Citizenship proof could prove to be a hardship

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New identification requirements – aimed at removing illegal immigrants from the Medicaid rolls – went into effect last week, but it will be some time before hospitals, clinics and other health care providers will be able to determine what effect the changes will have on their businesses.
As of July 1, anyone applying for the state-funded health program must have a certified birth certificate and a picture identification card. People with U.S. passports, certificates of naturalization or certificates of citizenship only need one form.
“It’s basically proof of citizenship,” said Cindy DeBoer, associate administrator of patient finance for Memorial Hospital. “The program always has been for citizens only, but in the past you could assert citizenship by checking the box on the enrollment form. Now, you have to have identification.”
Memorial says the additional administrative burden will be at the state level, where workers will have to verify citizenship. While the hospital is not responsible for determining eligibility for the program, administrators are concerned about the long-term effects of the new requirements.
“We understand the need to qualify and clarify citizenship,” said John Suits, associate administrator of business and government affairs. “But we are concerned that it might increase the length of time to verify someone’s eligibility.”
Another concern is that Medicaid reimbursement levels will drop. Currently, the hospital is reimbursed about 26 cents for every dollar it spends.
“Medicaid operates from a pool of funds,” Suits said. “And that pool is very limited. If the state has to hire more people to verify these documents, where is the money for their salaries coming from? If it comes from this limited pool, then reimbursement rates will drop.”
Memorial is required — both by state law and city ordinance — to treat all patients regardless of their ability to pay. If Medicaid enrollment drops — the Congressional Budget Office anticipates a savings of $735 billion by 2015 — then the hospital carries more of the financial burden for caring for these patients.
“And we have no choice but to pass those costs along to the patients who pay through their insurance companies,” DeBoer said. “We’re required to treat people.”
Suits said he is keeping a close watch on federal and state efforts to curb the flow of illegal immigrants. And while the new requirements are an effort to keep illegal immigrants from receiving health benefits, new legislation could make the hospital’s mission to care for all patients difficult.
“What happens if the federal government says we can’t treat illegal immigrants?” Suits asked. “But someone goes to the health department and is positive for TB. Do we treat him, or do we let him loose in the general public? I say we treat him, but if legislation says we can’t, there’s a problem.”
The current identification requirements could pose a problem for some people who were born in the United States. Some of the more rural areas of the country did not issue birth certificates, Suits said.
“There’s a county in Arkansas that didn’t start issuing birth certificates until 1914,” Suits said. “People born before then don’t have a birth certificate, and can never get one.”
That leaves the elderly who are using the Medicaid program in a tenuous position, DeBoer said. The requirements do allow for an affidavit from family members, but getting one isn’t always possible.
“I’m very concerned for that group,” she said. “What if they can’t come up with the documentation and there’s no family around. I hope that would be a rare circumstance. But I’m concerned about the elderly or the mentally impaired that just don’t have the family around anymore, or can’t find the documentation.”
At Peak Vista Community Health Centers, the concern is about the ability to pay to receive the documentation, as well as the number of patients who will be affected by the new requirements.
Peak Vista serves 8,653 Medicaid patients, some of whom are very transient. Administrators at Peak Vista worry that patients must repeat the application process annually, causing an enormous burden.
“Medicaid patients having trouble complying with the new law, because they cannot get the necessary documentation, or do not have money to pay for that documentation, will certainly experience difficulties accessing health care,” said Lynn Pelz, director of external communications for the organization. “There will be a financial and human impact to that audience, and the providers who serve them.”
A certified copy of a birth certificate can cost as much as $27. For patients who must have a birth certificate and a state identification card, the cost is more than $30 for each family member, Pelz said.
Peak Vista receives an average of 800 applications a month, with an average of four family members to an application, which could make the cost overwhelming.
“It’s a financial impossibility for Medicaid families,” she said.
Administrators at Peak Vista and Memorial say they will treat patients, regardless of their Medicaid standing.
“Peak Vista will continue to serve these clients on a sliding fee scale if they lose Medicaid eligibility, but will have to re-evaluate other business decisions if the loss of this revenue for this population is as significant as we fear,” said B.J. Scott, president and CEO of Peak Vista.
Some estimates say as many as 3 million people could lose state health care benefits because of the new requirements. For Suits, that is too many people without benefits.
“It’s just horrific to imagine,” he said. “We hope that many people don’t fall through the cracks. Some might, but we hope it’s not thousands.”