Health-care Citizenship Massachusetts recently passed legislation that would make major reforms to its health-care system. As of July 1, a new federal law would require anyone trying to sign up for Medicaid to show a passport, birth certificate or other proof of U.S. citizenship. Scott Helman, political reporter for The Boston Globe, explains what the bill will do.

Health-care Citizenship

Health-care Citizenship

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Massachusetts recently passed legislation that would make major reforms to its health-care system. As of July 1, a new federal law would require anyone trying to sign up for Medicaid to show a passport, birth certificate or other proof of U.S. citizenship. Scott Helman, political reporter for The Boston Globe, explains what the bill will do.


This is TALK OF THE NATION. I'm Michel Martin in Washington. Massachusetts recently passed legislation that would make major reforms with healthcare. As of July 1st, a new federal law would require anyone trying to sign up for Medicaid to show a passport, a birth certificate, or other proof of U.S. citizenship. Under that law, undocumented residents will be denied Medicaid coverage except in the case of emergency Medicaid care. We'd like to hear what you think. If you work in the healthcare industry, would you deny care to a patient who doesn't meet the new requirement? Our number here in Washington is 800-989-8255. That's 800-989-TALK. And joining me is Scott Helman. He wrote about this in today's Boston Globe. He joins us by phone from his office at the Boston Globe State House Bureau in Boston, Massachusetts. Welcome, Scott.

Mr. SCOTT HELMAN (Reporter, Boston Globe): Good to be with you, Michel.

MARTIN: How did you hear about this or, this law was passed as part of a deficit reduction act earlier this year.

Mr. HELMAN: That's right.

MARTIN: How did the impact of this provision on the state come to your attention?

Mr. HELMAN: It's one of those strange scenarios where you end up calling about one thing, and end up being told about something completely different that's more interesting. In this case, I had been making inquiries with local healthcare experts and providers about our new health plan, and how, in particular, it would pertain to immigrants. And what I found is that there was a fair amount of concern among, you know, advocates and community health centers. Folks that followed this stuff very closely about this new federal law, which has not gotten very much attention, cause it was part of this huge, you know, budget bill that ostensibly was designed to reduce or sort of slow the growth of entitlement programs and thus, the federal budget.

MARTIN: What is the law requiring healthcare workers to do? Or how is the law supposed to be enforced at the state level?

Mr. HELMAN: Well, that's unclear. I mean, a lot of that is going to be decided by the regulations that the U.S. Department of Health and Human Services puts out. Now, they have not done that yet, and we're, you know, less than three months from the start date, so a lot of people are sort of wondering, you know, this is a pretty big change, and how's it going to affect us. HHS says they're working on that, you know, sort of, guidance to states, but it's unclear yet. Currently what happens is if you go, if you're on Medicaid, if you sign up for it, or you're renewing your Medicaid membership, you, if you're a citizen, you check a box. It just says, I'm a citizen, and then you sign, you know, sign the form under pains of perjury. What this requires as of July 1 is that you actually provide some proof of that, you know, a passport, a birth certificate, or some other document that's deemed satisfactory.

MARTIN: But don't you already have to show some proof of citizenship to get other benefits like, I mean, if you initially sign up for Medicaid, you don't have to show any proof of citizenship, or when you sign up for social security, you don't have to show any proof of citizenship?

Mr. HELMAN: Well, social security is different. I mean, there are other federal benefits, mainly social security, welfare I believe as well, where you do have to prove that you're a U.S. citizen. And so the people that are on both lists so to speak, the people you know who would get Medicaid but also welfare, they're going to have an easy time here presumably, because they've already proved to the government once that they're citizens. The trick is going to be for people who just get Medicaid. They may be old, they may be homeless, they may be mentally disabled, and the fear is that they're not going to have their birth certificate, or not going to be able to get one very easily, and in the meantime, the question is what happens? Do they get medical care? Do they get care but the provider isn't paid for it? These are all questions that are going to have to be answered.

MARTIN: So, currently they don't have to show, just so I understand it, when you initially sign up for Medicaid, if you aren't a beneficiary of these other programs, all you have to do is say, yes, I'm a citizen...

Mr. HELMAN: That's right.

MARTIN: ...and then check the box.

Mr. HELMAN: And then you sign it.

MARTIN: And sign it.

Mr. HELMAN: Exactly.

MARTIN: And the anxiety on the part of the healthcare workers is what? That people just would be too impaired to locate this documentation or what?

Mr. HELMAN: Yeah. It's the hard part with these things because it's so new and nobody knows how it's going to work yet. You know, it's unclear. Is this going to be a huge burden, is it only going to be a burden on a small group of people. That, we don't know that. I mean, one example that was cited is a lot of older African-Americans that were born, particularly in the south, they weren't allowed to be born in hospitals. And thus, they weren't, they don't have birth certificates. And if they've never had to provide one for anything before, what does this do? Where do they get one? How do they get one? And if they need a procedure in the meantime, can they afford to wait several months while they track down some sort of official record? These are all, you know, there are many kinds of examples. I mean, someone who's homeless, for example, gets Medicaid benefits, comes into a clinic once in a while, you know, what are the chances that he's got a nice little file on him at all times with his documents? You know, pretty low.

MARTIN: Let's go to a caller in Grand Junction Colorado. And Amy, what's on your mind?

AMY (Caller): Well, I just find it fascinating that people are acting as though this should be a shock. Medicare is a citizen right. If you're not a citizen, why should you have the right to healthcare that is so scarce for people who are born here, work here, and pay taxes here? Or, immigrate legally and pay taxes, and then get the benefits of those taxes.

MARTIN: Okay, thank you, Amy.

Mr. HELMAN: Thanks for the question. I mean, this whole new provision was put in by two Georgia congressmen who were concerned that illegal immigrants here were posing as citizens, essentially, and checking off the box and getting benefits when they aren't allowed to have them. Now, there's some debate as to whether that's a really a real problem, of course.

MARTIN: That was going to be my question. Is there data to show that this is true? That really, people who are not eligible are abusing the opportunity to get these services by the failure to present documents, by the lack of the requirement to present documentation?

Mr. HELMAN: Well, last summer, the Department of Health and Human Services has an Inspector General's office, they did a study of this very point last summer, and they issued a report that encouraged states and the government to be better about checking up on these things and following through to make sure that people weren't, you know, “gaming” the system. But they did not recommend such a sort of sweeping change as is in this new law, so a lot of, sort of, health advocates and critics of this new law say, you know, there's no evidence that this is a problem. Why are we going to inconvenience, you know, millions of American citizens across the country by requiring them to provide some proof of their citizenship, when there's, you know, no indication this really an issue?

MARTIN: Let's go to Oklahoma and Shawn(ph).

SHAWN (Caller): Hello.

MARTIN: Hello.

SHAWN: How are you? I'm up here on...

MARTIN: Sounds like you're driving.

SHAWN: Yeah, I am driving. Do I need to stop?

MARTIN: No. Well, I would like you to be safe, I'd like to make sure that you're safe.

SHAWN: I'm fine.


SHAWN: Here's my question. I'm a paramedic. What am I supposed to do? Deny care to people in urgent need? I mean, for those that's in emergency service, this is unconscionable. How are you going to screen emergency patients?

MARTIN: Okay Shawn, thank you so much.

Mr. HELMAN: Some of the healthcare providers I've talked to for this story note that, you know, they're not, it's not like, no matter what happens with this law, they're not going to, you know, have someone come in to their clinic with an arm falling off and say, I'm sorry sir, can I see a passport? I mean, I don't think anyone expects that to happen. And, I mean, as Shawn probably knows, there's federal law that requires people to be treated in an emergency, no matter what. So that what the bigger question might come down to is if a hospital or community healthcare center provides this service and treats somebody who can't show that they're a citizen, you know, will they get reimbursed by the government? You know, that's a pretty big question.

MARTIN: Okay. Let's go to Sacramento, California, and Bruce.

BRUCE (Caller): Yeah, my question was, how are we going to control people who arrive in this country with penicillin-resistant staph or with INH-resistant tuberculosis if they're turned away for not being citizens? And then, wouldn't that create a huge risk for, you know, the rest of the population?

MARTIN: Bruce, may I ask, do you work in the healthcare field, and do you treat such patients?

BRUCE: Well, I was in public health, I worked for two counties, and I was, yeah, in the healthcare field before that, and now I'm a consultant.

MARTIN: So, this wouldn't fall under the emergency care scenario that the earlier caller was talking about. You would not tend to present at a hospital with TB symptoms, but this really more speaks to the long-term, the need for sort of long-term care and follow-up. Is that correct?

BRUCE: Well, if you were coughing up blood, you know, that would be a sign of acute infection, and you might show up at the emergency room and...

MARTIN: You might, but you're saying, but that's one scenario, but your concern is that there might be people walking around with treatable conditions which are a public healthy concern which won't get treatment because of the impediment.

BRUCE: Well, yeah, that would be a disastrous condition because they'd be infecting everyone else and they'd go undetected because they wouldn't be eligible for any kind of... and then while they're not having acute symptoms, they would be exposing the general population to the illness that they have.

MARTIN: Thank you Bruce. Thanks for that frightening scenario. But thanks for calling.

Mr. HELMAN: And that scenario, I'll point out quickly, is exactly what makes this whole issue of, you know, what benefits even illegal immigrants should get very complicated, because it's a big, not just a question of their health and well-being, it's a very big public health question for the rest of us. Particularly if we're at places where, you know, immigrants work and live and shop, etc. It's not just something that affects them.

MARTIN: What are the state health officials telling you about how they envision addressing this requirement?

Mr. HELMAN: The State Medicaid Director doesn't believe it's going to be a huge burden. She said that, for example, as you well know, Medicaid is, you have to meet certain income guidelines to begin with, even beyond the program, and those already require some sort of verification, most commonly a W-2 tax form. So to her, this is just another thing that one has to do, and it won't be a huge burden. But again, without any guidance yet from the federal government as to how strictly they're going to want to enforce it, and what kind of documentation they're going to require, and what kind of reporting all the rest, it's really hard to know at this point exactly how much this is going to change things.

MARTIN: What is the level of concern that you detect among healthcare workers? What is their primary concern? Is it like Bruce, the caller who was concerned that he might not, that people who need treatment in a way that affects the rest of the population, might not get it? Or is it that healthcare workers, say, I don't want to be the police?

Mr. HELMAN: Well, it's both. I mean, you know, again, this really affects, I mean this law doesn't change anything in regards to undocumented or illegal immigrants getting care, this just purely, this sort of strengthens the requirement for citizens. And the fear is that a lot of these people that are on Medicaid, any sort of barrier you throw up makes it harder for them to get care. And so, you know, a, from sort of just kind of a psychological perspective, they feel like, oh, I have to show something else? You know, I guess I won't just sign up because I don't know where it is. To, people who really have a legitimate problem getting some kind of documentation, people who are in, you know, institutions for the mentally disabled, the homeless, like I said, the people who may be born in the south and were never given birth certificates. You know, what are they going to? How are they going to be able to show that they are citizens and can they do it in time to get the services that they need?

MARTIN: You're listening to TALK OF THE NATION from NPR News. Let's talk to Bernice, in St. Paul, Minnesota. Bernice?

BERNICE (Caller): Hello?

MARTIN: Hello.

BERNICE: Hi. I'm calling about universal healthcare. As far as I know, U.S. citizens traveling in Canada or other countries with universal healthcare systems are not asked for identification proving citizenship if they get sick or have an accident. This is whole thing, everything about it, identification, is such a punitive, very typical of recent Washington action, kind of bill. In Canada, and other countries with universal healthcare programs, the administrative cost for a program like that is similar to Medicare, like about three percent over the amounts paid out, with private insurance the overhead is about 20 to 25 percent. We spend way much more than we should.

MARTIN: Why do you think that is?

BERNICE: Because it's set up as a commodity to be bought and sold, rather than a basic human right.

MARTIN: Well, thank you Bernice, thank you for calling.

BERNICE: Mm-hmm.

MARTIN: Well, Scott, I think that maybe, beyond this kind of the scope of your reporting on this issue, is this, how are state officials likely to proceed here? What are healthcare workers kind of lobbying them to be more -- I don't know that they have that much discretion in how they can interpret the bill.

Mr. HELMAN: Yeah, no, they don't. I mean, a lot of these things, the law is written and then it's up to the different agencies to sort of interpret them and come up with regulations. So, you now, they do have some discretion. But the law is pretty clear that stands, and the state of Massachusetts, like any other state, doesn't have much of a choice, as I see it, in how they're going to enforce this, and the kind of identification that they're going to require. So, you know, a lot of them, as often happens with these sort of obscure federal policies, they sort of wait, and they're somewhat confused, they know its coming. They don't know exactly how it's going to affect them, they're worried about the ramifications, and they're bracing for them.

MARTIN: Okay Scott, thank you for joining us.

Mr. HELMAN: My pleasure, Michel.

MARTIN: Scott Helman is a reporter for the Boston Globe. He joined us by phone from his office at the Boston Globe statehouse bureau in Boston, Massachusetts.

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