Limiting access: Will Medicaid fail its citizenship test?

The federal government last month eased the new requirement that Medicaid recipients prove their U.S. citizenship. But the changes won't help everyone, say doctors who treat these patients.

Take David Bell, for example.

About 65 years old, Bell was born into 1940s Alabama. The son of sharecroppers, he says he was one of about 16 children in his family. His mother died when he was small. Like his siblings, with whom he has no contact, he was not born in a hospital. He has no birth certificate.

"We grew everything -- cotton, corn, peanuts, cucumbers," the soft-spoken man said in an interview in the waiting room of the medical clinic at Bread for the City, a community health center in Washington, D.C., that serves many low-income Medicaid recipients. "By being so many of us, we went hungry most of our lives."

The law, which took effect July 1, mandates that individuals seeking care through Medicaid show proof of U.S. citizenship, such as a birth certificate, passport or other acceptable form of identification. The measure, signed by President Bush in February as part of the Deficit Reduction Act, is supposed to prevent illegal immigrants from abusing the system.

But many doctors argued that the real victims would be millions of impoverished Americans, particularly elderly black patients, and that the law was unnecessary.

"People are not trying to get around the system," said Randi Abramson, MD, the medical director at Bread for the City, which provides a variety of services to the needy, including food. "In reality, most people tell the truth." Her assessment of the law: "It's built on fear and based on nothing."

The federal government last month changed the citizenship requirement to exempt people already enrolled in Medicare or receiving Supplemental Security Income. The Centers for Medicare & Medicaid Services estimated that this exemption would cover about 8 million of the roughly 55 million people in Medicaid.

Bell is just the type of person the move aimed to help. But he is not enrolled in Medicare and doesn't receive SSI, so he's still out of luck.

"I'm a survivor, with these tools," Bell said, slowly turning the palms of his rough hands upward. "I still have the spirit and the blessing, and I do what I have to do to survive."

Bread for the City helps him with his diabetes medication. But he has to use far cheaper, older drugs that are managing the disease now but usually prove less effective.

Bell is a long way from producing the documents that would let him access Medicaid and other federal programs despite years of struggle to establish his identity with the help of lawyers at a local church and at Bread for the City. The clinic has gotten as far as obtaining school records from Alabama, but they don't match Bell's belief that he was born on Oct. 26, 1941. Without a witness to confirm his birth date, one of the alternative routes to proving his identity under the new law, he has nowhere to turn.

"Are they going to believe you or the school record? That's going to be the lawyer's next problem," Dr. Abramson said. "The school record is clearly wrong. It includes two kids born four months apart."

She added that the law should have allowed for simple interviews to establish the patient's citizenship.

Dr. Abramson said the Supplemental Security Income and Medicare exemption would be a big help for many of the patients who were worried about the citizenship requirement. But, she added, the development is of little comfort to Bell or a number of her other patients, such as low-income pregnant women, who don't fit that category. She said her center will continue to see people without documentation, but their access to specialists or prenatal care will be hurt.

Savings at what cost?

The Congressional Budget Office has estimated that the new law will save the federal government $220 million over five years and $735 million over a decade, with about 35,000 people, mostly undocumented immigrants, losing coverage by 2015. But the Center on Budget and Policy Priorities, a nonprofit group that analyzes fiscal policy issues, estimated before CMS announced the exemption that between 3 million and 5 million people could lose coverage because they lack documentation.

Judith Solomon, a senior fellow at the center, said at the time that between 1.4 million and 2.7 million children would be affected by the law. The figures came from a survey conducted by the Opinion Research Corp. for the center.

A January poll of 2,026 adults found that 8% earning less than $25,000 lacked a passport or birth certificate, which is equivalent to 1.7 million Medicaid patients. More than 10% on such an income level lacked documents for at least one of their children. African-Americans were more exposed -- 9% of them lacked documents, compared with 5.7% of all adults.

Robert Greenstein, the executive director of the center, said the CMS exemption was "commendable" but that many beneficiaries and future beneficiaries still could be affected unfairly. Many foster children in low-income households, for instance, might lose coverage if their foster parents are unable to obtain the appropriate documentation, he said.

"The new requirements still are likely to force significant numbers of U.S. citizens who are fully eligible for Medicaid -- primarily poor children and parents -- to go without health care because they are waiting for paperwork from a government bureaucracy or are unable to get the paperwork," he said. The center does not yet have new numbers that take the exemption into account.

Hurricane Katrina survivors, residents of nursing homes and the homeless also are thought to be at risk but were not included in the January survey, the center said. Medicaid recipients filed a class-action lawsuit in federal district court in Chicago in an attempt to prevent the law from taking effect. A similar effort has been launched in Washington, D.C.

One doctor's struggle

The difficulty some Medicaid patients face is familiar to Kim Bullock, MD, associate director of Providence Hospital's emergency department, a typically overstretched institution in the famously underserved eastern half of Washington, D.C. Just as Medicaid patients are being asked to do under the new law, she at one point had to prove the American citizenship of her parents in order to obtain Medicare benefits for them. Dr. Bullock found she could not. Even after a successful life that culminated in becoming the first black funeral directors in Boston, they could not prove they were Americans.

She contacted authorities in Virginia, where both her parents, now in their 80s, were born, and was told no birth certificate existed for either of them. Dr. Bullock would have spent all her assets on their medical care had she not been able to get together the "well over $150,000" in legal fees she needed to establish her parents' citizenship.

It took six to eight months before a court finally ruled it was "foolish" to conclude the couple was anything other than American. She thought her parents' situation was unusual until she began to mull the new citizenship requirement's effect on her more vulnerable patients.

Dr. Bullock shares the concerns of other physicians who fear the consequences of the law will be an increased lack of access to preventive care, particularly among vulnerable pregnant women, who present with easily avoidable conditions in emergency departments. She worries that the rules will slow down Medicaid approval for more women and increase delays in treating problems like vaginal bleeding, hypoglycemia and fetal complications.

"All these things are treatable and preventable," she said. "We track these conditions to access issues, and a lot of them are down to hurdles they have to overcome to get Medicaid. The failure to treat these women affects the health of the children for years to come."

She often lectures students about the Central and South American patients who come to Baltimore and try to get Medicaid unlawfully so they can get dialysis that they cannot get at home. Now some Medicaid applicants who are actually entitled to the care might not be able to get it, she said.

Immigrants alarmed

Dr. Jose Aponte, a physician from El Salvador who runs La Clinica del Pueblo in Washington, D.C., says the U.S. political climate has his patients, mostly undocumented immigrants, scared. From an immigrant's perspective, the broader backdrop for the new Medicaid requirement is the attempt by Congress to approve comprehensive immigration reforms.

The prospect of a new immigration law, which could provide relief for many undocumented immigrants, has simultaneously spread anxiety among that population because so much uncertainty surrounds its outcome, with the Senate and the House at press time widely divided over the legislation.

Most of the patients who visit the clinic don't qualify for Medicaid, but some do, and whichever category they belong to, unless they already have permanent residency, they are all worried.

"They come to us with a lot of fear," Dr. Aponte said through an interpreter, Sally Hamlon. The most nervous group is perhaps the approximately 40 HIV patients they have been fighting to get on to Medicaid for years with increasing success. "They wonder whether they'll need a birth certificate too now," he said.

Many undocumented people have posttraumatic stress disorder because of the circumstances under which they arrived and because of being separated from family.

The new anxiety about the immigration changes is reviving their symptoms, said Dr. Aponte, who has never obtained his license in the United States but is a qualified general medicine and general surgery specialist in El Salvador, which he left 23 years ago.

Asked how his clinic handles referrals for undocumented people, he said: "First, we pray. Second, we have a network of connections and agreements with hospitals." He has a small chapel within the inviting, pastel-colored walls of his clinic, which he says is well used.

He was clearly shocked by the new Medicaid rule, which he said simply presents another barrier to care.

"I see health as a human right, not a privilege, and any barrier placed before a sick person that slows them down in their search for recovery is an attack on human dignity. That's just not right in this most powerful country," he said. "We are denying people the most valuable and basic thing."

David Glendinning contributed to this story.