[Congressional Record (Bound Edition), Volume 152 (2006), Part 3]
[Senate]
[Pages 2901-2904]
[From the U.S. Government Publishing Office, www.gpo.gov]




              REPEAL OF MEDICAID VERIFICATION REQUIREMENT

  Mr. AKAKA. Mr. President, we must enact my legislation, S. 2305, 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. Congress must act to repeal 
this shortsighted policy before it goes into effect July 1, 2006, 
because it will create barriers to health care, is unnecessary, and 
will be an administrative burden to implement.
  Mr. President, I ask unanimous consent that additional letters of 
support

[[Page 2902]]

for S. 2305 from the California Immigrant Welfare Collaborative, the 
Coalition for Humane Immigrant Rights of Los Angeles, the National 
Health Law Program, Families USA, the Children's Defense Fund, the 
National Association for the Advancement of Colored People, and the 
American Public Health Association, be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                              California Immigrant


                                        Welfare Collaborative,

                                Sacramento, CA, February 16, 2006.
     Senator Daniel Kahikina Akaka,
     U.S. Senate,
     Washington, DC.
       Dear Senator Akaka: The California Immigrant Welfare 
     Collaborative (CIWC) is a statewide partnership of four 
     immigrant rights organizations: Asian Pacific American Legal 
     Center of Southern California, Coalition for Humane Immigrant 
     Rights of Los Angeles, National Immigration Law Center and 
     Services, Immigrant Rights and Education Network of San Jose. 
     We work directly in communities as well as with policy makers 
     in order to respond to changes in health and welfare laws and 
     to advocate for low-income immigrants.
       We are writing in support of your Senate 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 nationality as a 
     condition for receipt of medical assistance under the 
     Medicaid program. This provision would apply to all current 
     beneficiaries and future applicants, allowing 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. 
     About 49 million U.S.-born citizens (and two million 
     naturalized citizens) who are covered by Medicaid over the 
     course of a year would be required to submit these documents 
     or forfeit their health insurance coverage. New Medicaid 
     applicants also would have to meet this requirement.
       According to a recent survey conducted by the Center on 
     Budget and Policy Priorities and by the Opinion Research 
     Corporation the new requirement could have large consequences 
     on the health insurance coverage of millions of low-income 
     U.S. citizens. Key findings from the survey include:
       About one in every twelve (8 percent) U.S.-born adults age 
     18 or older who have incomes below $25,000 report they do not 
     have a U.S. passport or U.S. birth certificate in their 
     possession. Applying this percentage to the number of adult 
     citizens covered by Medicaid over the course of a year 
     indicates that approximately 1.7 million U.S.-born adults who 
     are covered by Medicaid could lose their health insurance 
     because of the new requirement or experience delays in 
     obtaining coverage as they attempt to secure these documents.
       More than one tenth of U.S.-born adults with children who 
     have incomes below $25,000 reported they did not have a birth 
     certificate or passport for at least one of their children. 
     This indicates that between 1.4 and 2.9 million children 
     enrolled in Medicaid appear not to have the paperwork 
     required.
       Taken together, the survey indicates that Medicaid coverage 
     could be in jeopardy for 3.2 to 4.6 million U.S.-born 
     citizens because they do not have a U.S. passport or birth 
     certificate readily available.
       Some types of citizens would shoulder a greater risk of 
     losing Medicaid than others because they are less likely to 
     have the required documents. While 5.7 percent of all adults 
     in the survey (i.e., adults at all income levels) reported 
     they lack these documents, the percentage was larger for 
     certain groups: African American adults: 9 percent; Senior 
     citizens 65 or older: 7 percent; Adults without a high school 
     diploma: 9 percent; Adults living in rural areas: 9 percent.
       These data and earlier research also suggest that elderly 
     African Americans with low incomes may experience particular 
     difficulties because a significant number of them were never 
     issued birth certificates.
       These results are conservative as many of those who would 
     be most likely to experience difficulty in securing these 
     documents--such as nursing-home residents, Katrina survivors 
     living in temporary facilities, and homeless people--were not 
     represented in the survey. Had the survey included such 
     people, the percentage of people likely to be harmed by the 
     requirement would almost certainly have been found to be 
     higher.
       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. 
     We see no flexibility in the amendments as passed to allow 
     for families with no disposable income to obtain the birth 
     certificates timely.
       We understand that the new requirement for documentation in 
     Medicaid is intended to prevent undocumented immigrants from 
     declaring they are citizens and obtaining Medicaid benefits. 
     The HHS Inspector General however found no substantial 
     evidence that this is occurring. Instead, the principal 
     effect of the provision would likely be to endanger health-
     care coverage for millions of poor U.S. citizens, because 
     substantial numbers of native-born citizens do not have a 
     passport or birth certificate readily available. We also 
     anticipate the provision will add yet another barrier and 
     have a chilling effect on the many immigrants who are 
     federally eligible for Medicaid but may get turned away due 
     to confusion in the rules when this is implemented in all 50 
     states. We support your efforts to repeal this amendment as 
     it could have terrible consequences for all Medicaid 
     recipients.
           Sincerely,
                                               Jeanette Zanipatin,
     Statewide Policy Analyst/CIWC.
                                  ____

                                          The Coalition for Humane


                              Immigrant Rights of Los Angeles,

                                                  Los Angeles, CA.
     Senator Daniel Kahikina Akaka,
     U.S. Senate,
     Washington, DC.
       Dear Senator Akaka: The Coalition for Humane Immigrant 
     Rights of Los Angeles (CHIRLA) is a multi-ethnic nonprofit 
     coalition founded in 1986 to advance the human and civil 
     rights of immigrants and refugees in Los Angeles; promotes 
     harmonious multi-ethnic and multi-racial human relations; and 
     through coalition-building, advocacy, community education and 
     organizing, empower immigrants and their allies to build a 
     more just society.
       We are writing in support of your Senate 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 nationality as a 
     condition for receipt of medical assistance under the 
     Medicaid program. This provision would apply to all current 
     beneficiaries and future applicants, allowing 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. 
     About 49 million U.S.-born citizens (and two million 
     naturalized citizens) who are covered by Medicaid over the 
     course of a year would be required to submit these documents 
     or forfeit their health insurance coverage. New Medicaid 
     applicants also would have to meet this requirement.
       According to a recent survey conducted by the Center on 
     Budget and Policy Priorities and by the Opinion Research 
     Corporation the new requirement could have large consequences 
     on the health insurance coverage of millions of low-income 
     U.S. citizens. Key findings from the survey include:
       About one in every twelve (8 percent) U.S.-born adults age 
     18 or older who have incomes below $25,000 report they do not 
     have a U.S. passport or U.S. birth certificate in their 
     possession. Applying this percentage to the number of adult 
     citizens covered by Medicaid over the course of a year 
     indicates that approximately 1.7 million U.S.-born adults who 
     are covered by Medicaid could lose their health insurance 
     because of the new requirement or experience delays in 
     obtaining coverage as they attempt to secure these documents.
       More than one tenth of U.S.-born adults with children who 
     have incomes below $25,000 reported they did not have a birth 
     certificate or passport for at least one of their children. 
     This indicates that between 1.4 and 2.9 million children 
     enrolled in Medicaid appear not to have the paperwork 
     required.
       Taken together, the survey indicates that Medicaid coverage 
     could be in jeopardy for 3.2 to 4.6 million U.S.-born 
     citizens because they do not have a U.S. passport or birth 
     certificate readily available.
       Some types of citizens would shoulder a greater risk of 
     losing Medicaid than others because they are less likely to 
     have the required documents. While 5.7 percent of all adults 
     in the survey (i.e., adults at all income levels) reported 
     they lack these documents, the percentage was larger for 
     certain groups: African American adults: 9 percent; senior 
     citizens 65 or older: 7 percent; adults without a high school 
     diploma: 9 percent; and adults living in rural areas: 9 
     percent.
       These data and earlier research also suggest that elderly 
     African Americans with low incomes may experience particular 
     difficulties because a significant number of them were never 
     issued birth certificates.
       These results are conservative as many of those who would 
     be most likely to experience difficulty in securing these 
     documents--such as nursing-home residents, Katrina survivors 
     living in temporary facilities, and homeless people--were not 
     represented in the survey. Had the survey included such 
     people, the percentage of people likely to be harmed by the 
     requirement would almost certainly have been found to be 
     higher.

[[Page 2903]]

       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. 
     We see no flexibility in the amendments as passed to allow 
     for families with no disposable income to obtain the birth 
     certificates timely.
       We understand that the new requirement for documentation in 
     Medicaid is intended to prevent undocumented immigrants from 
     declaring they are citizens and obtaining Medicaid benefits. 
     The HHS Inspector General however found no substantial 
     evidence that this is occurring.
       Instead, the principal effect of the provision would likely 
     be to endanger health-care coverage for millions of poor U.S. 
     citizens, because substantial numbers of native-born citizens 
     do not have a passport or birth certificate readily 
     available. We also anticipate the provision will add yet 
     another barrier and have a chilling effect on the many 
     immigrants who are federally eligible for Medicaid but may 
     get turned away due to confusion in the rules when this is 
     implemented in all 50 states. We support your efforts to 
     repeal this amendment as it could have terrible consequences 
     for all Medicaid recipients.
           Sincerely,
                                                   Joseph Villela,
     State Policy Advocate.
                                  ____



                                  National Health Law Program,

                                Washington, DC, February 16, 2006.
     Senator Daniel K. Akaka,
     Senate Hart Office Building,
     Washington, DC.
       Dear Senator Akaka, The National Health Law Program (NHeLP) 
     supports the repeal of Section 6036 of the Deficit Reduction 
     Act. This section requires documentation evidencing 
     citizenship or nationality as a condition of receipt of 
     Medicaid. The arbitrary and unnecessary documentation 
     requirements embedded in Section 6036 will adversely and 
     disproportionately deny medical care to elderly, minority, 
     and rural U.S. citizens.
       Currently, citizens are allowed to self-declare their 
     citizenship under penalty of perjury when they apply for 
     Medicaid. Proponents of Section 6036 suggest the provision 
     will prevent immigrants from falsely obtaining Medicaid by 
     claiming they are citizens. Yet the Office of the Inspector 
     General of the Department of Health and Human Services 
     conducted a comprehensive review of this subject and did not 
     recommend new documentation requirements such as those 
     contained in Section 3145, and the Centers for Medicare & 
     Medicaid Services concurred in that judgment.
       Rather, to the extent that Section 6036 would produce cost 
     savings, it would do so by denying desperately needed health 
     care coverage to many of this country's neediest native-born 
     citizens, especially those who are African American, Native 
     American, elderly and/or born in rural areas. For example, a 
     study by the Center on Budget and Policy Priorities noted 
     that approximately 1.7 million adult citizens and 1.4 to 2.9 
     million citizen children on Medicaid do not have a passport 
     or birth certificate available at home. Some of these 
     individuals cannot get a birth certificate because they were 
     not born in hospitals. For example, a 1950 study found that 
     one out of five African Americans lacked a birth 
     registration. And the difficultly of obtaining the 
     documentation, especially for those with mental disabilities, 
     will effectively preclude eligible individuals from enrolling 
     in Medicaid.
       Even without its likely discriminatory impact, Section 6036 
     represents bad policy. Adding new paperwork requirements 
     imposes unnecessary delays at a time when many need prompt 
     medical coverage. Individuals could face long delays in 
     getting birth certificates due to the high volume of requests 
     that state vital statistics offices will need to field. 
     Further, Section 6036 effectively creates an application fee 
     for Medicaid--a passport currently costs $97.00; copies of a 
     birth certificate can cost $5 to $23. As a result, native-
     born citizens poor enough to qualify for Medicaid will often 
     be too poor to prove that they qualify because they cannot 
     afford the required documentation.
       We applaud your introduction of a bill to repeal Section 
     6036. Please feel free to contact Mara Youdelman at 202-289-
     7661 if you would like to discuss this or any other issue 
     about which we may be of assistance.
           Sincerely,
                                                Laurence M. Lavin,
     Director.
                                  ____

                                    Washington, DC, Feb. 21, 2006.
     Senator Daniel K. Akaka,
     Hart Senate Office Building,
     Washington, DC.
       Dear Senator Akaka: Families USA thanks you for introducing 
     S. 2305, a bill that would remove provisions requiring 
     Medicaid recipients to prove their citizenship by producing a 
     passport or birth certificate, and we hope to see your 
     proposed bill enacted into law.
       We are concerned that increasing documentation requirements 
     to access Medicaid would wrongfully block many native-born 
     American citizens and legal immigrants that qualify for 
     Medicaid from enrolling. In fact, 5.7% of all adults at all 
     income levels report that they lack birth certificates or 
     passports, and that number is even higher for African-
     Americans, senior citizens, Americans residing in rural 
     areas, and foster children. The Center on Budget and Policy 
     Priorities estimates that more than 51 million individuals 
     would be burdened by having to produce this additional 
     documentation. If the documentation provisions are not 
     repealed, then otherwise eligible beneficiaries would be 
     unable to prove their own citizenship and therefore be forced 
     to go without health care, adding to our nation's already 
     burgeoning pool of 46 million uninsured.
       The Office of the Inspector General of the Department of 
     Health and Human Services concluded that no evidence exists 
     that shows that immigrants are enrolling in Medicaid by 
     claiming to be U.S. citizens. Since government officials 
     investigating the matter concluded that there is no problem, 
     and since enacting any provisions that would require 
     beneficiaries to show more documents would cost millions of 
     dollars in increased administrative expenses to a number of 
     government agencies, Families USA believes policies calling 
     for more documentation to be neither prudent nor responsible 
     uses of taxpayers' dollars.
       Denying Medicaid to some of our Nation's neediest citizens 
     in order to chase the phantom problem of illegal immigrants 
     dubiously enrolling in Medicaid is an unacceptable 
     inefficiency that will increase the tax burden on hard-
     working Americans. We appreciate your insight in correcting 
     such a deficient policy and support your proposed 
     legislation.
           Sincerely,
                                                Ronald F. Pollack,
     Executive Director.
                                  ____



                                      Children's Defense Fund,

                                                    March 3, 2006.
     Hon. Daniel K. Akaka,
     U.S. Senate, Hart Senate Office Building, Washington, DC.
       Dear Senator Akaka: I am writing to offer the support of 
     the Children's Defense Fund for your bill, S. 2305, to repeal 
     one of the harmful amendments made to Title XIX of the Social 
     Security Act by the Deficit Reduction Act of 2005. We support 
     the elimination of the new requirement that U.S. citizens 
     eligible for Medicaid must confirm their citizenship by 
     submitting a birth certificate or passport (or other 
     naturalization papers) to receive Medicaid.
       This harmful and unnecessary provision will deny health 
     care to millions of children and adults who need it to 
     address their health and mental health needs and who are 
     legally entitled to it. A recent survey conducted by the 
     Opinion Research Corporation indicates that between 1.4 and 
     2.9 million children could lose their Medicaid coverage 
     because their U.S. born parents do not have birth 
     certificates or passports for them. In California and Texas, 
     just two of the states where CDF has offices, it is estimated 
     that as many as 11 million individuals could be denied health 
     care because of this requirement.
       While this provision was intended to prevent immigrants who 
     are not eligible for Medicaid from receiving it illegally, 
     the Centers for Medicare and Medicaid Services and the Office 
     of the Inspector General agree that there is no substantial 
     evidence that immigrants are attempting to obtain Medicaid by 
     falsely attesting to their citizenship.
       S. 2305 will help spare children and adults, who need 
     health and mental health care, from having to navigate 
     through additional red tape to receive benefits from the 
     Medicaid program. We applaud your effort to take a step 
     forward in making affordable health care available to those 
     who need it.
       The Children's Defense Fund looks forward to working with 
     you to ensure that all children receive health care without 
     the unwanted burden of producing unnecessary documentation.
           Sincerely,
     Marian Wright Edelman.
                                  ____

         Washington Bureau, National Association for the 
           Advancement of Colored People,
                                   Washington, DC, March, 3, 2006.
     Re NAACP support for S. 1580, the Healthcare Equality and 
         Accountability Act

     Hon. Daniel Akaka,
     U.S. Senate,
     Washington, DC.
       Dear Senator Akaka. On behalf of the National Association 
     for the Advancement of Colored People (NAACP), our nation's 
     oldest, largest and most widely-recognized grassroots civil 
     rights organization, I am writing to let you know that at our 
     recent Annual Meeting we passed a resolution expressing our 
     strong support of S. 1580, the Healthcare Equality and 
     Accountability Act.
       The fact of the matter is that huge discrepancies remain in 
     health care in the United

[[Page 2904]]

     States today. The quality and quantity of health care 
     services you receive depends greatly upon your racial or 
     ethnic background, the make-up and location of the community 
     in which you live, and your economic status. Currently, one 
     seventh of all Americans, 42 million people, lack insurance 
     and suffer unnecessary illness and premature death; a 
     disparate number of these people are racial or ethnic 
     minority Americans.
       Despite being first in spending, the World Health 
     Organization has ranked the United States 37th among all 
     nations in terms of meeting the health care needs of its 
     people. Furthermore, despite the numerous advances that have 
     been made in health care over the decades, racial and ethnic 
     minority Americans continue to suffer disproportionately from 
     many severe health problems and have higher mortality rates 
     than whites for many treatable health conditions. Diabetes 
     strikes African Americans 70% more often than Caucasian 
     Americans; Hispanic Americans twice as often as whites; the 
     diabetes rate for Native Americans is even higher. striking 
     members of this community 180% more often than Caucasian 
     Americans. African Americans are 40% more likely to die from 
     coronary heart disease and 35% more likely to die from cancer 
     than Caucasian Americans.
       It is because of these glaring disparities, the NAACP 
     strongly supports the efforts of the Congressional Black 
     Caucus, the Congressional Hispanic Caucus and the 
     Congressional Asian/Pacific Islander Caucus to address these 
     problems with the introduction of comprehensive legislation 
     which expands health care access, improves health care 
     quality, strengthens key academic institutions and research 
     centers, and bolsters the health care infrastructure in 
     underserved communities.
       Given the importance of this legislation, and the NAACP's 
     historic mission to eliminate racial disparities wherever 
     they exist and to promote affordable, adequate health care 
     among racial and ethnic minorities it is our honor, as well 
     as our duty as some might argue, to support this legislation 
     in the strongest terms possible. Thus the NAACP is committed 
     to using all of our available resources to see this bill's 
     quick enactment.
       Thank you for your leadership in this area: I look forward 
     to working with you toward our common goal. Should you have 
     any questions, please feel free to contact us.
           Sincerely,
                                                Hilary O. Shelton,
     Director.
                                  ____

                                                   American Public


                                           Health Association,

                                    Washington, DC, March 7, 2006.
     Hon. Daniel Akaka,
     U.S. Senate,
     Washington, DC.
       Dear Senator Akaka: On behalf of the American Public Health 
     Association (APHA), the oldest, largest and most diverse 
     organization of public health professionals in the world, 
     dedicated to protecting all Americans and their communities 
     from preventable, serious health threats and assuring 
     community-based health promotion and disease prevention 
     activities and preventive health services are universally 
     accessible in the United States, I write in support of S. 
     2305. This legislation would repeal the provision of the 
     Deficit Reduction Act of 2005 that would require 
     documentation evidencing citizenship or nationality as a 
     condition for being enrolled in the Medicaid program.
       APHA strongly supports efforts to reverse the cuts and 
     changes to the Medicaid program included in the Deficit 
     Reduction Act of 2005 that jeopardize the health of our 
     nation's most vulnerable, including Medicaid beneficiaries. 
     Several Medicaid reforms included in the bill have unintended 
     and severe consequences and will not result in the projected 
     cost savings. Of note is the provision in the legislation 
     that requires individuals to present citizenship or residency 
     documentation in order to enroll in the Medicaid program. 
     Although not its intent, this provision is expected to have a 
     devastating impact on the health coverage and status of 
     native-born citizens who are in every way eligible for the 
     Medicaid program.
       Citizenship and verification requirements in Medicaid and 
     the State Children's Health Insurance Program have been 
     proven to reduce enrollment in the programs among the 
     eligible population. The provision included in the Deficit 
     Reduction Act of 2005 that would require individuals to 
     present documentation proving citizenship or nationality in 
     order to enroll in the Medicaid program is expected to cause 
     thousands of Medicaid beneficiaries who are native-born 
     citizens but do not have a birth certificate or passport in 
     their possession to join the country's uninsured ranks. This 
     provision will likely exacerbate existing racial/ethnic and 
     rural/urban health disparities, as it is expected to 
     disproportionately affect elderly African Americans, 
     individuals residing in rural areas and Katrina survivors, 
     many of whom were not born in a hospital or lost such 
     documentation during Hurricane Katrina or other life 
     tragedies. Also, Medicaid beneficiaries and applicants with 
     mental disorders will likely be adversely affected, as the 
     provision did not include exceptions for any populations, 
     including those with severe physical or mental impairments 
     such as Alzheimer's disease.
       Therefore, there is the need to now take a vital step to 
     protect the public's health and repeal this harmful provision 
     included in the Deficit Reduction Act of 2005. We thank you 
     for taking a leadership role in doing so, and look forward to 
     working with you as this legislation moves forward.
           Sincerely,
                                              Georges C. Benjamin,
     Executive Director.

                          ____________________