Thread: Are you an American? Prove it.

Are You an American? Prove It
A citizenship rule costs states millions but nets few illegals.

By Barbara Basler

March 2008

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Bernice Todd's Choctaw family roots are sunk deep in the soil of Oklahoma, a state whose very name is Choctaw for "red people." But in the middle of a debilitating battle with cancer, Todd, a 39-year-old who cleans homes at a trailer park and baby-sits for a living, lost her state Medicaid health care coverage because, although she's a Native American, she could not prove she is a U.S. citizen.

While Todd's case is rich in irony, she is one of tens of thousands of Americans who are falling victim to a new federal rule—aimed at keeping illegal immigrants off the Medicaid rolls—requiring that recipients prove their citizenship and identity with documents many don't have.

In today's troubled economy, when more and more people find their jobs and thus their health coverage in jeopardy, access to Medicaid for those who are eligible is a key concern, experts say.

"Even though I'm eligible for Medicaid and my family has been here forever, they had to drop me," says Todd, who lives in Ardmore, Okla., where her grandparents settled decades ago. "I just got a bill for $11,000. When I feel a bit better I'm going after those [citizenship] papers. But this is just one thing I didn't need right now."

States have always been required to check a Medicaid applicant’s eligibility, which includes citizenship. But a July 2006 rule, enforced by the federal Centers for Medicare & Medicaid Services (CMS), now demands specific documents as proof, such as a passport or a birth certificate, driver's license or military record. States face fines if they don't comply.

The rule, which neither CMS nor the Bush administration requested, was adopted by the Republican-dominated Congress in 2005 despite the fact that there was no evidence that undocumented immigrants were falsely claiming U.S. citizenship to get Medicaid.

"This rule was the answer to a problem that really doesn’t exist," says Donna Cohen Ross, an analyst with the Center on Budget and Policy Priorities in Washington, a nonpartisan research organization.

In fact, the year the rule was passed, Mark McClellan, then the administrator for CMS, said that a report by the CMS inspector general did "not find particular problems regarding false allegations of citizenship, nor are we aware of any." Most states agreed with that assessment.

"In 2007 we added $1 million to our budget just to handle the cost of this new rule when we had absolutely no indication there was a problem with illegal immigrants getting Medicaid in Kansas," says Andrew Allison, Kansas Medicaid director and deputy director of the state Health Policy Authority.

There are no complete figures on how many recipients the rule has forced from Medicaid rolls because most states don’t track those numbers. And CMS staff experts say it's impossible to calculate the deterrent effect of the rule on potential applicants.

But many states do report that the rule is backfiring, forcing U.S. citizens, most of them children and the working poor, to lose their Medicaid health coverage.

In Oklahoma, for example, more than 20,000 of its 700,000 Medicaid recipients—almost 13 percent are American Indians—have been dropped from the program, "not because they aren't citizens, but because they're having a tough time coming up with the right pieces of paper at the right time," says Mike Fogarty, chief executive officer of the Oklahoma Health Care Authority, the agency overseeing Medicaid.

Fogarty says Oklahoma, like most states, has been doing aggressive outreach to help residents get the documents they need, diverting resources and effort that "could have been spent improving our program."

So far, he says, Oklahoma has uncovered no illegal immigrants on its rolls. And Arizona, where immigration is a huge issue, has filed two reports since the rule went into effect, each saying the state uncovered "zero" illegal immigrants among its 1 million Medicaid recipients. Kansas has found one illegal immigrant on its Medicaid rolls.

"Before this rule took effect, we did our own audit, and we were very confident Arizona was already screening out people who didn't belong," says Rainey Daye Holloway, spokeswoman for the Arizona Health Care Cost Containment System. The rule, she adds, has not caused a drop in its rolls, which are continuing to increase.

A U.S. Government Accountability Office survey of the states last year found that that the requirement caused eligible U.S. citizens to lose Medicaid coverage while increasing administrative costs. A close analysis of six states, the report says, showed that for every $100 spent to implement the rule, only 14 cents was saved.

In fact, nationwide the rule has added millions of dollars in administrative costs.

In Wisconsin, the legislature and the governor initially authorized $1.8 million "just to deal with this rule," says James Jones, a deputy administrator in the state Department of Health and Family Services. "And we estimate it will continue to cost $800,000 a year."

Even though Wisconsin and other states are running computer checks to match birth records and other official documents to help residents qualify, many states report they are still losing eligible Medicaid recipients. Yet giving eligible residents good health care means they can be "productive and on the job or in school, and out of hospital emergency rooms. It makes good sense for the state," Jones says.

"We've tracked this, and most of the people we're losing are adults who are parents of children," he says, "and the next highest number is children under age 16." He adds that 80 to 90 percent of the Wisconsin residents with Medicaid coverage are from working families, where the adults often work two or three low-paying jobs.

"These people live tough, chaotic lives, and they can't take time out to track down documents, stand in line, come into an office and swear out affidavits," Jones says. "So their health care and the health care of their children are suffering."

Most states, says Allison, the Medicaid director in Kansas, have long had good quality and eligibility controls for their programs.

"But if a state has a problem with citizenship," he says, "then give them a range of alternatives to fix that. What the feds need is a new state-specific approach, not a one-size-fits-all rule." What Congress did, he says, was "take the most draconian approach to fix a phantom problem."

And so Bernice Todd of Oklahoma, who can trace her Choctaw family back for generations, plans, after her next radiation treatment, to go to Oklahoma City, nearly 90 miles away, to get in line and pay $10 for a certified birth certificate. Then she'll start thinking about how to get an official photo ID. All so this American can prove her citizenship.

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There a millions of children of illegal aliens who are getting Medicaid, so yes, illegal aliens are receiving medicaid. It's money in the bank to them.

Maybe it's not much of a problem any more in OK because they passed that anti-illegal bill, but here in CA there are millions of their children on Medical.