Health officials in many states warn that a federal law requiring Medicaid recipients to prove citizenship starting July 1 could lead to long lines, dropped coverage and general confusion for the program's participants.
At least 46 million poor people on Medicaid for the first time will need to produce documents showing they were born in the United States or are here legally, the result of a budget-cutting measure signed by President Bush in February. The law targets illegal immigrants (who aren't eligible for Medicaid), but administrators say it also will hurt American citizens.
Four states - Georgia , Montana , New Hampshire and New York - already require Medicaid applicants to prove their citizenship with documents.
The rest rely on sworn statements from Medicaid enrollees. But after this month, that won't be enough. Recipients in all states will have to show a birth certificate, passport or other citizenship documents to receive health coverage.
That creates problems for Americans without birth certificates or those who can't easily find them. And it also means headaches for people who have their documents; they'll have to bring their papers to social service agencies instead of mailing in applications or filling them out online.
Two Georgia congressmen, Reps. Charlie Norwood (R) and Nathan Deal (R), led the effort to impose the restrictions.
Norwood spokesman John Stone said the measure would ensure that illegal immigrants were not receiving taxpayer-financed medical benefits while Medicaid struggled to cover U.S. citizens. He said the issue hit home for Norwood , a former dentist, when Georgia began considering Medicaid cuts.
"Because of the increased pressure illegal aliens were putting on our Medicaid system, we were looking at eliminating all childhood dental benefits to our children. I mean this is devastating: Taking away the health care benefits of the poorest people of our state and giving them to illegal immigrants, now that's wrong," Stone said.
He said the change would save the country at least $735 million over the next decade, pointing to what he called a conservative estimate by the Congressional Budget Office.
State officials are scrambling to implement the new rules, because the Department of Health and Human Services told states only three weeks before the changes kick in what documents are acceptable as proof of citizenship.
"Obviously, we are concerned with our ability to be fully in compliance with this," said Kathryn Falls , a deputy secretary for the New Mexico Human Services Department. "We're concerned about the impact that it has on our clients. But we are going to do everything we can."
Elaine Ryan, the deputy executive director of the American Public Human Services Association, a group of government-run social service agencies, called the transition "an impossible task."
"If people believe this provision will unearth widespread Medicaid fraud, they'll be disappointed," she said. Instead, Ryan predicted, few cases of fraud would be found, but people who normally would be eligible for Medicaid will have to wait for their health insurance.
She said people who are dropped from Medicaid would likely seek treatment in emergency rooms, which she called a "perversity" because emergency treatment costs more and Medicaid foots part of that bill too.
Sandra Shewry, director of the California Department of Health Services, said state officials there had little time to digest the new rules, create new procedures and then train county workers who enroll Medicaid applicants.
"We're probably in the exact same position as all other states, which is, the federal law goes into effect, we're going to implement it," she said.
States could have a lot at stake in meeting the deadline. While penalties for not complying aren't spelled out, the law ties states' compliance with their receipt of federal matching funds.
Medicaid is a joint state-federal project that cost $330 billion in 2005. The federal government provided roughly 57 percent of that.
A letter from the Centers for Medicare and Medicaid Services (CMS) told state Medicaid directors that CMS would audit states to see how well they document citizenship.
The letter classifies different types of documentation from most reliable to least reliable. "CMS will monitor the extent to which the state is using primary evidence to establish both citizenship and identity and will require corrective action to ensure the most reliable evidence is routinely being obtained," the letter said.
To prepare for the law, states are revamping their applications, retooling their computer systems, informing state workers and local agencies about the changes, and figuring out how to explain things to people on Medicaid.
For example, Louisiana officials are drafting two lists of acceptable documentation: one for people born in the United States, and one for people born abroad. "We're trying to keep it simple and not give people more information than they need," said Ruth Kennedy, a deputy Medicaid director for Louisiana .
The impact of the new law will not be as sudden as this January's implementation of the new Medicare prescription drug benefit. The overnight move of 6 million poor seniors from Medicaid prescription drug coverage to Medicare went roughly, and most states used stopgap measures to prevent people from going without their medicine.
People already in Medicaid will have to show their documentation sometime over the next year as part of their regular renewal, not all at once. And new applicants can still be enrolled while they make "good faith" efforts to obtain the needed papers.
"There's nobody in a hospital or nursing home receiving treatment that's going to be thrown out. … So it won't be one fell swoop, on July 1 everything changes," said Stone, Norwood 's spokesman.
Several state administrators who talked to Stateline.org said they were looking for ways to efficiently use existing electronic records to confirm people's citizenship, but they have questions about whether those efforts would be allowed.
Many states want more details from the federal government about the rules.
For example, only citizens can receive Social Security benefits. But states don't know whether the federal government will let them assume that people who are receiving Social Security checks are citizens.
Many states have online access to their own vital records, such as birth certificates, but getting records for out-of-state-births can be more difficult.
In some cases, states know exactly when and where a Medicaid recipient was born, because Medicaid paid for the delivery.
But the APHSA's Ryan said federal officials told a gathering of state Medicaid directors in early June that Medicaid's own birth records wouldn't be enough to establish citizenship. (A spokeswoman for the Department of Health and Human Services said the agency hasn't decided that question.)
A study of New York 's Medicaid system, which already requires documentation, indicated that most Medicaid recipients were able to produce proof of citizenship without much problem.
However, the study, conducted for the Kaiser Commission on Medicaid and the Uninsured, found that New York 's rules are looser than the federal regulations, so Medicaid enrollees there may have to prove their citizenship again after July 1.
There are many reasons people may not have birth certificates. Many older Americans were born in farmhouses or on Indian reservations, not in hospitals. In the days of segregation, blacks in the South were often denied admittance to hospitals for childbirth.
And even those born in hospitals could have incomplete records. For example, one New York caseworker told the Kaiser researchers that Orthodox Jewish boys often leave the hospital without a first name, because they don't receive their given name until circumcision. That means their birth certificates read "Baby Boy" and the child's last name.
But not all states are expecting major changes in July.
Georgia just started checking citizenship documents in January. "We've not heard of any significant problems of any individuals not being able to produce documents," said Julie Kerlin, a spokeswoman for the Georgia Department of Community Health.
Montana has required documentation of citizenship for more than 20 years. Still, because of the new law, Montana no longer will consider religious records of such events as baptisms to support citizenship claims, said Linda Snedigar, the state's Medicaid policy supervisor.
"We're just glad we've been doing it all along," she said