nathan Deal has launched a new
attack on House health insurance legislation that would cover about 5 million
uninsured lower-income children, according to Congressional Budget Office
estimates. Rep. Deal charged the bill opens Medicaid and the State Children’s
Health Insurance Program (SCHIP) to illegal immigrants, encourages more illegal
immigrants to enter the United States, and reflects an “eagerness to offer free
services to illegals at taxpayer expense.”
The charges are false.
What the Provisions at Issue Would Actually Do
The charges revolve around two provisions of the
health legislation that is headed to the House floor.
- One addresses severe problems that resulted
from a poorly designed provision enacted in 2006 that imposes more burdensome
requirements on U.S. citizens applying for Medicaid than on eligible legal
immigrants and has caused thousands of poor, eligible citizen children and
parents to be denied entry into Medicaid (or to have their entry into the
program delayed). Many of these children and parents apparently became
or remained uninsured as a result.
- The second broadens a provision of current
law, under which certain categories of legal immigrants can qualify for
Medicaid and SCHIP after residing for five years in the United States, to give
states an option to cover legal immigrant children and pregnant women during
their first five years here. The National Governors Association and the
National Conference of State Legislatures have both endorsed this change on a
bipartisan basis. It would not make any undocumented immigrants
1. The Provision Dealing with “Citizenship
Undocumented immigrants have never
been eligible for Medicaid (other than for some emergency medical care) or
SCHIP. Eligible legal immigrants have always been required to provide various
documents to prove that they have legal status and that their particular legal
status lets them qualify for Medicaid under federal law. In addition, any
citizens whose citizenship is in question have always been required to prove
it. In 2005, Dr. Mark McClellan, then-Administrator of the Centers for Medicare
and Medicaid Services, wrote that this policy “allows states to enroll eligible
individuals while preserving program integrity.”
In 2006, however, Congress changed the law.
A proposal authored by Rep. Deal and the late Rep. Charles Norwood requires
every citizen child and parent receiving or applying for Medicaid to provide an
original birth certificate, passport, or similar document to prove his or her
citizenship. Congress enacted the provision even though Dr. McClellan had
indicated there was no evidence that it was needed.
Supporters said the provision was
necessary to keep undocumented immigrants out of Medicaid and that it would have
no impact on citizens. Studying the issue in 2005, however, the Department of
Health and Human Services’ (HHS) Inspector General did not find evidence of a
As Dr. McClellan, who was CMS Administrator at the time, noted concerning the
Inspector General’s report, “The report does not find particular problems
regarding false allegations of citizenship, nor are we aware of any.”
Furthermore, the results of the
provision have proved just the opposite of what Rep. Deal forecast: Tens of
thousands of children who are U.S. citizens have been shut out of the program
because their parents lacked ready access to a birth certificate or passport,
while virtually no undocumented immigrants have been identified.
- Numerous states have reported that, due to
the new requirement, thousands of U.S. citizen children have been removed from,
or denied entry into, Medicaid. Many of them apparently became or remained
uninsured. The Government Accountability Office (GAO), the House Oversight and
Government Reform Committee, and the Center on Budget and Policy Priorities have
reported these results, based on data that the states collected.
- The six states that examined this issue in
greatest detail found that they have spent $17 million so far to administer the
burdensome requirement, have denied health insurance to tens of thousands of
needy children and parents as a result, and have identified just eight
undocumented individuals (whom they may have caught under the previous
For example, the number of low-income children insured through Medicaid has
dropped 11,000 in Virginia and 14,000 in Kansas due to the new requirements;
each state identified one applicant who incorrectly claimed to be a citizen.
- The three states that collected data by
racial/ethnic group have found that the children losing coverage due to the
requirement are overwhelmingly non-Hispanic white and non-Hispanic black
children. Hispanic children are far less affected. In Virginia, for example,
enrollment has fallen significantly among white and black children since the
requirement took effect, while it has actually climbed among Hispanic children.
This would not be occurring if the provision were affecting undocumented
immigrants; an estimated 78 percent of undocumented immigrants are from Mexico,
Central America, or South America, according to the respected Pew Hispanic
Governors have sharply criticized the
provision. In a letter last month to leaders of both parties on the House
Energy and Commerce Committee, California Gov. Arnold Schwarzenegger wrote that
it has increased state administrative costs, put barriers in the way of eligible
applicants, and “created a situation where U.S. citizens actually have fewer
rights than non-citizens when applying for Medicaid benefits”
(in that the documentation requirements now imposed on citizens have proved more
difficult for many of them to comply with than the substantial documentation
requirements placed on eligible legal immigrants).
The House Provision
A provision of the House bill is
designed to give states flexibility to address these problems without allowing
undocumented immigrants into Medicaid.
- The House bill would give states increased
flexibility in how to ensure that children applying for Medicaid are citizens
or eligible legal immigrants. (The House bill does not change the 2006
provision with respect to parents.)
- Parents in all states would be required to
sign, under penalty of perjury, that their children are U.S. citizens and to
provide the children's Social Security numbers.
- The bill would let states either retain the
procedures mandated in 2006 or modify them. But all states would be required to
conduct annual audits to ensure their procedures were keeping undocumented
immigrants out of the program. And states whose audits found
undocumented immigrants in the program would be required to fully repay the
federal government for the costs of allowing undocumented individuals to
receive Medicaid. They also would have to repay the costs of serving any
legal immigrants who are not part of an eligible legal immigrant category.
The House provision would be
considerably more stringent than the provisions that governed Medicaid prior to
2006, evidently without causing problems. The House provision would have the
- An estimated 100,000 low-income children who
otherwise would not receive Medicaid coverage under current law would be
covered due to the House provision, and these children would overwhelmingly be
U.S. citizens, according to the Congressional Budget Office.
- The House provision would reduce federal and
state administrative costs by allowing states to use more cost-efficient
procedures to assure that undocumented immigrants do not receive Medicaid.
- The provision contains tough safeguards
through its requirement for annual state audits.
- The provision would make no undocumented
The provision responds to requests from governors
in a number of states – including Oklahoma, Washington, New Mexico, Wisconsin,
Michigan, Oregon, Virginia, Maryland, Pennsylvania, New Jersey, New York,
Massachusetts, and California, among others – for greater flexibility in this
area. The National Association of State Medicaid Directors also called for
such a change.
2. State Option to Cover Legal Immigrant
Children and Pregnant Women in Their First Five Years Here
The House bill also contains this
state option, which governors and the National Conference of State Legislatures
requested on a bipartisan basis, and which the Senate approved on a bipartisan
basis in 2003 as part of the Senate’s Medicare prescription drug bill. This
provision would make no undocumented immigrants eligible.
Rep. Deal claims that if subsequent
legislation allows undocumented immigrants to legalize, they will be able to get
Medicaid and SCHIP due to this provision. That is not correct. Any future
legislation that allows undocumented immigrants to legalize will itself set the
rules for whether those individuals will qualify for benefits.
 See Rep. Nathan Deal, “New Entitlement for Illegal
Aliens: Oppose the CHAMP Act,” July 30, 2007; email from Todd Smith, deputy
chief of staff for Rep. Deal, to all Members of the House, July 30, 2007;
and “A new entitlement for illegals,” Washington Times, July 30, 2007.
 Memorandum from Mark B. McClellan to Daniel R. Levinson,
Acting Inspector General, April 8, 2005, printed as Appendix D in Office of
Inspector General, U.S. Department of Health and Human Services,
“Self-declaration of U.S. Citizenship for Medicaid,” June 2005.
 Office of Inspector General, U.S.
Department of Health and Human Services, “Self-declaration of U.S.
Citizenship for Medicaid,” June 2005.
 McClellan, op. cit.
 Government Accountability Office, States Reported That
Citizenship Documentation Requirement Resulted in Enrollment Declines for
Eligible Citizens and Posed Administrative Burdens, June 2007; “Medicaid
Citizenship Documentation Requirements Deny Coverage to Citizens And Cost
Taxpayers Millions,” Majority Staff, Committee on Oversight and Government
Reform, July 24, 2007; Donna Cohen Ross, “Medicaid Requirement
Disproportionately Harms Non-Hispanics, State Data Show,” Center On Budget
and Policy Priorities, July 10, 2007, and “New Medicaid Citizenship
Documentation Requirement Is Taking A Toll,” Center on Budget and Policy
Priorities, March 13, 2007.
 Committee on Oversight and Government Reform, op. cit.
 Donna Cohen Ross, “Medicaid Requirement
Disproportionately Harms Non-Hispanics, State Data Show,” op. cit.
 An estimated 13 percent are from Asia, and 9 percent are
from Europe, Africa, and other areas. Jeff Passel, “The Size and
Characteristics of the Unauthorized Migrant Population in the United
States,” Pew Hispanic Center, March 2006.
 Governor Arnold Schwarzenegger, Letter to Reps. John
Dingell, Joe Barton, Frank Pallone, and Nathan Deal, June 5, 2007.