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The Deficit Reduction Act of 2005 Section 6036, has thrown a significant barrier into the path of Medicaid applicants and recipients. Beginning July 1, federal law requires those claiming to be U.S. citizens or nationals to document their claims at the time of Medicaid application. Current recipients must supply the documentation at their next annual re-determination or face termination of Medicaid eligibility. Verification must only be provided once. It is important to note that the rules governing who qualifies for Medicaid are not changing. A person does not have to be a citizen to qualify for Medicaid (the federal name for the program called “Medical Assistance” in Pennsylvania). However, for those claiming to be U.S. citizens or nationals, the new law could mean the loss of their health insurance. The preferred method of documentation under the statute is a U.S. passport, certificate of naturalization, or certificate of U.S. citizenship. In some states (not Pennsylvania), a valid state-issued driver’s license will suffice. These documents prove both citizenship and identity, as required by the new law. Those who don’t have one of the preferred documents will need to separately prove citizenship and document their personal identity. A birth certificate (or a certification of birth abroad, U.S. citizenship ID card, or report of birth abroad of a citizen of the United States) can be used to document citizenship. Department of Health and Human Services (HHS) Secretary Michael Leavitt is authorized by law to specify other documents that provide proof of U.S. citizenship or nationality. In a draft “Dear Medicaid Director” letter, circulated to the states in April for comment, Leavitt listed “a religious record of birth, recorded in the United States or its territories within three months of birth, which indicates a U.S. place of birth,” or “an affidavit made by two blood relatives . . . who have personal knowledge of the event(s) establishing the applicant’s claim of citizenship” as acceptable proofs of citizenship. It is unclear whether a religious record of birth would include an entry in a family bible. Personal identity can be proven with an identity document described in section 274A(b)(1)(D) of the Immigration and Nationality Act, or by “any other documentation of personal identity of such other type as Leavitt finds, by regulation, provides a reliable means of identification.” Eschewing the regulatory process, the secretary is expected to announce via the same “Dear State Medicaid Director” letter that proof of identity can be documented by a current state driver’s license with picture, or a state issued identity card available to non-drivers bearing the individual’s photo (such as can be obtained in Pennsylvania through PennDOT), or any other document that the state finds establishes the true identity of the applicant or recipient. Some populations apparently will be exempt from the documentation requirement. The statute specifically exempts aliens receiving SSI or Medicare, although this language is confusing because the documentation requirement does not apply to aliens. Citizens receiving SSI or Medicare are not exempted. However, Leavitt has preliminarily told states that they can rely on a computer-generated list of SSI recipients, supplied to them by the federal government, as evidence of citizenship. Citizens on this list must still document personal identity. Leavitt has also indicated that he may create an exception for children in foster care. The law, which apparently targeted noncitizens, will likely cause confusion and expense for poor citizens and could lead to many losing health insurance. Few poor people have a passport. Many of those who do not will have to document citizenship and identity. Obtaining a birth certificate will be expensive and difficult, if not insurmountable, for some, especially for elderly persons, those born out of state, those not born in a hospital, the homeless, those who have lost records in a disaster and those with mental illness. The Center on Budget and Policy Priorities reports that surveys show that 8 percent of U.S.-born adults aged 18 or older with incomes below $25,000 have neither a passport nor a birth certificate. Research by staff of the Pennsylvania Health Law Project disclosed that South Carolina charges $12 for a birth certificate, requires the full name of the mother and father, and has records only back to 1915. Mississippi does not accept out-of-state checks for a birth certificate. Florida charges $9, and requires a signature and valid ID of persons seeking a birth certificate. Puerto Rico has birth certificates only from 1931 on. Of course, the birth needs to have been recorded for a birth certificate to exist. And proving identity could be equally troublesome, especially for nondrivers. Families USA cites a Congressional Budget Office report that the provision will reduce Medicaid spending by $220 million between 2006 and 2010. However, Families USA goes on to suggest that much of the savings will be achieved by denying Medicaid to otherwise eligible citizens rather than ridding the system of immigrants who are illegally obtaining coverage. According to the Center on Budget and Policy Priorities, a recent examination by the HHS Office of Inspector General indicated that the new law was unnecessary, because states already possess the legal authority to investigate suspect claims. Organizations such as the American Hospital Association have written to urge Leavitt to allow maximum flexibility in determining acceptable documents, and at least one bill has been introduced (S.2305) to repeal the documentation requirement. In what was once the seventh-floor chapel of Philadelphia Mercy Hospital I recently viewed a stained glass window containing a quote by Catherine McAuley, founder of the Sisters of Mercy. It reads, “It is better to relieve 100 imposters than to suffer one really distressed person to be sent away empty.” I can’t help but observe how far we have gone down the opposite path. MICHAEL CAMPBELL is the executive director of the Pennsylvania Health Law Project.

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