[Congressional Record Volume 153, Number 45 (Thursday, March 15, 2007)]
[Senate]
[Pages S3215-S3220]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Akaka, Mr. Kerry, and Mrs. 
        Clinton):
  S. 909. A bill to amend title XIX of the Social Security Act to 
permit States, at their option, to require certain individuals to 
present satisfactory documentary evidence of proof of citizenship or 
nationality for purposes of eligibility for Medicaid, and for other 
purposes; to the Committee on Finance.
  Mr. BINGAMAN. Mr. President, the legislation I am introducing today 
is designed to make several very important changes to current law to 
ensure that U.S. citizens receive the Medicaid to which they are 
entitled.
  Since July 1, 2006, most U.S. citizens and nationals applying for or 
renewing their Medicaid coverage face a new Federal requirement to 
provide documentation of their citizenship status. Recent reports 
indicate that tens-of-thousands of U.S. citizens, and in particular 
children, inappropriately are being denied Medicaid benefits simply 
because they don't have access to newly required documentation. The 
articles below and report by the Center on Budget and Policy Priorities 
highlight this very serious problem. Hospitals, physicians, and 
pharmacies may not be willing to treat these individuals until they 
have a source of payment, but they cannot qualify for Medicaid until 
they produce a birth certificate and ID.
  This new Federal requirement was added to Medicaid by the Deficit 
Reduction Act of 2005, DRA, enacted February 8, 2006. The Tax Relief 
and Health Care Act of 2006, TRHCA, signed into law December 20, 2006, 
included some amendments to the DRA citizenship documentation 
requirement, primarily to exempt certain groups. Prior to enactment of 
the DRA, States were permitted to use their discretion in requiring 
such citizenship documentation.
  Under Section 6036 of the DRA, citizens applying for or renewing 
their Medicaid coverage must provide ``satisfactory documentary 
evidence of citizenship or nationality.'' The DRA specifies documents 
that are acceptable for this purpose and authorizes the HHS Secretary 
to designate additional acceptable documents. No Federal matching funds 
are available for services provided to individuals who declare they are 
citizens or nationals unless the State obtains satisfactory evidence of 
their citizenship or determines that they are subject to a statutory 
exemption.
  It is important to note that citizenship documentation requirements 
do not affect Medicaid rules relating to immigrants--they apply to 
individuals claiming to be citizens. Most new legal immigrants are 
excluded from Medicaid during their first 5 years in the U.S. and 
undocumented immigrants remain eligible for Medicaid emergency services 
only.
  The legislation I am introducing would make several very important 
changes to current law to ensure that U.S. citizens receive the 
Medicaid to which they are entitled.
  First, the legislation would restore citizenship verification to a 
State option. Specifically, States would be permitted to determine when 
and to what extent citizenship verification is required of U.S. 
Citizens. States would also be permitted to utilize the standards most 
appropriate to the their population as long as such standards were no 
more stringent than those currently used by the Social Security 
Administration and includes native American tribal documents when 
appropriate.
  Second, the legislation would ensure that individuals are afforded a 
reasonable time period to provide citizenship documentation utilizing 
the same reasonable time period standard that is available to legal 
immigrants to provide satisfactory evidence of their immigration 
status.
  Third the legislation protects children who are U.S. citizens by 
virtue of being born in the United States from being denied coverage 
after birth because of citizenship verification requirements.
  Fourth, the legislation also clarifies ambiguities in federal law to 
ensure that these citizen children, regardless of the immigration 
status of their parents, are treated like all other low-income children 
born in the United States and are deemed eligible to receive Medicaid 
services for one year.
  Finally, the legislation also ensures that the thousands of citizen 
children and adults, who were erroneously denied Medicaid coverage, may 
receive

[[Page S3216]]

retroactive Medicaid eligibility for coverage they were inappropriately 
denied because of citizenship verification requirements.
  I urge my colleagues in the Senate to support this critical 
legislation, which protects low-income U.S. citizens from being 
inappropriately denied Medicaid coverage because of lack of 
documentation.
  I ask unanimous consent that the text of the bill and supporting 
documentation be printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                 S. 909

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

     SECTION 1. STATE OPTION TO REQUIRE CERTAIN INDIVIDUALS TO 
                   PRESENT SATISFACTORY DOCUMENTARY EVIDENCE OF 
                   PROOF OF CITIZENSHIP OR NATIONALITY FOR 
                   PURPOSES OF ELIGIBILITY FOR MEDICAID.

       (a) In General.--Section 1902(a)(46) of the Social Security 
     Act (42 U.S.C. 1396a(a)(46)) is amended--
       (1) by inserting ``(A)'' after ``(46)'';
       (2) by adding ``and'' after the semicolon; and
       (3) by adding at the end the following new subparagraph:
       ``(B) at the option of the State and subject to section 
     1903(x), require that, with respect to an individual (other 
     than an individual described in section 1903(x)(1)) who 
     declares to be a citizen or national of the United States for 
     purposes of establishing initial eligibility for medical 
     assistance under this title (or, at State option, for 
     purposes of renewing or redetermining such eligibility to the 
     extent that such satisfactory documentary evidence of 
     citizenship or nationality has not yet been presented), there 
     is presented satisfactory documentary evidence of citizenship 
     or nationality of the individual (using criteria determined 
     by the State, which shall be no more restrictive than the 
     criteria used by the Social Security Administration to 
     determine citizenship, and which shall accept as such 
     evidence a document issued by a federally-recognized Indian 
     tribe evidencing membership or enrollment in, or affiliation 
     with, such tribe (such as a tribal enrollment card or 
     certificate of degree of Indian blood, and, with respect to 
     those federally-recognized Indian tribes located within 
     States having an international border whose membership 
     includes individuals who are not citizens of the United 
     States, such other forms of documentation (including tribal 
     documentation, if appropriate) that the Secretary, after 
     consulting with such tribes, determines to be satisfactory 
     documentary evidence of citizenship or nationality for 
     purposes of satisfying the requirement of this 
     subparagraph));''.
       (b) Limitation on Waiver Authority.--Notwithstanding any 
     provision of section 1115 of the Social Security Act (42 
     U.S.C. 1315), or any other provision of law, the Secretary of 
     Health and Human Services may not waive the requirements of 
     section 1902(a)(46)(B) of such Act (42 U.S.C. 
     1396a(a)(46)(B)) with respect to a State.
       (c) Conforming Amendments.--Section 1903 of such Act (42 
     U.S.C. 1396b) is amended--
       (1) in subsection (i)--
       (A) in paragraph (20), by adding ``or'' after the 
     semicolon;
       (B) in paragraph (21), by striking ``; or'' and inserting a 
     period; and
       (C) by striking paragraph (22); and
       (2) in subsection (x) (as amended by section 405(c)(1)(A) 
     of division B of the Tax Relief and Health Care Act of 2006 
     (Public Law 109-432))--
       (A) by striking paragraphs (1) and (3);
       (B) by redesignating paragraph (2) as paragraph (1);
       (C) in paragraph (1), as so redesignated, by striking 
     ``paragraph (1)'' and inserting ``section 1902(a)(46)(B)''; 
     and
       (D) by adding at the end the following new paragraph:
       ``(2) In the case of an individual declaring to be a 
     citizen or national of the United States with respect to whom 
     a State requires the presentation of satisfactory documentary 
     evidence of citizenship or nationality under section 
     1902(a)(46)(B), the individual shall be provided at least the 
     reasonable opportunity to present satisfactory documentary 
     evidence of citizenship or nationality under this subsection 
     as is provided under clauses (i) and (ii) of section 
     1137(d)(4)(A) to an individual for the submittal to the State 
     of evidence indicating a satisfactory immigration status.''.

     SEC. 2. CLARIFICATION OF RULES FOR CHILDREN BORN IN THE 
                   UNITED STATES TO MOTHERS ELIGIBLE FOR MEDICAID.

       Section 1903(x) of such Act (42 U.S.C. 1396b(x)), as 
     amended by section 1(c)(2), is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (C), by striking ``or'' at the end;
       (B) by redesignating subparagraph (D) as subparagraph (E); 
     and
       (C) by inserting after subparagraph (C) the following new 
     subparagraph:
       ``(D) pursuant to the application of section 1902(e)(4) 
     (and, in the case of an individual who is eligible for 
     medical assistance on such basis, the individual shall be 
     deemed to have provided satisfactory documentary evidence of 
     citizenship or nationality and shall not be required to 
     provide further documentary evidence on any date that occurs 
     during or after the period in which the individual is 
     eligible for medical assistance on such basis); or''; and
       (2) by adding at the end the following new paragraph:
       ``(3) Nothing in subparagraph (A) or (B) of section 
     1902(a)(46), the preceding paragraphs of this subsection, or 
     the Deficit Reduction Act of 2005, including section 6036 of 
     such Act, shall be construed as changing the requirement of 
     section 1902(e)(4) that a child born in the United States to 
     an alien mother for whom medical assistance for the delivery 
     of such child is available as treatment of an emergency 
     medical condition pursuant to subsection (v) shall be deemed 
     eligible for medical assistance during the first year of such 
     child's life.''.

     SEC. 3. EFFECTIVE DATE.

       (a) Retroactive Application.--The amendments made by this 
     Act shall take effect as if included in the enactment of the 
     Deficit Reduction Act of 2005 (Public Law 109-171; 120 Stat. 
     4).
       (b) Restoration of Eligibility.--In the case of an 
     individual who, during the period that began on July 1, 2006, 
     and ends on the date of enactment of this Act, was determined 
     to be ineligible for medical assistance under a State 
     Medicaid program solely as a result of the application of 
     subsections (i)(22) and (x) of section 1903 of the Social 
     Security Act (as in effect during such period), but who would 
     have been determined eligible for such assistance if such 
     subsections, as amended by sections 1 and 2, had applied to 
     the individual, a State may deem the individual to be 
     eligible for such assistance as of the date that the 
     individual was determined to be ineligible for such medical 
     assistance on such basis.
                                  ____


               [From the Associated Press, Nov. 29, 2006]

       KS: Sebelius: New Medicaid Rules Could Cost State Millions

                            (By John Hanna)

       The state could face millions of dollars in additional 
     costs because of federal rules requiring Medicaid recipients 
     to verify their citizenship, Gov. Kathleen Sebelius said 
     Wednesday.
       Sebelius said she's worried the state will have to pick up 
     the full cost of caring for some poor, frail and elderly 
     Kansans who are living in nursing homes, instead of sharing 
     the cost with the federal government. Also, she said, she 
     will propose adding state employees to verify the citizenship 
     status of Medicaid recipients and applicants.
       The governor told reporters she hopes Congress reviews the 
     issue and other attempts to prevent illegal immigrants from 
     obtaining social services or using driver's licenses as 
     identification.
       ``There was no input from the states on how realistic these 
     were or what the cost was,'' Sebelius said during a brief 
     news conference following an unrelated meeting.
       Under Medicaid requirements that took effect July 1, 
     recipients must provide either a passport or two other 
     documents, such as a birth certificate and a driver's 
     license, to verify citizenship.
       While the measure is targeted at illegal immigrants, some 
     advocates for the needy have worried that citizens will 
     either lose or be denied services because they have trouble 
     finding the necessary documents.
       State officials say the number of Kansans covered by 
     Medicaid dropped almost 7 percent since July 1, down to 
     253,000 from 271,000. They believe much of the decline can be 
     attributed to the new requirements.
       Typically, every $1 the state spends on Medicaid is matched 
     by about $1.50 from the federal government. If someone loses 
     their coverage, then the state faces paying the entire bill 
     for their services, Sebelius said.
       ``You're at 100 percent state dollars or push them out the 
     door,'' she said.
       Also, Sebelius said, the state needs to ``ramp up'' its 
     staffing to handle the additional verification work. The 
     governor is working on the budget proposal she'll submit to 
     the 2007 Legislature, which convenes Jan. 8.
       ``We're certainly going to put some of them in place,'' she 
     said. ``We're trying to make a careful analysis of how many 
     we need.''
       She said that if the state refuses to comply with the law, 
     it could face the loss of all federal health care dollars.
       ``We don't have a lot of latitude to say we're not going to 
     do this,'' she said. ``There are literally hundreds of 
     millions of dollars at stake.''
       Meanwhile, Sebelius expressed concern about a federal law 
     on driver's licenses passed last year.
       Starting in 2008, federal agencies won't treat a state's 
     licenses as valid ID unless a state requires license 
     applicants to document that they're living in the United 
     States legally. Lack of ID could prevent someone from 
     entering a federal building or boarding a plane.
       Sebelius said the law will require local driver's licenses 
     offices to certify that someone has the proper documentation 
     and to store the information.
       ``Exactly how that's going to happen, we're not quite 
     sure,'' Sebelius said. ``We don't basically have any of the 
     equipment that's required to do that in any of the rural 
     areas.''

[[Page S3217]]

     
                                  ____
               [From the Associated Press, Nov. 29, 2006]

    KS: Thousands In Kansas Off Medicaid Following Citizenship Rules

       Thousands of low-income Kansans have lost or been denied 
     state health care coverage because of new rules requiring 
     them to prove they are American citizens, state officials 
     say.
       Since the federally mandated rules took effect July 1, the 
     number of Medicaid recipients in Kansas has decreased by 
     about 18,000, to 253,000. While officials can't determine 
     exactly how much of the 7 percent drop can be attributed to 
     the new rules, they believe much of it can.
       ``The impact to the consumer has been severe,'' said John 
     Anzivino, a vice president for MAXIMUS, a Reston, Va., 
     company that helps administer the joint federal-state 
     Medicaid program in Kansas. ``From our perspective, this has 
     possibly been the most dramatic change and challenge to the 
     Medicaid program since its inception.''
       The new rules were included in last year's federal deficit 
     reduction law and were designed to prevent illegal immigrants 
     from enrolling in the state programs providing health 
     coverage.
       But consumer advocates said many vulnerable people who 
     legitimately were eligible for assistance would lose coverage 
     because they couldn't produce the necessary documentation.
       ``We expect that many of these that have lost coverage will 
     regain coverage once they have gathered and provided the 
     necessary documentation,'' Marcia Nielsen, executive director 
     of the Kansas Health Policy Authority, told the Lawrence 
     Journal-World. ``They will, however, experience a gap in 
     coverage that could prove to be significant for some.''
       Medicaid applicants can prove their citizenship by 
     providing a passport. Or they can provide other documents 
     that verify both their citizenship, such as a birth 
     certificate, and their identities, such as a driver's 
     license.
       Anzivino said most people seeking benefits don't have a 
     passport and are left scrambling to find birth certificates 
     and other documents.
       The number of calls each month to a Kansas Medicaid 
     clearinghouse has more than doubled to 49,000 from 23,000, 
     official said.
       Meanwhile, Rep. Dennis Moore, a Democrat whose district is 
     centered on the state's portion of the Kansas City area, said 
     federal officials were aware of states' problems with the new 
     rules and probably would work on it when the new Congress 
     takes office in January.
                                  ____


                [From the Baltimore Sun, Jan. 22, 2007]

  MD: Medicaid Called Harder for Poor; Health Advocates Fear Document 
                   Rules Cause Many To Lose Coverage

                         (By Kelly Brewington)

       Public health advocates fear that a new federal regulation 
     requiring Medicaid applicants to supply proof of identity and 
     citizenship has resulted in thousands of poor Marylanders 
     losing their health insurance.
       The requirement, part of the federal Deficit Reduction Act 
     that went into effect in Maryland in September, was designed 
     to prevent illegal immigrants from fraudulently receiving 
     Medicaid, the nation's premier health insurance program for 
     the poor.
       But advocates and health officers in some Maryland counties 
     insist the rule has burdened citizens who need health care 
     the most and is likely responsible for thousands of 
     Marylanders being kicked off the Medicaid rolls.
       ``It's a completely unnecessary law and Congress made a big 
     mistake in passing it,'' said Laurie Norris, an attorney with 
     the Public Justice Center. ``The people who are on Medicaid 
     in Maryland are supposed to be on Medicaid.``
       The announcement of the regulations last June sparked an 
     uproar among advocates and state health officials, who were 
     given a July 1 deadline to enforce the mandate or risk losing 
     federal funding. The officials complained they were not given 
     enough time to train staff and inform Maryland's 
     approximately 650,000 affected Medicaid recipients that they 
     must furnish such identification as birth certificates, 
     driver's licenses and passports.
       Nationwide, advocates feared huge enrollment declines, 
     saying many of Medicaid's neediest recipients don't possess 
     the necessary documents and would have to struggle to come up 
     with the money to obtain them. Maryland, for instance, does 
     not automatically issue birth certificates, which may be 
     ordered for $12.
       Last summer, the federal government exempted from the 
     requirement elderly and disabled Medicaid recipients who 
     receive Supplemental Security Income from Social Security, 
     and last month it extended the exemption to foster children. 
     Still, states such as Virginia, Iowa, Wisconsin and New 
     Hampshire noted plunging Medicaid enrollment figures and 
     backlogs related to the regulation, according to a report 
     released earlier this month by the Kaiser Family Foundation's 
     Commission on Medicaid and the Uninsured. In Virginia, 12,000 
     children have been dropped from Medicaid rolls in the 
     requirement's first four months of implementation, the report 
     stated.
       In Maryland, Medicaid enrollment numbers are down overall, 
     but state health officials say they are unsure whether the 
     drop is due to the new rule, a point that has frustrated 
     county health officers eager for evidence of the regulation's 
     impact that they could use to push for change.
       From August through December 2006, the state Department of 
     Health and Mental Hygiene recorded about 6,000 fewer Medicaid 
     enrollees statewide compared with the same period in 2005. 
     Maryland officials say the enrollment computer system is not 
     configured to determine the exact cause of the decline.
       ``It is imperative that the state disclose data to 
     demonstrate the impact of this law,'' said Dr. Joshua 
     Sharfstein, Baltimore health commissioner. ``There are 
     warning signs that a major erosion in health coverage could 
     be happening as a result of this new law. This is really 
     concerning. . . .''
       Charles Lehman, who oversees eligibility issues in the 
     state's Medicaid office, said the agency has concentrated its 
     limited resources on ``keeping people on Medicaid rather than 
     tracking the people going off.''
       ``It may not sound like we are doing everything we can, but 
     really, we are, with the resources we have,'' he said. ``It's 
     not just the clients, not just the caseworkers, everyone has 
     been impacted by this.''
       Officials said while applicants are typically allowed a 30-
     day grace period, caseworkers will not discontinue the 
     insurance if applicants are ``making a good-faith effort'' to 
     obtain the documents.
       ``I think we have done a good job applying the law 
     appropriately but not in a way that arbitrarily cuts people 
     off,'' said Lehman. ``We have made our best effort to keep 
     people on.''
       The department has spent $1 million for a toll-free number 
     to help applicants, 866-676-5880.
       The state health department has also partnered with other 
     state databases to verify the citizenship and identity of 
     beneficiaries, without requiring recipients to hand over 
     documents. In July, the agency searched birth certificate 
     records for about 600,000 Medicaid enrollees at the cost of 
     $12 per search, said Lehman.
       But the effort has not gone as smoothly as hoped, said 
     Norris, with the Public Justice Center. For instance, the 
     databases are not automatically synched--staff must print out 
     the information and check it by hand.
       ``The state has been severely hampered in information 
     technology,'' she said.
       Norris alerted state lawmakers to the problem at a briefing 
     in Annapolis last week. The problems come during a push by 
     advocates and some lawmakers and business groups to expand 
     Medicaid and help about 780,000 uninsured Marylanders.
       Officials with local agencies have increased outreach and 
     said they have allowed people extra time to provide the 
     documents they need.
       Nevertheless, in Anne Arundel County, for example, denial 
     rates for the state's Medicaid program for pregnant women and 
     children have jumped from an average of 18 percent from June 
     through December 2005 to 42 percent for the same period in 
     2006.
       ``It's really shocking,'' said Frances Phillips, the 
     county's health officer. ``This is so serious because the 
     people we are talking about are either children with no 
     insurance and no way to access health care, or pregnant 
     women.''
       Many applicants eventually produce the documents and get 
     back on Medicaid, Phillips noted. But for vulnerable 
     populations, any discontinuation in coverage can be harmful, 
     she said.
       A health department program in which nurses make home 
     visits to women with at-risk pregnancies has focused on 
     educating women on the documentation. ``We just feel that 
     this is so critical,'' said Phillips. `` . . . We touch base 
     with the women, find out what is going on with them and make 
     sure they get insurance.''
       In Baltimore, outreach workers with Baltimore HealthCare 
     Access Inc., which assists some of the city's estimated 
     200,000 Medicaid enrollees, are making home visits and 
     contacting state agencies on applicants' behalf.
       The agency received $5,000 from the Abell Foundation to 
     help applicants cover the cost of documents.
       ``We are plowing away that money pretty quickly,'' said 
     Kathleen Westcoat, the organization's president.
       The funding helped Brenda Kent, 36, pay for her birth 
     certificate last month. She lost her wallet two months before 
     she was due to apply for Medicaid benefits for herself, her 
     twin sons and a daughter.
       ``I didn't know how I was supposed to get it,'' said Kent, 
     who does not work. ``If they didn't help me with the cost, it 
     would have taken me longer to do it.''
                                  ____


               [From the Associated Press, Sept. 1, 2006]

        NC: U.S. Citizenship Proof Required for Medicaid in N.C.

       A requirement that Medicaid recipients in North Carolina 
     prove they hold U.S. citizenship probably won't uncover a 
     large amount of fraud, a state official says.
       Starting Sept. 1, new Medicaid applicants and nearly every 
     current beneficiary must provide documentation of their 
     citizenship as part of a new federal law designed to prevent 
     illegal immigrants from receiving the health care coverage.
       ``I would be very surprised if we had a problem in our 
     state with any large number of people receiving benefits who 
     were not entitled to receive them,'' said Mark Benton, senior 
     deputy director for the state Division of Medical Assistance.
       The law was to have taken effect nationwide July 1, but 
     North Carolina delayed its start while it prepared for the 
     changes.

[[Page S3218]]

       Under the old rules, social services workers were supposed 
     to ask applicants about their citizenship status. They were 
     permitted to accept an applicant's word unless there was 
     reasonable doubt.
       Now, the person seeking Medicaid will have to provide a 
     U.S. passport, or an original birth certificate with a 
     driver's license, or other combinations of eligible 
     documents.
       Regardless of citizenship, people who need emergency care 
     will continue to receive it through Medicaid, although this 
     type of care is for a limited time period.
       Officials say there is no way to know how many illegal 
     immigrants are on Medicaid. Some argue illegal immigrants 
     aren't enrolling in large numbers in a government program 
     like this for fear of being deported.
       Illegal immigrants received emergency care of nearly $53 
     million in 2005, more than double the amount from 2000, 
     according to the division.
       The changes nationwide will save Medicaid, the government-
     run health care program for the poor and disabled, about $735 
     million by 2015, according to Congressional Budget Office 
     estimates.
                                  ____


                  Children Dropping Off Medicaid Rolls

       (AP) For several years, there has been a steady increase in 
     the number of children enrolling in Virginia's health 
     insurance program for the poor. Beginning July 1, state 
     officials say, an unprecedented slide began.
       Over the following five months, about 12,000 children 
     dropped off the state's Medicaid rolls.
       ``An entire year's growth has been wiped out,'' said 
     Cynthia Jones, chief deputy director for the state's 
     Department of Medical Assistance Services.
       The drop-off, Jones points out, began about the time a new 
     federal law took effect. The law states that U.S. citizens 
     applying for Medicaid or renewing their participation must 
     present proof of their citizenship and identity. The law 
     emerged out of concern that illegal immigrants were obtaining 
     access to health insurance coverage sponsored by the 
     government.
       But some officials say that's not who is losing coverage.
       Besides Virginia, some other states are also reporting 
     declines in children enrolled in Medicaid or a decline in 
     applications. They include Iowa, Louisiana, New Hampshire and 
     Wisconsin. Health researchers say they don't know if the 
     states are representative of a nationwide pattern.
       The states singled out as experiencing enrollment declines 
     were included in a report issued Tuesday by the Kaiser Family 
     Foundation, which conducts health research, and by the Center 
     on Budget and Policy Priorities, a liberal think tank.
       The states experiencing declines are adamant that U.S. 
     citizens and certain legal immigrants are dropping off the 
     Medicaid rolls, not illegal immigrants.
       ``There is no evidence that the decline is due to 
     undocumented aliens leaving the program,'' said Anita Smith 
     of the Iowa Department of Human Services. ``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.''
       Medicaid is a health insurance program serving about 55 
     million people that is financed by the federal government and 
     the states. The declines cited would indicate that just a 
     fraction of the people enrolled in the program have dropped 
     out as a result of the documentation requirements, but they 
     do represent vulnerable populations, such as pregnant women 
     and children.
       ``We've delayed coverage for those children, and if those 
     children need medical care, there's going to be ramifications 
     for them,'' said Donna Cohen Ross, outreach director for the 
     Center on Budget and Policy Priorities.
       But the agency that oversees Medicaid questioned claims 
     that would link enrollment declines to the new documentation 
     requirements.
       ``We believe we've given the states tools they need to both 
     implement the law and provide sufficient flexibility to 
     assist individuals in establishing their citizenship,'' said 
     Jeff Nelligan, spokesman for the Centers for Medicare and 
     Medicaid Services. ``We continue to monitor state 
     implementation and are not aware of any data that shows there 
     are significant barriers to enrollment.
       ``If states are experiencing difficulties, they should 
     bring them to our attention as we certainly want to 
     understand why they are not using the flexibilities we have 
     provided.''
       After Congress passed the documentation requirements, 
     Medicaid officials released rules that established which 
     documents would suffice in meeting the law.
       Primary evidence, namely a U.S. passport or a certificate 
     of U.S. citizenship, is considered the ideal. Secondary 
     evidence or lower-tier evidence must be accompanied by a 
     document showing identity. Such evidence includes birth 
     certificates, insurance records, and as a last resort, 
     written affidavits.
       Original documents or copies certified by the issuing 
     agency are required by the regulation. Copies are not 
     acceptable. The federal government excluded millions of 
     seniors and disabled people from the new documentation 
     requirements. In December, Congress also approved an 
     exception for foster children.
                                  ____


 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 six months following implementation of the new 
     requirement, states are beginning to report 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.
       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 
     and New Hampshire. The data show the following:
       All six 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.

[[Page S3219]]

       The Medicaid enrollment declines identified in this memo 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 memo as having sustained a drop in 
     Medicaid enrollment saw its food stamp caseload rise during a 
     similar period.
       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 five months--between August and December 
     2006--a total of 14,034 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: 69 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 17 percent who did not provide the required 
     citizenship documents and 14 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.
       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  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: In two months--September and October of 2006--
     Louisiana experienced a net loss of more than 7,500 children 
     in its Medicaid program despite a vigorous back-to-school 
     outreach effort and a significant increase in applications 
     during the month of September.
       According to state officials, the enrollment decline is not 
     driven by population loss from Hurricane Katrina and 
     contrasts dramatically with enrollment spikes that usually 
     occur in September and have reached up to 13,000 in the past. 
     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.
       Virginia: Since July, enrollment of children in the state's 
     Medicaid program has declined steadily each month. By the end 
     of November, the total net decline stood at close to 12,000 
     children. During the same period, enrollment of children in 
     the state's separate SCHIP program, not subject to the new 
     requirement, increased. Virginia also reported a substantial 
     backlog in application processing at its central processing 
     site, with 2,600 cases pending approval for Medicaid in 
     September, 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.
       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.


                  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. Their findings are as 
     follows:
       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.
       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.''

[[Page S3220]]

       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.
                                 ______