Stupid Policy Tricks (And Mean-Spirited Too!)

by hilzoy

From the Washington Post:

"A Medicaid rule takes effect tomorrow that will require more than 50 million poor Americans to prove their citizenship or lose their medical benefits or long-term care.

Under the rule, intended to curb fraud by illegal immigrants, such proof as a passport or a birth certificate must be offered at the time a person applies for Medicaid benefits or during annual reenrollment in the state-federal program for the poor and disabled.

Critics fear that the provision will have the unintended consequence of harming several million U.S. citizens who, for a variety of reasons, will not be able to produce the necessary paperwork. They include mentally ill, mentally retarded and homeless people, as well as elderly men and women, especially African Americans born in an era when hospitals in the rural South barred black women from their maternity wards.

"My clients are absolutely dependent on Medicaid for their care," said Andrea Sloan, a lawyer and court-appointed guardian for more than 40 District residents. Many suffer from dementia, lack family contacts and have little in the way of paper trails. Although Sloan is convinced of their citizenship, she is not always sure of such details as their birthplace."

Thinks this is an exaggeration? Consider these cases:

"On Wednesday, a lawsuit challenging the Medicaid rule was filed in Chicago by a coalition of advocacy groups that wants the suit certified as a national class action. (...) Among the plaintiffs in that case are Ruby Bell, 95, born in an Arkansas county that did not issue birth certificates until 1914, and George Crawford, 80, who is so incapacitated from strokes that he cannot speak. According to attorneys, the church members who care for Crawford in Illinois don't even know where to start looking for documents that would pass muster."

And it's not just those two people. The Center for Budget and Policy Priorities did a national survey to find out how many people this might affect. Their findings:

• About one in every twelve (8 percent) U.S.-born adults age 18 or older who have incomes below $25,000 report they do not have a U.S. passport or U.S. birth certificate in their possession. Applying this percentage to the number of adult citizens covered by Medicaid over the course of a year indicates that approximately 1.7 million U.S.-born adults who are covered by Medicaid could lose their health insurance because of the new requirement or experience delays in obtaining coverage as they attempt to secure these documents.
• More than one tenth of U.S.-born adults with children who have incomes below $25,000 reported they did not have a birth certificate or passport for at least one of their children. This indicates that between 1.4 and 2.9 million children enrolled in Medicaid appear not to have the paperwork required.
• Taken together, the survey indicates that Medicaid coverage could be in jeopardy for 3.2 to 4.6 million U.S.-born citizens because they do not have a U.S. passport or birth certificate readily available.
• Some types of citizens would shoulder a greater risk of losing Medicaid than others because they are less likely to have the required documents. While 5.7 percent of all adults in the survey (i.e., adults at all income levels) reported they lack these documents, the percentage was larger for certain groups:
  
  • African American adults: 9 percent
  
  
  • Senior citizens 65 or older: 7 percent
  
  
  • Adults without a high school diploma: 9 percent
  
  
  • Adults living in rural areas: 9 percent
  
  
• These data and earlier research also suggest that elderly African Americans with low incomes may experience particular difficulties because a significant number of them were never issued birth certificates.

And, as the CBPP notes:

"These results are conservative. Many of those who would be most likely to experience difficulty in securing these documents — such as nursing-home residents, Katrina survivors living in temporary facilities, and homeless people — were not represented in the survey. Had the survey included such people, the percentage of people likely to be harmed by the requirement would almost certainly have been found to be higher."

In case you're wondering: no: this policy has no exceptions for people who lost their records during Hurricane Katrina or some other natural disaster, people with Alzheimer's or dementia, or, well, anyone.

It would be one thing if there were some reason to think that Medicaid fraud by illegal immigrants was, in fact, a serious problem. But there isn't. CPBB again:

"In fact, a comprehensive study conducted last year by the HHS Inspector General failed to find any substantial evidence that illegal immigrants are fraudulently getting Medicaid coverage by claiming they are citizens, and the Inspector General did not recommend requiring that documentation of citizenship be required. State officials interviewed by the Inspector General’s office also noted that such a requirement would add significant administrative costs and burdens. Half of the state officials interviewed said they would have to hire more eligibility personnel to handle the increased workload."

As far as I can tell, this is just one more anti-immigrant gesture that sounds like necessary toughness, but on closer examination turns out to impose serious hardships on people for no good reason other than some politicians' need to convince their constituents that they're being tough on immigrants. Sort of like the recent decision by a Georgia town to stop buying books in Spanish*, only with much more serious consequences. And it manages to increase complexity and paperwork at the same time! I mean, what's not to love?

***

* And what a dumb decision that was. It's not as though the only people who read books in Spanish are illegal, or even native Spanish speakers. Sometimes, strange to say, English speakers try to read books in other languages. This is a good thing: it's not as though we in the US have an excess of citizens who can speak several languages, or anything. But even if, for some unfathomable reason, only illegal immigrants ever read books in Spanish, cutting the book budget (by all of $3,000!) wouldn't cause the number of illegal immigrants to go down; it would just mean that the illegal immigrants in this town would be less likely to spend their time reading. And why would anyone want that?

Comments

[hilzoy]

It occurs to me that I should probably have said something about what procedures are now in place to protect against fraud. If one applies as a legal immigrant, one must provide papers. If one applies as a citizen, every state other than Montana, New Hampshire, New York and Texas allows one to swear, under penalty of perjury, that one is a citizen. (As of a July 2005 report by the HHS Inspector General.) Of the 47 states that allow this, 44 reported having "a written or informal 'prudent person policy' requiring documentation if the statements of the applicant seem questionable" (p. 9). About half of these states also do follow-up assessments on the quality of their screening, to check for fraud. This number should (imho) plainly be increased. It's a lot better than requiring people with dementia to find their possibly nonexistent birth certificates.

[liberal japonicus]

Hil,
People with dementia don't vote (at least dementia stemming from Alzheimer's) Why should the current Republican leadership worry about groups that either don't vote or aren't reliably Republican? ;^)

[Bernard Yomtov]

According to the article this is supposed to save Medicaid $735 million over the next ten years. That's about a quarter per US resident per year.

Will it even save that? At an administrative cost of $1.50 per recipient per year the policy will cost about $750 million over that period.

Maybe it won't cost $1.50, but even without the legal proceedings there are going to be extra employees, time spent on administrative procedures and mixups, etc., so the net savings will be even less than that quarter.

All so a few sick illegal immigrants can't get care.

Lovely.

[Matt McIrvin]

It could save a lot if almost nobody can actually collect Medicaid benefits.

[dr ngo]

LJ: People with dementia don't vote (at least dementia stemming from Alzheimer's) Why should the current Republican leadership worry about groups that either don't vote or aren't reliably Republican? ;^)

And on what do you base your conclusion that people with dementia aren't reliably Republican?

[liberal japonicus]

I was trying to snarkily suggest that the dementia brought on by Alzheimer's shouldn't be confused with the symptom of being a reliable Republican and this was the closest I could get.

[Bernard Yomtov]

It could save a lot if almost nobody can actually collect Medicaid benefits.

Sad to say, it wouldn't surprise me if some of the people supporting this felt just that way.

[Bruce Baugh]

Remember that, as Malcolm Gladwell documented well for New Yorker, the Bush administration buys into the moral-hazard criticism of US health care, which says that most people are getting too much health care.

[Peter Clay]

This is probably a step towards a UK-style National Database. The next step will be offering to build a giant biometric database so that people who can't get medical care because they can't "prove who they are" can get it.

[cleek]

OT: but this is a must-read.

[Robert]

This seems like a dumb implementation of a reasonable idea.

Since the problem of illegal use of the system is relatively minor, it would be far more sensible to start requiring identification/proof of citizenship for NEW enrollees. This would give people coming up on the enrollment age plenty of time to get their documentation in order in a leisurely fashion, without inconveniencing the existing population at all.