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.
The result is that plenty of people who qualify for Medicaid are unable to get it, and a large proportion of them are Native Americans, and we're wasting a lot of money that could have been better spent than denying people medical care that they need:
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.
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."
So, because we were worried that foreigners might be using up our precious medical supplies (which was one of the top concerns over immigration on this poll, and of course isn't true), we have adopted a "solution" that instead deprives thousands of actual citizens of health care. Brilliant.