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2005 August 04 Thursday
Weak Citizenship Verification For Medicaid Applicants

One of the costs of large scale immigration (both legal and illegal) is the subsidies for medical care and other social services. Employers get cheap labor and the rest of us pick up the bill. In theory applicants for Medicaid are supposed to be American citizens. How well is this requirement enforced? Not well at all in turns out. A report from the Office of Inspector General Daniel R. Levinson of the Department of Health & Human Services has found that most states make little effort to prove citizenship of Medicaid benefits applicants. (PDF format)

Forty-seven States allow self-declaration of U.S. citizenship for Medicaid; nearly all of these require evidence if statements seem questionable. Pursuant to Federal policy, States may accept a signed declaration as proof of U.S. citizenship from applicants seeking Medicaid benefits. Currently, 40 Medicaid directors report that their State allows self-declaration of citizenship. An additional seven report that self-declaration is sometimes allowed. The four remaining directors report that self-declaration is not permitted in their State. These States are Montana, New Hampshire, New York, and Texas.

Forty-four of the forty-seven States that allow or sometimes allow self-declaration have “prudent person policies” which require evidence of citizenship if statements seem questionable to eligibility staff.

I bet in practice welfare office workers rarely ask for evidence of citizenship even when someone can barely speak English. The ethos of such agencies very frequently is to help the poor and down trodden.

Thirty-two of these have written prudent person policies, and the remaining 12 have unwritten, informal policies requiring documentation for questionable statements.

Twenty-seven States do not verify the accuracy of any U.S. citizenship statements as part of their posteligibility quality control activities.

In fiscal year 2003, 27 of the 47 States that allow self-declaration did not conduct quality control activities that included verification of statements of U.S. citizenship. Of the 20 States that did review statements, 9 did so for a nonrepresentative sample of the entire Medicaid population. Consequently, some groups that could pose vulnerability to Medicaid integrity were not included in the review sample.

Some States use types of evidence that are not accepted by CMS or SSA to document citizenship for Medicaid. As reported earlier, seven States sometimes allow and four States do not allow Medicaid applicants to self-declare citizenship. Of these 11 States, 4 use types of evidence to document citizenship that are not accepted by CMS or SSA. Furthermore, 13 of the 20 States that report conducting quality control to verify statements of U.S. citizenship use types of evidence that are not accepted by CMS or SSA, such as school records, family Bibles, voter registration records, and marriage licenses.

Social Security is tougher on eligibility than Medicaid.

Medicaid-related programs are more likely to verify citizenship; their verifications may be a useful resource for Medicaid. SSA states that all applicants must provide documentary evidence of U.S. citizenship in order to receive a Social Security number or qualify for Supplemental Security Income (SSI) benefits. Forty-two of fifty-one foster care directors report that staff document U.S. citizenship when determining eligibility for Title IV-E foster care maintenance payments. Twenty-seven of fifty-one TANF directors report documenting or sometimes documenting citizenship for purposes of eligibility.

In the majority of instances, we found that these Medicaid-related programs draw on evidence accepted by CMS or SSA to document statements of U.S. citizenship. These citizenship verifications may be a useful resource for Medicaid.

Oregon is the only state to have done an audit looking for non-citizen beneficiaries and they were able to establish that in their sample about 3% of the audited cases were non-citizens and therefore not eligible. Well, imagine what the rate of non-citizen usage must be in states like California which have much higher percentages of illegal aliens living in them.

Only one State reports conducting an audit looking at self-declaration of U.S. citizenship, and it found vulnerabilities

We asked States for any quality control audits or evaluations that looked at self-declaration of citizenship. Only one State director provided an audit on this topic. This audit report found vulnerabilities related to the process of self-declaration of U.S. citizenship.

Specifically, the audit, conducted in January 2002 by the Secretary of the State of Oregon, found that the State provided full Medicaid benefits to 25 beneficiaries (of the sample of 812) who were noneligible noncitizens. The audit report concludes that there are potential risks involved in allowing applicants to self-declare their U.S. citizenship on mail-in applications, which do not allow workers to verify the accuracy of statements of U.S. citizenship.

Well, no kidding. If someone doesn't even have to show up to apply then that person could make up all the fake documents they need and simply assert their citizenship. The claims processing offices are ill-equipped to do much in the way of verification.

My guess is that official estimates of the medical costs which immigrants impose on the US citizenry greatly underestimate the real costs because a big chunk of the money going to non-citizens is labelled as money going to citizens.

Tax money going to pay for medical care for illegals is just one way we pay more for their medical care. First off, illegals are now having about 10% of the babies being born in the United States. Those babies, as US citizens, are eligible for government funded medical care. So we pay that way too.

Illegal immigration is driving up the number of medically uninsured and also one in every twelve dollars spent on medical insurance premiums goes to the cost of paying for the medically uninsured. So illegal immigration and also legal immigration of low wage workers drives up the costs of medical insurance that natives pay. The illegal immigrants can not possibly pay for their own medical insurance because low wage workers can not afford to pay medical insurance premiums.

“The cost of family health insurance is rapidly approaching the gross earnings of a full-time minimum wage worker,” said Drew Altman, President and CEO of the Kaiser Family Foundation. “If these trends continue, workers and employers will find it increasingly difficult to pay for family health coverage and every year the share of Americans who have employer-sponsored health coverage will fall.”

Low wage jobs are effectively taxpayer subsidized jobs. When people advocate for large scale immigration of people with few talents effectively they are advocating for more taxpayer subsidized work.

Cheap immigrant laborers, by going to emergency rooms for medical care, by having children they can't afford to pay for, by reducing native employment, and also by driving down wages for lower income native workers, is creating a growing segment of society that lives off of government provided subsidized paid for by middle and higher income workers.

Share |      By Randall Parker at 2005 August 04 09:40 PM  Immigration Economics


Comments
Derek Copold said at August 5, 2005 1:46 PM:

Ahh, but the fun is just beginning:
http://www.nytimes.com/2005/08/04/business/worldbusiness/04retire.html?oref=login&pagewanted=print

"In recent decades, millions of working-age Mexicans have entered the United States. Most of them have come illegally, taking jobs on the bottom rungs of the American labor market.

While much of the attention remains on the persistent inflow of illegal workers, a new question is beginning to worry some analysts and policy makers on both sides of the border: What will happen when the 10 million Mexicans living in the United States become too old to work? Will they retire in the United States or will they return to Mexico?

As they age, the choices these old-timers make could fray the social fabric on both sides of the border.

Mexico is not prepared to receive them back. With a rapidly aging population living in Mexico and virtually no public system of social security or health insurance, Mexico could hardly cope with millions of returning immigrants who spent their working lives in the United States.

"If we add to the dynamic of aging the return of Mexicans who don't have coverage," said Rodolfo Tuirán, a respected demographer who is under secretary of social development in the Mexican government, "then we are talking about a significant problem."

But the United States is also unprepared to deal with millions of poor, aging immigrants, eking out a living without recourse to Social Security, Medicare, Medicaid or most other forms of federal assistance."

Prepare to be bilked, even more.

John S Bolton said at August 6, 2005 5:55 AM:

Immigrants can and do go on to these programs in large numbers; they use fake ID, or get waved on regardless of the legal requirements. The cost of family health insurance is a proxy for what an immigrant costs, if he has any dependents. Already, it is thousands of dollars per person. The cheapest of these would leave one in the same position as the uninsured, if expenses go beyond some sum. Thus, the underinsured have an unmentioned public health insurance policy, so to speak. That is why you can't really go below thousands per person, in determining the medical implicit insurance costs af an additional immigrant. In round numbers, $5000 is what an additional immigrant, assumed to have, or soon to have , one dependent, will add on to the medical costs of the society, understood as implicit insurance. The median personal income of foreign born is only $16,000, though. We can't tax low income people more than a third of their income to cover medical, plus some tiny share of their other public subsidies. They're too marginal as it is. One gets called petty, ungenerous and mean spiirited for pointing these facts out, but an increase in aggression on the net taxpayer caused by immigration policy, is an obvious wrong.

John S Bolton said at August 8, 2005 1:21 AM:

Officials can't talk about this source of growth in public subsidies, if they are for unselective immigration of any considerable magnitude. If the median foreign born personal income is 16k as the government admits, and its over 4k for medical, including one dependent, and over 4k for one child in public school for every two of them, the main group of immigrants costs over 25k to the society. That is, if there are more than 1k of other subsidies at a minimum level. 16 + 4 + 4 +1 = 25 or higher. From this perhaps 3k in taxes may be subtracted. Is $22,000 too little to draw in the unemployed, or the part time to full time? We have an extreme and perverse conflict of interest here between the employer who uses immigrant help below the upper percentiles of immigrant incomes, and the net taxpayer. There is no way to resolve it so long as the redistributional features of government persist. Some of these employers will simply have to be pushed to extinction, of their line of business, as it is done today. Others can adjust to a higher wage scale on the low end, so long as their local competitiors also must do so.

D Flinchum said at August 8, 2005 4:35 AM:

Derek Copold poses an interesting question regarding what will become of millions of working-age Mexicans who have entered the United States mostly illegally, taking lower level jobs, when they are too old to work. I predict that we will get a preview of this problem when the current building boom slows significantly. Will hundreds of thousands if not millions of construction workers now employed in the housing boom return to Mexico, taking their families with them? If they stay in the US in hopes of finding other jobs, how will the US cope with them?

John S Bolton, as usual, clearly and concisely points out the enormous financial costs that "unselective immigration of any considerable magnitude" poses on the community (net taxpayers) at large. Quality of life issues - beyond financial - abound in this area as well. A person making $16,000 cannot actually afford to live unassisted in the most populous areas of the US even without health care needs, children in school, and sending money back to Mexico. This is why we are seeing such huge over-crowded housing problems (3 houses on Long Island with 100+ inhabitants among them). Conflicts regarding Day Worker Centers are tearing communities apart. Public schools are struggling as more and more special needs students make providing regular students with even a minimum education next to impossible. The list goes on and on.


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