Why is NH Proposing to Replace Proven Electronic Citizenship Verification with Burdensome Medicaid Paperwork Requirements?

My home state of New Hampshire is proposing to add burdensome paperwork requirements for U.S. citizens to prove eligibility for Medicaid. That’s one of the requests they are making in the Medicaid waiver proposal that is up for state comment before the end of the week. This is perplexing because the state and federal governments have spent millions of dollars establishing systems that electronically verify citizenship and qualified immigration status efficiently and accurately through the Social Security Administration and the Department of Homeland Security. If, and only if, eligibility cannot be electronically verified, are applicants required to provide paperwork to prove their status.

Now the state wants to return to an inefficient and costly paperwork system that will burden state employees and reintroduce red tape to the application process. We’ve been there, done that; and experience shows that it had a significant negative impact on U.S. citizen children and low income families who were eligible for Medicaid. In 2006, the Deficit Reduction Act of 2005 enacted new, inflexible requirements on citizens to prove citizenship with paper documentation (also known as “cit-doc”). Unless applicants had a passport, one document – like a birth certificate – wasn’t good enough. To be clear, this change did not impact lawfully residing non-citizens as verifying qualified immigration status had been a federal requirement for some time.

At the time this law took effect, I was the CEO of New Hampshire Healthy Kids (NHHK), a legislatively-created nonprofit organization that administered the state’s Children’s Health Insurance Program (CHIP) from 1997 until 2011. The federal change in 2006 wreaked havoc on uninsured U.S. citizen children in need of health coverage so they could get check-ups, dental care, immunizations, prescription drugs and other health care services they need to thrive in school and in life.

NHHK served as the mail-in application unit for Medicaid and CHIP for children. We worked hard to help families understand what documents were required to act on their applications. Due to the extra hurdles to overcome with a paper-driven process, on average, only about 34 percent of the applications we received each month included all of the documents needed to verify eligibility. That completion rate dramatically dropped by half to an average of only 16% of applications in the six-month period after the “cit-doc” requirement went into place.

At NHHK, we took our mission seriously. Our goal was to ensure that every eligible child was enrolled. So we spent a lot of time and effort following up with families to obtain missing documents. I’ve kept these data all these years to illustrate the impact of administrative changes that complicate rather than streamline the process. It was a great relief when the 2009 reauthorization of CHIP provided a better path to verify citizenship electronically. The process was further improved with the Affordable Care Act, which centralized access to multiple data sources through the federal data services hub.

All states use these electronic processes and, as previously noted, states and the federal government have spent millions implementing electronic verification systems. These systems work and there are other safeguards for auditing eligibility determinations, including some new ones announced by the Center for Medicaid and CHIP services this week. Adding these red-tape barriers will cost taxpayers money as the state will need to update websites and application instructions, retrain state eligibility workers who must process piles of paperwork manually, and inform community organizations who help families apply and enroll. Simply stated, there is no legitimate reason to throw out the current data-driven system and return to outdated manual procedures. As the old adage goes, if it ain’t broke, don’t fix it.