[Congressional Record Volume 152, Number 20 (Thursday, February 16, 2006)]
[Senate]
[Pages S1424-S1427]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. AKAKA (for himself, Mr. Obama, Mr. Bingaman, Mr. Inouye, 
        Mr. Lautenberg, Mr. Jeffords, Mr. Kerry, and Mr. Lieberman):
  S. 2305. A bill to amend title XIX of the Social Security Act to 
repeal the amendments made by the Deficit Reduction Act of 2005 
requiring documentation evidencing citizenship or nationally as a 
condition for receipt of medical assistance under the Medicaid program; 
to the Committee on Finance.
  Mr. AKAKA. Mr. President, I rise to introduce legislation to repeal a 
provision in the Deficit Reduction Act that will require people 
applying or reapplying for Medicaid to verify their citizenship with a 
U.S. passport or birth certificate. I thank my cosponsors of this 
legislation, Senators Obama, Bingaman, Inouye, Lautenberg, Jeffords, 
Kerry, and Lieberman for their support.
  This provision must be repealed before it goes into effect July 1, 
2006. We have arrived at this conclusion because it will create 
barriers to health care, and from information we have gathered from 
agencies, it is unnecessary and will be an administrative burden to 
implement. These are reasons for this legislation. The Center on Budget 
and Policy Priorities estimates that more than 51 million individuals 
in this country would be burdened by having to produce additional 
documentation. In 16 States--Arizona, California, Florida, Georgia, 
Illinois, Louisiana, Massachusetts, Michigan, Missouri, New York, North 
Carolina, Ohio, Pennsylvania, Tennessee, Texas, and Washington--more 
than a million Medicaid beneficiaries will be required to submit the 
additional documents to receive or stay on Medicaid. In Hawaii, an 
estimated 392,000 people who are enrolled in Medicaid will be required 
to produce the additional documentation.
  The requirements will disproportionately impact low-income, racial 
and ethnic minorities, indigenous people, and individuals born in rural 
areas without access to hospitals. Due to discriminatory hospital 
admission policies, a significant number of African-Americans were 
prevented from being born in hospitals. One in five African Americans 
born during 1939-1940 do not have birth certificates.
  We need to ensure that Medicaid beneficiaries are not discriminated 
against and do not lose access to care, simply because they do not have 
a passport or birth certificate. Data from a survey commissioned by the 
Center on Budget and Policy Priorities is helpful in trying to 
determine the impact of the legislation. One in 12 U.S.-born adults, 
who earn incomes less than $25,000, report they do not have a U.S. 
passport or birth certificate in their possession. Also, more than 10 
percent of U.S.-born parents, who have incomes below $25,000, do not 
have a birth certificate or passport for at least one of their 
children. An estimated 3.2 to 4.6 million U.S. born citizens may have 
their Medicaid coverage threatened simply because they do not have a 
passport or birth certificate readily available.
  Some groups are at a greater risk for losing their Medicaid coverage. 
Nine percent of African-American adults reported they did not have the 
needed documents. Seven percent of people over age 65 also report that 
they do not have birth certificates. Many others will also have 
difficulty in securing these documents, such as Native Americans born 
in home settings, Hurricane Katrina survivors, and homeless 
individuals.
  It is difficult enough to get access to health care, let alone 
acquire a birth certificate or a passport before seeking treatment. 
Some beneficiaries may not be able to afford the financial cost or time 
investment associated with obtaining a birth certificate or passport. 
The Hawaii Department of Health charges $10 for duplicate birth 
certificates. The costs vary by State and can be as much as $23 to get 
a birth certificate or $87 to $97 for a passport. Taking the time and 
obtaining the necessary transportation to acquire the birth certificate 
or a passport, particularly in rural areas where public transportation 
may not exist, creates a hardship for Medicaid beneficiaries. Failure 
to produce the documents quickly may result in a loss of Medicaid 
eligibility.
  Further compounding the hardship is the failure to provide an 
exemption for individuals suffering from mental or physical 
disabilities from the new requirements. I am really afraid that those 
suffering from diseases such as Alzheimer's may lose their Medicaid 
coverage because they may not have or be able to easily obtain a 
passport or birth certificate.
  It is likely these documentation requirements will prevent 
beneficiaries who are otherwise eligible for Medicaid to enroll in the 
program. This will result in more uninsured Americans, an increased 
burden on our healthcare providers, and the delay of treatment for 
needed health care.
  The hardships that will be imposed are unnecessary due to existing 
requirements that check immigration status. A 2005 study by the Health 
and Human Services Office of the Inspector General concluded there is 
no substantial evidence indicating that illegal immigrants claiming to 
be U.S. citizens are successfully enrolling in Medicaid.
  Twenty-eight of 47 Medicaid directors, surveyed by the Health and 
Human Services Inspector General, indicated that requiring documentary 
evidence of citizenship would delay eligibility determination. Twenty-
five believe that providing additional evidence would result in 
increased eligibility personnel costs. State Medicaid Agencies would 
likely have to hire additional personnel to handle the increased 
workload with significant, additional administrative and financial 
costs. Twenty-one believe that it would be burdensome or expensive for 
applicants to obtain a birth certificate or other documentation.
  In my home State, the Hawaii Primary Care Association estimates the 
administrative costs for our Department of Human Services will result 
in an increased cost of $640,000. Mr. John McComas, the Chief Executive 
Officer, of AlohaCare, stated, ``We anticipate that there will be 
significant administrative costs added to our already overburdened 
Medicaid programs. These

[[Page S1425]]

provisions are absolutely unnecessary and place an undue burden on the 
Medicaid beneficiary, to our entire Medicaid program, and ultimately to 
our entire state.''
  I am frequently frustrated by the inability of the Congress to enact 
measures to improve health care for Americans. A misconceived provision 
to mandate these additional documentation requirements will cause real 
people real pain, and create public health and administrative 
difficulties. The provision in the Deficit Reduction Act will force 
every current and future Medicaid beneficiary to produce a passport or 
birth certificate. I look forward to my colleagues working with me to 
repeal this provision. I am hopeful that as my friends in the Senate go 
home during recess, they talk with their constituents at health 
centers, State Medicaid offices, and social service organizations, and 
hear how important it is to them for this legislation to be enacted to 
protect access to Medicaid.
  Mr. President, I ask unanimous consent that the full text of the bill 
be printed in the Record, as well as letters of support and concern 
from AlohaCare, the Association of Asian Pacific Community Health 
Organizations, Maternal and Child Health Access, the Hawaii Primary 
Care Association, and Siren.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 2305

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. REPEAL OF REQUIREMENT FOR DOCUMENTATION EVIDENCING 
                   CITIZENSHIP OR NATIONALITY AS A CONDITION FOR 
                   RECEIPT OF MEDICAL ASSISTANCE UNDER THE 
                   MEDICAID PROGRAM.

       (a) Repeal.--Subsections (i)(22) and (x) of section 1903 of 
     the Social Security Act (42 U.S.C. 1396b), as added by 
     section 6036 of the Deficit Reduction Act of 2005, are each 
     repealed.
       (b) Conforming Amendments.--
       (1) Section 1903 of the Social Security Act (42 U.S.C. 
     1396b) is amended--
       (A) in subsection (i)--
       (i) in paragraph (20), by adding ``or'' after the semicolon 
     at the end; and
       (ii) in paragraph (21), by striking ``; or'' and inserting 
     a period;
       (B) by redesignating subsection (y), as added by section 
     6043(b) of the Deficit Reduction Act of 2005, as subsection 
     (x); and
       (C) by redesignating subsection (z), as added by section 
     6081(a) of the Deficit Reduction Act of 2005, as subsection 
     (y).
       (2) Subsection (c) of section 6036 of the Deficit Reduction 
     Act of 2005 is repealed.
       (c) Effective Date.--The repeals and amendments made by 
     this section shall take effect as if included in the 
     enactment of the Deficit Reduction Act of 2005.
                                  ____



                             Maternal and Child Health Access,

                               Los Angeles, CA, February 16, 2006.
     Hon. Daniel Akaka,
     U.S. Senate,
     Washington, DC.
       Dear Senator Akaka: I am pleased to write a letter of 
     support for your bill to amend title XIX of the Social 
     Security Act to repeal the amendments made by the Deficit 
     Reduction Act of 2005 requiring documentation of citizenship 
     or nationality as a condition for receipt of medical 
     assistance under the Medicaid program.
       Maternal and Child Health Access has provided assistance to 
     thousands of families seeking medical coverage since the 
     early 1990s. In addition to the families we serve, we educate 
     and train other social service agencies and clinics about 
     health coverage programs and thus have the opportunity to 
     hear their experiences in assisting low-income people to 
     apply for Medicaid. In California, we are ecstatic that 
     nearly 90% of the children eligible have been enrolled in 
     Medicaid or our S-CHIP program, Healthy Families. We have 
     celebrated the fact that with few exceptions, the process of 
     obtaining health care coverage for low-income families 
     presents fewer barriers than in prior years. The requirement 
     that Medicaid applicants provide birth certificates would be 
     an unfortunate reversal of that trend.
       Even now, even with no requirement for such documentation, 
     Eligibility Workers mistakenly demand birth certificates as 
     part of the Medicaid application process. We see that the 
     need to provide such documentation causes untoward delays in 
     obtaining health care. For example, my office recently 
     assisted the family of a two-year-old child who had never had 
     Medi-Cal due to the Los Angeles County Eligibility Worker's 
     erroneous demand for a birth certificate from the client's 
     home state, which had been impossible to obtain. The child's 
     health care visits were delayed and inferior to what a two-
     year-old should have had.
       In California, birth certificates cost $17 and require a 
     notarized application, or sworn statement under penalty of 
     perjury. In addition to the added expense of notarizing, an 
     additional $25-$50 depending on the ability of often-
     unscrupulous notaries to charge, making people swear under 
     penalty of perjury is intimidating and will discourage people 
     from applying. It takes four to six months to obtain birth 
     certificates for newborns and if obtained in person, require 
     travel to a different office than for duplicate copies that 
     might be needed for adults or other children who need them. I 
     see no flexibility in the amendments as passed to allow for 
     families with no disposable income to obtain the birth 
     certificates timely.
       There is absolutely no need for a drastic measure of this 
     sort. A comprehensive study conducted last year by the Health 
     and Human Services Inspector General, ``Self-Declaration of 
     U.S. Citizenship Requirements for Medicaid,'' July 2005, 
     failed to find any substantial evidence that illegal 
     immigrants are fraudulently getting Medicaid coverage by 
     claiming they are citizens. Notably, the Inspector General 
     did not recommend requiring that documentation of citizenship 
     be required. State officials interviewed by the Inspector 
     General's office also noted that such a requirement would add 
     significant administrative costs and burdens. Half of the 
     state officials interviewed said they would have to hire more 
     eligibility personnel to handle the increased workload.
       Requiring a birth certificate will cause delays in 
     obtaining needed medical coverage and care and unnecessary 
     costs for applicants, states and counties. If we truly care 
     about ensuring that children, pregnant women, disabled 
     people, seniors and others in need obtain the health care 
     that may enable them to continue to be productive citizens or 
     ensure their readiness for school, we should not be putting 
     unnecessary costly barriers in their way.
       I thank you on behalf of the low income people my agency 
     serves daily.
           Sincerely,
                                                      Lynn Kersey,
     MA, MPH, Executive Director.
                                  ____



                             Hawai`i Primary Care Association,

                                   Honolulu, HI, January 25, 2006.
     Hon. Senator Daniel Akaka,
     Re Proposed birth certificate or passport requirement for 
         Medicaid application.

       Dear Senator Akaka: The Hawai`i Primary Care Association 
     would like to register our strong opposition to recently 
     proposed federal legislation that would require a birth 
     certificate or passport for each Medicaid applicant, and to 
     ask for your assistance to avert this mandate. We object to 
     this change because it is completely unnecessary to prevent 
     application fraud but would be a considerable barrier to 
     legitimate applicants and add to the cost incurred by public 
     and private agencies to complete and process applications.
       Unnecessary barrier. In the ample experience of community 
     health centers in Hawai`i and the Primary Care Association's 
     Hawai`i Covering Kids Project, immigrants, fearful of 
     jeopardizing their immigration status, are hesitant to apply 
     for programs for which they are clearly eligible. 
     Undocumented immigrants are even less likely to call 
     attention to themselves, for obvious reasons. The Hawai`i 
     State Department of Human Services, which monitors and checks 
     into self-declared eligibility status, has found no evidence 
     of fraud in this area.
       The following are some of the ways this proposed 
     requirement would deter legitimate applicants: Some people do 
     not have birth certificates because they were born at home or 
     in areas with no official registries (e.g., on plantations). 
     People who are mentally ill or homeless may be unable to 
     produce original or duplicate birth certificates. In the 
     event of a hurricane or other disaster, many people will be 
     unable to find documents, and public agencies may be in 
     disarray so that they can't provide duplicates. In an 
     emergency medical situation, an uninsured person may not be 
     able to find a birth certificate. The Hawai`i Department of 
     Health (DOH) charges $10 for duplicate birth certificates. 
     Procuring one for each family member that is applying or 
     renewing not only takes the applicant away from work or other 
     activities to stand in line at DOH, but also can be 
     prohibitively expensive. The application and enrollment 
     procedure will take longer and result in delays in coverage 
     that might cause serious health problems and put the health 
     care provider and individual at financial risk.
       Processing costs. If this regulation is implemented it will 
     result in more administrative costs for DHS and for agencies 
     that assist applicants. All current Medicaid customers must 
     also be asked to submit a birth certificate or passport. This 
     requires paper, envelopes, and mailing costs. When documents 
     arrive at a Medicaid office, they must be matched to a 
     record, noted in the electronic case file, and stored in the 
     customer's case file. If the customer does not produce the 
     required document, the case will be closed. However, this 
     person is otherwise eligible for benefits, therefore when 
     she/he locates a birth certificate a new application will not 
     only be submitted, but also the Medicaid office must review 
     it and open a new case. Hawai`i's Medicaid offices receive 
     approximately 66,000 applications annually. New applications 
     without birth certificates or passports attached will be sent 
     ten-day pending notices. This requires paper, envelopes, and 
     mailing costs. If the document is not received in the time 
     allotted, the application will be denied. If mailing notices 
     and updating or closing each current Medicaid file takes at 
     least 10 minutes of public workers' time, the current Med-
     QUEST enrollment of over 200,000 customers will take 33,333 
     hours and cost $640,000.
       Assumptions: 15 minutes to send notices and update or close 
     files. 2,080 is the number

[[Page S1426]]

     of work hours per year. Salary plus operating costs per 
     worker is $40,000 per year.
       Cost: 16 eligibility workers will work full-time for a year 
     at a cost of $640,000.
       In summary, we believe there is no good reason to implement 
     the proposed regulations and ample reasons to maintain the 
     current procedure that allows self-declaration. We ask for 
     your help in this matter to make sure Medicaid continues to 
     serve the most vulnerable members of our communities.
           Sincerely,
                                                    Beth Giesting,
     Executive Director.
                                  ____

       Dear Senator Akaka: I have just been informed about your 
     bill to repeal the citizenship documentation requirements 
     contained in the reconciliation bill. On behalf of the 
     Services, Immigrant Rights and Education Network (SIREN), I 
     write to express our support for Senator Akaka's bill.
       SIREN is a leading organization in Silicon Valley dedicated 
     to providing immigrant rights advocacy, community education 
     and naturalization assistance to Santa Clara County's diverse 
     immigrant communities. We believe that a requirement to check 
     citizenship status for Medicaid recipients will be costly and 
     an additional barrier to accessing this much needed program. 
     In addition, it is unnecessary and continues the stereotype 
     that immigrants are in this country to access social 
     services, which we know to be false. Immigrants come to this 
     country to create a better life for themselves and their 
     families. They contribute to the social and economic fabric 
     of our country every day.
       Thank you for your efforts to protect immigrants and to 
     save our country from a needless expense.
           Warmly,
     Larisa Casillas.
                                  ____

                                      Association of Asian Pacific


                               Community Health Organizations,

                                    Oakland CA, February 10, 2006.
     Hon. Daniel Akaka,
     U.S. Senate,
     Washington, DC.
       Dear Senator Akaka: The Association of Asian Pacific 
     Community Health Organizations, AAPCHO, a national non-profit 
     association of community health centers, is writing to 
     support your efforts to repeal an amendment requiring 
     individuals to provide evidence of citizenship when applying 
     for Medicaid benefits.
       We believe that these amendments, which are introduced in 
     the Deficit Reduction Act of 2005, will not only raise the 
     ranks of the uninsured, but more importantly, that they will 
     leaves scores of our most vulnerable citizens without 
     critically needed health care services.
       As you well know, there are currently over 45 million 
     people without health insurance, many of whom are Asian 
     American, Native Hawaiian and Pacific Islander. Requiring 
     Medicaid beneficiaries to provide a birth certificate or 
     passport to prove their citizenship could lead to millions of 
     low-income Americans either losing Medicaid coverage and 
     becoming uninsured, or being delayed coverage for necessary 
     medical care. At AAPCHO's member community health centers 
     across the country, this regulation would instantly put the 
     lives and health of a significant number of low-income 
     adults, children, elderly, and disabled individuals at risk.
       We thank you for continuing your fight to provide health 
     care for our most vulnerable populations, and we appreciate 
     your introduction of this important bill.
           Sincerely,
                                        Jeffrey B. Caballero, MPH,
     Executive Director.
                                  ____



                                                    AlohaCare,

                                   Honolulu, HI, February 6, 2006.
     Hon. Daniel K. Akaka,
     U.S. Senate,
     Washington, DC.
       Dear Senator Akaka: We applaud your concerns about the 
     proposed changes in Medicaid. We wish to lend our support to 
     the Amendment that you are proposing that will remove one of 
     the most draconian aspects of the proposal in Section 6037 of 
     the Budget Reconciliation Bill that will require that 
     everyone who is applying for Medicaid, whether current or 
     new, to provide proof of their citizenship.
       The primary forms of documentation acceptable would be 
     either a passport or a birth certificate presented in 
     conjunction with proof of identity such as a drivers' 
     license. For people who are naturalized citizens 
     naturalization papers would be accepted. This essentially 
     means that native-born citizens would have to produce birth 
     certificates or passports.
       The new requirements, which a recent study by the Inspector 
     General of the Department of Health and Human Services shows 
     to be unnecessary, would almost certainly create significant 
     enrollment barriers to millions of low-income citizens who 
     would otherwise meet all Medicaid eligibility requirements. 
     Because of Hawaii's demographics we believe that we would be 
     heavily impacted.
       On July 1, 2006 these new requirements will apply to all 
     applications or redeterminations of Medicaid eligibility that 
     occurred after that date, without exceptions, even for people 
     who are extremely old or have severe physical or mental 
     impairments, such as Alzheimer's disease.
       A major concern is that many people on Medicaid do not 
     travel or have not had a need for a passport. Others no 
     longer live near where they were born or have long since lost 
     their birth certificate. Many of the elderly in Hawaii were 
     born outside of hospitals or places where birth certificates 
     were not commonly issued.
       We anticipate that there will be significant administrative 
     costs added to our already overburdened Medicaid programs. 
     These provisions are absolutely unnecessary and will place an 
     undue burden on the Medicaid beneficiary, to our entire 
     Medicaid program, and ultimately to our entire state.
       Please don't hesitate to contact us if we can be of any 
     assistance to you in your efforts to protect the Medicaid 
     beneficiaries in Hawaii.
           Sincerely yours,
                                                     John McComas,
                               Chief Executive Officer, AlohaCare.

  Mr. OBAMA. Mr. President, as our Nation faces staggering healthcare 
costs, rising rates of chronic conditions, and a growing wage gap 
between the haves and the have-nots, we must acknowledge the vital 
importance of this Nation's safety net--the Medicaid program. The 
Medicaid program is the provider of healthcare for more than 50 million 
Americans--young and old, black and white, and the disabled.
  As many of us would argue, and as stated by the President in this 
year's State of the Union Address, the government has a responsibility 
to help provide healthcare for the poor and the elderly. I ask you to 
question whether we meet that responsibility with section 6036 of the 
Deficit Reduction Act that requires citizenship documentation for 
individuals seeking Medicaid. In order for our country to have healthy 
children, a healthy workforce and healthy communities, we must not 
deter Americans from seeking medical care, and yet this provision would 
do just that.
  Much of the public scrutiny on Medicaid spending has focused on the 
costs of providing care to undocumented immigrant populations. Some 
believe that requirements for documentation of citizenship will curtail 
alleged abuse of the Medicaid program by illegal immigrants. Yet, a 
study conducted by the HHS Inspector General failed to find any 
substantial evidence that illegal immigrants are fraudulently getting 
Medicaid coverage by claiming they are citizens, and he did not 
recommend any new requirements for documentation of citizenship.
  If the requirement to document citizenship will not affect illegal 
immigrants, who are in fact not using the Medicaid program, than we 
must ask ourselves who will be affected by this requirement?
  Let's think about the senior with Alzheimer's disease and the 
difficulty she experiences in remembering the name of her daughter, let 
alone where she placed her birth certificate. Let us think about the 
families who survived Hurricane Katrina, who lost their homes with all 
their possessions, including their passports. Let us think about the 
children being raised by cash-strapped grandparents and other 
relatives, who will incur additional costs for obtaining required 
documents.
  About one out of every twelve U.S.-born adults, or 1.7 million 
Americans, who have incomes below $25,000 report that they do not have 
a U.S. passport or birth certificate in their possession. In addition, 
studies have shown that there are up to 2.9 million Medicaid-eligible 
children without such documentation.
  These figures are even higher for other populations. While 5.7 
percent of all adults at all income levels report they lack birth 
certificates or passports, this percentage rises to 7 percent for 
senior citizens age 65 or older, and 9 percent each for African 
American adults, adults without a high school diploma and adults living 
in rural areas. Notably, these figures do not include many other groups 
who would also experience difficulty in securing these documents, such 
as Native Americans born in home settings, nursing-home residents, 
Hurricane Katrina survivors, and homeless individuals. The 
documentation requirements in section 6036 would apply to all current 
beneficiaries and future applicants, allowing for no exceptions, even 
for those with serious mental or physical disabilities such as 
Alzheimer's disease or those who lack documents due to homelessness or 
a disaster such as Hurricane Katrina.
  The costs to individuals applying for Medicaid coverage is matched by 
the overwhelming administrative costs associated with the documentation 
requirements. If birth certificates or passports are required for 
Medicaid enrollment, approximately 50 percent of

[[Page S1427]]

state officials have reported that they would have to hire additional 
personnel to handle the increased workload with significant, additional 
administrative and financial costs. The National Association for Public 
Health Statistics and Information Systems predicts a 50 percent 
increase in the volume of birth certificate requests if requirements 
for birth certificates or passports for Medicaid applications are 
imposed, resulting in significant delays in processing all birth 
certificate applications. State resources are already stretched too 
thin, and we should not impose additional and unnecessary burdens.
  At a time when this administration is touting health care tax breaks, 
which will benefit those who need the least help, it is critical that 
members of Congress remember the worst off and the most vulnerable 
members of our society. Medicaid is their lifeline to a healthy and 
productive future, and we should not obstruct access to this program.
  Senator Akaka, Senator Bingaman and I have introduced this bill to 
eliminate requirements for citizenship documentation from Medicaid, and 
I urge all of my colleagues to support us in passing this critical act.
                                 ______