Francisco Rivera, trauma tech,
at UCSD Medical Center
attending to a broken foot.

Citizenship mandate for Medicaid is condemned

June 07, 2006
by Michael Johns, Project Manager
As reported in the The San Diego Union-Tribune on June 6 by Cheryl Clark, Staff Writer.

A move by federal officials to require Medicaid patients to prove they are U.S. citizens would have disastrous consequences for millions of Americans, patient advocates said yesterday.

The Bush administration's new rules are set to take effect July 1. They would affect the nation's estimated 50 million recipients of Medicaid, called Medi-Cal in California. The state has some 6.8 million Medi-Cal patients, who are low-income, elderly or disabled.

Medicaid officials are expected to issue the guidelines for citizenship verification this week. They would likely ask for documents such as passports, birth certificates or naturalization papers. The change is designed to save tax dollars by making it harder for non-citizens, including illegal immigrants, to get government subsidized, non-emergency care at hospitals, clinics, doctors' offices and pharmacies.

The new rules would probably discourage many people, including non-citizens, from applying for Medicaid, patient advocates said. These individuals would likely turn to hospital emergency rooms, where they legally can't be turned away, as a last resort for medical care. That would have a major impact on hospitals, which would have to absorb the additional costs.

"This really won't solve any problem that we know about. But it will require thousands of citizens to provide additional documentation, and we're concerned about that," said Stan Rosenstein, a deputy director for the Department of Health Services in Sacramento.

For some people, there is no birth certificate because the "birth was recorded in the family Bible," Rosenstein said. "And this could affect seniors . . . someone with Alzheimer's in a nursing facility who will need assistance verifying citizenship. And we will need special rules for children."

Children account for about half of Medicaid recipients, while people 65 and older make up roughly 10 percent.

In addition, the homeless and those with serious disabilities who long ago began receiving Medicaid may no longer be able to find their passports, birth certificates or other key documents, said Sherreta Lane of the California Hospital Association in Sacramento.

People "who are absolutely, appropriately legal citizens who just won't have the resources or wherewithal to get their documentation in order will be denied instead," Lane said.

Documentation would be required when a person applies for Medicaid or when eligibility is recertified on or after July 1. Typically, people would have 45 days to prove they're citizens. Disabled individuals would have 90 days.

The Centers for Medicare and Medicaid Services would oversee the new rules. Mark McClellan, the agency's administrator, said he is sensitive to the concerns. He indicated that federal regulators are crafting a process for granting exceptions.

"We want to provide a reasonable amount of leeway," McClellan said. "Not everyone, at least in a timely way, can produce the statutory documents. We do expect that the vast majority of people will have little difficulty given enough time."

The policy change was approved in the February Deficit Reduction Act, which detailed $35 billion in spending cuts over five years, much of it from Medicaid. It came about when the inspector general for the U.S. Department of Health and Human Services found that a majority of states don't verify claims of U.S. citizenship by those seeking Medicaid benefits.

Nationwide yesterday, many health providers hoped federal officials would allow states to also accept documents such as voter registration cards, tribal documents, driver's licenses and military identification in lieu of a passport, birth certificate or naturalization certificate. They also asked that certain affidavits suffice as an alternative method of verification.

Mission Federal Credit Union
For the past 15 years, California has generally required a Social Security number and signed declaration to become eligible for Medi-Cal. San Diego County also asks for a driver's license, proof of employment or school enrollment, receipt of public assistance, proof of voter registration and a rent or utility receipt.

The federal government's changes will cause an administrative nightmare for county processing agencies that ascertain Medi-Cal eligibility, several health experts said.

"What will happen is a huge delay," Lane said. "People will be jamming up with the application process."

It will be a difficult situation statewide, said Vicki Mizel, a deputy director for San Diego County's Health and Human Services Agency.

"When we start asking for documentation that up to now has never had to be provided, it will be a big problem," Mizel said. "I hope the advocates will work on this issue relentlessly."

One of those advocates, Greg Knoll, an attorney and director of San Diego's Consumer Center for Health Education and Advocacy, predicted such a "bureaucratic approach . . . will end up hurting possibly thousands of people who would otherwise be able to access health benefits."

He added that many immigrants who are here legally don't access health services they need "because they are afraid doing so will affect their legal status. And all this does is raise the fear level another notch."

Frank Mecca, executive director of the County Welfare Directors Association of California, said his group is very worried that eligible people will be wrongfully dropped from Medi-Cal and won't get the care they need, such as in-home support services.

For example, he said, there are African-Americans who lack birth certificates because they came from the South, where many of their mothers were not allowed to give birth in hospitals decades ago.

"These are the kind of people we're concerned about," Mecca said. "I really believe this is everyone's concern."

Chris Perrone, senior program officer for the California Healthcare Foundation in Oakland, said the new federal verification requirements are coming at an awkward time.

"States are still working through the Medicare Part D prescription drug plan morass to make sure Medicaid recipients are getting drug coverage they're eligible for," he said.

The Associated Press and New York Times News Service contributed to this report.

This article is taken from The San Diego Union-Tribune, June 6, 2006.

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