EXAMINING THE IMPACT OF 

ILLEGAL IMMIGRATION ON THE 

MEDICAID PROGRAM AND OUR 

HEALTHCARE DELIVERY SYSTEM 

HEARINGS 

BEFORE THE 

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED NINTH CONGRESS 

SECOND SESSION 

AUGUST 10 AND 15, 2006 

Serial No. 109-134 

Printed for the use of the Committee on Energy and Commerce 

Available via the World Wide Web: http://www.access.gpo.gov/congress/house 

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WASHINGTON : 2006 

For sale by the Superintendent of Documents, U.S. Government Printing Office 

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31-460PDF 
COMMITTEE ON ENERGY AND COMMERCE 

JOE BARTON, Texas, Chairman 

RALPH M. HALL, Texas 

MICHAEL BILIRAKIS, Florida 

 Vice Chairman 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

PAUL E. GILLMOR, Ohio 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

CHARLIE NORWOOD, Georgia 

BARBARA CUBIN, Wyoming 

JOHN SHIMKUS, Illinois 

HEATHER WILSON, New Mexico 

JOHN B. SHADEGG, Arizona 

CHARLES W. “CHIP” PICKERING, Mississippi 

 Vice Chairman

VITO FOSSELLA, New York 

ROY BLUNT, Missouri

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

CHARLES F. BASS, New Hampshire 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

C.L. “BUTCH” OTTER, Idaho 

SUE MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

JOHN D. DINGELL, Michigan 

 Ranking Member 

HENRY A. WAXMAN, California 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

EDOLPHUS TOWNS, New York 

FRANK PALLONE, JR., New Jersey 

SHERROD BROWN, Ohio 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

ALBERT R. WYNN, Maryland 

GENE GREEN, Texas 

TED STRICKLAND, Ohio 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MIKE DOYLE, Pennsylvania 

TOM ALLEN, Maine 

JIM DAVIS, Florida 

JAN SCHAKOWSKY, Illinois 

HILDA L. SOLIS, California 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

BUD ALBRIGHT, Staff Director 

DAVID CAVICKE, General Counsel

REID P. F. STUNTZ, Minority Staff Director and Chief Counsel

(II)
CONTENTS 

Page 

Hearings held: 

August 10, 2006 ................................................................................................................. 1 

August 15, 2006 .................................................................................................................. 62 

Testimony of: 

Ketron, Hon. Bill, Member, Tennessee State Senate ........................................................ 12 

Rowland, Hon. Donna, Member, Tennessee State House of Representatives .................. 15 

Gordon, Darin J., Deputy Commissioner, Bureau of TennCare......................................... 25 

Smith, Dennis G., Director, Center for Medicaid and State Operations, Centers for 

Medicare & Medicaid Services...................................................................................... 29 

Flores, Richard, Vice President of Revenue Cycle, LifePoint Hospitals ........................... 47 

Duncan, Bob, Vice President for Advocacy and Government Relations, Methodist 

Healthcare-LeBonheur Children’s Medical Center ....................................................... 49 

Perrizo, Gary, Director of Patient Accounting, Department of Finance, Vanderbilt 

University Medical Center ............................................................................................. 52 

Cagle, Hon. Casey, Member, Georgia State Senate ........................................................... 74 

Rogers, Hon. Chip, Member, Georgia State House of Representatives............................. 80 

Thompson, Hon. Curt, Member, Georgia State Senate ...................................................... 87 

Sheil, Jean, Director, Family and Children’s Health Program, Center for Medicaid and 

State Operations, Centers for Medicare & Medicaid Services...................................... 107 

Siskin, Dr. Alison, Specialist in Immigration Legislation, Domestic Social Policy 

Division, Congressional Research Service .................................................................... 112 

Ortiz, Abel C., Health and Human Services Policy Advisor, Office of the Governor, 

State of Georgia.............................................................................................................. 120 

Gardner, Jr., James E., President and Chief Executive Officer, Northeast Georgia 

Health System ................................................................................................................ 146 

Stewart, Charles, Chief Executive Officer, Hutcheson Medical Center ............................ 150 

Michaels, Dr. Marty, Chair, Georgia Chapter, American Academy of Pediatrics............. 157 

(III) 

(1) 

EXAMINING THE IMPACT OF ILLEGAL 

IMMIGRATION ON THE MEDICAID 

PROGRAM AND OUR HEALTHCARE 

DELIVERY SYSTEM 

THURSDAY, AUGUST 10, 2006 

HOUSE OF REPRESENTATIVES, 

COMMITTEE ON ENERGY AND COMMERCE, 

Brentwood, TN. 

 The committee met, pursuant to notice, at 10:00 a.m., in the Main 

Room, Brentwood City Hall, 5211 Maryland Way, Brentwood, 

Tennessee, Hon. Nathan Deal [member of the committee] presiding. 

Members present: Representatives Deal and Blackburn. 

Staff present: Ryan Long, Counsel; Brandon Clark, Policy 

Coordinator; Chad Grant, Legislative Clerk; Purvee Kempf, Minority 

Professional Staff Member. 

 MR. DEAL. The Committee will come to order, and the Chair 

recognizes himself for an opening statement. 

 This morning will hold the first session of a 2-day field hearing 

entitled, “Examining the Impact of Illegal Immigration on the Medicaid 

Program and Our Healthcare Delivery System.” 

 Today, we will hear from three panels of distinguished and expert 

witnesses about the impact that illegal immigration is having on our 

healthcare delivery system and get their perspective on a few recent 

legislative provisions that were produced by this Committee in an effort 

to help address this ever-growing problem. 

 Once this portion of the field hearing has concluded, we will recess 

until Tuesday morning, at which point we will reconvene in Dalton, 

Georgia, to learn more about how illegal immigration is impacting that 

community and what steps Governor Perdue and others in Georgia are 

taking to address this problem. 

 Given that there are well over 11 million illegal aliens currently 

residing in the United States and the fact that this number is rapidly 

growing every day that we allow our borders to remain unsecured and 

our immigration laws to remain unenforced, there is no question that the 

problem of illegal immigration is one of the most important public policy 

debates currently in Congress. 
2

 I stand with my Republican colleagues in House in strong support of 

enacting an immigration reform bill that does what the American people 

expect and deserve. 

 We want to strengthen our borders and enforce our immigration 

laws. Because as any healthcare provider will tell you, an ounce of 

prevention is certainly worth a pound of cure. 

 Unfortunately, it is clear that there are those on the other side of this 

issue that have absolutely no plan for securing our borders and no plan 

for stopping the flood of illegal immigration that is currently negatively 

impacting our public safety, our children’s schools, and our healthcare 

system. 

 In 1996, Congress responded to the will of the people and passed the 

Illegal Immigration Reform and Immigration Responsibility Act, and one 

of the main provisions of that legislation was to limit all Federal benefits, 

including Medicaid coverage, to those who are lawfully in the United 

States. 

 Of course, people on the other side of this issue opposed that 

provision back then because they believed that your hard-earned tax 

dollars should go to pay for healthcare services for people that are in this 

country illegally. 

 And, it is a lot of these same people that are now opposing our 

efforts, to ensure that only citizens get access to the taxpayer-funded 

benefits. 

 The most unfair thing about what our opponents are advocating is 

that an illegal immigrant on Medicaid would almost certainly have a 

better healthcare benefits package than what is available to most 

taxpayers who are paying for those Medicaid benefits, and are paying for 

their own healthcare out of their own pockets. 

 Of course, we are not just sitting back and waiting for one single 

comprehensive legislative solution to pass both Houses of Congress. We 

intend to address this problem whenever and wherever we can. 

 To help address the negative impact of illegal immigration on our 

healthcare system, the Energy and Commerce Committee produced two 

important provisions in the Deficit Reduction Act of 2005, which is 

commonly known as the “DRA.” 

 One of the provisions that I authored and fought to include in the 

DRA was a provision that requires States to obtain documentary 

evidence that the person applying for Medicaid benefits is actually a 

United States citizen, as required by law. 

 This is not a new concept for government programs, since the 

Medicare and SSI programs both require proof of citizenship for all 

beneficiaries. It’s just that Medicaid hasn’t been seriously reformed 

since the 1960s and was a little behind the times. 
3

 Before the enactment of this provision, the Inspector General of the 

Department of Health and Human Services found that 46 States and the 

District of Columbia allowed self-declaration of citizenship for Medicaid 

eligibility, and 27 of those States never verified any citizenship 

statements at any point. 

 This means that people simply had to say that they were citizens, in 

whatever language they choose to say it in, and that they would be 

eligible for thousands of dollars of taxpayer funded Medicaid benefits. 

 I believe that is simply unacceptable. 

 Of course, the advocates on the other side of this issue fought very 

hard to prevent this provision from being included in the DRA and they 

fought very hard to defeat this needed legislation when it was being 

voted on by Congress. 

 And now, some of those same advocates are fighting just as hard to 

weaken this common-sense provision as much as possible, but it is my 

hope that those who are implementing this provision will stand firm on 

what I consider a very important issue. 

 Another provision we included in the Deficit Reduction Act was a 

provision to allow States the flexibility to impose cost sharing on 

healthcare services furnished in an emergency room that a physician 

determines is not a real medical emergency, such as an ear infection or 

strep throat. 

 To protect beneficiaries, this provision requires that an available and 

accessible alternative must be available to the beneficiary and the 

treating hospital must refer the individual to that alternative site in order 

for the co-pay, which we have provided, to be charged. 

 Like the citizenship-verification provision, this provision is designed 

to eliminate millions of dollars of waste in the Medicaid system by 

helping to ensure that Medicaid patients receive care in the most 

appropriate setting. 

 This provision, I believe, also helps patients. Studies have shown 

that patients who receive care in the appropriate setting have better 

healthcare outcomes. 

 As we all know, the ER is not the best place to receive primary care 

services or preventative healthcare. 

 Although this provision only applies to Medicaid beneficiaries, it 

will also help reduce some of the negative impact of illegal immigrants 

improperly utilizing the ER, and it provides $50 million in grant funding 

to the States to establish alternative non-emergency providers in 

communities across the United States. 

 In addition to the increased number of alternative non-emergency 

providers, this provision will also make hospital personnel more familiar 

and comfortable with referring non-emergency patients to the appropriate 
4

healthcare providers. It will also increase communication between ER 

personnel and those non-emergency providers. 

 The logic behind this provision is also very simple. It costs 

approximately $340 to care for a non-emergency patient in the 

emergency department while it costs less than $70 to care for the same 

patient in a health clinic or physician’s office. 

 That means over five people can be treated in a physician’s office for 

less money than one person can be seen in the emergency department. 

 Again, I believe that this is a common sense approach to reforming a 

Medicaid program, and I believe it is one of those serious reforms that 

we should help sustain. 

 As always, I am looking forward to having a cooperative and 

productive conversation on this topic today and to working with my 

colleagues to come up with even more effective solutions to the 

problems that I’m sure we will address during this hearing. 

 Again, I would like to thank all of our witnesses who will be 

participating today. We look forward to hearing your testimony. 

 And again, I express my appreciation to Congresswoman Blackburn 

and her staff. 

 At this time, as a part of the committee formalities, I would like to 

ask unanimous consent that all Members be allowed to submit statements 

and questions for the record. Without objection, it is so ordered. 

 I would also like to ask unanimous consent that all members be 

given 10 minutes of question time per panel and that all members be 

given 5 minutes for opening statements at both venues of this field 

hearing, and, without objection, it is so ordered. 

 I would like at this time to recognize my friend from Tennessee, 

Mrs. Blackburn, for 5 minutes for an opening statement. 

 [The prepared statement of Nathan Deal follows:] 

PREPARED STATEMENT OF THE HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS 

FROM THE STATE OF GEORGIA

3⁄4 The Committee will come to order, and the Chair recognizes himself for an opening statement. 

3⁄4 This morning will hold the first session of a two-day field hearing entitled “Examining the 

Impact of Illegal Immigration on the Medicaid Program and Our Healthcare Delivery 

System.” 

3⁄4 Today, we will hear from three panels of distinguished and expert witnesses about the impact 

that illegal immigration is having on our healthcare delivery system and get their perspective 

on a few recent legislative provisions that were produced by this Committee in an effort to 

help address this ever-growing problem. 
5

3⁄4 Once this portion of the field hearing has concluded, we will recess until Tuesday morning, at 

which point we will reconvene in Dalton, Georgia, to learn more about how illegal 

immigration is impacting that community and what steps Governor Perdue and others in 

Georgia are taking to address this problem. 

3⁄4 Given that there are well over 11 million illegal aliens currently residing in the United States 

and the fact that this number is rapidly growing every day that we allow our borders to remain 

unsecured and our immigration laws to remain unenforced, there is no question that the 

problem of illegal immigration is one of the most important public policy debates currently 

before Congress. 

3⁄4 I stand with my Republican colleagues in House in strong support of enacting an immigration 

reform bill that does what the American people expect and deserve. 

3⁄4 We want to strengthen our borders and enforce our immigrations laws. Because as any 

healthcare provider will tell you, an ounce of prevention is worth a pound of cure. 

3⁄4 Unfortunately, it is clear that those on the other side of the issue have absolutely no plan for 

securing our borders and no plan for stopping the flood of illegal immigration that is so 

negatively impacting our public safety, our children’s schools, and our healthcare system. 

3⁄4 In 1996, Congress responded to the will of the people and passed the “Illegal Immigration 

Reform and Immigrant Responsibility Act,” and one of the main provisions of this legislation 

was to limit all Federal benefits, including Medicaid coverage, to those who are lawfully in the 

United States. 

3⁄4 Of course, people on the other side of this issue opposed this provision back then because they 

believed that your hard-earned tax dollars should go to pay for healthcare services for people 

that are in your country illegally 

3⁄4 And it is a lot of these same people that are now opposing our efforts to ensure that only 

citizens get access to the taxpayer funded benefits. 

3⁄4 The most unfair thing about what our opponents are advocating is that an illegal immigrant on 

Medicaid would almost certainly have a better healthcare benefits package that what is 

available to most of the taxpayers who are paying for those Medicaid benefits. 

3⁄4 Of course, we are not just sitting back and waiting on a single comprehensive legislative to 

pass both Houses of Congress. We intend to address this problem whenever and wherever we 

can. 

3⁄4 To help address the negative impact of illegal immigration on our healthcare system, the 

Energy and Commerce Committee produced two important provisions in the Deficit 

Reduction Act of 2005, which is commonly known as the “DRA.” 

3⁄4 One of the provisions that I authored and fought to include in the DRA was a provision that 

requires States to obtain documentary evidence that the person applying for Medicaid benefits 

is actually a U.S. citizen, as required by law. 

3⁄4 This is not a new concept for government programs, since the Medicare and SSI programs 

both require proof of citizenship for all beneficiaries. It’s just that Medicaid hadn’t been 

seriously reformed since the 1960’s and was a little behind the times. 

3⁄4 Before the enactment of this provision, the Inspector General of the Department of Health and 

Human Services found that 46 states and the District of Columbia allowed self-declaration of 

citizenship for Medicaid, and 27 of those States never verified any citizenship statements at 

any point. 

3⁄4 This means that people simply had to say that they were citizens, in whatever language they 

chose to say it in, and they would be eligible for thousands of dollars of taxpayer funded 

Medicaid benefits. 

3⁄4 This was simply unacceptable. 

3⁄4 Of course, the advocates on the other side of this issue fought very hard to prevent this 

provision from being included in the DRA and they fought very hard to defeat this needed 

legislation when it was being voted on by Congress. 

3⁄4 And now, these same advocates are fighting just as hard to weaken this common-sense 

provision as much as possible, but it is my hope that those implementing this provision will 

stand firm on this important issue. 

3⁄4 Another provision we included in the Deficit Reduction Act was a provision to allow States 

the flexibility to impose increased cost-sharing on healthcare services furnished in an 

emergency room that a physician determines is not a real medical emergency, such as an ear 

infection or strep throat. 
6

3⁄4 To protect beneficiaries, this provision requires that an available and accessible alternative 

must be available to the beneficiary and the treating hospital must refer the individual to that 

alternative site in order for the co-pay to be charged. 

3⁄4 Like the citizenship-verification provision, this provision is designed to eliminate millions of 

dollars of waste in the Medicaid system by helping to ensure that Medicaid patients receive 

care in the appropriate setting. 

3⁄4 This provision also helps patients. Studies have also shown that patients who receive care in 

the appropriate setting have better health outcomes. 

3⁄4 As we all know, the ER is not the best place to receive primary care services or preventative 

healthcare. 

3⁄4 Although this provision only applies to Medicaid beneficiaries, it will also help reduce some 

of the negative impact of illegal immigrants improperly utilizing the ER by providing $50 

million in grant funding to the States to establish alternative non-emergency providers in 

communities across the United States. 

3⁄4 In addition to the increased number of alternative non-emergency providers, this provision 

will also make hospital personnel more familiar and comfortable with referring nonemergency patients to the appropriate healthcare providers. It will also increase 

communication between ER personnel and these non-emergency providers. 

3⁄4 The logic behind this provision is simple. It costs approximately $340 to care for a nonemergency patient in the emergency department while it costs less than $70 to care for the 

same patient in a health clinic or physician’s office. 

3⁄4 That means over five people can be treated in a physician’s office for less money than one 

person can be seen in the emergency department. 

3⁄4 Again, I believe that this is a common sense approach to reforming a Medicaid program that is 

in serious need of reform. 

3⁄4 As always, I am looking forward to having a cooperative and productive conversation on this 

topic today and to working with my colleagues to come up with effective solutions to the 

problems addressed at this hearing. 

3⁄4 Again, I would like to thank all of our witnesses for participating today. We look forward to 

hearing your testimony. 

3⁄4 And I would like to thank Congressman Blackburn and her staff for serving as such gracious 

hosts and for all their hard work that has made today’s field hearing possible. 

3⁄4 At this time, I would like to ask for Unanimous Consent that all Members be allowed to 

submit statements and questions for the record. 

3⁄4 I would also like to ask for Unanimous Consent that all Members be given 10 minutes of 

question time per panel and that all Members be given 5 minutes for opening statements at 

both venues of this field hearing. 

3⁄4 With that, I would like to recognize my friend from Tennessee, Ms. Blackburn, for 5 minutes 

for an opening statement. 

 MRS. BLACKBURN. Thank you, Mr. Chairman. I thank you for 

visiting our 7th District today to investigate the financial burden that is 

placed on our healthcare system by illegal immigration. 

 I also want to say thank you to the City of Brentwood, to the Mayor, 

the Commissioners, and the staff, for their hospitality in welcoming us 

and allowing the use of this facility today. Thank you also to the 

Committee staff, to your staff, and to my staff, for the preparations that 

have gone into today’s hearing. 

 I would like to also welcome and thank our witnesses who are 

joining us today to help our committee, the Energy and Commerce 

Committee, explore some of the anecdotal information we are hearing 

every day on the costs of this problem, and the problem that it is creating 

for our Nation’s healthcare delivery. 
7

 I was a bit amused with the headline in the Tennessean today, and 

then a part in their article where it says, “... and a Washington, D.C. think 

tank has begun to counter the arguments that it thinks might be brought 

up today.” 

 So, to our witnesses, may I assure you that we are definitely 

interested in, and want to hear, and need to hear, the information that you 

are bringing to us. It is not for the sake of argument that we come, but 

we come in search of solutions, and we thank you for joining us as we 

work toward a solution. 

 As the Chairman noted in his statement, for the past 20 years Federal 

benefits have been limited to those, to those, who have lawfully entered 

the United States. Yet, as we know, many of those legal limits are either 

ignored or avoided through fraud. We have a large and growing illegal 

entry problem, and along with that illegal entry we are increasingly 

finding that taxpayer funded benefits are being provided to illegal aliens. 

 The problem appears to be a mixture of legal loopholes, weak or 

nonexistent verification procedures, and false documentation. Our hope 

is that your testimony will, indeed, provide additional insight on these 

situations. 

 We know that the strain is on our emergency rooms, our schools, and 

our safety net programs for seniors and low-income Americans. They 

have already taken a toll, and it does not appear to be abating. 

 I do applaud Chairman Deal’s work on the issue and his effort to 

reform the residency verification process in Medicaid. I strongly 

supported his effort to add language to the Deficit Reduction Act to 

ensure that states verify lawful presence in the U.S. before approving a 

benefit. 

 As the Chairman stated, today’s hearing is one of many that will 

examine how States are implementing this money-saving provision and 

review the current status of Medicaid payments for both emergency and 

non-emergency care. 

 I want to state unequivocally that primary responsibility for 

preventing illegal entry rests with the Federal government. Border 

security is the Federal government’s obligation, but it is also necessary 

for local and State governments to be vigilant partners in guarding 

taxpayer dollars and benefit programs like Medicaid from abuse. 

 It benefits States to diligently keep records on the illegal use of 

taxpayer-funded services. To be good partners, the Federal government 

and our States have to know the extent of the problem--that’s one of the 

reasons, as I’ve said, that we are here today. 

 The House has also passed a border security bill which includes 

provisions of a bill I introduced to mandate the use of the Employer 

Verification Program. This one element I believe would help 
8

Government and employers quickly verify an individual’s legal presence 

in the United States. It’s a free program, so it does not add cost to an 

employer’s hiring process. 

 The primary point of our investigation is simple: We have limited 

resources to support programs for those in this country legally, and it is 

simply inappropriate that taxpayer dollars be used for those who have 

broken our laws and are defrauding our system. To know the extent of 

the costs involved, Congress must hold hearings like this one today. 

 I am looking forward to hearing from the witnesses on the costs that 

they are seeing and having their thoughts regarding how we might best 

address the misuse of taxpayer dollars. As I’ve said, your knowledge 

and your insights are vital components of a workable solution. 

 Again, I thank the Chairman for holding the hearing, and I yield back 

the balance of my time. 

 [The prepared statement of Marsha Blackburn follows:] 

PREPARED STATEMENT OF THE HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 

CONGRESS FROM THE STATE OF TENNESSEE

Mr. Chairman, 

 Thank you for visiting our 7th District today to investigate the financial burden 

being placed on our health care system by illegal immigration. 

 I also want to thank the witnesses joining us today to help our Energy and 

Commerce Committee explore some of the anecdotal information we’re hearing every 

day on the costs this problem is creating for the nation’s health care delivery. 

 For the past 20 years, federal benefits have been limited to those who are lawfully in 

the United States. 

 Yet, as we know, many of those legal limits are either ignored or avoided through 

fraud. We have a large and growing illegal entry problem and along with that illegal 

entry we’re increasingly finding that taxpayer funded benefits are being provided to 

illegal aliens. 

 The problem appears to be a mixture of legal loopholes, weak or nonexistent 

verification procedures, and false documentation. 

 The strain on our emergency rooms, schools, and safety net programs for seniors 

and low-income Americans has already taken a toll and does not appear to be abating. 

 I applaud Chairman Deal’s work on this issue and his effort to reform the residency 

verification process in Medicaid. I strongly supported his effort to add language to the 

Deficit Reduction Act to ensure that states verify lawful presence in the U.S. before 

approving a benefit. 

 Today’s hearing is one of many that will examine how states are implementing this 

money-saving provision and review the current status of Medicaid payments for 

emergency and non-emergency care. 

 I want to state unequivocally that primary responsibility for preventing illegal entry 

rests with the federal government. Border security is the federal government’s 

obligation, but it also necessary for local and state governments to be vigilant partners in 

guarding taxpayer dollars and benefit programs like Medicaid from abuse. 

 It benefits states to diligently keep records on the illegal use of taxpayer-funded 

services. To be good partners, the Federal government and our States have to know the 

extent of the problem -- that’s one of the reasons we’re here today. 
9

 The House has also passed a border security bill which includes provisions of a bill I 

introduced to mandate the use of the Employer Verification Program. This is one 

element I believe would help government and employers quickly verify an individuals 

legal presence in the U.S. It’s a free program so it does not add cost to an employers 

hiring process. 

 The primary point of our investigation is simple -- We have limited resources to 

support programs for those in this country legally and it is simply inappropriate that 

taxpayer dollars be used for those who’ve broken our laws and are defrauding our 

system. To know the extent of the costs involved Congress must hold hearings like this 

one. 

 I am looking forward to hearing from the witnesses on the costs they’re seeing and 

thoughts regarding how we might best address this misuse of taxpayer dollars. 

 Again, I thank the Chairman for holding this important hearing and yield the balance 

of my time. 

 MR. DEAL. Well, I thank the gentlelady, and at this time we are 

ready to proceed into the testimony from the first panel of witnesses, and 

if they would both take their seat at the podium here. 

 We are pleased to have as our first panel Representatives from the 

legislature here in the State of Tennessee. First of all, the Honorable Bill 

Ketron, who is a Tennessee State Senator; and the Honorable Donna 

Rowland, who is a Member of the Tennessee House of Representatives. 

 Lady and gentleman, we are pleased to have you here. Normally, 

southern hospitality would require that I recognize the gentlelady first, 

but in looking at her statement she sort of makes a reference to your 

statement first Senator, I will begin with you. 

 You are recognized, Senator Ketron. 

STATEMENTS OF HON. BILL KETRON, MEMBER, 

TENNESSEE STATE SENATE; AND THE HON. DONNA 

ROWLAND, MEMBER, TENNESSEE STATE HOUSE OF 

REPRESENTATIVES 

 MR. KETRON. Thank you very much, Mr. Chairman, members of the 

subcommittee. 

 I would like to first welcome you to the great State of Tennessee, the 

Volunteer State, and hope you enjoy your short stay here with us today. 

We are very proud of our State and its leaders, including the 

Congressman from the 7th District, Marsha Blackburn. 

 I also want to take the opportunity to meet with you today to discuss 

the illegal immigration problem here in the United States, and 

specifically here in Tennessee. 

 I will start by repeating something that I heard the other day, which 

is very relevant. Every State is a border State. Ten years ago, many 

people would have chuckled if you said that illegal immigration would 

have been a problem anywhere, except for Texas, Arizona, California, or 
10

New Mexico. In Tennessee, particularly over the last few years, the 

number of illegal immigrants have appeared to rise dramatically. 

 As a State Senator, I have spent the past 4 years working on changes 

in our public policy in regard to illegal immigration. One of the specific 

areas of concern to me was that the ease for illegal immigrants to obtain 

valid Tennessee driver’s licenses. I have heard repeatedly the stories and 

news accounts of the astounding number of immigrants coming to 

Tennessee to get a driver’s license. I did not feel that Tennessee needed 

to be in the business of providing driver’s licenses to those who had not 

established their true identity so that they could be free to move about the 

country. I am proud to say that Tennessee now prohibits the acceptance 

of matricular consular card by the Department of Safety as proof of 

identification for the driver’s license application and issuance purposes. 

 I also feel Tennessee has been attractive to illegal immigrant 

population due to one of the most generous healthcare plans in the 

United States which is called TennCare. Although there is debate over 

how much Medicaid actually goes to illegal immigrants, it is very clear 

that the emergency care in the hospitals and state clinics have felt the 

burden of healthcare to the community. 

 Furthermore, Tennessee’s job opportunities due to tremendous 

growth have spurred the need of thousands of jobs that illegal 

immigrants are willing to do for less money than the legal citizen 

workforce. 

 I hear many individual accounts of how illegal immigration has 

taken a toll on Tennessee, but three common themes persist. First, illegal 

immigration is eating away at the foundation of our State’s healthcare 

systems. Second, our K-12 educational systems are struggling to deal 

with a huge influx of illegal aliens--many of whom do not yet speak 

English or read English. Third, our law enforcement system is besieged 

with the problem of how to deal with the rising number of illegals 

crowding jails that are already at capacity, not to mention the rise of 

violent crimes committed by undocumented immigrants. 

 These are some of the questions that I have been asked. How many 

illegal immigrants are getting free healthcare while Tennesseans go 

without? 

 How many of our tax dollars are spent on healthcare for illegal 

immigrants? 

 How many of the prisoners in our State and local prisons are illegal 

immigrants? 

 What is the effect of having children in our classrooms who cannot 

speak English? 

 Is it true that illegal immigrants are still getting driver’s licenses? 
11

 How many Tennesseans have been victims of crimes at the hands of 

illegal immigrants? 

 We, here in Tennessee, are working to find the answers but we could 

use your help. 

 At their core, the people in Tennessee want to see Tennessee families 

come first. This State has to make a decision to remove several thousand 

people from receiving healthcare, yet when illegal immigrants 

continually fill our emergency rooms and State clinics, people want to 

know why their neighbors and relatives don’t have greater access to 

healthcare. 

 Tennesseans want criminals locked up and off the streets, and when 

they realize that our prisons are overcrowded and our tax dollars are 

paying for illegal immigrants who should not be here in the first place, 

they question our law enforcement priorities. We must protect our 

citizens from the most dangerous criminals. 

 Tennessee has fallen behind in education, and teachers are forced to 

lay a foundation for many of our students who cannot yet speak or read 

English while trying to advance students who have mastered and passed 

the basics. We have to challenge the students, not slow them down. 

 Aside from the three prevailing themes I have already mentioned, I 

personally plan to continue my focus on the driver’s license restrictions 

in our State. We have got to protect our citizens on the road every day. I 

have fought for English-only driver’s testing in Tennessee, but that was a 

small fix considering we have many illegal immigrants on the road every 

day. Tennessee has been unfortunate through this summer to see its 

issues effects on the lives of people every day. 

 I would like to conclude my remarks by saying that it’s been an 

honor to address this distinguished body. I hope that together, at both the 

State and the Federal level, we can come up with some common-sense 

solutions to solve the problem now but not later. 

 Mr. Chairman, we, here in Tennessee, feel the same way that you do 

in Washington. Our forefathers came here to establish laws that all of us 

as citizens of this country must obey. We, like Representative Rowland, 

ourselves, like you, you established laws that we all must abide by to 

keep from having chaos in our country. 

 When we pass laws for people to abide, it’s not fair to turn a blind 

eye for those who don’t have to obey the laws, and that’s what’s 

happening and it continues, and that’s what’s causing the divide in this 

country. We must all obey the laws, no matter who you are or where you 

come from. And, if it says that you are legal, then you must be legal. 

That is the law. That’s all we request. 

 Thank you. 

 [The prepared statement of Bill Ketron follows:] 
12

PREPARED STATEMENT OF THE HON. BILL KETRON, MEMBER, TENNESSEE STATE SENATE

Mr. Chairman, Members of the Subcommittee: 

 I would like to first welcome you to the great state of Tennessee, the Volunteer state, 

and hope you enjoy your short stay. We are very proud of our state and its leaders, 

including the Congressman from the 7th District, Marsha Blackburn. 

 I want to also thank you for the opportunity to meet with you today to discuss the 

illegal immigration problem in the United States, and specifically here in Tennessee. 

 I will start by repeating something I heard the other day that is very relevant. Every 

state is a border state. Ten years ago many people would have chuckled if you said that 

illegal immigration would be a problem anywhere except Texas, Arizona, California, and 

New Mexico. In Tennessee, particularly over the last few years, the number of illegal 

immigrants has appeared to rise dramatically. 

 As a state Senator, I have spent the past 4 years working on changes in our public 

policy in regard to illegal immigration. One of the specific areas of concern to me was 

the ease for illegal immigrants to obtain a valid Tennessee driver’s license. I have heard 

repeatedly the stories and news accounts of the astounding number of immigrants coming 

to Tennessee to get a driver’s license. I did not feel that Tennessee needed to be in the 

business of providing driver licenses to those who had not established their true identity 

so that they could be free to move about the country! I am proud to say Tennessee now 

prohibits the acceptance of matricula consular cards by the Department of Safety as proof 

of identification for a driver’s license application and issuance purposes. 

 I also feel Tennessee has been attractive to the illegal immigrant population due to 

one of the most generous healthcare plans in the United States--TNCare. Although there 

is a debate over how much Medicaid actually goes to illegal immigrants, it is very clear 

that emergency care in the hospitals and state clinics have felt the burden of healthcare to 

this community. 

 Furthermore, Tennessee’s job opportunities due to tremendous growth have spurred 

the need for thousands of jobs that illegal immigrants are willing to do for less money 

than the legal citizen workforce. 

 I hear many individual accounts of how illegal immigration has taken a toll on 

Tennessee, but three common themes persist. First, illegal immigration is eating away at 

the foundations of the states Health Care systems. Second, our K-12 educational systems 

are struggling to deal with a huge influx of illegal aliens—many of whom do not yet 

speak or read English. Third, our law enforcement system is besieged with the problem 

of how to deal with rising numbers of illegals crowding jails that were already at capacity 

— not to mention the rise in violent crimes committed by undocumented immigrants. 

These are some questions that I have been asked: 

How many illegal immigrants are getting free health care while many Tennesseans 

go without? 

 How many of our tax dollars are spent on health care for illegal immigrants? 

 How many of the prisoners in our state and local prisons are illegal immigrants? 

 What is the effect of having children in our classrooms who cannot speak English? 

 Is it true that illegal immigrants are still getting driver’s licenses? 

How many Tennesseans have been victims of crimes at the hands of an illegal 

immigrant? 

 We, here in Tennessee, are working to find the answers but we could use your help. 
13

 At their core, the people in Tennessee want to see Tennessee families come first. 

This state had to make a decision to remove several thousand people from receiving 

healthcare, yet when illegal immigrants continually fill our emergency rooms and state 

clinics, people want to know why their neighbors and relatives don’t have greater access 

to healthcare. 

 Tennesseans want criminals locked up and off the streets, and when they realize that 

our prisons are overcrowded, and our tax dollars are paying for illegal immigrants who 

should not be here in the first place, they question our law enforcement priorities. We 

must protect our citizens from the most dangerous criminals. 

 Tennessee has fallen behind in education, and teachers are forced to lay a foundation 

for many of our students who can’t yet speak or read English while trying to advance 

students who have mastered and passed the basics. We have to challenge our students, 

not slow them down. 

 Aside from the three prevailing themes I have already mentioned, I personally plan 

to continue my focus on driver’s license restrictions in our state. We have got to protect 

our citizens on the road every day. I have fought for English-only driver’s testing in 

Tennessee, but that is a small fix considering we have many illegal immigrants on the 

road every day. Tennessee has been unfortunate enough this summer to see how this 

issue affects the lives of people every day. 

 I would like to conclude my remarks by saying what an honor it has been to address 

this distinguished body. I hope that together, at both the state and federal level, we can 

come up with some common sense solutions to solve this problem now - not later. 

 MR. DEAL. Thank you, Senator. 

 Representative Rowland, you are recognized for your statement. 

 MS. ROWLAND. Good morning, Mr. Chairman, honorable members 

of the subcommittee. It’s a pleasure to be here today and to give some 

southern charm to each of you. 

 I want to welcome you to Tennessee and for this opportunity to 

express my community’s concerns regarding illegal immigration. 

 My colleague, Senator Ketron, has done an excellent job of 

providing you an overview of the issues we hear on a daily basis. 

 I first want to commend you on the passage of the Deficit Reduction 

Act with the inclusion of the Citizenship Verification Provision. But, 

please allow me to express some strengths that must remain a part of that 

provision. 

 Since acceptable documentation under this provision includes 

driver’s license, the Federal government must immediately require States 

to issue driver’s license and any other government-issued document only 

to those that can prove that they are a citizen or legal resident of said 

State. 

 In the case of questionable self-documents and declarations, simply 

requiring that a reasonable person find such statement suspect cause a 

very legally challengeable situation. The term reasonable is open for 

interpretation. Unfortunately, we can no longer take for granted that 

your definition of reasonable or my definition of reasonable mirrors 

anybody else’s definition of reasonable. 
14

 Regrettably, self-declaration or the honor system has not proven to 

be a trusted avenue for citizenship verification. Our country has spent 

years, via the Social Security Administration and the department 

formerly known as Immigration and Naturalization Services, to develop 

systems of tracking citizens and legal residents. There are so many steps 

in life at which someone must prove their identity. At birth, for example, 

a Social Security number is issued. If it is missed there, a Social Security 

number is required for tax returns. If it is missed there, a Social Security 

number is required for admission into our education system. The process 

for receiving and verifying a Social Security number, or other legal 

immigration documents, allow for the verification of one’s identity and 

legal status, and it must be included and not deviated from. 

 I understand that there are variations from State to State. Due to the 

Federal funding that you provide to each State, you can, and you do have 

the power, to require this verification process be consistent. 

 Governments do this all the time. For example, just recently on the 

State level in Tennessee, we developed a standard parenting plan form to 

be used in the court systems. Now, this plan had been implemented and 

successful for many years, and it was an excellent tool for our court 

systems to use, but there were as many different forms as there were 

counties, because the locals were allowed to design the form. We are 

such a mobile society that the degree of continuity must exist in order for 

law and order to be effective. 

 Detailed checklists must be provided. This continuity has to exist 

among the States. Unless this is accomplished, States will continue to 

have multiple reinventions of the wheel. I’m proposing to the Federal 

government nothing more than I proposed time and again to my local 

State government, in the way of continuity and consistency. 

 Now, I want to address our efforts to date here in the State of 

Tennessee. As a responsible representative of this State, I have 

introduced and supported numerous bills that would have protected 

Tennesseans, and I’m going to give you a list of those. 

 Require citizenship or legal residence to receive a driver’s license. 

 Forbid Certificates of Driving for illegal aliens. 

 Require citizenship proof prior to registering to vote. 

 Require driver’s license exam to be taken in English only. 

 Require citizenship verification for non-emergency healthcare 

services. 

 Require Tennessee to join the Federal program for verification of 

work authorization. 

 Require the Tennessee Highway Patrol to assist the Federal 

government in enforcement by way of a memo of understanding. It is 
15

my understanding that the State Department is very excited about the 

possibility of working with the States in this manner. 

 Regrettably, each of those bills failed in Tennessee this year. On the 

other side, States such as Arizona, Colorado, Georgia, Idaho, Kansas, 

Oklahoma, and Wyoming have been successful in implementing 

legislation similar to those I just mentioned that were introduced in 

Tennessee. 

 Unfortunately, in Tennessee we have a majority of elected officials 

who prefer to publicly state that illegal immigration is just a Federal 

issue. 

 My colleague has already stated that, from his perspective, every 

State is a border state. I too submit to you that every State is a border 

State. But, additionally, every town is a border town. At the Federal 

level, as elected officials, you have the responsibility for securing our 

borders. On the State level, it is my duty, and the belief of my 

constituents, to protect the borders of the State of Tennessee. 

 Today, I come to you and ask for your help, and this is how you can 

help us on the Federal level. 

 By requiring consistency among States. 

 By clearly defining processes, acceptable documentation, et cetera. 

 By clarifying that illegal immigration is a Federal issue, is a State 

issue, is a town issue. 

 The process for legal immigration is not meant to hinder anyone, it is 

meant to assure this great country is protected from such hindrances as 

illnesses, acts of aggression, et cetera. 

 We must all work together and stop passing the responsibility from 

one entity to the next. If we don’t, soon we will no longer be the greatest 

country there is. We will no longer be a country. 

 I will conclude my remarks by saying what an honor it has been to 

address this body. I do look forward to working on this issue and other 

issues in partnership with other States and the Federal government, for a 

better and more secure future, and I would welcome the opportunity to 

discuss in detail any of the legislation that I’ve brought forward that we 

discussed this year. 

 Thank you very much for this opportunity. 

 [The prepared statement of Donna Rowland follows:] 

PREPARED STATEMENT OF THE HON. DONNA ROWLAND, MEMBER, TENNESSEE STATE 

HOUSE OF REPRESENTATIVES

Mr. Chairman and Honorable members of this Subcommittee: 

Welcome to Tennessee and thank you for the opportunity to appear and express my 

community’s concerns regarding Illegal Immigration. 

My colleague, Senator Ketron has done an excellent job of providing an overview of 

the concerns we hear daily regarding this issue. 
16

I would like to commend you on the passage of the Deficit Reduction Act with the 

inclusion of the Citizenship Verification Provision. Please allow me to express some 

strengths that are absent from this provision. 

Since acceptable documentation under this provision includes driver’s license, the 

federal government must immediately require states to issue driver’s license and any 

other government issued photo card or identification document only to those that can 

prove they are a citizen or legal resident of said state. 

In the case of questionable self declaration statements, simply requiring that a 

reasonable person find such statement suspect causes a very legally challengeable 

situation. The term reasonable is open for interpretation. We can no longer take for 

granted that your definition of reasonable mirrors anyone else’s definition of reasonable. 

Regrettably, self declaration or the Honor system has not proven to be a trusted 

avenue for citizenship verification. Our country has spent years via the Social Security 

Administration, as well as the former Immigration and Naturalization Services to develop 

systems of tracking and identifying citizens and legal residents. There are so many steps 

in life at which some one must prove their identity. At birth, a social security number or 

taxpayer identification number is assigned, if it is missed there, a social security number 

or taxpayer identification number is required for tax returns, if it is missed there; a social 

security number or taxpayer identification number is required for admission into our 

education system. The process for receiving and verifying a social security number or 

taxpayer identification or other legal immigration document allows for verification of 

one’s identity and legal status. 

I understand that there is variation among the states for citizenship verification. Due 

to the Federal funding each state receives, you have the power to make this verification 

process consistent. 

Governments do this all the time. Just recently on the state level, Tennessee 

developed a standard parenting plan form to be used in the court systems. While this 

plan, which had been implemented years before was an excellent tool, there were as 

many different forms as there were counties due to the form design being left to the locals 

to develop. We are such a mobile society now that some degree of continuity must exist 

for law and order to be effective. 

Detailed checklists must be provided in order for continuity to exist among the 

states. Unless this is accomplished, states will continue to have multiple re-inventions of 

the wheel. I am proposing to the Federal Government nothing more than I propose time 

and again to my own state government in the way of continuity and consistency. 

Now, to address our efforts to-date. As a responsible representative of this state, I 

have introduced and supported numerous bills that would have protected Tennesseans. 

Require citizenship or legal residence to receive a driver’s license. 

Forbid Certificates of Driving for illegal aliens. 

Require citizenship prove prior to registering to vote. 

Require driver’s license exam to be taken in English only. 

Require citizenship verification for non emergency health care services. 

Require Tennessee to join the federal program for verification of work 

authorization. 

Require the Tennessee Highway patrol to assist the federal government in 

enforcement by way of a memo of understanding (It is my understanding that the 
17

State Department is very much in support of working together with our law 

enforcement in this manner). 

Regrettably, each of these bills failed in Tennessee this year. Yet other states 

(Arizona, Colorado, Georgia, Idaho, Kansas, Oklahoma, and Wyoming) have been 

successful in implementing legislation similar to those we introduced in Tennessee. 

Unfortunately, in Tennessee we have a majority of elected officials who prefer to 

publicly state that illegal immigration is a federal issue. 

My colleague has already stated that, from his perspective, every state is a border 

state. I too submit to you that every state is a border state. Additionally, every town is a 

border town. At the federal level, as elected officials you have the responsibility of 

securing our borders. On the state level, it is my duty (and the belief of my constituents) 

to protect the borders of the state of Tennessee. 

Today I ask you to help us. 

By requiring consistency among states. 

By clearly defining processes, acceptable documents, etc. 

By clarifying that illegal immigration is a federal issue, a state issue and a town 

issue. 

The process for legal immigration is not meant to hinder anyone, it is meant to 

assure this great country is protected from such hindrances as illness, acts of aggression, 

etc. 

We must all work together and stop passing the responsibility. If we don’t soon we 

will no longer be the greatest country there is. We will no longer be a country. 

I will conclude my remarks by saying what an honor it has been to address this 

distinguished body. I look forward to addressing this and other issues in partnership with 

other states and the federal government. 

 MR. DEAL. Well, thank you both very much. I will begin the 

questions, and then turn to Mrs. Blackburn after that. 

 I think you have accurately summarized the problems. Years ago, 

when I was first elected to Congress, I became an active member of the 

Immigration Reform Caucus, and people kept asking me, well, Georgia 

is not a border State, why are you interested in this issue? I kept saying, 

come to my district and you would believe otherwise. That problem over 

the last decade has definitely magnified, and that’s why as this hearing 

will now have its second segment in my congressional district in Dalton, 

Georgia, which is certainly one of those hubs where illegal immigration 

is very manifest. I think you are appropriate in your analysis there. 

 Senator, as you have characterized the three big categories where the 

impacts are felt most profoundly are in healthcare, in education, and in 

law enforcement. Obviously, the jurisdiction of our Health 

Subcommittee primarily restricts itself to that first inquiry, but the truth 

of the matter is, they are so integrated within themselves that you really 

can’t separate one from the other. 
18

 Representative Rowland, I think that, hopefully, as we hear the 

second panel, and we will have Dennis Smith from CMS, who will 

expound upon some of the verification procedures that we have put in 

place, and he is implementing now through the regulatory process. I 

think you will be pleased to see that we are making some real progress. 

 As you know, on your issue of having some uniformity on driver’s 

licenses, we took what I think is an important step with what we call the 

Real Idea Act. To say that if you are going to use a State driver’s license 

for any Federal purpose, the one we commonly think of, since we travel 

so much going back and forth to Washington, is to board an aircraft that 

you must meet certain Federal criteria. That Act will be in the process of 

being implemented. I believe it will be, perhaps, one of the greatest 

boosts to your efforts here at the State level to change your State law, as 

you have both indicated you would like to do. 

 I am very impressed with your testimony. I’m very impressed with 

what you are trying to do at the State level. As you mentioned, my State 

of Georgia, the legislature last year took a monumental step in the 

direction of dealing with this issue, and maybe, quite frankly, now may 

be the most profound step by any State Legislature in recent times. So, I 

commend you for that. We will hear from my colleagues at the State 

level in Georgia next week. Just keep up the efforts, that’s what I will 

say to you, and I will allow my colleague to have the remaining amount 

of my time. 

 Mrs. Blackburn. 

 MRS. BLACKBURN. Thank you so much, and I want to thank both of 

you for your interest in the issue, and then for coming before us today, 

and thank you for your well-prepared testimony. 

 Senator Ketron, I will say I have to agree with you in your closing 

remarks about laws. I think Ben Franklin, in his discussion of whether 

we were a democracy or a republic, noted the fact that the laws that we 

have certainly, and the requirement to obey the laws, was one of the 

reasons we were a republic, and I think that is a founding principle that 

the laws of the land, the Constitution, be obeyed and be upheld. 

 I do have a couple of questions that I want to ask, I would like to 

propose to you, and, Senator Ketron, the questions you outlined in your 

testimony are so appropriate, I think that they are questions that we are 

hearing here in the State of Tennessee, and I would like to ask that you 

submit to us the answers to those, because they are some of the 

questions, as I was making my notes during your testimony, I know that 

we had heard at one point from the TennCare Administration that they 

felt there was not a problem with illegal immigrants, because there were 

very few, if any, who were getting TennCare. And, I would be interested 

in your assessment of that, and then when you get quantifiable data 
19

having that submitted to us for the record, and, of course, we will 

continue to talk with Mr. Gordon about that issue. 

 Would you care to respond to that? 

 MR. KETRON. Absolutely, Congressman. 

 I think everybody tries to sidestep that issue when it comes to illegal 

immigrants going into our emergency rooms, but it is a fact, and I’ll be 

happy to try to retrieve that data if at all possible. 

 One of your colleagues I heard on a radio show some time back in 

the spring, Steven King, Congressman Steven King made a comment that 

we need to remove the Anchor Baby Provision in our country, like 

Canada has done 4 or 5 years ago, but that Anchor Baby Provision on a 

Federal level continues to allow illegal immigrants to come here and 

locks down, by putting that anchor in, it allows them to continue to use 

our healthcare services by going to the emergency room. 

 You know, we kicked off close to 300,000 people off of our 

TennCare Medicaid program, that had lived here all of their lives, but 

you let an illegal immigrant from whatever country outside of our 

country that is illegal come here and go into the emergency room, by 

law, Federal law, the hospitals have to pick up and pay for that, 

TennCare pays for that. 

 We have got to correct that situation, it’s not fair to let those people 

come in front and go to the front of the line. 

 I talked to a lady just the other day in Lewisburg, Tennessee, just 

south of here. She immigrated from Portugal just a few years ago, and 

she was really upset of all the problems that she had to go through, the 

hassles, and waiting time, and going through Memphis, through 

Immigration Control down in Memphis, and then anybody else just 

comes in and they get to go in the front of the line. 

 MRS. BLACKBURN. Let me ask you this also. You mentioned the 

matricular consular cards were no longer accepted as an ID source. 

When was that change made? 

 MR. KETRON. We changed that, Representative, 2 years ago. 

 MS. ROWLAND. Two thousand and four. 

 MR. KETRON. Two thousand and four. 

 MRS. BLACKBURN. In 2004. 

 And, do you know if there has been a decrease in requests for 

medical care for illegal entrants since that time? You do not? 

 MR. KETRON. Not to my knowledge. 

 MRS. BLACKBURN. Okay. All right. 

 And, Representative Rowland, you mentioned several bills that had 

been supported this year that did not pass. Requiring citizenship or legal 

residence to receive a driver’s license. Forbidding Certificates of 

Driving for illegal immigrants. Requiring citizenship proof prior to 
20

registering to vote. Requiring driver’s license exam to be taken in 

English only. Requiring citizenship verification for non-emergency 

healthcare services, and requiring Tennessee to join the Federal program 

for verification of work authorization. 

 So, to be certain that I understand you correct for the record, all of 

these were legislation pieces that were submitted but did not pass, they 

were bills that were introduced and moved forward in the Legislature but 

did not pass. 

 MS. ROWLAND. Congressman, that is correct. We had some success 

in the Senate with passing legislation. Every piece failed in the House, 

either in subcommittee, full committee, or in a vote on the floor. 

 MRS. BLACKBURN. Considering the situation as it is, then would you 

favor having some of those items, like the citizenship verification for 

non-emergency healthcare services, driver’s license exam taken in 

English only, to receive reciprocity, the AMVA standards, citizenship 

proof prior to registering to vote, joining the Federal program for the 

verification of work authorization, would you consider receiving those as 

mandates, Federal mandates, on Tennessee State law in order to get them 

passed? 

 MS. ROWLAND. Our local governments do not like us putting 

mandates on them. We do not like receiving mandates when they are 

necessary. Above all, though, it is our responsibility as a government 

body in Tennessee to implement these. If it takes mandates to do that, I 

welcome the assistance. It is our responsibility to introduce commonsense legislation and protect the borders of the State of Tennessee, and if 

we fail in that effort to do that then it is your responsibility to step in as a 

Federal government and dictate to us what should happen in order to 

protect our borders. 

 MRS. BLACKBURN. Okay, thank you very much, and that’s all the 

questions I have. 

 MR. DEAL. I want to assure those of you who are familiar with 

legislation that I’ve introduced at the Federal level, I did not put the good 

Senator up to talking about anchor babies. Since he did, let me tell you 

that I am the author of legislation that will do away with the birthright 

citizenship. 

 On that subject, it is one of those magnets, I believe, it is not 

probably as large a magnet as jobs themselves, but it, nevertheless, is a 

magnet. We are in a distinct minority in the world community now of 

nations that recognize birthright citizenship. By that I mean, if you are 

born on American soil, regardless of the circumstances whereby your 

parents got here, legally, illegally, or otherwise, you are considered a 

resident. 
21

 There are 135 countries in the world, all of Europe no longer 

recognizes that, and we are only one of 36, I believe now, that still 

continues to do that. 

 I believe it is an issue, and we do have legislation at the Federal 

level. We are gaining support. I think we are up to about 88 cosponsors, we are gaining. I think it’s an issue that, hopefully, we will 

address at the Federal level. 

 I’m very impressed with both of your testimonies, and we will make 

it, of course, a part of the record for this committee, and we thank you 

both for what you’ve done here today by presenting it, and also for what 

you will continue to do at your legislative level in Tennessee. 

 MRS. BLACKBURN. I have one more. 

 MR. DEAL. Yes, Mrs. Blackburn. 

 MRS. BLACKBURN. Mr. Chairman, if I may, looking back through 

my notes I did skip a question that I had for Senator Ketron. In his 

testimony he spoke about law enforcement, as he spelled out the three 

issues with the healthcare system, the education system, and law 

enforcement. The hearing that we did in San Diego, we heard from some 

of the sheriffs there, in Texas and in California, that the incarcerated 

population of some of their facilities as much as 80 percent of it would 

be an illegal population, illegal entrants. Do you have an idea of what 

the percentage of illegal entrants are in the incarcerated population? 

 MR. KETRON. Congressman Blackburn, this is off the cuff, but we 

did discuss this this past year. One of my colleagues, Senator Steve 

Southerland from Hamlin County up in Morristown, he came with a bill 

that was requesting some relief because his jail in his county, because of 

the large number, I think next to Senator Tracy who is here today, who 

has the largest population of illegal immigrants, up in Morristown he has 

the second largest, and their jail has become so over crowded, over 45 

percent with illegal immigrants. They have lost their accreditation, and, 

consequently, when you lose your accreditation from the State then you 

receive less dollars in order to be reimbursed, so it’s falling back upon 

the citizens of the community to help pay for that, albeit, many of those 

are not State offenses, but because of that the community, the county, is 

still having to pay for the healthcare, they are having to take them to 

dentist, or if they come in with TB, they have to now have a TB isolation 

chamber within the jail. They come in with no shots, no health criteria as 

far as inoculation coming into our country, and we do require that for 

other citizens who come here. 

 So, I think that is a problem, and I think if we were able to run some 

numbers we would find that in many areas across our State, that it’s over 

30 percent anyway. 
22

 MRS. BLACKBURN. Okay. Mr. Chairman, I would like to ask as he 

submits answers on the other questions that were posed that we have that 

information, not that it’s pertinent to this subcommittee, but to the 

overall it definitely is, and I would appreciate the submission. 

 MR. DEAL. Without objection, it will be made a part of the record. 

 MRS. BLACKBURN. Thank you. 

 MR. DEAL. Thank you both. 

 MR. KETRON. And, do I send that back to your office, Mr. 

Chairman? 

 MR. DEAL. Either to Congresswoman Blackburn’s office or to my 

office, either one will be sufficient. 

 Thank you both. 

 MR. KETRON. You are quite welcome. 

 MRS. BLACKBURN. Thank you. 

 MS. ROWLAND. Thank you, Mr. Chairman. 

 MR. DEAL. I will now ask our second panel if they would come 

forward. 

 Gentlemen, we are pleased to have you here, let me introduce you to 

the audience. First of all, we have Mr. Darin J. Gordon, who is the 

Deputy Commissioner of the Bureau of TennCare here in the State of 

Tennessee, and we have Mr. Dennis G. Smith, who is the Director of the 

Center for Medicaid and State Operations at Centers for Medicare and 

Medicaid Services, in Washington. 

 Gentlemen, we are pleased to have you here, and we’ll start with 

you, Mr. Gordon, for your opening statement. 

STATEMENTS OF DARIN J. GORDON, DEPUTY 

COMMISSIONER, BUREAU OF TENNCARE; AND DENNIS 

G. SMITH, DIRECTOR, CENTER FOR MEDICAID AND 

STATE OPERATIONS, CENTERS FOR MEDICARE & 

MEDICAID SERVICES 

 MR. GORDON. Thank you, I’d like to thank Congressman Blackburn 

and the Chairman for having us here today to provide testimony on this 

important issue. 

 Just to give you a little background on TennCare in our State, we are 

a program, Medicaid program, that looks very similar to other Medicaid 

programs. We serve low-income children, pregnant women, and the 

disabled. We serve, approximately, 1.2 million people across the State, 

and we operate with, approximately, a $7 billion budget. It should also 

be pointed out that we are also a State that functions with 100 percent 

managed care. 
23

 Today, TennCare does not provide eligibility entitlement benefits to 

Medicaid enrollees. As you are well aware, there are Federal laws 

prohibiting those entitlement benefits, as well as the fact that we have 

our Tennessee law that requires proof of residency within the State as 

well. 

 As you mentioned previously, some of the requirements in the DRA 

that added and gave specificity to the types of documents people can use 

as proof of citizenship, our State has been able to look at what we had 

been doing and make very minor modifications in order to comply with 

that requirement. 

 I would like to thank the Chairman and this committee for their help 

in clarifying some aspects of the DRA, with regards to the dually eligible 

individuals and those individuals with SSI, that helped tremendously, 

and we thank you for that. 

 We do also want to point out, as I’m sure you’ve heard from other 

States, there are still some limited circumstances in which individuals in, 

primarily, rural or mountain areas that aren’t born in hospitals, in which 

case there are still some--these are U.S. citizens, there is just some 

further comments on how to better address proof of citizenship in those 

limited circumstances, and we appreciate the Committee and CMS’ help 

in trying to get those clarifications. 

 The fact with the DRA coming out has not changed that illegal 

immigrants are not eligible for entitlement benefits on our program. I 

need to point out that there is a law, as has been mentioned on this point, 

that does require the State to provide reimbursement to our hospitals for 

the emergency care to those illegal immigrants that would otherwise 

have been eligible for our program if they had U.S. citizenship. We do 

not consider this reimbursement eligibility for our program, nor do we 

provide eligibility to our program just due to the fact that they are 

eligible, hospitals are eligible for the reimbursement for the services they 

provide. 

 It should also be noted that TennCare takes a strict interpretation of 

the definition of emergency services, as is required by this mandate. 

Medicaid only provides reimbursement for the emergency episode itself. 

We do not provide reimbursement to the providers for any follow-up 

care. 

 And, I should also point out that this is only reimbursement to 

hospitals for those illegal immigrants who fall into existing Medicaid 

categories, for example, if they are aged, blind, or disabled, or a pregnant 

mother, and meet income and resource requirements. So, it may not 

fully encompass, the reimbursement that we provide may not fully 

encompass other issues that hospitals see with regards to illegal 

immigrants. 
24

 Within our program, just to put it in perspective at the Tennessee 

level, looking at the month of July, and we cover about 1.2 million 

people as I said previously, in the month of July we provided 

reimbursement for 62, emergency services for 62 illegal immigrants to 

our State’s hospitals. The amount of reimbursement for the services that 

these people received amounted to $1.7 million over the full treatment of 

their emergency condition. 

 Because of the very nature of emergency episodes, it should be 

pointed out, though, that single cases could easily eclipse the total 

reimbursement we pay for these 62 individuals. For example, an 

individual burned in a car accident could cost upwards of $2 million. 

 However, we primarily see reimbursements related to labor and 

delivery, that’s primary. If you look at the illegal immigrants, the 

emergency services that we get requests for reimbursement for, it’s 

primarily in that area. And, it’s also important to point out, which was 

referenced earlier, is that that child, when born, is a U.S. citizen and is 

entitled to 12 months of Medicaid eligibility coverage from that point 

forward, and it’s also important to emphasize in that instance the need to 

provide the neonatal care immediately following delivery to ensure that 

that child does not have complications that cost the State and the Federal 

government more money than it would have otherwise, if they had 

received that proper follow-up care. 

 I should also point out that, as I’ve mentioned earlier, that the 

hospitals do not receive reimbursement for any of those individuals that 

wouldn’t have met Medicaid eligibility criteria. So, there will be some 

unreimbursed costs due to the fact that hospitals are unable to turn away 

those people seeking care in the emergency room that they do not receive 

funding from Medicaid on, and I’m sure the hospitals and other members 

of the panel will probably speak to that. 

 To remove funding from what Medicaid currently pays for, would 

again put additional unreimbursed cost burdens on the hospitals, even 

though ours is limited in the whole scope of what unreimbursed costs 

that hospitals incur, it is something to take into consideration. 

 I also need to point out that in our State we do not currently have a 

disproportionate share hospital payment, and I’m sure the hospitals will 

definitely speak to that. Usually, many States would use that to help 

offset some of that uncompensated care that those hospitals incur, 

including more than likely costs that they would incur related to 

treatment to those non-Medicaid-eligible illegal immigrants. 

 In conclusion, the Federal mandates placed on State Medicaid 

programs puts us in a precarious position of balancing the demand for the 

Federal government with fiduciary responsibility of the State of 

Tennessee. The State Medicaid program, we are in a difficult position, 
25

as I see you all are as well. On one hand, we must comply with Federal 

requirements to pay for emergency care for illegal immigrants, and on 

the other hand we must live within the State’s limited resources to 

address the healthcare needs of our own citizens. 

 Medicaid is a payer, not a direct healthcare provider. A s a result, 

the Federal mandates related to the illegal immigrant population further 

stretches limited State resources. The Federal government should 

examine ways to relieve some of these financial pressures these 

mandates place on States’ healthcare systems, and I understand it’s a 

difficult situation, I know we provide services only in emergency cases, 

but it’s something that the States are further stretching their limited 

resources to try to accomplish. 

 Thank you. 

 [The prepared statement of Darin Gordon follows:] 

PREPARED STATEMENT OF DARIN J. GORDON, DEPUTY COMMISSIONER, BUREAU OF 

TENNCARE

 Good morning. 

 I would like to thank Congressman Blackburn and the members of the Energy and 

Commerce Committee for inviting TennCare to provide testimony on the impact of 

illegal immigration on our state’s Medicaid program. It is a pleasure to be with you 

today. 

 TennCare is Tennessee’s expanded Medicaid program, providing health care 

coverage to approximately 1.2 million Tennesseans with a $7 billion budget. Today, our 

program is much more like traditional Medicaid programs across the country, largely 

serving low-income children and pregnant women and the disabled. 

Current Medicaid eligibility includes a requirement that an individual prove U.S. 

citizenship and Tennessee state residency before Medicaid entitlement benefits are 

available. Illegal immigrants are not eligible for full Medicaid entitlement benefits in 

Tennessee. Under federal law (42 U.S.C.A. §1396b(v)) no payment may be made to a 

State for medical assistance furnished to an illegal immigrant. An illegal immigrant is an 

immigrant who is not lawfully admitted for permanent residence. 

There is one exception in federal law. Payment shall be made for care and services 

that are furnished to an illegal immigrant only if such care and services are necessary for 

the treatment of an emergency medical condition of the individual, and such care and 

services are not related to an organ transplant procedure. Therefore, TennCare provides 

reimbursement to hospitals for emergency healthcare services to illegal immigrants who 

would otherwise qualify for Medicaid. 

According to federal regulations, the term “emergency medical condition” means a 

medical condition (including emergency labor and delivery) manifesting itself by acute 

symptoms of sufficient severity (including severe pain) such that the absence of 

immediate medical attention could reasonably be expected to result in— 

(A) placing the patient’s health in serious jeopardy, 

(B) serious impairment to bodily functions, or 

(C) serious dysfunction of any bodily organ or part. 

Emergency Medicaid coverage is initiated in Tennessee when an application is filed 

with the state Department of Human Services. Typically, the emergency has already 

occurred and Medicaid is reimbursing the hospital for the emergency treatment costs 
26

associated with the care already provided. An illegal immigrant receiving emergency 

medical services must meet the same income and resource standards as any other 

Medicaid enrollee. Examples of emergencies that trigger eligibility are childbirth, car 

accidents, heart attacks and stroke. The reimbursement of emergency services is covered 

for the time the qualified individual is admitted to the hospital only. No follow-up 

treatment or care is paid for by Medicaid. 

Using state and federal funds to pay for emergency healthcare for illegal immigrants 

places real burdens on state governments in addition to the entire healthcare delivery 

system. Our program’s experience can offer some insight into the effects of illegal 

immigration in Medicaid programs and its effects on Tennessee’s health care providers. 

Tennessee’s Medicaid program experience has been that this federal mandate 

involves an extremely small number of individuals compared to our program’s total 

population of 1.2 million people. For example, in July 2006, TennCare was required 

under federal mandate to pay for 62 illegal immigrants’ emergency care services. The 

total combined cost for these 62 individuals was approximately $1.7 million. 

However, it is also important to note that because of the nature of an emergent 

episode, one individual’s cost can easily exceed the cost of treating these 62 individuals 

in any given month. In addition to these month-to-month cost fluctuations, there is also 

the potential for overall increases in emergency care costs for illegal immigrants should 

the illegal immigrant population continue to grow. 

The vast majority of illegal immigrants who receive emergency Medicaid are 

pregnant mothers entering the hospital emergency room in active labor. The children are 

born U.S. citizens and immediately qualify for full Medicaid benefits for the first year of 

their lives. The cost of providing coverage for labor and delivery services for these 

illegal immigrants must be weighed against the fact that the provision of this service may 

reduce birth complications and subsequent costs that the Medicaid program would incur 

caring for an infant with health problems resulting from such complications. 

Medicaid programs must also recognize the circumstance from which hospital 

providers cannot escape. Federal emergency medical treatment and active labor act 

(EMTALA) regulations require hospitals to provide emergency medical treatment to 

anyone regardless of ability to pay or citizenship status. The cost of providing 

uncompensated care to illegal immigrants today is offset by required Medicaid 

reimbursement for a small subset of that population. Medicaid does not reimburse 

hospitals for emergency care provided to all illegal immigrants, but only for those who 

meet all other Medicaid eligibility criteria except citizenship. 

Therefore, hospitals are bearing the total cost of uncompensated emergency care to 

illegal immigrants that do not qualify for Medicaid reimbursement. To remove the 

funding that providers receive from the Medicaid program would result in additional 

unreimbursed costs for hospitals. 

In many states, disproportionate share hospital payments (DSH) are used to offset 

unreimbursed cost to hospitals. DSH payments are federally matched dollars that help 

offset the cost of uncompensated healthcare provided by hospitals. When TennCare was 

created in 1994, Tennessee’s DSH allotment at the federal level was removed because it 

was believed the program would be able to cover the uninsured population and remove 

most, if not all, of the charity care experienced by the hospitals. However, due to rapid 

growth, the program quickly closed to the uninsured without a reinstatement of DSH 

payments to hospitals. 

 Now that TennCare is aligned with more traditional Medicaid programs, we believe 

that DSH payments are once again appropriate mechanism for uncompensated care 

reimbursement to hospitals. Tennessee does not have the flexibility that almost all other 

Medicaid programs have in offering a mechanism to help offset increases in 

uncompensated care. TennCare is allowed to offer a fixed amount in essential access 
27

payments (EAP) to a limited number of hospitals treating the majority of Medicaid 

enrollees. 

This limited supplemental pool plan does not afford Tennessee hospitals the means 

to address the escalation of uncompensated care costs that DSH allotments allow other 

states. Healthcare utilization, the decline in private sector health care benefits, in addition 

to a number of other factors, leave hospitals facing an ever increasing uncompensated 

care burden and no mechanism to fairly address the increased costs to Tennessee. 

Finally, Medicaid programs often receive criticism from taxpaying citizens who are 

concerned that state funds are directed away from providing healthcare assistance to legal 

residents and toward paying for illegal immigrant emergency care. The federal mandate 

places state Medicaid programs in a precarious position of balancing the demands of the 

federal government with a fiduciary responsibility to Tennessee taxpayers. Ultimately, 

all taxpaying U.S. citizen and health insurance consumers bear the healthcare costs to 

provide these services for illegal immigrants. Tax dollars are spent to provide direct 

reimbursement to hospitals for emergency Medicaid for those illegal immigrants who 

qualify for such assistance, while the costs of caring for other illegal immigrants are 

passed on to consumers indirectly in the form of higher costs for healthcare services that 

ultimately results in increased health insurance premiums. 

In final summary, as a state Medicaid program we are in a difficult position. On one 

hand, we must comply with the federal requirement to pay for emergency care for illegal 

immigrants and on the other hand, we must live within the state’s limited resources to 

address the healthcare needs of our own citizens. Medicaid is a payer, not a direct 

healthcare service provider. 

As a result, the federal mandates related to the illegal immigrant population further 

stretches limited state resources. The federal government should examine options to 

relieve some of the financial pressures these mandates place on states’ healthcare 

systems. 

Thank you. 

 MR. DEAL. Thank you. 

 Mr. Smith. 

 MR. SMITH. Thank you very much, Mr. Chairman. It’s a pleasure to 

be with you today, and I thank Mrs. Blackburn for inviting me back to 

Tennessee. It’s a great pleasure to be with you here today. 

 I do have a full statement for the record that has been submitted, and 

I’d like to take my time just to really kind of reflect on what we’ve heard 

here this morning. And first, I was taken by Mrs. Blackburn’s remarks 

about confronting these real problems and finding solutions, and I want 

to commend you for doing exactly that, because when you have faced a 

problem you took it on and you found solutions. 

 For 20 years now, an individual applying for Medicaid had to declare 

whether or not they were a citizen or a legal alien, in order to receive 

Medicaid. For Medicaid, you were required to provide a Social Security 

number. 

 Ten years ago, in welfare reform, confronted the issue of legal aliens 

coming to the country and getting immediately on public assistance 

programs. Applications actually being filled out in the country prior to 
28

even getting to the United States, applications for our public programs, 

getting on SSI, getting on Medicaid. Congress put a stop to that. 

 Now, if you are a legal alien coming to the United States, you cannot 

be eligible for Medicaid for a 5-year period of time. The individual who 

brought you here has agreed in bringing you to the United States to be 

responsible for your care, including for your healthcare. So, we found a 

solution to a problem that was very, I think, important to do. 

 In the Balanced Budget Act of 1997, Congress responded by 

providing over $100 million over a 4-year period of time to assist States 

with the cost of providing emergency room services to undocumented 

aliens, regardless of their Medicaid eligibility. 

 In the Medicare Modernization Act, again, Congress saw a problem, 

worked with the Administration, provided $1 billion over a 4-year period 

to provide direct payments to hospitals for the cost of care that they were 

not otherwise going to be paid for. 

 And now, in the Deficit Reduction Act, finding the solution that, 

again, to the documentation of citizenship, I think being very important 

to the American public, to assure them that the integrity of the public 

programs, in fact, are being upheld. 

 But, it went beyond that in the DRA, provided $150 million to the 

States for transformation grants to help them to reshape their Medicaid 

programs, to help them to deal with some of the issues and problems that 

they face, and to modernize their programs, and a $50 million grant 

program, specifically, Mr. Chairman, putting in there for the States to 

help them to establish alternatives to emergency room care, and I think 

that that is a very important piece as well, as we do know that our 

hospital emergency rooms are over-burdened providing great quality of 

care, but at the highest cost, that is, the most inefficient way to provide 

healthcare services. We know this from States in a variety of different 

ways, again, finding those alternatives to the emergency rooms are very 

important. 

 So, I think that to begin with, to be commended for facing these 

challenges head on, and working together to find solutions. 

 I was also struck by the State Senator’s remarks about how these 

things are interrelated. And again, in healthcare we often know, if you 

touch one part of healthcare you have touched all parts of healthcare, 

because they are interrelated, and interdependent. 

 I think the issue of immigration reform is very similar. The State 

Senator mentioned healthcare, but also corrections and education, and 

again, I think all of those things touching together do lead us back to 

those previous examples of doing comprehensive approaches, giving 

comprehensive solutions, and I want to end on that, that the 

Administration wants to work with you to find these comprehensive 
29

solutions, but again, to also congratulate you for taking them on, and 

facing what is in front of us. 

 I will mention very quickly on citizenship documentation, again, I 

thank the Chairman for all of his work in that area. I think, again, we 

took a very balanced approach first and foremost protecting those 

American citizens who are eligible for Medicaid, to make certain that 

they do not lose their eligibility. There are many different ways to help 

establish their citizenship, and we are working with the States, having 

provided guidance to them, and our regulations help to protect their 

Medicaid eligibility for citizens who, in fact, are eligible. 

 These solutions, again, I think are very balanced. They work 

because we know they work in other areas. Our approach is, basically, 

the Social Security Administration’s approach, how they authenticate an 

individual’s identity, how they authenticate an individual’s citizenship. 

These are not really new ways in terms of eligibility workers, eligibility 

workers who have worked for Social Security, worked in these other 

programs, are very familiar that you need to have an authentic document, 

you have to be able to have confidence in that document that is being 

presented to you, to have that, to be able to provide that eligibility. 

 That is why, again, we go through the hierarchy of documentation, to 

say this document is more reliable than that document. That’s why those 

things are important, to assure that those documents are authentic. But, 

we do have other ways, again, to help preserve the ability for an 

individual who is currently on Medicaid to make certain there is time to 

find their appropriate documentation, so that their eligibility is not at 

risk. 

 Ways that the States have to share their databases to affirm 

citizenship and identity, States have a great deal of information about 

individuals. They are able to share that information, again, to preserve 

someone who is a citizen to make certain their Medicaid is not 

jeopardized. 

 So, I think we have taken a very balanced approach, but again, have 

assured the American people the integrity of the program. We worked 

with you on these different areas that we have discussed, and look 

forward to working with you on comprehensive immigration reform as 

well. 

 Thank you, Mr. Chairman. 

 [The prepared statement of Dennis Smith follows:] 

PREPARED STATEMENT OF DENNIS G. SMITH, DIRECTOR, CENTER FOR MEDICAID AND 

STATE OPERATIONS, CENTERS FOR MEDICARE & MEDICAID SERVICES

Thank you for inviting me to speak with you about the impact of undocumented 

immigrants on the Medicaid program and the health care delivery system and express the 
30

Administration’s support for comprehensive immigration reform that increases border 

security, establishes a robust interior enforcement program, creates a temporary worker 

program, and addresses the problem of the estimated 11 to 12 million illegal immigrants 

already in the country. 

Medicaid is a partnership between the Federal government and the states. While the 

Federal government provides financial matching payments to the states, each state is 

responsible for overseeing its Medicaid program, and each state pays a portion of its cost 

through a statutorily determined matching rate, currently ranging between 50 and 

approximately 76 percent. The Centers for Medicare & Medicaid Services (CMS), which 

oversees the Federal responsibility for Medicaid, ensures states enforce Medicaid 

eligibility requirements. Recently, CMS issued guidance and an interim final regulation 

to the states as part of the implementation of the Deficit Reduction Act of 2005 (DRA), 

which requires Medicaid applicants who declare they are citizens to document their 

citizenship and identity. 

CMS, in regards to the broader health care system, also enforces regulations that 

require hospitals to medically screen and provide stabilizing treatment or an appropriate 

transfer to any person seeking emergency care, regardless of payment method or 

citizenship status. 

Immigrants and Medicaid Eligibility 

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 

(PRWORA) significantly changed the eligibility of non-citizens for Federal means-tested 

public benefits, including Medicaid and subsequently the State Children’s Health 

Insurance Program (SCHIP). This change, however, did not alter eligibility for 

undocumented and nonimmigrant aliens, who generally remain ineligible for nonemergency Federal benefits. As a general rule, only “qualified aliens” may be eligible for 

Medicaid and SCHIP coverage. Qualified aliens include aliens lawfully admitted for 

permanent residence under the Immigration and Nationality Act. Refugees, those granted 

asylum, and victims of a severe form of trafficking (as certified by the Office of Refugee 

Resettlement of the Department of Health and Human Services) among several other 

categories also may be considered qualified aliens. 

 Under PRWORA, states are required to provide Medicaid to certain qualified aliens 

who otherwise meet the eligibility criteria of the state’s Medicaid program, unless subject 

to a five-year bar. This five-year bar applies only to qualified aliens who entered the 

United States on or after August 22, 1996 with some exceptions. Typically the bar 

applies to lawful permanent residents and aliens granted parole for at least one year. 

Some qualified aliens are exempt from the five-year bar, including refugees, those 

granted asylum, and trafficking victims, among others. A qualified alien who is 

honorably discharged from the military; on active duty in the U.S. military; or the spouse 

(including a surviving spouse who has not remarried) or unmarried dependent child of an 

honorably discharged veteran or individual on active duty in the U.S. military also is 

exempt from the five-year bar. 

However, the five-year bar and other eligibility restrictions do not apply to aliens 

who are applying only for treatment of an emergency medical condition. Thus, all aliens 

– both qualified and non-qualified aliens (including undocumented immigrants) – may be 

eligible for treatment of an emergency medical condition, provided they otherwise meet 

the eligibility criteria (such as income level, for example) for the state’s Medicaid 

program. 

CMS Issues Guidance on Citizenship and Identity Documentation for Medicaid 

Eligibility 

American citizenship or legal immigration status have, for many years, been a 

requirement for Medicaid eligibility. However, previously, in many states applicants 
31

could assert their citizenship status by merely checking a box on a form. (A number of 

states have long required their applicants to document citizenship, including New York, 

New Hampshire and Montana.) The DRA now holds states financially responsible for 

Medicaid expenditures for individuals claiming to be United States citizens unless such 

individuals provide actual documentary evidence supporting their citizenship and 

identity. This new requirement applies to new applications for Medicaid eligibility and 

re-determinations beginning July 1, 2006. 

In order to give states some initial guidance on the implementation of this provision, 

on June 9, 2006 CMS issued a State Medicaid Director letter. On July 12, 2006 the 

Department published an interim final regulation for states to implement this new 

requirement. Comments on the interim final rule are due on August 11, 2006. We expect 

to publish a final rule shortly. 

The law requires that a person provide evidence of both citizenship and identity. In 

some cases, a single document will be enough to establish both citizenship and identity, 

such as a U.S. passport. However, if secondary documentation is used to establish 

citizenship, such as a birth certificate, the individual will also need evidence of his or her 

identity. Once citizenship has been proven, it need not be documented again with each 

eligibility renewal unless later evidence raises a question.

The law specifies certain forms of acceptable evidence of citizenship and identity 

and provides for the use of additional forms of documentation as established by Federal 

regulations, when appropriate. If an applicant or recipient presents evidence from the 

listing of primary documentation, such as a U.S. passport, certificate of naturalization, or 

a certificate of U.S. citizenship, no other information is required. When such evidence 

cannot be obtained, our regulations require the states to look to the next tier of acceptable 

forms of evidence. However, a state must first seek documents from the primary list 

before looking to the secondary or tertiary lists. Because individuals who receive 

Medicare and individuals who are on Supplemental Security Income (SSI) in a state 

using SSI for Medicaid eligibility purposes already have met certain documentation 

requirements, the regulation does not include new documentation requirements for these 

groups. This exemption reflects the special treatment of these groups in the statute. 

At the time of application or re-determination, the state must give an applicant or 

recipient a “reasonable opportunity” to present documents establishing U.S. citizenship or 

nationality and identity. An individual who is already enrolled in Medicaid will remain 

eligible if he/she puts forth a good faith effort to present satisfactory evidence of 

citizenship and identity. Applicants who despite their good faith effort are unable to 

present documentation should be assisted by the state in securing these documents. 

States may use data matches with the State Data Exchange (SDX) or vital statistics 

agencies in place of a birth certificate to assist applicants or recipients to meet the 

requirements of the law. As a check against fraud, states are also required to use 

currently available capabilities to conduct a match of the applicant’s name against the 

corresponding Social Security number that was provided. In addition the Federal 

government encourages states to use automated capabilities to verify citizenship and 

identity of Medicaid applicants. We specifically asked for public comment on whether 

there are other electronic data systems that should be identified to assist states in 

determining an individual’s citizenship or identity. 

As with other Medicaid program requirements, states must implement an effective 

process for assuring compliance with documentation of citizenship in order to obtain 

federal matching funds, and effective compliance will be part of Medicaid program 

integrity monitoring. In particular, audit processes will track the extent to which states 

rely on lower categories of documentation with the expectation that such categories 

would be used relatively infrequently and less often over time, as State processes and 

beneficiary documentation improve. When future automated capabilities to verify 

citizenship and identity of Medicaid applicants becomes available, states also will be 
32

required to match for individuals who used third or fourth tier documents to verify 

citizenship and identity. In the meantime, states must ensure that all case records within 

this category are identified so that they may be made available to conduct these 

automated matches. States will receive the normal 50 percent match for administrative 

expenses related to implementation of the new law. 

The law also requires that the Secretary develop an outreach program which is 

intended to educate individuals who are likely to be affected by the requirements of this 

provision of the law. CMS has already conducted numerous teleconferences with states 

and other organizations interested in this provision. In addition, we are developing an 

outreach plan that provides strategic direction and coordination for an integrated 

education and outreach program to inform states, Medicaid recipients, and others of these 

new documentation requirements. This initiative will be implemented to promote active 

and informed involvement by states and people with Medicaid in providing beneficiaries 

the necessary information about the new documentation requirements. The plan will 

ensure that all stakeholders know of the new requirements, understand the documents 

which satisfy these requirements, assist the streamlined implementation by states, and 

ensure continued uninterrupted access to Medicaid for citizens. 

EMTALA 

Regarding the broader health care system, CMS enforces the 1986 Emergency 

Medical Treatment and Labor Act (EMTALA). Under EMTALA, hospitals have 

obligations to any individual, regardless of citizenship, who requests treatment for a 

medical condition. EMTALA was designed to ensure that people will receive 

appropriate screening and emergency treatment regardless of their ability to pay. 

CMS’ regulations implementing EMTALA require that hospitals with dedicated 

emergency departments provide an appropriate medical screening examination to any 

person who comes to the hospital emergency department and requests treatment or 

examination of a medical condition. They also require that these hospitals provide an 

appropriate medical screening examination to any person who presents himself on 

hospital property requesting evaluation or treatment of an emergency medical condition. 

In both cases, a request may be made by another individual on behalf of the person for 

whom examination or treatment is sought, or a request can be considered to have been 

made if a prudent layperson believes that based on the behavior of the individual an 

emergency medical condition exists. If the examination reveals an emergency medical 

condition, the hospital must also provide either necessary stabilizing treatment or arrange 

for an appropriate transfer to another medical facility. 

EMTALA applies to all Medicare-participating hospitals with dedicated emergency 

departments and applies to all individuals regardless of immigration status who present 

themselves requesting examination or treatment of a medical condition. Hospitals with 

specialized capabilities have a responsibility under EMTALA to accept appropriate 

transfers regardless of whether the hospital has a dedicated emergency department. A 

hospital that violates EMTALA may have its ability to participate in Medicare terminated 

and may be subject to civil penalties of up to $50,000 per violation. An individual who 

has suffered personal harm and any hospital to which a patient has been improperly 

transferred and that has suffered a financial loss as a result of the transfer are also 

provided a private right of action against a hospital that violates EMTALA. 

Hospitals also are required to maintain lists of physicians who are on call for duty 

after the initial examination to provide necessary stabilizing treatment. Hospitals have 

discretion to develop their on-call lists in a way that best meets the needs of their patients 

requiring services required under EMTALA. 

Under CMS’ regulations, EMTALA does not apply after an individual has been 

admitted for inpatient hospital services, as long as the admission is made in good faith 

and not in an attempt to avoid the EMTALA requirements. 
33

Section 945 of the MMA required the Secretary of Health and Human Services to 

establish a technical advisory group (TAG) to review EMTALA policy, including the 

regulations and interpretive guidance outlining hospitals’ responsibilities under 

EMTALA. This TAG, which includes hospital, physician and patient representatives, 

has already met 4 times. The TAG will complete its deliberations and submit a report of 

its findings and recommendations to the Secretary by October 2008. 

Conclusion 

Thank you again for this opportunity to discuss the impact of undocumented 

immigrants on Medicaid and the health care system. I would also like to take this 

opportunity to once again express the Administration’s support for comprehensive 

immigration reform. I would be happy to answer any questions you might have. 

 MR. DEAL. Thank you, Mr. Smith. 

 Let me sort of set the stage for my questions. For those of you who 

have not followed this discussion over the last decade or so, as we have 

dealt with the issues, especially those alluded to with Mr. Smith, 

Medicaid had been one of those areas where we really had not put the 

same kind of requirements in terms of verification of eligibility, as you 

alluded to that we are currently in, Social Security, SSI, and Medicare. 

 And, as you heard in my opening statement, we found as we started 

looking into this that 46 States, including the District of Columbia, 

making 47 major jurisdictions, used what was called “self declaration of 

eligibility.” Now, let me just sort of walk you through, and I know the 

two gentlemen here at the table understand this in great detail, but for 

those of you in the audience let me walk you through what that really 

means. 

 For years, I had been hearing the complaints from my constituents 

that people that they thought probably were not eligible for Medicaid 

were showing up with Medicaid cards at the doctor’s offices and other 

healthcare settings. I have somewhat facetiously made the comparison 

that it was the substitute for what we all used to hear about the 

complaints about Food Stamps with a person in front of them at the 

checkout line at the grocery store who had paid with Food Stamps and 

they thought that was an abused program, it now sort of migrated into the 

healthcare arena through Medicaid. 

 For years, I kept asking my people at the State level, and at the 

Federal level, do you verify the immigration status of people who apply 

for Medicaid? The answer kept being, yes, we do. 

 It took me a while to realize I was asking the wrong question. The 

first question is always, are you a citizen? There was no verification of 

your answer to that. You could say, yes, wee, si, whatever language you 

choose to use, if it was an affirmative response, there was no verification 

required, and that’s what we call self-declaration of eligibility. 

 Now, I bet I could suggest to this audience that there are a number of 

Federal and State programs that have eligibility requirements, and if all 
34

that was required to get on the rolls of receiving those benefits was for 

you to say you are eligible. I think you would say that would make a 

mockery of the system. That’s what we had in Medicaid, and that’s why 

the reforms that we put in place about requiring documentation of 

eligibility were so significant. 

 Why? Because what we found was, when States like mine asked the 

questions of individuals that appeared to be, perhaps, not eligible, they 

were accused of profiling. They were threatened with lawsuits by the 

Civil Rights Division, that if you do this and ask for documentation of 

only selected individuals who you suspect might not be a citizen, then 

you are violating the Civil Rights rules because you should treat 

everybody equally. 

 So, if you hear anybody complaining about the fact that grand 

momma doesn’t have a birth certificate, she’s been on Medicaid, and 

now they are going to kick her off. First of all, as Mr. Smith said, that’s 

not true, and there are procedures to go by to get those proper 

documentations. 

 We’ve heard from the opponents of this solution that it is going to 

just be so cumbersome and difficult. I guess first of all, Mr. Gordon, I 

would ask you, since you are in the process and in the position of having 

to implement this reform, what has been your sense of being able to 

enforce this provision at the State level? 

 MR. GORDON. Actually, here in Tennessee at least, and, obviously, I 

can’t speak to other States, but with our experience we currently contract 

with our State Department of Human Services that would do this for us. 

 Initially, there was some concern, but I believe the clarification 

around Social Security eligible individuals and the Medicare populations 

really relieved the vast majority of our concerns. 

 Speaking with the agency, the Commissioner of that agency, just 

yesterday, just following up and seeing how that’s progressing, they had 

to modify some of their processes in how they retained the 

documentation and trying to do that through, just from a pure filing and 

imaging type process. But, other than that, they felt that this was 

something that they could implement and comply with. 

 MR. DEAL. Well, that’s the experience that my State people are 

telling me as well. 

 Mr. Smith, let me ask you to amplify on this, and in so doing would 

you talk about the question that the Representative and the Senator 

alluded to for States like Tennessee that currently are still issuing 

driver’s licenses without the verification of citizenship for the issuance of 

that license. How do States like that fit into the presentation of the 

necessary documentation for Medicaid eligibility? And, what validity, if 

any, do you place on documents like that kind of driver’s license? 
35

 MR. SMITH. Yes, Mr. Chairman. 

 Again, to step back for a second, the States do the eligibility 

determinations for Medicaid. Many States, it is not the Medicaid agency 

actually doing the determination, but a Department of Social Services, or 

an enrollment broker, or someone else like that. 

 The guidance that we have given to the States is very specific, in 

terms of making certain the State understands that they need to rely on 

documents that are authentic and verifiable. The States should also be 

doing cross matches of Social Security numbers, to assure, again, that 

when you are presented with information the State is at risk to make 

certain that information, in fact, is correct, and that they are relying on 

documents that are correct and authentic. 

 So, if the State does not have confidence in any type of document, 

then they should be doing something else to move beyond that then to 

request something else. 

 There are documents, again, in the hierarchy, there are some 

documents that provide both citizenship and identity, like a passport, but 

in many cases, in most cases, States are going to be looking for probably 

a combination of documents, a birth certificate that provides the 

citizenship status, and another document that provides the identity. So, 

you need to look at both of them together. 

 But, the States can also do cross matching of their own databases, 

with other databases, with other States as well, but again, what we would 

be looking for in coming behind the State is, did you make the 

determination of eligibility on information that was authentic and that 

you had confidence that that was correct information. 

 So, a State should not accept information that they don’t have 

confidence in. Again, we have said, do not accept copies. Do not--you 

know, there are, and again, this is not any different than guidance that 

Social Security uses, they would not accept a copy of a document. So, it 

lays out, I think, very clearly what the States should do in situations, if 

you are presented with information that you don’t have confidence in 

you should be looking out for something else as well, you should be 

cross matching the Social Security number, et cetera. 

 MR. DEAL. In the letter you’ve sent to State Medicaid Directors, it 

goes into great detail about outlining the processes, the steps, and the 

kinds of documents that you would be looking for, for that verification. 

Is that right? 

 MR. SMITH. Yes, Mr. Chairman. 

 MR. DEAL. All right. 

 MR. SMITH. Yes, sir. 
36

 MR. DEAL. I don’t think we need to go into all the details of that for 

purposes of this hearing, because it is an official document that has been 

sent to all State verification agencies. 

 I do think, though, however, it is going to require diligence. Both at 

the Federal level as you go behind and check States as to their 

verification and certification processes. My understanding is that if you 

find that they have not complied with this change in the law then they are 

subject to a penalty in the form of losing Medicaid matching money from 

the Federal government. Is that correct? 

 MR. SMITH. That’s correct, Mr. Chairman. The law requires to 

participate, to get FFP from the Federal government, you must come into 

compliance. 

 But also, at the individual level, again, where you have an individual 

on an audit review, we will be looking for that information as well, that 

you’ve complied programmatically in implementing them, but also on an 

individual basis you want to make certain, as Darin alluded to, you have 

to make sure the file is complete also, to when they are looked behind, 

again, audits are generally a sample of files, whether it’s eligibility or at 

a provider level, you are looking at a sample. So, you want to make 

certain that the file is complete, again, that you have relied on documents 

that are authentic and that you have confidence in. 

 MR. DEAL. As I understand it, there is a 12-month phase in on this 

program, so that people who are currently under the Medicaid program, 

that may not have the documentation that the new change in the statute 

requires. The States will have a 12-month period in order to provide that 

documentation. Is that correct? 

 MR. SMITH. It is correct for individuals, Mr. Chairman, in two 

different ways. One, if you are an applicant, if you are applying for the 

first time, then you need to provide the documents at tine of application. 

 But, in Medicaid, we also have what is called redetermination, so no 

less than every 12 months a State needs to redetermine that individual’s 

eligibility. States vary in terms of that amount of time, and how 

frequently they redetermine. So, come September you are looking at all 

new applicants, and then those individuals that were up for 

redetermination in September, et cetera, as you move forward every 

month. 

 In terms of the individual, if they are on Medicaid currently, and 

again, we have exempted people on Medicare, we’ve exempted people 

on Social Security, they do not have to do this again. They do not have 

to-- 

 MR. DEAL. Because they’ve already done that. 

 MR. SMITH. --that is correct. 
37

 But, if you are not in that exempt category, and you are on but you 

don’t have the documents, then you have what is called a “reasonable 

opportunity.” Again, the State will continue to have you enrolled into 

Medicaid, but give you a reasonable opportunity to provide that 

documentation, which again, is currently a standard in the Medicaid 

program. 

 MR. DEAL. Mrs. Blackburn, I will yield you whatever remaining 

balance of my time, plus your time. 

 MRS. BLACKBURN. Thank you, Mr. Chairman. I appreciate that. 

 I do have several questions for each of you. 

 Let me stay with this verification issue for right now, if I may. Mr. 

Gordon, let me come to you first. You said that you all, basically, are 

contracting with DHS-- 

 MR. GORDON. That’s correct. 

 MRS. BLACKBURN. --to handle all of this. So, they are handling 

your verification process, and what documents are they using to verify 

the citizenship, residency, income limits, et cetera, of those applying for 

TennCare? 

 MR. GORDON. Well now, based on the DRA, there’s the list that are 

set forth that you go through the different phases. 

 MRS. BLACKBURN. Right, and I agree with your statement that clear 

definition of who is responsible for what is helpful, and I think the DRA 

did do that. But, prior to that, what were you doing? 

 MR. GORDON. They will use similar types of documents. 

 MRS. BLACKBURN. Okay. 

 MR. GORDON. The retention of those documents would be checked 

at the individual check for those types of documents. 

 MRS. BLACKBURN. Okay. 

 MR. GORDON. But, there are other circumstances in which case-- 

 MRS. BLACKBURN. All right, and how are they obtaining the 

citizenship documents? 

 MR. GORDON. Whenever the individual comes in to be checked for 

verification, they are asked to bring proof. 

 MRS. BLACKBURN. Okay. So, they have to bring the originals, no 

copies? 

 MR. GORDON. I’m not clear whether or not it was at that point in 

time or at any point in time, whether or not it stipulated copy or original. 

 MRS. BLACKBURN. Okay. 

 MR. DEAL. But, it’s clear now that the copy is now allowed, right? 

 MR. GORDON. That’s correct. 

 MRS. BLACKBURN. Okay. 

 MR. DEAL. Excuse me. 
38

 MRS. BLACKBURN. Listen, that’s great, and go ahead, Mr. 

Chairman, and add in. I think this is something that we have, it speaks to 

what we hear as a lot of the anecdotal information that we hear, and what 

we want to hear from you is what you are dealing with so that it helps us 

in the decision-making matrix. 

 Okay. So, and the reason I’m asking this, I had read and had kept an 

article that had run from the city paper here, where a woman, a Ms. 

Garner, with Department of Human Services, she’s the Medical Policy 

Director and handles the TennCare enrollment, and speaking of the 

changes we were making in the DRA had said, well, it could backfire 

and harm our citizens who are really in need most. And, as you’ve heard 

the Chairman say, and as Mr. Smith has said, you’ve got your reasonable 

opportunity to go through and present. And so, it was interesting to me 

that that would be a first flush, and I was wanting to verify for the record 

what you had used, and then how you obtained what you had used. 

 MR. GORDON. And, as I stated, the types, similar documents were 

asked for, again, as I alluded to in my remarks, there are circumstances, 

and I believe that might have been what she was referring to in rural 

settings where individuals are not born in hospitals, in which case, in 

earlier years, but part of your clarification helped in that area. 

 MRS. BLACKBURN. Let me ask you this, we know that Georgia, New 

York, Montana, New Hampshire, have all had strict proof of citizenship 

for Medicaid eligibility, some for decades. And, they have not reported 

any problems with this. Do you have people from TennCare, and from 

DHS, talking with these other States to see what their best practices are, 

and what protocols they are using, and what template they are working 

from? 

 MR. GORDON. There are multiple State calls going on through 

various associations, which I’m sure you are familiar with, whether it be 

the NGA, or whether it be the State Medicaid Directors, that, basically, 

walk through this, and there’s also some of those calls orchestrated by 

CMS themselves, in which case we participate. 

 MRS. BLACKBURN. Okay. Dr. Smith, I always appreciate your 

incites, let me say that, and I appreciate you diligence in working with us 

to find answers to whether it’s Medicare or Medicaid, but any of the 

CMS web of services that exist. Let me ask you, Representative 

Rowland had spoken in her testimony about the verification process, and 

some of the concerns there. Would CMS endorse the use of the 

Employer Verification Program for verifying legal residency status? 

Would they, do you think they would endorse that/ 

 If we look at having something that is a nationwide template, that 

can be used by the States, if we say the Federal government is going to 

address a part of this. If some of the States were to accept some things 
39

that were mandated, if you will, would CMS endorse the use of that 

program? 

 MR. SMITH. I’m not familiar enough with the Employer Verification 

Program. I think this would be an Administration position, rather than a 

CMS position, and in the development of the guidance and the regulation 

to the States, we certainly had input from Homeland Security. I think 

this is an area that they are the ones who have the expertise in. But, I 

think it’s consistent with, again, the discussions that are going on of 

having a reliable system that everybody knows and everybody 

understands that it’s reliable, but again, it is one that is uniform as well, 

because it is difficult. You do it for, this program has its set of rules, 

another program has another set of rules. I think in this area there is a lot 

of discussion about how do you get this to--you have the confidence, but 

also easier to administer because everybody knows what those rules are. 

 MRS. BLACKBURN. So, basically, uniformity is what you are looking 

for, rather than a universal program. 

 MR. SMITH. I think that’s correct. 

 MRS. BLACKBURN. Okay. 

 MR. SMITH. And again, that would be an Administration position. 

 MRS. BLACKBURN. All right, great. 

 I want--the reasonable opportunity for reverification, let me go to 

that for just a second. How long do you all allow at the State level for 

that? 

 MR. GORDON. We get 12 months of eligibility, and beyond that I’m 

not-- 

 MRS. BLACKBURN. A full 12 months. 

 MR. GORDON. --that’s how much eligibility you get. As far as the 

reasonable opportunity to show proof at that time of redetermination, I’m 

not sure exactly how much time we have allotted for that. 

 MRS. BLACKBURN. Okay. All right. 

 At the Federal level? 

 MR. SMITH. I think reasonable opportunity is generally 45 days. 

 MRS. BLACKBURN. Forty-five days. 

 MR. SMITH. But again, you are looking to the individual cooperating 

with you and helping you to find the documents that you are asking for. 

 MR. SMITH. Okay, so Tennessee is much more lenient than the 

Federal standard. 

 MR. SMITH. Well, in terms of the 12-month eligibility, that is a State 

decision of how long you are going to go out, but reasonable opportunity, 

these are sort of well established in the appeals and grievances decisions 

that Medicaid follows. 

 MRS. BLACKBURN. Okay, great. 
40

 Mr. Gordon, let’s look at the TennCare expenditures for illegal 

immigrants, and you mentioned last month you had, is it $1.2 million, 62 

individuals, $1.7 million in your testimony. So, has the State reported 

any TennCare expenditures for illegal immigrants to CMS, and were 

they only Section 1011 reimbursements, or how did that work? 

 MR. GORDON. In the $1.7 million, just to clarify, is all the care that 

we ended up reimbursing to the facilities for those 62 individuals. 

 MRS. BLACKBURN. Okay. 

 MR. GORDON. So, it didn’t all $1.7 occur in the month of July, some 

of them may have had such conditions that may have spanned a little bit 

more than a month. 

 So again, it varies month to month. I think in many months we only 

see single digit numbers of individuals that providers are seeking 

reimbursement for. 

 I would tell you that, I would say on an annual basis you’d be 

looking at probably about $15 million total annually. 

 MRS. BLACKBURN. So, $15 million is what you are billing back to 

CMS for illegal immigrant healthcare. 

 MR. GORDON. For the emergency services. 

 MRS. BLACKBURN. Emergency? 

 MR. GORDON. Yes. 

 MRS. BLACKBURN. What about non-emergency that comes into-- 

 MR. GORDON. We don’t provide any non-emergency care. 

 MRS. BLACKBURN. Okay. All right. 

 And, that is all Section 1011. 

 MR. GORDON. I’m not familiar with Section 1011 with specificity. 

 MRS. BLACKBURN. Okay, emergency. 

 MR. GORDON. Yes. 

 MRS. BLACKBURN. That’s emergency. 

 MR. GORDON. Yes. 

 MRS. BLACKBURN. Okay. 

 MR. SMITH. If I may, Mrs. Blackburn. 

 MRS. BLACKBURN. Yes, please, go ahead. 

 MR. SMITH. One thousand and eleven came specifically out of the 

Medicare Modernization Act. 

 MRS. BLACKBURN. Right. 

 MR. SMITH. So, that is all Federal dollars. The States aren’t 

participating in that. So, CMS is directly reimbursing hospitals out of 

Section 1011, versus the emergency services reimbursed under Medicaid 

that I think the $1.7 Mr. Gordon was referring to is. 

 I also want to emphasize again, there is a definition of emergency 

services. So, going in for routine medical care would not qualify, and 
41

also it would be for an individual who would otherwise be eligible for 

Medicaid. So, those are constraints as well. 

 MRS. BLACKBURN. Well, and that’s why I was coming back to Mr. 

Gordon on the non-emergency, because the anecdotal that we are 

hearing, and we can talk about this with the hospitals in a few minutes, is 

that there is a good bit of that non-emergency that is coming into those 

emergency rooms, and the Chairman spoke so well to that in his 

testimony, $340 for a routine emergency room, and then you are looking 

at the same thing could be treated for about $70 in a doctor’s office, a 

physician’s office. And, we continue to hear this. 

 Now, $15 million, and TennCare’s budget now is-- 

 MR. GORDON. Seven billion. 

 MRS. BLACKBURN. --$7 billion? 

 MR. GORDON. Yes. 

 MRS. BLACKBURN. You know, then that doesn’t sound like a whole 

lot, and so we’ve got a little bit of discrepancy in what anecdotally we’re 

hearing and what you are saying, well, go ahead, clarify. 

 MR. GORDON. One thing I would point out is, since we are only 

required to provide reimbursement in those emergency situations, that 

sometimes you do have situations that an individual presents at an 

emergency room that if in a normal circumstance that care could have 

been delivered at another setting the hospital will--an application will be 

sent in describing the emergency, we will have our Medical Director 

review that, and I will tell you, child delivery in an emergency room is 

probably not the most appropriate place for child delivery, yet that does 

occur and that is one of the areas that we are to cover. 

 MRS. BLACKBURN. Okay. Let me jump through a couple more 

questions. My time is up, and I realize that, and I do still have some 

questions. 

 Mr. Gordon, Georgia is beginning to check W2s, to verify income 

for applying for Medicaid. Is Tennessee doing something similar? 

 MR. GORDON. We have, historically, checked with our labor and 

wage files that we collect in the State, for checking the income. 

 MRS. BLACKBURN. Okay. 

 MR. GORDON. As well as other data matches. 

 MRS. BLACKBURN. Let me ask you this, too. I know we’ve heard a 

good bit about this anecdotally, but in how many cases did people who 

were applying for TennCare claim that their official documents were 

unavailable? And, what were the main reasons for that unavailability? 

And then, in your reverification, how do you go back and check to see if 

those are truly unavailable? Could you give me an idea of that? 

 MR. GORDON. Well, I tell you, similar to what I was hinting toward 

earlier, especially, and again, most of it being addressed by covering 
42

most of those that are aged, that you have situations, as far as percentage, 

I couldn’t tell you that off the top of my head, but I would tell you that 

it’s situations where individuals were born, had delivered children with 

midwives or something usually earlier on in rural areas, in the mountain 

areas of our State, in which case some of those documents that were 

listed are not always available. 

 Based on the DRA, we’ll have to encourage those people to go 

through the process of trying to obtain some of those documents. 

Otherwise, they cannot be eligible for our program, period. 

 MRS. BLACKBURN. Okay. And then, going back to your payouts, 

out of TennCare’s $7 billion, how much was paid out for emergency or 

temporary TennCare for those who were either ineligible for the 

program, or couldn’t pay for the care, or couldn’t find their 

documentation? 

 MR. GORDON. Again, we’ve always required some documentation 

for U.S. citizenship. So, we wouldn’t have let them on if they didn’t 

have some documentation. It may not have been included in the current 

list that’s in the DRA, but we’ve required some proof of documentation. 

 MRS. BLACKBURN. And, do you have any idea of what percentage 

of that was for illegal immigrants? 

 MR. GORDON. No, because we wouldn’t have let you on if you were 

not able to produce some proof of citizenship. 

 MRS. BLACKBURN. Okay. 

 MR. GORDON. So, we wouldn’t have had any expenditures if you 

were--again, going back to requiring that they prove something, while it 

may not be on the DRA list, but we used other sources of documentation. 

So, again, with the list we’ll be asking more specific questions. 

 MRS. BLACKBURN. Okay. Has TennCare ever used documentation 

not accepted by CMS or Social Security to document citizenship? 

 MR. GORDON. Actually, one of the things, I think, let me, under the 

DRA, what was previously being accepted, and I think this is not unique 

to Tennessee, I think it’s safe to say in many States, there wasn’t one set 

standard on what should be considered acceptable for citizenship. 

 So, we were looking for different types of documents, again, some of 

which didn’t fit with the list currently today. 

 I would tell you, seeing that we use Department of Human Services 

that also interacts with Medicare and Social Security on a regular basis, 

that might be part of why our transition may not be as difficult as others 

who are used to some of those processes, and have incorporated some of 

those processes in determining eligibility for other programs that people 

may be eligible for. 

 MRS. BLACKBURN. Okay. Mr. Smith, anything to add? 
43

 MR. SMITH. I think we’ve, again, the importance of what the DRA 

did to instill the confidence that public programs are truly being used 

appropriately by U.S. citizens, protecting those who are most vulnerable, 

those on Medicare, those on SSI, are exempt from it. I think we 

achieved that balance, and again, I think the experiences that I’ve 

described in looking at this in a comprehensive approach sort of leads us 

down that path again, because I think we were very successful, and 

again, you all are to be commended for coming up with the solutions that 

you offered, whether in 1011 or the other special payments to meet the 

needs that we have. 

 MRS. BLACKBURN. Let me ask you this, Mr. Smith, before I leave 

you. Looking at the 1011 payments, and Mr. Gordon might have a little 

bit on this, too, and we heard from our State Senator and our State Rep, 

and finding a solution on how to address this funding issue has to be a 

partnership situation with your local, State and Federal government, 

clearly defining, clearly working through this process. 

 So, Representative Rowland had said every town is a border town, so 

what about our local health departments, are you hearing from local 

health departments, does TennCare hear from them, about the impact on 

them? Does CMS hear from them saying, what about Section 1011, can 

these local health departments access some of those funds? Hence, those 

are Federal funds that are going directly to the hospitals and the care 

centers. 

 MR. SMITH. I think this is an area, in particular, that we are still 

learning from and having the discussion with the hospitals. 

 For example, the billion dollars that Congress put in for the hospitals 

to meet this need, in some respects hospitals said, well, we don’t want to 

get into verification of someone’s status. So, we need to continue to talk 

with the hospitals about how to strike the balance. 

 The billion dollars is specifically for undocumented, and it’s not for 

people who are not undocumented. It’s not supposed to be just for 

anyone who walks in to the emergency room. So, the billion dollars has 

a very specific purpose. 

 Hospitals have to tell us how they are using that in a way that, again, 

we know that the billion dollars that Congress put in there is being used 

for what it was intended for. 

 So, I think that dialogue is still continuing. Many hospitals are, 

hospitals, for example, have taken on proxies in terms of using Social 

Security numbers, whether or not that is completely accurate or not is, 

again, still part of the dialogue. I think the General Accountability 

Office has been looking at 1011 also. 
44

 So, I think you did the right thing, but how it’s implemented and 

executed I think still takes a little bit of dialogue between CMS and the 

hospital. 

 MRS. BLACKBURN. And, I appreciate that, because listening to Mr. 

Gordon, it seems that what I’m hearing him say is, well, TennCare feels 

we don’t really have a problem with illegal immigration. We had $1.7 

million that was paid out in one month, and about $15 million total for a 

year for these services, many of which are child births. Am I correct in 

restating that, sir? 

 MR. GORDON. Except for the fact that I consider $15 million a lot of 

money, but other than yet, yes. 

 MRS. BLACKBURN. Well, I do, too. I consider it to be an incredibly 

large amount of money. 

 Looking at TennCare’s budget of $7 billion, and then you start 

saying this is where our problem is, then my question is, if you all feel 

you do not have a problem with illegal immigration, and you are, 

basically, saying we have set some processes in place so this is not a 

problem, but we are hearing from our local governments that emergency 

rooms are full, that our health clinics, our community health centers are 

full, we’ve got a disconnect somewhere. 

 And, what I want to do is figure out where this disconnect is. Every 

dollar a taxpayer spends is a lot of money. 

 MR. GORDON. And, I think maybe where some of that disconnect 

may come from is the fact again, we only cover those people that would-

-we only reimburse hospitals for those people that would otherwise have 

been eligible for our program. That is not a very broad category. So 

there, and again, I think hospitals will be better prepared to speak to that. 

 MRS. BLACKBURN. One more question for you, and I have way over 

stayed my time, and we do have other panels, I would like to know if you 

have reverified or are in the process of reverifying individuals currently 

on TennCare going back to when TennCare was put in place in January, 

‘95, and then coming up through the time that Tennessee exercised the 

additional leniencies in its driver’s license policies, and coming forward 

with the DRA. And, you can submit this in writing, I’m not going to put 

you on the spot to submit it right now, but I think, Mr. Chairman, it 

would be helpful for us to know what kind of reverification process you 

all plan to engage in to ensure CMS and the citizens, that those that are 

on the program, on TennCare, are legally in the country and are the 

individuals that are to be on that program. 

 MR. GORDON. Absolutely. 

 MRS. BLACKBURN. Thank you. I appreciate it. 

 Mr. Chairman, I yield back, and thank you for your consideration. 

 MR. DEAL. Let me just follow up very quickly. 
45

 Mr. Gordon, I’m sure you are not totally surprised, since your 

verification process did require some evidence of citizenship, but the 

documents don’t correspond, as you indicated to the current standard. 

I’m sure you are not going to be totally surprised to find that many of 

those documents you were relying on were fraudulent and forged 

documents. You are not going to be surprised by that, are you? 

 MR. GORDON. I would have no way of knowing whether or not they 

were or weren’t. 

 MR. DEAL. The reason I say that is, that document fraud is one of 

the biggest problems that we have in this country in every program. I 

think that’s what the challenge that Mr. Smith and his agency has is to 

try to get back to non-forgible documents. Have that as the basis for 

certification of eligibility, and that’s going to require cooperation at both 

the State and the Federal level, working together to achieve that goal. 

 One final question, Mr. Smith, is it not true that if Mr. Gordon, the 

Representative, or anyone from the State of Tennessee or any other State, 

wishes to make further comments that you are still in the comment 

period with regard to some of these issues? 

 MR. SMITH. Mr. Chairman, you are correct, but we only have one 

more day. 

 MR. DEAL. Oh, good thing I asked the question today then. 

 MR. SMITH. Yes, sir, and we have received comments. 

 MR. DEAL. Well, good. Thank you. 

 Thanks to both of you for being here. 

 MR. DEAL. I’ll call our third panel to the front. 

 This panel is Mr. Richard Flores, who is Vice President of Revenue 

Cycle at LifePoint Hospitals here in Brentwood, Tennessee, Mr. Bob 

Duncan, who is Vice President for Advocacy and Government Relations 

of Methodist Healthcare-LeBonheur in Memphis, and Mr. Gary Perrizo, 

who is the Director of Patient Accounting, Department of Finance, at 

Vanderbilt University. 

 Gentlemen, we are pleased to have you here, and we will hear your 

opening statements beginning with Mr. Flores. 

STATEMENT OF RICHARD FLORES, VICE PRESIDENT OF 

REVENUE CYCLE OPERATIONS, LIFEPOINT 

HOSPITALS, INC.; BOB DUNCAN, VICE PRESIDENT FOR 

ADVOCACY AND GOVERNMENT RELATIONS, 

METHODIST HEALTHCARE-LE BONHEUR CHILDREN’S 

MEDICAL CENTER; AND GARY PERRIZO, DIRECTOR OF 

PATIENT ACCOUNTING, VANDERBILT UNIVERSITY 

MEDICAL CENTER 
46

 MR. FLORES. Thank you, sir. 

 Good morning, I’m Richard Flores, Vice President of Revenue Cycle 

Operations at LifePoint Hospitals here in Brentwood, Tennessee. Thank 

you for inviting me to testify today. 

 LifePoint owns seven rural hospitals located across Tennessee. The 

local hospital is often one of the largest employers in the community, 

along with a great number of family-owned farms. The south middle 

part of the State, where several of our hospitals are located, is well 

known for its tree nurseries. Needless to say, there are quite a few 

uninsured people living in these areas. 

 Our hospitals are ready and willing to serve the people who live in 

their communities. Many of them come to the emergency rooms because 

they do not have insurance and they have no other place to go to get care. 

Some of these individuals may be undocumented immigrants. 

 As you know, the Federal Emergency Medical Treatment and Active 

Labor Act, called EMTALA, requires hospitals to treat anyone who 

comes through the door, regardless of their immigration status. This 

Federal law prohibits hospitals from asking anyone who comes into the 

emergency room any financial information until they are medically 

screened. By that time, they have become our patients. It would be an 

impossible task for hospitals to determine a patient’s legal status prior to 

providing care due to Federal rules and regulations. 

 Tennessee hospitals are experiencing unprecedented uncompensated 

care levels, which includes charity care as well as bad debt. Tennessee 

claims data show a continuing increase in uninsured volumes. From 

calendar year 2004 to calendar year 2005, the cost to Tennessee hospitals 

of treating the uninsured in the emergency room increased by $144 

million. In 2005, the unreimbursed TennCare cost, combined with the 

cost of charity care, bad debt, and medically indigent care, reached over 

$1 billion. 

 Due to the 2005 TennCare disenrollment changes, LifePoint 

Hospitals in Tennessee experienced a reduction of $10.2 million in 

TennCare gross revenues in the first 6 months of 2006 versus the same 

period in 2005. During that same period, we experienced an increase of 

$5.3 million in self-pay gross revenues. Similarly, TennCare emergency 

room visits declined 23 percent while self-pay emergency room visits 

increased 42 percent. Please keep in mind that rural hospitals have far 

fewer referral options, such as indigent clinics, than our urban hospital 

counterparts. 

 Tennessee’s Medicaid program is similar to other States, with the 

exception of having access to a disproportionate share of hospital 

allotment, commonly referred to as DSH. Access to a DSH allotment 

would allow Tennessee’s hospitals the ability offset the ever-growing 
47

costs of providing services to those without insurance. We should be 

allowed to have Tennessee’s hospital on a level playing field with all 

other hospitals in the country, since we are one of only two hospitals that 

do not receive a DSH payment. 

 I would like to acknowledge and thank Congresswoman Blackburn 

for supporting Tennessee’s hospitals’ effort to secure a permanent DSH 

payment for Tennessee hospitals. 

 Now, Tennessee’s DSH payment should be consistent with DSH 

payments received by other States with a similar number of enrollees. 

Without it, hospitals may downsize, potentially reduce, or even 

eliminating important healthcare services to support the communities, 

especially in rural areas. 

 I want to thank you for the opportunity to explain the uninsured and 

uninsurables, how they are impacting our hospitals and emergency room 

utilization. We strongly urge you to consider approving Tennessee’s 

request for a permanent DSH payment, since it will help offset the 

constantly increasing amount of uncompensated care that hospitals are 

providing for the people who live in their communities. 

 Thank you. 

 [The prepared statement of Richard Flores follows:] 

PREPARED STATEMENT OF RICHARD FLORES, VICE PRESIDENT OR REVENUE CYCLE,

LIFEPOINT HOSPITALS

Good morning! I am Richard Flores, vice president of revenue cycle operations at 

LifePoint Hospitals in Brentwood, Tennessee. Thank you for inviting me to testify today. 

LifePoint owns seven rural hospitals located across Tennessee. The local hospital is 

often one of the largest employers in the community, along with a great number of 

family-owned farms. The south middle part of the state, where several of our hospitals 

are located, is known for its tree nurseries. Needless to say, there are quite a few 

uninsured people living in these areas. 

Our hospitals are ready and willing to serve the people who live in their 

communities. Many of them come to the emergency rooms because they do not have 

insurance and they have no other place to go to get care. Some of these individuals may 

be undocumented immigrants. 

As you know, the federal Emergency Medical Treatment and Active Labor Act, 

called EMTALA, requires hospitals to treat anyone who comes through the door, 

regardless of their immigration status. This federal law prohibits hospitals from asking 

anyone who comes to the emergency room any financial information until they are 

screened. By that time, they have become our patients. It would be an impossible task 

for hospitals to determine a patient’s legal status prior to providing care due to federal 

rules and regulations. 

 Tennessee hospitals are experiencing unprecedented uncompensated care (charity 

and bad debts) levels. Tennessee claims data show a continuing increase in uninsured 

volumes. From calendar year 2004 to calendar year 2005, the cost to Tennessee hospitals 

of treating the uninsured in the emergency room increased by $144 million. In 2005, the 

unreimbursed TennCare cost, combined with the cost of charity care, bad debt and 

medically indigent care, reached over $1 billion. 
48

 Due to the 2005 TennCare disenrollment changes, LifePoint Hospitals in Tennessee 

experienced a reduction of $10.2 million in TennCare gross revenues in the first six 

months of 2006 versus the same period in 2005. During that same period, we 

experienced an increase of $5.3 million in self-pay gross revenues. Similarly, TennCare 

emergency room visits declined 23 percent while self-pay emergency room visits 

increased 42 percent. Keep in mind that rural hospitals have far fewer referral options, 

such as indigent clinics, than urban hospitals. 

Tennessee’s Medicaid program is similar to all other states, with the exception of 

having access to a disproportionate share hospital allotment, commonly referred to as 

DSH. Access to a DSH allotment would allow Tennessee’s hospitals the ability to offset 

the ever growing cost of providing services to those without insurance. We should be 

allowed to Tennessee’s hospitals on a level playing field with all other hospitals in the 

country since we are one of only two states that do not receive a DSH payment. 

Tennessee’s DSH payment should be consistent with DSH payments received by 

other states with similar numbers of enrollees. Without it, hospitals may downsize, 

potentially reducing or eliminating important healthcare resources that support their 

communities, especially in rural areas. 

Thank you for the opportunity to explain how the uninsured and uninsurables are 

impacting our hospitals and emergency room utilization. We strongly urge you to 

consider approving Tennessee’s request for a permanent DSH payment since it will help 

offset the constantly increasing amount of charity care that hospitals are providing for the 

people who live in their communities. 

Thank you. 

 MR. DEAL. Thank you. Mr. Duncan. 

 MR. DUNCAN. Thank you, sir. Good morning, I’m Bob Duncan, 

Vice President of Advocacy and Government Relations for Methodist 

Healthcare-LeBonheur Children’s Medical Center in Memphis, 

Tennessee. Thank you for inviting me to be here and the opportunity. 

 Before I begin my formal testimony, I would like to recognize and 

thank Representative Blackburn for her concern, commitment, and 

support for Le Bonheur Children’s Medical Center. She has been a 

leader in bringing greater access and quality healthcare to the children of 

Tennessee and the surrounding States. Thank you, Congressman 

Blackburn. 

 The mission of our hospital, like other institutions in Tennessee, is to 

take care of people in our community who are sick, injured, or entered 

the world with severe medical problems. When admitting a patient or 

tending to a sick child or newborn with life-threatening conditions, it 

does not matter whether they are documented or undocumented 

immigrants, uninsured individuals, people on commercial plans, or those 

enrolled in TennCare. Our number one priority is to provide healthcare 

services to all the people who need it. We are obligated to do so. 

 As you know, Tennessee’s Medicaid program, TennCare, has just 

completed a fairly significant restructuring. As a result of the changes, 

TennCare is now similar to the other States Medicaid programs. While 

we support many of the changes that occurred, Tennessee hospitals 

continue to see growth in uncompensated care. 
49

 In fact, in 2005 Tennessee’s hospitals provided over $1 billion in 

uncompensated TennCare, charity care, and bad debt, an amount that is 

expected to increase this year and well beyond. Many of the uninsured 

will continue to seek primary and emergency care through hospital 

emergency rooms. 

 This past year our system alone had approximately $47.5 million in 

charity write offs, $8 million of this coming from our emergency room. 

 We believe that the Federal government, along with State 

government, has a role in paying for charity care. Hospitals are not paid 

what it costs them to provide care to uninsured individuals and charity 

patients. In 2004, 48 of Tennessee’s 130 acute care hospitals were losing 

money. Another seven hospitals had operating margins below 2 percent. 

As a result, over 42 percent of Tennessee’s hospitals are at financial risk. 

As you can see, we need your help to remedy this situation. 

 As Richard mentioned, Tennessee is now one of only two States that 

does not have a permanent Medicaid disproportionate share hospital 

payment to help offset uncompensated care costs for charity and 

TennCare patients. Tennessee had a Medicaid DSH program prior to the 

implementation of TennCare in 1994. The State gave up that DSH 

program under the assumption that TennCare’s coverage of the 

expansion populations would drive charity care levels down, thereby 

eliminating the need for the DSH payments. This never proved true, 

however, and charity care costs were back at pre-TennCare levels in 

2000. 

 It is imperative that Tennessee’s hospitals obtain a permanent 

Medicaid DSH payment to help offset at least some of the costs 

providers incur caring for charity and TennCare patients. We’d like to 

thank you again for this opportunity to tell you our concerns about caring 

for some of the most vulnerable people in our community and appreciate 

your interest in addressing the issue of uninsured care and finding 

solutions. 

 Thank you, have a good day. 

 [The prepared statement of Bob Duncan follows:] 

PREPARED STATEMENT OF BOB DUNCAN, VICE PRESIDENT FOR ADVOCACY AND 

GOVERNMENT RELATIONS, METHODIST HEALTHCARE-LEBONHEUR CHILDREN’S MEDICAL 

CENTER

Good morning! I am Bob Duncan, vice president for advocacy and government 

relations at Methodist Healthcare-Le Bonheur Children’s Medical Center in Memphis, 

Tennessee. Thank you for inviting me to testify today. 

Before I begin my formal testimony, I would like to recognize and thank 

Representative Blackburn for her concern, commitment and support for Le Bonheur 

Children’s Medical Center. She has been a leader in bringing greater access and quality 

health care to the children of Tennessee and the surrounding states. 
50

The mission of our hospital, like other institutions in Tennessee, is to take care of 

people in our community who are sick, injured or entered this world with severe medical 

problems. When admitting a patient or tending to a sick child or newborn with lifethreatening conditions, it does not matter whether they are documented or undocumented 

immigrants, uninsured individuals, people on commercial plans or those enrolled in 

TennCare. Our number one priority is to provide healthcare services to all the people 

who need it. We are obligated to do so. 

As you know, Tennessee’s Medicaid program, TennCare, has just completed a fairly 

significant restructuring. As a result of the changes, TennCare is now similar to other 

states’ Medicaid programs. While we support many of the changes that occurred, 

Tennessee hospitals continue to see growth in uncompensated care. 

In 2005, Tennessee’s hospitals provided over $1 billion in uncompensated 

TennCare, charity care and bad debt, an amount that is expected to increase this year and 

beyond. Many of the uninsured will continue to seek primary and emergency care 

through hospital emergency rooms. 

This past year, our system had approximately $47.5 million in charity write-offs. 

Included in this number is $8 million of ER charity care. 

We believe the federal government, along with state government, has a role in 

paying for charity care. Hospitals are not paid what it costs them to provide care to 

uninsured individuals and charity patients. In 2004, 48 of Tennessee’s 130 acute care 

hospitals were losing money. Another seven hospitals had margins below 2 percent. As 

a result, over 42 percent of Tennessee’s hospitals are at financial risk. As you can see, 

we need your help to remedy this situation. 

Tennessee now is one of only two states that does not have a permanent Medicaid 

disproportionate share hospital payment to help offset uncompensated care costs for 

charity and TennCare patients. Tennessee had a Medicaid DSH program prior to the 

implementation of TennCare in 1994. The state gave up that DSH program under the 

assumption that TennCare’s coverage of the expansion populations would drive charity 

care levels down, thereby eliminating the need for the DSH payments. This never proved 

true, however, and charity care costs were back at pre-TennCare levels in 2000. 

 It is imperative that Tennessee hospitals obtain a permanent Medicaid DSH payment 

to help offset at least some of the costs providers incur caring for charity and TennCare 

patients. We thank you for the opportunity to tell you our concerns about caring for some 

of the most vulnerable people in our community and appreciate your interest in 

addressing the issue of uninsured care. 

 Thank you. 

 MR. DEAL. Thank you. Mr. Perrizo. 

 MR. PERRIZO. Thank you, Chairman Deal and Congresswoman 

Blackburn, for allowing me to testify in this important field hearing. I 

am Gary Perrizo, Director of Patient Accounting, at Vanderbilt 

University Medical Center, located here in Nashville. 

 I will summarize my testimony and request the full written testimony 

already provided be included in the records of this hearing. 

 MR. DEAL. It will be included. 

 MR. PERRIZO. Thank you. 

 I would like to explain how an illegal immigrant actually enters into 

the Vanderbilt system. Basically, through the emergency room or 

brought directly to our trauma center. If the patient is admitted, our 

registration staff will try to determine if the patient is a possible illegal 
51

immigrant. If believed that they could be, the patient is referred to the 

Department of Human Services of the State of Tennessee. If DHS 

determines that it is an illegal immigrant, as I think we’ve already heard, 

the patient is enrolled in TennCare, but only for that single admission. 

 Vanderbilt will then receive payment from the TennCare MCO for 

the emergency admission at the TennCare contractual rates. Some recent 

data that we have assimilated is that so far in 2006, this calendar year, we 

have admitted 174 undocumented patients. This is a 17 percent increase 

over the same period last year. 

 One hundred twenty of this year’s undocumented patients had been 

deemed illegal immigrants by DHS, and had been granted TennCare 

coverage. The reimbursement received, like all TennCare cases, is 

approximately 65 percent of the actual cost for services provided. This 

results in a loss to Vanderbilt of approximately $599,000 on these 

admissions thus far. 

 Forty-seven of the patients are under review by DHS at this time. If 

these patients are not granted TennCare coverage, the estimated loss will 

increase by another $755,000. 

 For the illegal immigrants that were admitted for this same period in 

2005, more than 20 percent of those patients returned for non-emergency 

care, which was not covered by TennCare. 

 Another category of patients are the illegal immigrants that receive 

emergency room care but are not admitted, the treat and release 

population. Registration staff in an ER cannot determine if the patient is 

in the United States legally or illegally. 

 For visits from January 2005 through March of this year, 504 visits 

were made by possible illegal immigrants. The total unreimbursed cost 

of these visits is $858,000. This results in an estimated annual cost of 

unreimbursed care to illegal immigrants at Vanderbilt of $3.8 million. 

 Although this is significant, it pales in comparison to the overall 

uncompensated care Vanderbilt provides in this community. We are 

morally and legally bound to provide care in an emergency condition. 

This is consistent with our mission and consistent with the compassion of 

the just society in which we live. 

 Under Federal laws, like EMTALA, we are required to provide 

emergency care regardless of a patient’s immigration status or ability to 

pay. The moral and legal requirements carry a significant price tag for 

hospitals and doctors, especially at our Nation’s academic medical 

centers. 

 At Vanderbilt in the past 12 months, the cost of providing care to 

patients that are unable to pay topped $74 million. 

 I would like to briefly mention three concerns we have at Vanderbilt. 

First, the implementation of TennCare in 1994 resulted in the elimination 
52

of the Medicaid disproportionate share payments. TennCare, though, has 

evolved where eligibility is functionally equivalent to traditional 

Medicaid in other sites in which a disproportionate share payment is 

made. It is imperative that Tennessee be provided with a 

disproportionate share payment allotment under Federal law. 

 Secondly, the House immigration bill would criminalize any 

caregiver who knowingly provides care to an illegal immigrant. We do 

not believe that the intent of this bill would have doctors and nurses 

stand by and not intervene to save a human life or prevent suffering. 

This would be a direct contradiction to the Federal EMTALA law. 

 Lastly, for many families, especially those of limited resources and 

ability, gathering the required documentation to enroll in TennCare could 

be a significant challenge. For women that are expecting a child, any 

delay in gathering the required documentation could result in delays in 

obtaining prenatal care. We believe that in the case of pregnancy, the 

law ought to allow prenatal care to begin while documentation is 

gathered and prepared. 

 I would like to thank Chairman Deal and Congresswoman 

Blackburn, and her support for Tennessee getting a DSH payment, and 

would answer any questions you might have. 

 Thank you. 

 [The prepared statement of Gary Perrizo follows:] 

PREPARED STATEMENT OF GARY PERRIZO, DIRECTOR OF PATIENT ACCOUNTING,

DEPARTMENT OF FINANCE, VANDERBILT UNIVERSITY MEDICAL CENTER

Thank you for the opportunity to testify at this important field hearing. My name is 

Gary Perrizo and I am the Director of Patient Accounting at Vanderbilt University 

Medical Center. I have been asked to discuss the impact of treating illegal immigrants on 

our medical center. 

Let me begin by explaining how illegal immigrants enter our system. Primarily 

these individuals come to either our emergency department or they are transported to our 

trauma center. If it is necessary to admit an individual to the hospital, our registration 

staff makes an initial effort to determine citizenship/immigration status. If it is believed 

that the patient may be an illegal immigrant, the case is referred to the Tennessee 

Department of Human Services (DHS) for their review. If DHS determines that the 

patient is an illegal immigrant and is in need of hospitalization, the individual will be 

enrolled in TennCare for a single period of hospitalization and we will receive payment 

from a TennCare MCO for their emergent care at TennCare contractual rates. I can 

provide some data about Vanderbilt’s recent experience with this category of patients. 

For the period January 1, 2006 through August 6, 2006, Vanderbilt has admitted 174 

undocumented patients, an increase of 17% over the same period last year. Thus far, 

DHS has determined that of these 174 patients, 120 were illegal immigrants and were 

granted TennCare coverage. The reimbursement received by Vanderbilt for these cases 

(as is true of all TennCare cases) is approximately 65% of the actual costs incurred in 

treating these patients, resulting in a net loss to the Vanderbilt of approximately $589,000 

over the past 7 months. The remaining 47 patients have been determined to have no 

resources with which to pay for their care and we are awaiting a DHS determination of 
53

their eligibility for coverage under TennCare. If no reimbursement is obtained for these 

47 undocumented admissions, the estimated loss will increase by $755,000. For 7 

admissions, other insurance coverage for the undocumented patients was obtained 

through workers compensation or other programs and that provide full reimbursement to 

Vanderbilt. 

For illegal immigrants who had received emergency admissions at Vanderbilt in 

2005, more than 20% returned for follow-up care that was not covered by the TennCare 

program and those costs are not included in our estimates above. 

Now let me discuss a second category of patients -- illegal immigrants who are seen 

for emergency care but not admitted to the hospital. Typically the registration staff in an 

emergency room have no way of knowing or tools to determine if a patient is in the 

United States legally or illegally. Of the visits between January 1, 2005 and March 31, 

2006, 504 are possible illegal immigrants based on the information provided at 

registration. The total unreimbursed cost of these visits to the Medical Center is 

approximately $858,000. 

Based on these figures, I estimate that our annual cost of unreimbursed care for 

services provided to illegal immigrants is about $3.8 million. It is a significant 

contribution but pales in comparison to the overall price tag that Vanderbilt bears in 

providing uncompensated care within our community. 

We are morally and legally obligated to provide care for anyone who is in urgent 

need. It is consistent with our mission and it is consistent with the compassion of the just 

society in which we live. Under other federal statutes, particularly EMTALA, we are 

required to provide emergency care to all who present themselves at our emergency 

department, regardless of their citizenship/immigration status, and regardless of whether 

they have insurance coverage or the ability to pay. 

But that moral commitment and legal requirement to care for those in need has come 

to carry a significant price tag for hospitals and doctors alike especially those at our 

nation’s academic medical centers. At Vanderbilt in the past 12 months alone our cost 

for providing care to individuals who were unable to pay for that care topped $74 million. 

While only a small fraction of our charity and indigent care patients are undocumented, 

we have seen a steady growth of undocumented patients paralleling the growth of our 

immigrant population in general. 

Let me briefly mention three specific issues of concern to Vanderbilt. First, since 

the establishment of TennCare in 1994, Medicaid Disproportionate Share Payments were 

eliminated under the state’s Section 1115 Waiver. TennCare has evolved, however, so 

that eligibility for coverage is functionally equivalent to traditional Medicaid programs in 

other states that receive DSH payments. As such it is imperative that Tennessee be 

provided with a DSH allotment under federal law. 

Second, the House immigration bill would criminalize any caregiver who knowingly 

provides care to an illegal immigrant. We do not believe that the drafters of this bill 

intended to have doctors and nurses stand by and not intervene to save a life or prevent 

suffering. To do so would be repugnant to our values as a nation and to our oaths taken 

as providers. It is also in direct contradiction to the federal EMTALA law. 

Finally, for many families, especially those of limited means and those who may or 

may not have strong language and cultural skills, gathering and preparing the necessary 

documentation to establish their eligibility for TennCare or immigration status could 

from time to time present challenges. For a woman who has recently discovered she is 

expecting a child, the inevitable delays in assembling documentation may result in delays 

in securing appropriate pre-natal care. We believe that in the case of pregnancy, the law 

ought to allow pre-natal care to begin while documentation is prepared. The avoided 

costs of precise pre-natal care are well documented in literature. The principle that 

should guide in the case of a pregnant woman ought to be to treat first and sort the rest 

out later. 
54

Thank you for the opportunity to present to this committee and this chance to 

comment on such an important topic. I am happy to answer any questions you or 

members of the Committee may have. 

 MR. DEAL. All right, thank you gentlemen. 

 First of all, let me pick up, Mr. Perrizo, with some of your 

comments. Your concern, as I understand it, is that you think the House 

version of the immigration reform would criminalize anyone who would 

provide medical care. Let me assure you that that is not my 

understanding. It is an issue that, in light of your comment, we will 

certainly go back and review. It is, I’m sure, not the intent of anyone to 

do that, because there you would have, as you point out, a conflict 

between the requirements of EMTALA, I don’t think, let me assure you, 

is the intent of the House of Representatives. 

 I think the intent of the House of Representatives is that we stop 

having a wink and a nod on this issue of illegal immigration. It’s going 

to require institutions such as hospitals to be cooperative in that effort. 

 As was pointed out earlier by Mr. Smith, I believe it was this $1 

billion that we authorized under the MMA to pay for uncompensated 

care for illegal immigrants. I haven’t heard the latest, but what I have 

been told is that, as he indicated, most hospitals are not particularly 

interested in that. They would just as soon not apply for those funds 

because it requires them to submit information and documentation that 

says we are eligible for this amount of money under this billion dollars 

that’s been allocated. 

 The point I would make to you is, that if we are going to make these 

reforms is that we all have to work together cooperatively, and you are 

an important link in that chain. 

 I recognize, and I think I know Mrs. Blackburn and I both recognize, 

that EMTALA is one of the real problem points and pressure points for 

hospitals. As Mr. Flores pointed out, without some changes to that, by 

the time you go through the screening process in the emergency room 

you might as well go ahead and treat the patient, because the time and 

the effort that you’ve expended is already a considerable amount of what 

you would do, perhaps, anyway. 

 One of the things that we try to do under the DRA, in fact there was 

a provision that I fought for hard and fast, and we got it through the 

House. We could not get it through the conference committee because 

the Senate would not agree to it, was a provision that I think would put a 

common-sense approach to this. It says that if it is very obvious early on 

that this is not an emergency room matter, it is a non-emergency 

presentation, that the hospital and the doctor in charge would have the 

authority to divert that individual to a non-emergency room setting. 
55

 As you point out, many rural areas don’t have the opportunity for 

those non-emergency room settings, but many do, and many more will 

have. In fact, tonight I am speaking to what is now the largest free 

medical clinic in the State of Georgia, and one of the ten largest in the 

entire United States, which is in my hometown. My hometown of 

Gainesville, Georgia is not any thriving metropolis, and, quite frankly, 

it’s not nearly as large as the community where we sit here today. But, 

my medical community and my hospital, in fact, my local hospital has 

over the last 3 years donated a million dollars to this free medical clinic 

that accepts no governmental money, neither Federal, State, nor local. 

 So, I think we have to encourage those kind of things, but the key to 

a diversion, as I know all of you know, and as I know my doctor friends 

certainly recognize, is there has to be some liability protection for 

making that decision, because you are not going to always be 100 

percent correct. 

 In our legislation that we passed in the House, and Mrs. Blackburn 

was helpful in getting that through our Committee and then through the 

House version, provided that kind of protection for those in the 

emergency room who will make that diversionary decision. 

 As I said, unfortunately, it did not survive in the final version, but I 

think we have to revisit issues like that, because we can do all the good 

things that I think we’ve probably talked about. I think in general there 

is agreement that we ought to mean what we say when we pass a law that 

says that this is a program that is taxpayer supported and it’s intended for 

our citizens, and not intended for anybody else. We ought to mean that, 

and to enforce it. There are going to be some pressure points, but it does 

require all of us to work cooperatively, because when it is enforced in 

that regard what’s going to be the logical consequence? The emergency 

room is going to be the point of presentation. 

 What that says to me is that we just don’t throw up our hands and 

say, oh, well, it didn’t work, it simply says, it emphasizes the importance 

of our entire immigration structure and the enforcement of those coming 

into our country, so that we don’t have these problems developing as an 

after-the-fact consequence. 

 So, I want to tell you that we do appreciate what hospitals do. You 

provide valuable services. We are very cognizant of the fact that the 

EMTALA situation needs to be revisited. Quite frankly, I don’t know 

that there is the political will to do it, because the alternatives have not 

fully matured yet. 

 However, as a part of the DRA, we had $50 million that was there to 

encourage and help provide grants for these alternative clinics to be 

developed. So, I’m sure that our State representatives and senators, and, 

hopefully, governmental officials in the State of Tennessee, are taking a 
56

close look at that grant program, because those alternative sites will in 

large part be part of the answer that is there. 

 Now, that’s not to say that you don’t have to develop a pattern in 

patience, and you all recognize that very well. If they consider your 

emergency rooms to be their medical home, they are going to continue to 

show back up there. 

 So, part of the process is an education process that I’m sure many of 

you are already doing to educate people as to alternative sites that are 

less costly than your emergency rooms. 

 Does anyone want to comment about that aspect of it? 

 MR. PERRIZO. I’ll say a few words on that. 

 Yes, we realize that at Vanderbilt, as a matter of fact, our faculty 

staff, nurses, et cetera, actually help support by working, et cetera, at 

three clinics here in Nashville that are unfunded, as what you were 

talking about. 

 MR. DEAL. Right. Well, in fact, every State, according to my study, 

now has at least one free clinic, and many states like mine have as many 

as 30, I believe is the latest that we’ve seen. I think that is sort of the 

wave of the future, to help take some of this pressure off of what you are 

experiencing in your emergency rooms, and that is the most expensive 

point of presentation in the whole healthcare system. 

 So, I’m not going to take anymore of the time, and defer the 

remaining amount of my time to your Congresswoman, who does such a 

good job. 

 MRS. BLACKBURN. Thank you, Mr. Chairman. 

 Let’s go back to talk about the DSH payments for just a minute, to be 

certain that everyone who is watching this hearing, and those who are in 

the room, understand that when Tennessee decided in ‘94 that they were 

going to move to the TennCare program, and do under Section 1115, 

their managed care program, they decided to not have the DSH 

payments. They forewent those payments, and I think we need to 

understand that, that that was an Administration decision at that point in 

time. 

 The other part is, TennCare is an Executive Order program in this 

State. Representative Rowland and Senator Ketron, and their colleagues 

in the General Assembly, cannot go in and pass a law and change that. 

The same thing, we can’t go in and pass a law and change the TennCare 

program. That is a State program, and I want to be certain that everyone 

understands that premise as we move forward in our discussion. 

 So, with that understanding, going back to ‘94, and you can give this 

answer to me in ‘94 dollars and we can run it out, or you can give it to 

me in today’s dollars, so to each of you, for the hospitals that you have 
57

referenced, I would ask you, before TennCare how much money did you 

get in Medicaid and Medicare DSH payments? Any idea? 

 MR. PERRIZO. I can’t say for 1994, but in today’s dollars we have 

estimated that our DSH payment would be approximately $39 plus 

million. 

 MRS. BLACKBURN. Thirty plus-- 

 MR. PERRIZO. In today’s dollars. 

 MRS. BLACKBURN. --did you say million? 

 MR. PERRIZO. Million, Thirty plus million. 

 MRS. BLACKBURN. Since we are talking in millions and billions 

today, and very seldom in dollars and cents today, I want to be certain 

that we get that correct for our record. 

 Thank you, Mr. Perrizo. 

 MR. DUNCAN. I don’t have those numbers on the top of my head, 

but it would be roughly half that estimate. 

 MRS. BLACKBURN. Half that estimate. Okay, so you are saying 

about $15 million. 

 MR. DUNCAN. Yes. 

 MRS. BLACKBURN. That’s what you would have received in the 

DSH payments. 

 Mr. Flores, any idea? I don’t think LifePoint was even in existence 

in ‘94. 

 MR. FLORES. We were not, not until 1999. However, I did want to 

point out that based on CMS’ own estimates, Tennessee’s DSH 

allocation would have been $447 million in 2003. However, the State 

and CMS were able to provide $100 million in essential access payments 

to hospitals that year, which is approximately 22 percent of what we 

would have gotten had we received the DSH payment. 

 MRS. BLACKBURN. Okay. Let’s move to the essential access 

hospital payments, the EAH payments. So, this is what you all currently 

get. So, why don’t you tell me how much you are receiving each year. 

 And, Mr. Perrizo, we’ll start with you on the EAH payments. 

 MR. PERRIZO. I don’t know at this time. 

 MRS. BLACKBURN. You don’t know. 

 MR. PERRIZO. I could get you that information. 

 MRS. BLACKBURN. Perfect. 

 Mr. Duncan? 

 MR. DUNCAN. Approximately, $8 million. 

 MRS. BLACKBURN. Eight million. All right. 

 Okay, Mr. Flores? 

 MR. FLORES. Likewise, I would have to provide that. 

 MRS. BLACKBURN. Okay, if you will provide that. 
58

 And then, also provide for me in that number how that is broken 

down between the emergency and the non-emergency care, because if 

TennCare is saying they really don’t have a problem with the illegal 

immigration issue and the verification issue, and one of the promises, if 

you will, of TennCare was to be that you would solve the problem of 

charity care at the hospitals. You would at least be receiving something 

for the amount of charity care that you provided. 

 Of course, what we have seen is that it seems, and what we are 

hearing from your testimony is, the emergency care is increasing every 

single year at an increasing percentage than the year prior. 

 Everyone is nodding in agreement on that. 

 So, we can say that no longer holds forth, that premise of TennCare 

did not work, and the essential access payments are not meeting the 

needs that you would have from a DSH payment, and offsetting this. 

 Okay. Another thing that I would like to know as we look at this 

funding mechanism from the hospitals, and, Mr. Chairman, if I may, I 

see Mr. Becker, and I know that other hospitals are represented, I think 

that this may be a point that we would want to look at as we talk about 

managed care programs, looking at what percentage of the total budget 

the EAH and the DSH payments contribute, Medicare DSH payments, 

looking at what percentage of your total budget, your operating budget 

every year, what reliance there is upon those payments. 

 So, as you submit your figures, let’s submit that one also, so that we 

can be comparing apples to apples, and oranges to oranges, as we move 

forward in this discussion. 

 Mr. Flores, coming back to you, I think in your testimony you said 

that the primary emergency service was pregnancy and delivery? 

 MR. FLORES. No, but it was in testimony before. 

 MRS. BLACKBURN. Was that the prior testimony? Okay. All right. 

We’ve got too many sheets of paper around here. 

 What I would like to know from you all is the most common types of 

emergency and non-emergency ER, what you all are seeing in your 

hospitals, where the greatest pressure comes, because one of our 

concerns is the misuse of emergency room services and the increasing 

costs of that misuse to the taxpayer, and the fact that that misuse then 

does prohibit access, timely access, to citizens who are there to use those 

services. 

 Okay. Another question, just looking at--before we leave the DSH 

payment, when Tennessee made the decision to forgo the DSH payments 

in lieu of a restructured Medicaid payment, via TennCare, those extra 

dollars, does TennCare itself keep those dollars, or are those coming to 

you all via another revenue stream or another avenue? Are you seeing 

any increased revenue stream via TennCare funding? 
59

 MR. PERRIZO. No. 

 MRS. BLACKBURN. Mr. Perrizo, you are not. 

 MR. PERRIZO. No. 

 MR. DUNCAN. No. 

 MRS. BLACKBURN. Mr. Duncan, you are not. 

 MR. FLORES. No, ma’am. 

 MRS. BLACKBURN. You are not, okay, so we’ve got money just in 

thin air somewhere. Okay. 

 Physicians assistants and nurse practitioners in the ER, are you all 

extensively using those in the ER as you staff? 

 MR. PERRIZO. Yes. 

 MRS. BLACKBURN. You are. Okay. Is that a successful practice? 

Okay, it keeps some of the costs down? 

 MR. PERRIZO. Yes, it does. In some of our clinics that I was 

referring to earlier, are with nurse practitioners, very intensively, for 

primary care types of items. 

 MRS. BLACKBURN. You know, I’m hearing of some States and local 

governments that are beginning to send non-emergency care that is 

coming to the ER to clinics. Is that a practice that you all are 

considering? 

 MR. PERRIZO. We are actually trying to refer them to the right site 

for their service. 

 MRS. BLACKBURN. Okay, and you are doing the referral to the 

appropriate site and type caregiver. 

 MR. PERRIZO. Correct. 

 MRS. BLACKBURN. Correct. Okay. Mr. Duncan? 

 MR. DUNCAN. Doing the same thing. We have the church health 

center there, or the community help loops. 

 MRS. BLACKBURN. Okay, the community help centers? 

 MR. DUNCAN. Yes. 

 MRS. BLACKBURN. You are referring, okay. 

 And, are you doing that in Shelby County as well as in the outlying 

counties? 

 MR. DUNCAN. I couldn’t speak to the outlying counties, because our 

hospitals are all located in the Shelby County, other than Fayette. 

 MRS. BLACKBURN. Okay, one other question on the verification 

status, because we’ve heard from our elected officials, and then 

TennCare and CMS, about verifying an individual’s status. And, looking 

at the verification and then the reverification status through the 

documentation, I know that it would be very difficult to ask a patient 

about their immigration status before receiving care, but my question to 

you would be, as they continue in your care do you have a period of time 

in there where you ask a patient their immigration status or ask for 
60

documentation and paperwork as you are doing your paperwork? Do 

you all ever ask for that status? 

 Mr. Perrizo? 

 MR. PERRIZO. On the in-patient side, those patients I was referring 

to earlier, the 174 undocumented, our financial counselors actually work 

with the patients and/or their families while they are in house to try to 

obtain that information. That’s how we are able to actually say someone 

is undocumented. We don’t know if they are illegal. 

 MRS. BLACKBURN. Okay. So, you actually begin to move through 

that before you send them to DHS. 

 MR. PERRIZO. Correct. 

 MRS. BLACKBURN. To make their determination. 

 MR. PERRIZO. Yes, ma’am. 

 MRS. BLACKBURN. So, you would probably have a little bit of 

disagreement with Mr. Gordon then, when it comes to whether or not 

they are providing care for those that are in here illegally. 

 MR. PERRIZO. Well, we are already providing the care, it’s just will 

we get reimbursed. 

 MRS. BLACKBURN. Right, their payment for it. They had a total of 

$1.7 million in July for 62 patients, and you all, so far this year, have had 

174 patients, 120 were illegal, and about 65 percent of the actual cost 

incurred in treating these patients, that was a $589,000 loss over a sevenmonth period. 

 MR. PERRIZO. Correct. 

 MRS. BLACKBURN. Now, okay, you have that kind of loss over that 

period of time, and you, as one single facility in this State, have that type 

loss, and we hear from TennCare that they’ve got 62 people within a 

month, 62 individuals that are within this service, how do you go back 

and recoup those dollars? Are you cost shifting to the private sector? 

You are not getting a full reimbursement on your TennCare. We know 

what your Medicare reimbursement rate is, so how does a facility like 

Vanderbilt, you are the Director of Patient Accounting, and you’ve got to 

look at that bottom line, how do you square those numbers and recover 

and cover that type loss? 

 MR. PERRIZO. Well, as we were speaking earlier, the uncompensated 

care, not only at Vanderbilt, but in the State of Tennessee, is a problem. 

Not just from the illegal immigrants, but from the general uninsured and 

under-insured population. 

 A facility has no choice but to either raise their rates, renegotiate 

their contracts and shift those losses to the insurance companies paying 

those providers’ bill, or the private pay sector that can afford it are 

charged more. 
61

 MRS. BLACKBURN. I appreciate that. You know, we are hearing 

from some of those that oppose addressing the illegal immigration issue, 

that there is not a problem, or that no problem exists, and we don’t--but, I 

think that exactly what you are saying indicates there is a problem, there 

is a disconnect, between what is verified, what we hear from our entities 

as being verified and people that are on Medicaid, the care that is being 

delivered, we see that your charity care increases every single year, and 

somebody is going to pay the bill. And, it is many times going to be 

those private pay. 

 So, I would say that this refutes that argument that there is no 

problem, there is a problem and a pressure to the system. 

 Anything either of you would like to add to that? No. 

 Mr. Chairman, thank you. 

 MR. DEAL. Well, thank you, and on that latter point, I think we all 

recognize that as we see the number of uninsured in our country rise, 

anything that puts pressure to drive up the cost of private health 

insurance is necessarily going to increase the number of uninsured, 

because the insurance policy becomes even more unaffordable. So, this 

is one of those factors that drives up the cost of private insurance and, 

therefore, necessarily, increases the number of total uninsured in our 

country. So, it is a problem. 

 I want to thank you gentlemen for being here. We appreciate your 

testimony. 

 This concludes the panels that were scheduled to testify here today. 

As I indicated at the outset, this is a field hearing of the Health 

Subcommittee of the Energy and Commerce Committee, and as such we 

operate under the rules of that Committee, just as if we were holding this 

hearing in our chambers in our meetings rooms in Washington, D.C. As 

a result of that, it does not allow us, unfortunately, to have audience 

participation. 

 I’m sure Mrs. Blackburn and I will both be here for a little while, for 

those of you who may wish to follow up with anything with us 

personally. 

 This is the first of two hearings. The second will be in Dalton, 

Georgia, at 10:00 a.m. next Tuesday, the 15th, at the Trade Center there. 

In light of that, we will now stand in recess until that hearing resumes 

next Tuesday. 

 Thank you all. 

 [Whereupon, at 12:09 p.m., the committee was adjourned.] 
62

EXAMINING THE IMPACT OF ILLEGAL 

IMMIGRATION ON THE MEDICAID 

PROGRAM AND OUR HEALTHCARE 

DELIVERY SYSTEM 

THURSDAY, AUGUST 15, 2006 

HOUSE OF REPRESENTATIVES, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The committee met, pursuant to notice, at 10:00 a.m., in the Lecture 

Hall, Northwest Georgia Trade and Convention Center, 2211 Dug Gap 

Battle Road, Dalton, Georgia, Hon. Nathan Deal [member of the 

committee] presiding. 

 Members present: Representatives Deal, Norwood, and Solis. 

 Staff Present: Brandon Clark, Policy Coordinator; Katherine Martin, 

Professional Staff Member; Chad Grant, Legislative Clerk; and Amy 

Hall, Minority Professional Staff Member. 

 MR. DEAL. We will call the Subcommittee to order. This will be the 

second session of hearings that began last week in Nashville, Tennessee, 

a meeting of the Health Subcommittee of the Energy and Commerce 

Committee of the House of Representatives. 

 My name is Nathan Deal, I have the opportunity to chair that 

Subcommittee and I am pleased to have two of my colleagues here 

today, who I will introduce when it is appropriate for them to give their 

opening statements. 

 Let me just sort of give a general overview of the process that will be 

followed. This is a hearing, just as if it were a hearing in Washington, 

D.C., in our committee rooms there. It will be a panel of witnesses that 

are going to present testimony followed by questions from the Members 

of Congress who are here today. That is the format that we will follow 

and we will proceed and I will recognize myself for an opening statement 

at this time. 

 The topic which we are examining is: Examining the Impact of 

Illegal Immigration on the Medicaid Program and our Healthcare 

Delivery System. 

 Today, we are going to hear from three panels of distinguished and 

expert witnesses about the impact that illegal immigration is having on 

our healthcare delivery system and to get their perspective on a few 
63

recent legislative provisions that were produced by this Committee in an 

effort to help address this ever-growing problem. 

 There are well over 11 million illegal aliens currently residing in the 

United States and the fact that this number is rapidly growing every day. 

We allow our borders to remain unsecured and our immigration laws 

unenforced. I think there has been no question that the problem of illegal 

immigration is one of the most important topics and policy debates that is 

currently taking place before Congress. 

 I stand with my Republican colleagues in the House in support of the 

legislation that we passed just recently, which is a strong immigration 

bill that I believe does what most of the American public expects and 

deserves. We want to strengthen our borders and enforce our 

immigration laws. As any healthcare providers will tell you, and you 

will hear from some here today, an ounce of prevention is worth a pound 

of cure. Unfortunately, it is clear that some on the other side of the issue 

have no plan for securing our borders and no plan for stopping the flood 

of illegal immigration that is so negatively impacting our public safety, 

our children’s schools, and our healthcare system. 

 In 1996, Congress responded to the will of the people and passed the 

Illegal Immigration Reform and Immigration Responsibility Act. One of 

the main provisions of this legislation was to limit all Federal benefits, 

including Medicaid coverage, to those who are lawfully in the United 

States. Of course, people on the other side of this issue opposed that 

provision back then because they believed that your hard-earned tax 

dollars should go to pay for healthcare for people who are illegally in our 

country. It is a lot of the same people today who are now opposing the 

efforts to ensure that only citizens get access to taxpayer funded benefits. 

The most unfair thing about what our opponents are advocating is that an 

illegal immigrant on Medicaid would almost certainly have a better 

healthcare benefits package than what is available to most taxpayers who 

are actually paying for those Medicaid benefits. 

 Of course, we are not just sitting back and waiting on a single 

comprehensive legislative solution to pass both houses of Congress. We 

intend to address this problem whenever and wherever we can. To help 

address the negative impact of illegal immigration on our healthcare 

system, the Energy and Commerce Committee produced two important 

provisions in the Deficit Reduction Act of 2005, which is commonly 

referred to as the DRA. One of the provisions which I authored, along 

with my friend Congressman Charlie Norwood, who is with us today, 

and we fought to include in the DRA, was a provision that requires States 

to obtain documentary evidence that the person applying for Medicaid 

benefits is actually a United States citizen, as is required by law. This is 

not a new concept for government programs, since the Medicare and SSI 
64

programs both require proof of citizenship for all beneficiaries. It is just 

that Medicaid has not been seriously reformed since the 1960s and was a 

little behind the times. 

 Before the enactment of this provision, the Inspector General of the 

Department of Health and Human Services found that 46 States and the 

District of Columbia allowed self-declaration of citizenship for Medicaid 

eligibility, and 27 of those States never verified any citizenship 

statements at any point. This means that people simply had to say that 

they were citizens, in whatever language they chose to say it in, and they 

would be eligible for thousands of dollars of taxpayer funded Medicaid 

benefits. That simply, in my opinion, was unacceptable. 

 Of course, the advocates on the other side of this issue fought very 

hard to prevent this provision from being included in the DRA. They 

fought very hard to defeat this needed legislation when it was being 

voted on by Congress. Now some of those same advocates are fighting 

just as hard to weaken this common-sense provision as much as possible. 

But it is my hope that those implementing this provision will stand firm 

on this very important issue. 

 Another provision that was included in the Deficit Reduction Act 

was a provision to allow States the flexibility to impose cost sharing on 

healthcare services furnished in an emergency room that a physician 

determines is not a real medical emergency, such as an ear infection or 

strep throat. To protect beneficiaries, this provision requires that an 

available and accessible alternative must be available to the beneficiaries 

and the treating hospital must refer the individual to the alternative site in 

order for the co-pay to be charged. Like the citizenship verification 

provision, this provision is designed to eliminate millions of dollars of 

waste in the Medicaid system by helping to ensure that Medicaid patients 

receive care in the appropriate setting. This provision also helps patients. 

Studies have also shown that patients who receive care in the appropriate 

setting have better healthcare outcomes. As we all know, the ER is not 

the best place to receive primary care services or preventive healthcare 

services. 

 Although this provision only applies to Medicaid beneficiaries, it 

will also help reduce some of the negative impact of illegal immigration 

who improperly utilize the ER. It provides $50 million in grant funding 

to the States to establish alternative non-emergency providers in 

communities across the United States. 

 In addition to the increased number of alternative non-emergency 

providers, this provision will also make hospital personnel more familiar 

and comfortable with referring non-emergency patients to the appropriate 

healthcare providers. It will also increase communication between ER 

personnel and these non-emergency providers. The logic behind this 
65

provision is also simple. It costs approximately $340 to care for a nonemergency patient in the emergency department while it costs less than 

$70 to care for the same patient in a health clinic or a physician’s office. 

That means that over five people can be treated in a physician’s office 

for less money than one person can be seen in the emergency room. I 

believe this is a common-sense approach to reforming the Medicaid 

program, and it was in serious need of reform. 

 As always, I am looking forward to a more cooperative and 

productive conversation on this topic today and to working with my 

colleagues to come up with additional effective solutions to the problems 

that I am sure we will hear addressed in this hearing today. 

 Again, I would like to thank the witnesses on the panels that will 

testify and we look forward to hearing your testimony. 

 I would like at this time to recognize my colleague from California. 

She is a Congressman from the Los Angeles area, I believe, and we are 

pleased that she would travel so far to be with us here today, the 

Honorable Congresswoman Hilda Solis, and she is recognized for 5 

minutes for her opening statement. Ms. Solis. 

 [The prepared statement of Nathan Deal follows:] 

PREPARED STATEMENT OF THE HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS 

FROM THE STATE OF GEORGIA

3⁄4 The Committee will come to order, and the Chair recognizes himself for an opening 

statement. 

3⁄4 This morning will hold the second session of a two-day field hearing entitled 

“Examining the Impact of Illegal Immigration on the Medicaid Program and Our 

Healthcare Delivery System.” 

3⁄4 Today, we will hear from three panels of distinguished and expert witnesses about 

the impact that illegal immigration is having on our healthcare delivery system and 

get their perspective on a few recent legislative provisions that were produced by 

this Committee in an effort to help address this ever-growing problem. 

3⁄4 Given that there are well over 11 million illegal aliens currently residing in the 

United States and the fact that this number is rapidly growing every day that we 

allow our borders to remain unsecured and our immigration laws to remain 

unenforced, there is no question that the problem of illegal immigration is one of 

the most important public policy debates currently before Congress. 

3⁄4 I stand with my Republican colleagues in House in strong support of enacting an 

immigration reform bill that does what the American people expect and deserve. 

3⁄4 We want to strengthen our borders and enforce our immigrations laws. Because as 

any healthcare provider will tell you, an ounce of prevention is worth a pound of 

cure. 

3⁄4 Unfortunately, it is clear that those on the other side of the issue have absolutely no 

plan for securing our borders and no plan for stopping the flood of illegal 

immigration that is so negatively impacting our public safety, our children’s 

schools, and our healthcare system. 

3⁄4 In 1996, Congress responded to the will of the people and passed the “Illegal 

Immigration Reform and Immigrant Responsibility Act,” and one of the main 
66

provisions of this legislation was to limit all Federal benefits, including Medicaid 

coverage, to those who are lawfully in the United States. 

3⁄4 Of course, people on the other side of this issue opposed this provision back then 

because they believed that your hard-earned tax dollars should go to pay for 

healthcare services for people that are in your country illegally. 

3⁄4 And it is a lot of these same people that are now opposing our efforts to ensure that 

only citizens get access to taxpayer funded benefits. 

3⁄4 The most unfair thing about what our opponents are advocating is that an illegal 

immigrant on Medicaid would almost certainly have a better healthcare benefits 

package than what is available to most of the taxpayers who are paying for those 

Medicaid benefits. 

3⁄4 Of course, we are not just sitting back and waiting on a single comprehensive 

legislative solution to pass both Houses of Congress. We intend to address this 

problem whenever and wherever we can. 

3⁄4 To help address the negative impact of illegal immigration on our healthcare 

system, the Energy and Commerce Committee produced two important provisions 

in the Deficit Reduction Act of 2005, which is commonly known as the “DRA.” 

3⁄4 One of the provisions that I authored and fought to include in the DRA was a 

provision that requires States to obtain documentary evidence that the person 

applying for Medicaid benefits is actually a U.S. citizen, as required by law. 

3⁄4 This is not a new concept for government programs, since the Medicare and SSI 

programs both require proof of citizenship for all beneficiaries. It’s just that 

Medicaid hadn’t been seriously reformed since the 1960’s and was a little behind 

the times. 

3⁄4 Before the enactment of this provision, the Inspector General of the Department of 

Health and Human Services found that 46 states and the District of Columbia 

allowed self-declaration of citizenship for Medicaid eligibility, and 27 of those 

States never verified any citizenship statements at any point. 

3⁄4 This means that people simply had to say that they were citizens, in whatever 

language they chose to say it in, and they would be eligible for thousands of dollars 

of taxpayer funded Medicaid benefits. 

3⁄4 This was simply unacceptable. 

3⁄4 Of course, the advocates on the other side of this issue fought very hard to prevent 

this provision from being included in the DRA and they fought very hard to defeat 

this needed legislation when it was being voted on by Congress. 

3⁄4 And now, these same advocates are fighting just as hard to weaken this commonsense provision as much as possible, but it is my hope that those implementing this 

provision will stand firm on this important issue. 

3⁄4 Another provision we included in the Deficit Reduction Act was a provision to 

allow States the flexibility to impose increased cost-sharing on healthcare services 

furnished in an emergency room that a physician determines is not a real medical 

emergency, such as an ear infection or strep throat. 

3⁄4 To protect beneficiaries, this provision requires that an available and accessible 

alternative must be available to the beneficiary and the treating hospital must refer 

the individual to that alternative site in order for the co-pay to be charged. 

3⁄4 Like the citizenship-verification provision, this provision is designed to eliminate 

millions of dollars of waste in the Medicaid system by helping to ensure that 

Medicaid patients receive care in the appropriate setting. 

3⁄4 This provision also helps patients. Studies have also shown that patients who 

receive care in the appropriate setting have better healthcare outcomes. 

3⁄4 As we all know, the ER is not the best place to receive primary care services or 

preventative healthcare services. 
67

3⁄4 Although this provision only applies to Medicaid beneficiaries, it will also help 

reduce some of the negative impact of illegal immigrants improperly utilizing the 

ER by providing $50 million in grant funding to the States to establish alternative 

non-emergency providers in communities across the United States. 

3⁄4 In addition to the increased number of alternative non-emergency providers, this 

provision will also make hospital personnel more familiar and comfortable with 

referring non-emergency patients to the appropriate healthcare providers. It will 

also increase communication between ER personnel and these non-emergency 

providers. 

3⁄4 The logic behind this provision is also simple. It costs approximately $340 to care 

for a non-emergency patient in the emergency department while it costs less than 

$70 to care for the same patient in a health clinic or physician’s office. 

3⁄4 That means over five people can be treated in a physician’s office for less money 

than one person can be seen in the ER. 

3⁄4 Again, I believe that this is a common-sense approach to reforming a Medicaid 

program that is in serious need of reform. 

3⁄4 As always, I am looking forward to having a cooperative and productive 

conversation on this topic today and to working with my colleagues to come up 

with effective solutions to the problems addressed at this hearing. 

3⁄4 Again, I would like to thank all of our witnesses for participating today. We look 

forward to hearing your testimony. 

3⁄4 With that, I would like to recognize The Honorable Congresswoman from 

California, Ms. Solis, for 5 minutes for an opening statement. 

 MS. SOLIS. Thank you very much, Mr. Chairman, and good morning 

also to the panelists and to the audience. 

 I represent the 32nd Congressional District in Los Angeles, and yes, it 

was quite a challenge coming into your district here, but I felt very 

welcomed and yesterday, I spent some time in the area of Dalton to see 

how prosperous and how this community is thriving. So my hat is off to 

the mayor and to the citizens here for the economic building that I see 

going on here in your community. 

 On behalf of the Ranking Member John Dingell and my other 

Democratic colleagues on the Committee, I want to thank the community 

of Dalton for hosting this very important meeting today. 

 Today’s hearing is delaying and distracting the American people 

from the real issues at hand--the refusal of the Republican Congress and 

President Bush to enact comprehensive reform. Instead, my counterparts 

want to blame immigrants for driving up the cost of healthcare--in my 

opinion, a false claim. The overwhelming majority of evidence shows 

that immigrants, regardless of status, use less healthcare services than 

U.S. citizens. In 2003, healthcare costs by U.S. born citizens were more 

than double that of immigrants. For example, although emergency 

rooms are one of the few available healthcare venues for the 

undocumented, immigrants use emergency rooms less than nonimmigrants, only 6.3 percent of non-citizens used hospital emergency 

services in 2003, compared to 31.8 percent of U.S. citizens. 
68

 The real problem with our health system is not immigrants, but the 

fact that the system is broken. Too many uninsured. In America alone, 

46 million Americans lack any form of healthcare coverage, 6 million 

more than when President Bush took office in 2001. Too little funding 

for community care and folks on the other side of the aisle have 

consistently tried to cut funding for healthcare programs. Too few jobs 

that offer healthcare benefits. The number of employers offering 

coverage, as we know, has declined significantly over the last few years. 

 If Georgia had an influx of New Yorkers, Oklahomans, or 

Californians, rather than Mexicans, Koreans, or Salvadorans, the 

problem it is facing would still be similar. That is because the root of our 

healthcare problems remains unchanged. Many businesses cannot afford 

healthcare insurance. Many low-wage workers cannot afford to purchase 

insurance, even if it is offered. And many of our healthcare 

organizations are not receiving the Federal support they need to provide 

quality care. Forcibly removing immigrants from the U.S. or 

inhumanely denying them needed healthcare will not solve the healthcare 

problems. In fact, providing a legitimate pathway to allowing 

immigrants to work hard to earn their citizenship will provide them with 

better health insurance options and better incomes to afford insurance, 

possibly reducing the number of uninsured. 

 The contributions of undocumented immigrants and the benefits they 

provide to the U.S. economy more than balance the meager healthcare 

resources which they are eligible to receive. In fact, the Social Security 

Administration has reported $56 billion in earnings that are often 

attributed to immigrants, earnings that help to generate $6 billion to $7 

billion to the Social Security tax revenue, and an additional $1.5 billion 

in Medicare taxes. 

 More than 60,000 immigrants serve currently in active duty in our 

U.S. armed forces, including more than 35,000 who are green card 

holders, they are not U.S. citizens. 

 Undocumented immigrants contribute at least $300 billion to the 

U.S. gross national product annually. 

 In this politically contentious time, we must not lose sight of the 

issue at hand. Our primary obligation as elected officials is to protect the 

American people and to protect our borders. If Republicans had not 

repeatedly defeated our efforts to enhance border security over the last 4 

years, there would be 6,600 more Border Patrol agents, 14,000 more 

detention beds, and 2,700 more immigration enforcement agents along 

our border than now exist. Apprehension of undocumented individuals 

at the border has dropped by 31 percent under President Bush, compared 

to President Clinton’s record. And in 2004, folks, only three employers 

were fined for work site immigration violations--only three. 
69

 Republicans control the White House, the Senate, and the House of 

Representatives. And yet, due to the in-fighting on the other side of the 

aisle, in my opinion, they have failed to pass an immigration bill. 

 My colleagues on the other side of the aisle must stop stalling and 

help us deliver real immigration reform that provides security at our 

borders, helps to enhance the process so that individuals can work here 

that need to work here to help communities like Dalton continue to 

thrive. 

 And I would ask for that courtesy, that we have a civil discussion 

about this issue. 

 And again, I want to thank the panelists and the Chairman and the 

folks here in Dalton for inviting me to be here at this very important 

hearing. 

 Thank you very much, yield back. 

 MR. DEAL. Thank you. It is my pleasure now to introduce my 

colleague, who joins my district from the 9th District of Georgia, the 

Honorable Charlie Norwood, who is also a member of our Health 

Subcommittee. 

 MR. NORWOOD. Thank you very much, Mr. Chairman. I appreciate 

you having this hearing, and especially appreciate you having this 

hearing in Georgia. 

 We welcome our great panel of witnesses and it is a great delight to 

see so many Georgians participating in this today. Unlike in Washington 

when we have these, I cannot understand half the people in the audience, 

but I can understand most everybody in this room. So welcome, we are 

happy to see you here. 

 I want to, Mr. Chairman, if I may, re-remind myself of what this 

hearing is. This hearing is not about immigrants, this hearing is about 

illegal immigrants-- 

 [Applause.] 

 MR. NORWOOD. --who are breaking our laws by entering our 

country, who are breaking our laws by using bogus papers, who are 

breaking our laws by trying to get onto Medicaid that is designed by the 

American taxpayer to help the American citizens, not foreigners who are 

in our country illegally. 

 [Applause.] 

 MR. NORWOOD. Mr. Chairman, illegal aliens are placing a huge 

burden on our health system, we all know that. While illegal aliens 

enjoy these benefits, we have Americans that are forced to bear the entire 

cost of their healthcare in their own family. Take Medicaid as an 

example. The State of Georgia admitted they legally spent $88 million 

on emergency services for illegal aliens in 2005, $88 million. This 

demonstrates just how widespread the problem is in Georgia, since we 
70

really actually have no idea how much was actually spent on all of the 

services for illegal aliens any more than we have any idea how many 

illegal aliens use hospital services. The reason we do not is hospitals 

simply do not question people and ask them are you a citizen or not. So 

any numbers thrown out here today regarding that, of course, are bogus 

because nobody, including me, knows the answer to that. 

 Illegal aliens are not supposed to get routine Medicaid benefits. That 

has been the law of this land since 1986. That is not something we have 

just dreamed up yesterday. It is the law of the land. The problem is that 

in recent years, CMS encouraged self-declaration, which allowed people 

to be accepted as U.S. citizens simply because they said so. And we 

wonder why States are seeing their Medicaid expenses soaring. 

According to the Inspector General over at Health and Human Services, 

46 States and the District of Columbia allow self-declaration of U.S. 

citizenship for Medicaid. That is against the Federal law to do that. I 

will put that in simple terms. An illegal alien could have walked into 46 

States and the District of Columbia and say that they were a citizen and 

no one asked any other questions, 27 States did not verify citizenship at 

any point, even after benefits were provided. 

 We changed that through Section 6082 of the Deficit Reduction Act, 

and I am very pleased that we did. Now the supporters of open borders 

will say that the old way of business was just fine, they might argue that 

44 of these States require evidence of citizenship if statements seemed 

questionable. Were those States approving profiling based on accents 

and appearances? I have no clue how a reasonable person could 

conclude someone is illegal without asking for proof of citizenship. 

 Now I am not interested in discriminating against anyone, that is 

exactly why we should ask for documents from everyone that applies for 

Medicaid benefits. Remember what we are doing. A person comes in 

and says I need free healthcare. I want the citizens of America to furnish 

me healthcare, that is what you are asking for. Is it too much for us to 

ask could you please identify yourself, could you please determine if you 

are a citizen before the taxpayers of this country pay for your healthcare 

and Medicaid that is better than many citizens, working American 

citizens have in their own healthcare? I do not think it is too much. 

 I am also proud that CMS implemented this provision in a way that 

will see that citizens are accommodated. If you are on Medicare, you 

have met the standard. If you are on Social Security disability, you have 

met the standard. If you can produce one of dozens of documents to 

prove citizenship and identify, you have met the standard. We are also 

talking about emergency care. This provision does not even touch 

EMTALA. We will get into that, I am sure. 
71

 Nine groups of qualified illegal aliens have qualified for Medicaid, 

including permanent residents, battered alien women, and victims of 

human trafficking. 

 Mr. Chairman, what we faced was the outright theft of healthcare 

benefits for the low-income Americans by illegal aliens. We have heard 

the falsehood that illegal aliens only take jobs that American do not 

want. Are we now also saying they are only taking healthcare benefits 

that Americans do not want? The U.S. citizens that are losing Medicaid 

coverage will tell you they really need and want those benefits. 

 Mr. Chairman, I am glad this field hearing will further allow each 

party to declare where they stand--on the side of their low-income 

constituents, or on the side of the illegal aliens. Maybe some folks have 

no problem pandering to civil violators who add to our crimes by 

swindling taxpayers; maybe they do not understand that the match 

system and State balanced budgets limit how much money there is to go 

around. Fewer poor American citizens get Medicaid because illegal 

aliens get Medicaid. It is just that simple. Our provision, and what 

Georgia did even before we enacted it, will bring integrity back to our 

certification system for Medicaid. 

 And with that, Mr. Chairman, I thank you for the time. 

 [Applause.] 

 MR. DEAL. Thank you. 

 I will now ask our participants in the first panel if they would please 

come to the podium. 

 I am pleased to introduce some distinguished members of the 

Georgia State Senate, who have already been alluded to as leaders in an 

immigration reform package that passed the legislature of our State. In 

the estimation of most who have looked at the package of legislation that 

you gentlemen helped pass, it makes Georgia really the leader on this 

whole issue in the country, and we appreciate your efforts. 

 We have a third panelist who has been invited and was expected to 

be here and-- 

 MS. SOLIS. He is here, I believe he is here. 

 MR. DEAL. Oh, he is? 

 MS. SOLIS. Mr. Thompson. 

 MR. DEAL. All right. 

 First of all, I would like to introduce the Honorable Casey Cagle, 

who is a Member of the Georgia State Senate and represents the area on 

the eastern side of my Congressional District of Hall and Jackson 

Counties. Then, of course, the real leader of the legislation in the State 

General Assembly, the Honorable Chip Rogers from Atlanta, Georgia, 

and the Honorable Curt Thompson, who is also a Member of the State 

Senate from Atlanta. Gentlemen, we are pleased to have all of you here 
72

today, I look forward to your testimony and each of you will be given 5 

minutes to make oral presentations. Your written testimony has already 

been made a part of the record. We will begin with you, Mr. Cagle. 

STATEMENTS OF THE HON. CASEY CAGLE, MEMBER, 

GEORGIA STATE SENATE; THE HON. CHIP ROGERS, 

MEMBER, GEORGIA STATE HOUSE OF 

REPRESENTATIVES; AND THE HON. CURT ROGERS, 

MEMBER, GEORGIA STATE SENATE 

 MR. CAGLE. Thank you, Mr. Chairman and members of the 

Committee. It is indeed an honor to be before you today in a wonderful 

part of our State here in Dalton, and I appreciate you taking the time and 

the sacrifice to hear our comments today. 

 The impact of illegal aliens on our healthcare system represents one 

of the most important physical challenges facing Georgia. However, I 

would say at the outset, the real issue at hand here is not the cost of 

healthcare at all. Instead, it is the failure of the Federal government to 

properly secure America’s borders. 

 As Americans, we are a Nation of immigrants. No one wants to 

deny individuals who obey the law and follow the process an opportunity 

to have a shot at the dream of American citizenship. All we are saying is 

that those who choose to break the law and come here illegally should 

not receive taxpayer benefits as a result of doing so. Americans do not 

assume that we can illegally enter other countries and require them to 

give us benefits. We are simply asking the citizens of other nations to 

follow the same rules. 

 Unfortunately, Federal policies for the last several decades have 

encouraged foreign citizens not to follow the rules. Our unsecured 

borders have resulted in millions of citizens of other countries coming to 

America illegally. And these foreign nationals often need or want a 

broad range of social services when they arrive in individual States. This 

situation leaves State governments holding the bag for a problem that the 

Federal government has, quite candidly, utterly failed to solve. 

 I would therefore begin my remarks by urging Congress, in the 

strongest possible terms, to seal our borders. Unless and until we have 

secure borders and an immigration system that makes sense, any solution 

we find on social services or service issues such as healthcare will be a 

mere Band-Aid. 

 Senator Isakson, Congressman Deal, and Congressman Norwood 

have shown strong leadership on this front and I hope they are successful 

in encouraging their colleagues to put border security first. 
73

 Having said that, the issue of dealing with the impact of illegal aliens 

on the healthcare system is a significant one for Georgia. At its heart, the 

issue is one of basic fairness. Every day, citizens across Georgia find 

ourselves facing major healthcare problems that strain our financial 

resources. Maybe it is a young child being diagnosed with a cancer that 

is only covered at 80 percent by their healthcare plan. Or perhaps it is a 

senior citizen being forced to sell all of their worldly possessions in order 

to obtain affordable long-term care. Perhaps it is a family canceling a 

summer vacation in order to cover a sudden rise in insurance premiums. 

The bottom line is that for many everyday Georgia citizens, affordable 

healthcare coverage is rapidly becoming unreachable. After providing 

for their families, paying their taxes, and doing everything else that good 

citizens do, these working families find themselves unable to qualify for 

government-funded healthcare; yet, unable to pay for private healthcare 

insurance. 

 Now think about what happens when the same family learns that 

healthcare costs in Georgia are being significantly increased by the cost 

of providing free or subsidized care to citizens of other nations who 

broke Federal law to come here. The response from everyday Georgians 

is outrage. Our citizens are outraged because this kind of system is 

patently unfair. 

 We work hard every day to pay taxes and we deeply resent seeing 

those taxes siphoned off to provide free healthcare to aliens who come 

here illegally. I realize there are some people in Congress who think our 

outrage at this situation is wrong. I would just say that perhaps these 

folks would feel differently if they were forced to give up their taxpayerfunded health benefits and experience first hand the strain that rising 

healthcare costs put on Georgia families every day. 

 Based on the feedback I get from my constituents every day, I 

commend those in Congress who are working to ensure the taxpayerfunded Medicaid system benefits only individuals who are in American 

legally. Taking reasonable steps to reduce the burden illegal aliens place 

on Medicaid significantly and our hospitals generally is a virtual 

necessity in order for our State to maintain a sound financial footing. 

 Of course, the challenge here is identifying individuals who are here 

illegally in the context of providing healthcare. We obviously do not 

want to have any kind of system in place that makes it difficult for 

individuals with urgent healthcare needs to receive emergency treatment. 

We can and must ensure that our hospital facilities continue to offer 

lifesaving stabilization and care to anyone who arrives at their doors, 

regardless of how they got there. However, when our emergency rooms 

become primary care facilities of last resort for the non-urgent medical 

needs of illegal aliens, we have a problem. And the only way to solve 
74

that problem is to take steps to identify illegals and prevent them from 

obtaining free medical care paid for by American citizens. 

 At this point, the challenge becomes identifying illegal aliens prior to 

healthcare delivery. More than anything else, this represents the most 

contentious part of this debate. Because identifying members of a 

population that explicitly seeks to hide their identity represents a very 

difficult challenge. However, I believe we can and should meet that 

challenge by putting a basic identification system in place to ensure 

taxpayer-funded benefits are going only to legal citizens. 

 An argument frequently raised is that requiring citizenship 

verification for Medicaid benefits requires paperwork that can be 

difficult to fill out. In response to that argument, I would simply say 

getting any kind of healthcare in our current system involves often 

complex paperwork. We can and should focus on streamlining that 

paperwork, but to argue that illegal aliens from other nations deserve a 

process that is easier to handle than American citizens is absurd. 

 Individuals on Medicaid are receiving a valuable commodity from 

the Government. And asking for basic identification as a prerequisite 

represents a common sense policy supported by the vast majority of 

Georgia citizens. We require identification in order to drive a car, rent a 

movie, or purchase alcohol. There is simply no legitimate public policy 

reason not to make the same requirement a basic threshold for receiving 

taxpayer-funded healthcare. 

 In summary, I urge Congress to act immediately to seal our borders 

and ensure that the only individuals in our country are those who come 

here legally. Until we can achieve this goal, I strongly support efforts to 

prevent illegal aliens from receiving non-emergency health benefits paid 

for by hospitals themselves or taxpayer-funded. 

 Thank you, Mr. Chairman, members of the Committee. 

 [Applause.] 

 MR. DEAL. Thank you, Senator Cagle. 

 Senator Rogers, you are recognized for 5 minutes. 

 [The prepared statement of Casey Cagle follows:] 

PREPARED STATEMENT OF THE HON. CASEY CAGLE, MEMBER, GEORGIA STATE SENATE

The impact of illegal aliens on our healthcare system represents one of the single 

most important fiscal challenges facing Georgia. 

However, I would say at the outset that the real issue at hand here is not the cost of 

health care at all. Instead, it is the failure of the federal government to properly secure 

America’s borders. 

As Americans, we are a nation of immigrants. No one wants to deny individuals 

who obey the law and follow the process an opportunity to have a shot at the dream of 

American citizenship. All we are saying is that those who choose to break the law and 

come here illegally should not receive taxpayer benefits as a result of doing so. 
75

Americans do not assume that we can illegally enter other countries and require them to 

give us benefits. We are simply asking the citizens of other nations to follow the same 

rules. 

Unfortunately, federal policies for the last several decades have encouraged foreign 

citizens not to follow the rules. Our unsecured borders have resulted in millions of 

citizens of other countries coming to America illegally. And, these foreign nationals 

often need or want a broad range of social services when they arrive in individual states. 

This situation leaves state governments holding the bag for a problem that federal 

government has abjectly and utterly failed to solve. 

I would therefore begin my remarks by urging Congress in the strongest possible 

terms to seal our borders. Unless and until we have secure borders and an immigration 

system that makes sense, any solution we find on social service issues such as health care 

will be a mere band-aid. Senator Johnny Isakson, Congressman Nathan Deal and 

Congressman Charlie Norwood have shown strong leadership on this front, and I hope 

they are successful in encouraging their colleagues to put border security first. 

Having said that, the issue of dealing with the impact of illegal aliens on the 

healthcare system is a significant one for Georgia. At its heart, the issue is one of basic 

fairness. 

Every day, citizens across Georgia find ourselves facing major healthcare problems 

that strain our financial resources. Maybe it’s a young child being diagnosed with a 

cancer that’s only covered at 80% by a health plan. Or, perhaps it’s a senior citizen being 

forced to sell all of their worldly possessions in order to obtain affordable long term care. 

Perhaps it is a family canceling a summer vacation in order to cover a sudden rise in 

insurance premiums. 

The bottom line is that for many everyday Georgia citizens, affordable healthcare 

coverage is rapidly becoming unreachable. After providing for their families, paying 

their taxes and doing everything else that good citizens do, these working families find 

themselves unable to qualify for government funded healthcare, yet unable to pay for 

private health insurance. 

Now, think about what happens when the same family learns that health care costs 

in Georgia are being significantly increased by the cost of providing free or subsidized 

care to citizens of other nations who broke federal law to come here. 

The response from everyday Georgians is outrage. Our citizens are outraged 

because this kind of system is patently unfair. We work hard every day to pay taxes, and 

we deeply resent seeing those taxes siphoned off to provide free health care to aliens who 

come here illegally. 

I realize there are some people in Congress who think our outrage at this situation is 

wrong. I would just say that perhaps these folks would feel differently if they were 

forced to give up their taxpayer funded health benefits and experience firsthand the strain 

that rising healthcare costs put on Georgia families every day. 

Based on the feedback I get from my constituents every day, I commend those in 

Congress who are working to ensure the taxpayer funded Medicaid system benefits only 

individuals who are in America legally. Taking reasonable steps to reduce the burden 

illegal aliens place on Medicaid specifically – and our hospitals generally – is a virtual 

necessity in order for our state to maintain a sound financial footing. 

Of course, the challenge here is identifying individuals who are here illegally in the 

context of providing health care. 

We obviously do not want to have any kind of system in place that makes it difficult 

for individuals with urgent healthcare needs to receive emergency treatment. We can and 

must ensure that our hospital facilities continue to offer lifesaving stabilization and care 

to anyone who arrives at their doors, regardless of how they got there. 

However, when our emergency rooms become primary care facilities of last resort 

for the non-urgent medical needs of illegal aliens, we have a problem. And, the only way 
76

to solve that problem is to take steps to identify illegals and prevent them from obtaining 

free medical care paid for by American citizens. 

At this point, the challenge becomes identifying illegal aliens prior to health care 

delivery. More than anything else, this represents the most contentious part of this 

debate, because identifying members of population that explicitly seek to hide their 

identities represents a very difficult challenge. However, I believe we can and should 

meet that challenge by putting a basic identification system in place to ensure taxpayer 

funded benefits are going only to legal citizens. 

An argument frequently raised is that requiring citizenship verification for Medicaid 

benefits requires paperwork that can be difficult to fill out. In response to that argument, 

I would simply say getting any kind of healthcare in our current system involves often 

complex paperwork. We can and should focus on streamlining that paperwork, but to 

argue that illegal aliens from other nations deserve a process that is easier to handle than 

American citizens is absurd. Individuals on Medicaid are receiving a valuable 

commodity from the government, and asking for basic identification as a prerequisite 

represents a common sense policy supported by the vast majority of Georgia citizens. 

We require identification in order to drive a car, rent a movie, or purchase alcohol. 

There is simply no legitimate public policy reason not to make the same requirement a 

basic threshold for receiving taxpayer funded health care. 

In summary, I urge Congress to act immediately to seal our borders and ensure that 

the only individuals in our country are those who come here legally. Until we can 

achieve this goal, I strongly support efforts to prevent illegal aliens from receiving nonemergency health benefits paid for by hospitals themselves or taxpayer funds. 

Thank you. 

MR. ROGERS. Thank you, Mr. Chairman and members of the 

Committee. Thank you for allowing me to address you today on what I 

believe is the most important domestic issue facing the United States; 

and that is the impact of our unsecured borders on the citizens of this 

Nation. 

 While many questions surrounding illegal entry into our Nation are 

debatable, I would like to start my testimony with a few that are not. 

 The United States government has an obligation to secure our 

borders for its citizens. Any entry into the United States through a point 

other than a legal port of entry is a violation of these borders. Likewise, 

any foreign national remaining in the United States for a time beyond the 

granted legal stay is in violation of our Nation’s immigration laws. 

 Now why would a foreign national enter the United States through a 

means other than a legal port of entry or remain in the United States for a 

time in excess of his or her legal stay? I believe the answers are many, 

but fall mainly into two easily defined categories--employment and 

taxpayer-supported benefits. Therefore, any proposal that seeks to fulfill 

the responsibility of the United States government to secure our borders 

must include measures to eliminate the attraction of illegal entry. 

 With respect to the enforcement of employment laws, the 

Department of Homeland Security has all but stopped any effort to 

uphold the current law. The number of companies fined for hiring illegal 

workers dropped from 417 back in 1999 to just 3 in 2004. The result of 
77

this failure to enforce the law has been millions of additional illegal 

aliens present in our Nation. Many, but not all, of these illegal aliens are 

hired by criminal employers and invariably use taxpayer-funded services 

that are reserved for United States citizens and persons lawfully present 

in the United States. 

 This brings us to the second necessary area of enforcement--

taxpayer-supported benefits. While the Federal government is charged 

with the constitutional duties of national defense and the general welfare 

of this Nation, it is the States and the local governments that primarily 

administer taxpayer supported benefits. When considering the demands 

on our social safety net brought on by the presence of illegal aliens, it is 

clear that the financial impact is actually much greater on the States and 

the local governments. It is fact the States that pay for those particular 

services that are most demanded by illegal populations, including 

education, law enforcement, and today’s topic, healthcare services. 

 You will likely hear from many witnesses today that can debate the 

financial impact of illegal immigration. Economists are easily found 

who will confirm that illegal immigration is in fact a significant financial 

drain on our economy. You may find a few who actually believe that the 

importation of millions of unskilled and uneducated laborers is actually 

good for our system. But regardless of the financial numbers, the 

question to be asked by elected officials is not whether it is profitable, 

but is it fair. 

 Current Federal law, Title 8, Chapter 14, Sections 1611 and 1621, 

clearly define that a person not lawfully present in the United States is 

ineligible to receive almost all taxpayer-funded benefits. The few 

exceptions include emergency services and medical services to treat the 

symptoms of communicable diseases. In other words, the Federal law 

establishes the threshold of eligibility to receive taxpayer-funded benefits 

for non-U.S. citizens. 

 This, I believe, brings us to the critical question that must be 

answered if you believe illegal aliens should receive taxpayer-supported 

benefits. And that is, if a foreign national, who is in violation of U.S. 

immigration law is granted the right to receive taxpayer-funded benefits 

without meeting eligibility requirements, then why is the same exception 

not extended to American citizens? 

 In the State of Georgia, we have a wonderful program designed to 

pay for health insurance for children of poor families. This program is 

known as Peachcare. Should I, as a U.S. citizen and a Georgia resident, 

be required to meet the eligibility requirements to receive this benefit? 

Clearly the answer is yes. The failure to enforce this eligibility 

requirement means that I will receive taxpayer-supplied heath insurance 

for my children at the expense of those who do legally qualify. 
78

 What about a U.S. citizen from the State of Alabama? She he or she 

be required to meet the eligibility requirements of Georgia residency 

before receiving Georgia Medicaid benefits? Clearly again, the answer 

is yes. And again, the failure to enforce this eligibility requirements 

results in fewer benefits for legally eligible Georgians. 

 So if we have established the fact that U.S. citizens from Georgia 

and any other State must meet the eligibility requirements to receive 

taxpayer benefits, then how can we possibly suggest that a foreign 

national illegally present in the United States should not also meet those 

same eligibility requirements. 

 Unlike the Federal government, most States, including Georgia, have 

a balanced budget requirement. And under a balanced budget 

requirement, when a taxpayer benefit is given to an ineligible recipient, 

then by definition that benefit must be denied to an eligible recipient. 

 Let me illustrate this in real life terms. In Georgia today, there are 

12,700 children with severe physical disabilities, adults with mental 

retardation, and frail and elderly citizens who are on a waiting list for 

community-based services. These are 12,700 legal U.S. citizens who 

already qualify for our help, but are being denied because of a lack of 

funding. Each time a dollar is given to a person who does not qualify to 

receive it, that same dollar cannot be given to one of these 12,700 

Georgians who are currently on the waiting list. 

 One final example of the inequities created by ignoring our 

immigration law; it is called the priority group 8g. Military veterans may 

be familiar with this designation. The Veterans’ Administration annually 

places our United States veterans into distinct categories so as to 

determine who will receive medical care. This despite the fact that this 

medical care to which I refer was already promised these veterans upon 

their agreeing to serve our Nation’s armed forces. The current group 8g 

is no longer eligible to receive the promised care because veterans in this 

group had the audacity to go out and make more than $31,000 back in 

2004, and they had no service-related ailments. 

 Yet at the same time, a foreign national may illegally enter the 

United States, present no documentation to verify lawful status or 

income, and immediately receive those taxpayer-funded medical care 

services that should have gone to the United States veterans that are in 

group 8g. This bring me back to my earlier question: Is the current 

policy fair? 

 One of the eligibility requirements to receive non-emergency 

taxpayer-supported healthcare benefits is to be lawfully present in the 

United States. This would lead one to believe that surely the individual 

States are verifying the lawful status prior to giving away the taxpayers’ 

money. Sadly, the answer is no, they are not. 
79

 Only four States--Montana, New York, New Hampshire, and I am 

proud to say Georgia--require proof of citizenship to receive Medicaid 

benefits. 

 However, there is good news. Under the newly enacted Deficit 

Reduction Act, the requirement for proof of citizenship to receive 

Medicaid benefits is now going to be enforced nationwide. Additionally, 

this new law will remove the misguided policy of deducting indigent 

care expenses for illegal aliens from the States’ Medicaid funds. Georgia 

thanks you for this legislation. 

 Is the Deficit Reduction Act good public policy? Clearly, it is. As a 

taxpayer, we must all have the simple expectation--the simple 

expectation--that our taxpayer dollars are being used for only a lawful 

purpose. When false identification or lack of verification allows 

taxpayer dollars to be diverted to ineligible recipients, it is not a lawful 

purpose. 

 In Georgia, we have gone one step further. Under the new Georgia 

Security and Immigration Compliance Act, we will begin verifying the 

eligibility of all adult applicants for all taxpayer-supported benefits. 

 Let me be very clear here, the State of Georgia does not establish the 

criteria for qualifying for benefits. With respect to illegal aliens, 

Congress and President Bill Clinton established those criteria in 1996. 

Under Georgia law, we will simply verify eligibility. We will do so 

using the SAVE program that is offered to us by the United States 

Citizenship and Immigration Services. This electronic verification 

system will allow us to almost instantly verify the eligibility of any alien 

seeking taxpayer-supported benefits. 

 The requirement in Georgia to verify eligibility will ultimately mean 

that taxpayer benefits go to only those who meet the eligibility 

requirements. Does this mean the State will save money? Not 

necessarily. But what it will mean is that Georgians can trust that their 

taxpayer dollars are only going to persons legally eligible to receive 

them. 

 Finally, I will address the specific issue of taxpayer-supported nonemergency healthcare benefits to illegal aliens. Please note--and this is 

very important--you will hear a number of witnesses refer to a denial of 

healthcare rather than a denial of taxpayer-supported healthcare benefits. 

I believe characterizing this issue as simply a denial of healthcare is 

completely and totally inaccurate. 

 Any person, regardless of legal status, may purchase healthcare 

without the assistance of the taxpayers. Millions of American citizens do 

that each and every week. Additionally--and I address this to our 

medical professionals in the audience--any doctor or medical facility can 

simply give away their medical care. There is no requirement that they 
80

force somebody to pay for it. Again, free medical care can be found all 

across this Nation. 

 The question we are faced with today is very simple. If a person, 

legal or illegal, asks the taxpayers of this Nation to pay for his or her 

medical care, do the taxpayers have a right to expect that that person be 

eligible to receive the benefits? As an elected official and as a taxpayer, 

I hope you would all agree the answer is yes. 

 Again, I thank you for allowing me the opportunity to appear before 

you today to discuss this important issue. I will be glad to answer any 

questions pertaining to illegal immigration or the new Georgia law which 

seeks to limit the impact of illegal immigration on our State. 

 [Applause.] 

 [The prepared statement of Chip Rogers follows:] 

PREPARED STATEMENT OF THE HON. CHIP ROGERS, MEMBER, GEORGIA STATE HOUSE OF 

REPRESENTATIVES

Members of the Committee thank you for allowing me to address what I believe is 

the most important domestic issue facing the United States of America: the impact of our 

unsecured borders on the citizens of this nation. 

While many questions surrounding the illegal entry into our nation are debatable, I 

would like to start my testimony with a few that are not. 

The United States government has an obligation to secure the borders for its citizens. 

Any entry into the United States through a point other than a legal port of entry is a 

violation of these borders. Likewise, any foreign national remaining in the United States 

for a time beyond the granted legal stay is in violation of our nation’s immigration law. 

Why would a foreign national enter the United States through a means other than a 

legal port of entry or remain in the United States for a time in excess of his or her legal 

stay? 

I believe the answers are many but most fall into two easily defined categories: 

employment and taxpayer-supported benefits. 

Therefore any proposal that seeks to fulfill the responsibility of the United States 

government to secure our borders must include measures to eliminate the attraction of 

illegal entry. 

With respect to enforcement of employment laws, the Department of Homeland 

security has all but stopped any effort to uphold current law. The number of companies 

fined for hiring illegal workers dropped from 417 in 1999 to just 3 in 2004. 

The result of this failure to enforce the law has been millions of additional illegal 

aliens present in our nation. Many, but not all, of these illegal aliens are hired by 

criminal employers and invariably use taxpayer-funded services that are reserved for U.S. 

citizens and persons lawfully present in the United States. 

This brings us to the second necessary area of enforcement: taxpayer-supported 

benefits. 

While the federal government is charged with the constitutional duties of national 

defense and the general welfare of the nation, it is the states and local governments that 

primarily administer taxpayer-supported benefits. When considering the demands on our 

social safety net brought on by the presence of illegal aliens, it is clear that the financial 

impact is actually much greater on state and local governments. 
81

It is in fact the states that pay for those particular services most demanded by the 

illegal population including education, law enforcement and, today’s topic, health care 

services. 

You will likely hear many witnesses debate the financial impact of illegal 

immigration. Economists are easily found who will confirm that illegal immigration is a 

significant financial drain on our economy. You may find a few who actually believe the 

importation of millions of unskilled and uneducated laborers is actually good for our 

system. But regardless of the financial numbers the question to be asked by elected 

officials is not whether it is profitable but rather “Is it fair?” 

Current federal law, Title 8 Chapter 14 sections 1611 & 1621, clearly define that a 

person not lawfully present in the United States is ineligible to receive almost all 

taxpayer-funded benefits. The few exceptions include emergency services and medical 

services to treat the symptoms of communicable diseases. 

In other words, the federal law establishes the threshold of eligibility to receive 

taxpayer-funded benefits for non-U.S. citizens. 

This, I believe, brings us to the critical question that must be answered if you believe 

illegal aliens should receive taxpayer-supported benefits. 

If a foreign national, who is also in violation of U.S. immigration law, is granted the 

right to receive taxpayer-funded benefits, without meeting eligibility requirements, then 

why is this same exemption not extended to American citizens? 

In the state of Georgia we have a wonderful program designed to pay for health 

insurance for children of poor families. The program is known as Peachcare. Should I, 

as a U.S. citizen and a Georgia resident, be required to meet the eligibility requirements 

to receive this benefit? Clearly the answer is yes. The failure to enforce eligibility 

requirements means that I will receive taxpayer-supplied health insurance for my children 

at the expense of those who legally qualify. 

What about a U.S. citizen from the state of Alabama? Should he or she be required 

to meet the eligibility requirement of Georgia residency before receiving Georgia 

Medicaid benefits? Again the answer is yes. And again the failure to enforce the 

eligibility requirements results in fewer benefits for legally eligible Georgians. 

So if we have established that U.S. citizens from Georgia, or any other state, must 

meet eligibility requirements to receive taxpayer benefits, then how can we possibly 

suggest that a foreign national, illegally present in the United States, should not also meet 

eligibility requirements? 

Unlike the federal government, most states, including Georgia, have a balanced 

budget requirement. Under a balanced budget requirement when a taxpayer benefit is 

given to an ineligible recipient then by definition the benefit must be denied to an eligible 

recipient. 

Let me illustrate this in real life terms. In Georgia today there are 12,700 children 

with severe physical disabilities, adults with mental retardation, and frail and elderly 

citizens who are on a waiting list for community based services. These are 12,700 legal 

U.S. citizens who already qualify for our help, but are being denied because of a lack of 

funding. 

Each time a dollar is given to a person who by law does not qualify to receive it, 

then that same dollar cannot go to help one of these 12,700 Georgians on the waiting list. 

One final example of the inequities created by ignoring immigration law: it is called 

priority group 8g. Military veterans may be familiar with this designation. The Veterans 

Administration annually places our U.S. veterans into distinct categories so as to 

determine who will receive medical care. This despite the fact that the medical care to 

which I refer was promised to these veterans upon their agreeing to serve in our nation’s 

armed forces. The current group 8g is no longer eligible to receive the promised care 

because veterans in this group made more than $31,000 in 2004 and had no service 

related ailments. 
82

Yet at the same time a foreign national may illegally enter the United States, present 

no documentation to verify lawful status or income, and immediately receive taxpayerfunded medical care. 

This brings me back to my earlier question, “Is it fair?” 

One of the eligibility requirements to receive non-emergency taxpayer-supported 

healthcare benefits is to be lawfully present in the United States. This would lead one to 

believe that surely the individual states are verifying lawful status prior to giving away 

the taxpayers money. Sadly the answer is, no they are not. 

Only four states, Montana, New York, New Hampshire, and I am proud to say, 

Georgia, require proof of citizenship to receive Medicaid benefits. 

However, there is good news. Under the newly enacted Deficit Reduction Act the 

requirement for proof of citizenship to receive Medicaid is to be enforced nationwide. 

Additionally, this new law will remove the misguided policy of deducting indigent care 

expenses for illegal aliens from the states Medicaid funds. 

Is Deficit Reduction Act good public policy? Yes, it is. As a taxpayer we must all 

have the simple expectation that our taxpayer dollars are being used for a lawful purpose. 

When false identification, or lack of verification, allows taxpayer dollars to be diverted to 

ineligible recipients, it is not a lawful purpose. 

In Georgia we have gone one step further. Under the our new Georgia Security and 

Immigration Compliance Act we will begin verifying the eligibility of all adult applicants 

for taxpayer supported benefits. 

Let me be clear, the state of Georgia does not establish the criteria for qualifying for 

benefits. With respect to illegal aliens, Congress and President Clinton established those 

criteria in 1996. Under Georgia law we will simply verify eligibility. We will do so 

using the SAVE program offered to us by the United States Citizenship and Immigration 

Services. This electronic verification system will allow us to almost instantly verify the 

eligibility of any Alien seeking taxpayer-supported benefits. 

The requirement in Georgia to verify eligibility will ultimately mean that taxpayer 

benefits go only to those who meet the eligibility requirements. Does this mean the state 

will save money? Not necessarily. But it will mean that Georgians can trust their 

taxpayer dollars are going only to persons legally eligible to receive them. 

Finally, I will address the specific issue of taxpayer supported non-emergency 

healthcare benefits to illegal aliens. Please note you will likely hear a number of 

witnesses refer to a denial of healthcare rather than a denial of taxpayer supported 

healthcare benefits. I believe characterizing this issue, as simply a denial of healthcare, is 

inaccurate. 

Any person, regardless of legal status, may purchase healthcare without the 

assistance of the taxpayer. Millions of American citizens do so every week. 

Additionally, any doctor or medical facility can simply give away medical care. Again 

free medical care can be found all across our nation. 

The question we are faced with today is simple, if a person, legal or illegal, asks the 

taxpayers to pay for his or her medical care, do the taxpayers have a right to expect the 

applicant to be eligible to receive the benefit? 

As an elected official, and a taxpayer, I hope you would agree the answer is, yes! 

Again, I thank you for allowing me the opportunity to appear before you today to 

discuss this important issue. I will be glad to answer any questions pertaining to illegal 

immigration or the new Georgia law, which seeks to limit the impact of illegal 

immigration on our state. 

MR. DEAL. Senator Thompson, you are recognized for 5 minutes.

 MR. THOMPSON. Thank you, Mr. Chairman and thank you all for 

coming down here. Some of you came farther than others. 
83

 I would just encourage this Committee to be looking at practical 

solutions to real problems, both when it comes to the crisis of illegal 

immigration as well as the crisis in healthcare that faces this country, in 

that pretty much my district, District 5, is ground zero for both. 

 I do represent Georgia’s Fifth State Senate District situated along the 

interstate that comes from Gainesville where you will also hold a 

hearing, into Atlanta. We have some historic areas such as the picture 

postcard railroad depot and town square of Norcross, but primarily we 

live in suburbs begun during the 1970s when lots of Atlantans left their 

town after desegregation and lots of northerners left the rust belt after deindustrialization. Some of that rootless suburban population then moved 

again in the 1990s to points further out, taking with them some of the 

commercial infrastructure that had serviced them. What opened up was 

space for new residents making a home here or African-Americans 

finding a first home in the suburbs, urbanites fleeing the inflated home 

prices in Atlanta’s bohemian quarter, and immigrants. 

 My district and the neighborhoods around it are home to as diverse a 

population as one finds in the southeast. In fact, it is the most diverse 

State Senate seat in the General Assembly here. In our schools, students 

speak some 120 languages when at home. I have to campaign in 

English, Spanish, Korean, Hindi, Vietnamese, and Mandarin in order to 

keep my seat. I have attended Romanian Orthodox churches, spoken at 

Hindu temples, danced Cumbia at a Colombian festival, and cut the 

ribbon at the opening of a high end Chinese shopping center. At 

dinnertime, I have menu options as rich as a Congressional aide living in 

Adams-Morgan. I go home this evening to a wife who was born in 

Colombia and I am here to tell you that diversity works. 

 When that first wave of suburbanites left for the exurbs in the 1990s, 

they took along with them some of the commercial infrastructure that 

had serviced them. We lost jobs, storefronts stood vacant, dollars for 

development went elsewhere. With declining political clout, our schools 

got fewer resources, traffic worsened, and we had a tough decade or so. 

 We have turned a corner. We have done the hard work to get the 

broader community to form a community investment entity called the 

Gwinnett Village Community Improvement District, to redevelop and 

market our international community. We have also become a draw to 

new investment with new major retail outlets catering to our diverse 

community’s demands and plans for several major new urbanist livework-shop-play centers including the Super Pearl and Super H centers as 

well as proposals for mixed use developments at Gwinnett Place Mall 

and at the Jimmy Carter Boulevard intersection with Interstate 85. Large 

investments are coming from overseas, including the Asian Village, 

investors seeing our community as a place where they can feel at home 
84

and where they can prosper. Young professionals are relocating here to 

participate in our cosmopolitan lifestyle. The I-85 corridor is turning 

into a destination for consumers who appreciate our distinctive mix. 

Simply put, our turn-around is fueled by diversity that only immigrant 

communities can generate. 

 Do not mess this up for us. 

 Think of Vancouver, British Columbia, just north of Seattle, with a 

flourishing economy tied into the world market. Vancouver boomed 

when talented people and investors in Hong Kong wondered where they 

could go after the colony reverted back to Chinese Communist rule. 

Vancouver welcomed newcomers, made them feel at home like 

neighbors, and everybody got healthcare. It is important to make 

someone who is thinking of bringing talent and money and family into 

our community feel welcome. And in the real world, the modern world, 

part of that welcome is healthcare. 

 It is important to understand that immigrant communities are 

themselves diverse. Some are here legally, some are not. Some are in 

the twilight world because some bureaucrat has not had time to process 

the papers yet. And this diversity extends into families. Poppa has got a 

green card and does pretty well, momma works odd jobs because she 

does not have her papers, junior was not born here, so he may not get to 

go to college while sis carries a U.S. passport, having been born here. 

Mixed families are common. When politicians and activists gin up 

sentiments against the undocumented, it reverberates through any 

community, documented and undocumented, legal and illegal alike. Our 

global investors take notice. 

 That was the case earlier this year when our State legislature 

heatedly debated and eventually enacted an anti-immigrant bill designed 

to play on these sentiments to win elections while inciting fear in our 

communities and scaring away business investments. As a consequence, 

hard-working people in my district are afraid to get the health services 

they need. Many are afraid to take their citizen children for care and 

when they get sick enough, they will end up in the hospital emergency 

room and we all decry the over-crowding and cost of this emergency 

care, as though we had nothing to do with creating this. 

 One of the myths distorting the discussion about immigration is that 

the undocumented represent an unsustainable drain upon public 

resources. But that myth ignores the reality that these hard-working 

people are not only consumers of public services, but also contributors. 

A recent study by the Center on Budget and Policy Priorities, for 

example, finds that the Senate immigration bill, by creating a guest 

worker program,--that is the U.S. Senate immigration bill--expanding the 

number of family-sponsored and employment-based admissions, creating 
85

a process for the undocumented and illegal immigrants to legalize their 

status, and requiring those seeking to legalize to pay back taxes for 

earlier years would significantly increase the number of legal immigrants 

filing Federal tax returns. The net effect of welcoming these new 

workers is Federal revenues enhanced by some $12 billion, more than 

offsetting the growth of entitlements. 

 That is the macro economic level. I am here to tell you about the 

micro. In my small part of the world, investment and consumer spending 

gravitates to us because of, and not in spite of, our mixed and diverse 

population. The prosperity that is just around the corner for us more than 

offsets the public sector investments required. It even offsets the 

consequences of the “white flight” of the 1990s. 

 That is what I am asking you not to mess it up. 

 Specifically, it is important to make some adjustments in the short 

term in the area of healthcare, because failure to act may have a corrosive 

effect on my community’s social cohesion. The Federal government 

should let citizens who apply for Medicare to declare under penalty of 

perjury that they are citizens and who are making a good faith effort to 

secure their citizenship or identity documents, enroll in Medicaid while 

they are gathering their documents. This will ensure that pregnant 

women, children, and others who need timely medical care get it. There 

is no reason to delay preventive healthcare for children or prenatal care 

for women who are making a good faith effort to get their documents 

together. Moreover, States should have more flexibility in how to 

determine citizenship to help groups like foster care children, those 

affected by disasters and those whose birth certificates have been lost 

and so on. 

 Offering a legal pathway to earn citizenship can help immigrant 

workers get better jobs that offer employee benefits like health insurance, 

so that it can reduce the number of people who are uninsured. We 

should never criminalize a hospital or clinic that treats an illegal alien or 

undocumented worker without reporting the immigrant to law 

enforcement. 

 Why would failure to address these issues have a corrosive effect on 

my community’s social cohesion? Recall the mixed nature of the 

community, where the web of personal connections crisscrosses the lines 

of documents. While the Deficit Reduction Act’s provisions regarding 

verification of citizenship by Medicaid applicants were targeted at 

immigrants, they raise serious problems for U.S. citizens who are eligible 

for coverage, but will be adversely affected by the paperwork 

requirements, particularly children who are citizens but whose parents 

are undocumented. They are unlikely to have passports. They may not 

be verified by cross-matches with State vital records. Obtaining a birth 
86

certificate can create a Catch-22 for families if a government issued 

photo ID is required, inasmuch as young children typically do not have 

such IDs. 

 Throughout our immigrant communities, people will know someone 

or know someone who knows someone for whom the process of 

obtaining and presenting the necessary documentation will delay 

healthcare coverage. For providers, who are often from the immigrant 

communities too, the financial impact can be very serious, by adding to 

the burden of uncompensated care, the bills of seriously ill citizens who 

are eligible for Medicaid, but whose coverage is delayed or denied as a 

result of the bureaucratic requirements. Delaying coverage while an 

expectant mother tries to meet the documentation requirements delays 

prenatal care and in some cases will deter the mother from obtaining 

prenatal care altogether. 

 For nearly 2 decades, the States and CMS have used presumptive 

eligibility so that mothers and babies could get care without delay while 

eligibility paperwork is completed. In Georgia, this has increased the 

number of women receiving timely, adequate prenatal care and has 

helped reduce infant deaths. The new law undercuts that approach by 

denying full Medicaid coverage until citizenship is documented, at least 

how it is done here in Georgia. 

 It is penny wise and pound foolish to delay prenatal care for 

American mothers because it will mean a more adverse pregnancy 

outcome, with increased expenditures for neonatal intensive care and in 

some cases, the care of children with lifelong disabilities. Furthermore, 

it is utterly senseless to make a new born citizen with undocumented 

mother whose births are covered by Medicaid apply separately for 

Medicaid as infants when other newborn citizens are deemed eligible for 

a year at birth. This will only mean that babies go without early 

preventive care and all of them need to be healthy. 

 The social cohesion of my diverse community rests upon the 

expectation that people from wholly different backgrounds can work 

hard side by side and build prosperity together. We have a stake in that 

prosperity. We live our aspirations, not our fears. But aspiration and 

harmony give way to fear and antagonism in a heartbeat when parents 

cannot get healthcare for a newborn, and then the downward economic 

spiral returns. 

 We live in a global economy. Investors can put their funds in 

Norcross, Georgia or Mumbai, India or Durango, Mexico or Sydney, 

Australia. Here at home, we live in a mobile society where consumers 

can choose where to spend their discretionary income. I want those 

investments to flow to Georgia and I want that purchasing power aimed 

at Norcross, Chamblee, Doraville, Lilburn, and Duluth. But that will not 
87

happen if we do not adopt rational policies regarding immigration and 

healthcare that take full account of the benefits actually derived from a 

diverse and indeed global population. 

 [The prepared statement of Curt Thompson follows:] 

PREPARED STATEMENT OF THE HON. CURT THOMPSON, MEMBER, GEORGIA STATE SENATE

I represent Georgia’s 5th State Senate District, situated alongside the interstate that 

comes from Gainesville, where you will also hold a hearing, into Atlanta. We have some 

historic areas, such as the picture postcard railroad depot and town square of Norcross, 

but primarily we in the 5th live in suburbs begun during the Seventies, when lots of 

Atlantans left town after de-segregation and lots of Northerners left the Rustbelt after deindustrialization. Some of that rootless suburban population then moved again in the 

Nineties, to points further out, taking with them some of the commercial infrastructure 

that had serviced them. What opened up was space for new residents, and making a 

home here are African-Americans finding a first home in the suburbs, urbanites fleeing 

inflated home prices in Atlanta’s bohemian quarter, and immigrants. 

My district and the neighborhoods around it are home to as diverse a population as 

one finds in the Southeastern US. In our schools, students speak some 120 languages 

when at home. I campaign in English, Spanish, Korean, Hindi, Vietnamese and 

Mandarin. I’ve attended Romanian Orthodox Churches, spoken at Hindu Temples, 

danced Cumbia at a Colombian festival, and cut the ribbon at the opening of a high end 

Chinese Shopping Center. At dinnertime, I have menu options as rich as a Congressional 

aide living in Adams-Morgan. I go home this evening to a wife who was born in 

Colombia. I am here to tell you that diversity works. 

When that first wave of suburbanites left for the exurbs in the Nineties, they took 

along with them some of the commercial infrastructure that had serviced them. We lost 

jobs. Storefronts stood vacant. Dollars for development went elsewhere. With declining 

political clout, our schools got fewer resources. Traffic worsened. We had a tough 

decade or so. 

We have turned a corner. We’ve done the hard work to get the broader community 

to form a community investment entity called the Gwinnett Village Community 

Improvement District to redevelop and market our international community. We’ve also 

become a draw to new investment, with new major retail outlets catering to our diverse 

community’s demands, and plans for several major new-urbanist live-work-shop centers 

including the Super Pearl and Super H centers as well as proposals for mixed use 

developments at Gwinnett Place Mall and at the Jimmy Carter Boulevard intersection 

with Interstate 85. Large investments are coming from overseas including the Asian 

Village, investors seeing our community as a place where they can feel at home and 

where they can prosper. Young professionals are re-locating here to participate in our 

cosmopolitan lifestyle. The I-85 corridor is turning into a destination for consumers who 

appreciate our distinctive mix. Simply put, our turn-around is fueled by diversity that 

only immigrant communities can generate. 

Don’t mess this up for us. 

Think of Vancouver, British Columbia, just north of Seattle, with a flourishing 

economy tied into the world market. Vancouver boomed when talented people and 

investors in Hong Kong wondered where they could go after the Colony reverted to 

China. Vancouver welcomed newcomers. Made them feel at home. Like neighbors. 

And everybody got healthcare. It’s important to make someone who is thinking of 

bringing talent and money and family into our community feel welcome. And in the real 

world, in the modern world, part of that welcome is healthcare. 
88

It’s important to understand that immigrant communities are themselves diverse. 

Some are here legally. Some are not. Some are in a twilight world because some 

bureaucrat hasn’t had time to process papers yet. And this diversity extends into families. 

Poppa’s got a green card and does pretty well, Momma works odd jobs because she 

doesn’t have her papers, Junior wasn’t born here so may not get to go to college, while 

Sis carries a US passport. Mixed families are common. When politicians and activists 

gin up sentiments against the undocumented, it reverberates throughout my community, 

documented and undocumented alike. Our global investors take notice. 

That was the case earlier this year, when our State Legislature heatedly debated and 

eventually enacted an anti immigrant bill designed to play on these sentiments to win 

elections while inciting fear in our communities and scaring away business investments. 

As a consequence, hard-working people in my district are afraid to get health services 

they need. Many are afraid to take their citizen children for care. When they get sick 

enough, they will end up in the hospital emergency room, and we’ll all decry the 

overcrowding, and costs of this emergency care, as though we had nothing to do with it. 

One of the myths distorting the discussion about immigration is that the 

undocumented represent an unsustainable drain upon public resources. But that myth 

ignores the reality that these hard-working people are not only consumers of public 

services but also contributors. A recent study by the Center on Budget and Policy 

Priorities, for example, finds that the “Senate immigration bill, by creating a guestworker program, expanding the number of family-sponsored and employment-based 

admissions, creating a process for undocumented immigrants to legalize their status, and 

requiring those seeking to legalize to pay back taxes for earlier years would significantly 

increase the number of legal immigrants filing federal tax returns.” The net effect of 

welcoming these new workers is federal revenues enhanced by some twelve billion 

dollars, more than offsetting growth of entitlements. Moreover, offering a legal pathway 

to earned citizenship can help immigrant workers get better jobs that offer employee 

benefits like health insurance. Thus, it can reduce the number of people who are 

uninsured. 

That’s the macroeconomic level. I’m here to tell you about the micro. In my small 

part of the world, investment and consumer spending gravitates to us because of and not 

in spite of our mixed and diverse population. The prosperity that is just around the corner 

for us more than offsets the public sector investments required. It even offsets the 

consequences of the “White Flight” of the Nineties. 

That’s what I’m asking you not to mess up. 

Specifically, it is important to make some adjustments in the short term in the area 

of healthcare, because failure to act may have a corrosive effect on my community’s 

social cohesion. The federal government should let citizens who apply for Medicaid, 

who declare under penalty of perjury that they are citizens and who are making a good 

faith effort to secure their citizenship or identity documents, enroll in Medicaid while 

they are gathering their documents. This will ensure that pregnant women, children and 

others who need timely medical care get it. 

There is no reason to delay preventive health care for children if their families are 

making a good faith effort to get their documents together. Likewise, it is penny-wise 

and pound-foolish to delay treatment for a chronic condition while waiting for 

documents. Furthermore, it is utterly senseless to make newborn citizens with 

undocumented mothers whose births were covered by Medicaid apply separately for 

Medicaid when other newborn citizens are deemed eligible at birth for a year of 

coverage. This will only mean the babies go without the early preventive care all of them 

need to be healthy. Finally, states should have more flexibility in how to determine 

citizenship to help groups like foster care children, those affected by disasters, those 

whose birth certificates have been lost, and so on. 
89

Why would failure to address these issues have a corrosive effect on my 

community’s social cohesion? Recall the mixed nature of that community, where the 

web of personal connections crisscrosses the lines of documentation. While the Deficit 

Reduction Act’s provisions regarding verification of citizenship by Medicaid applicants 

were targeted at immigrants, they raise serious problems for U.S. citizens who are 

eligible for coverage but will be adversely affected by the paperwork requirements, 

particularly children who are citizens but whose parents are undocumented. They are 

unlikely to have passports. They may not be verified by cross-matches with state vital 

records. Obtaining a birth certificate can create a “Catch 22” for families, if a 

government-issued photo ID is required, inasmuch as young children typically do not 

have such IDs. 

Throughout our immigrant communities, people will know someone or know 

someone who knows someone for whom the process of obtaining and presenting the 

necessary documentation will delay healthcare coverage. For providers, who are often 

from the immigrant communities, too, the financial impact can be very serious, by adding 

to the burden of uncompensated care the bills of seriously ill citizens who are eligible for 

Medicaid, but whose coverage is delayed or denied as a result of the bureaucratic 

requirements. 

The social cohesion of my diverse community rests upon the expectation that people 

from wholly different backgrounds can work hard side by side and build prosperity 

together. We all have a stake in that prosperity. We live our aspirations, not our fears. 

But aspiration and harmony give way to fear and antagonism in a heartbeat when parents 

cannot get healthcare for a newborn. And then the downward economic spiral returns. 

We live in a global economy. Investors can put their funds into Norcross, Georgia, 

or Mumbai, India, or Durango, Mexico, or Sydney, Australia. Here at home, we live in a 

mobile society where consumers can choose where to spend their discretionary income. I 

want those investments to flow into Georgia. I want that purchasing power aimed at 

Norcross, Chamblee, Doraville, Lilburn, Lawrenceville, and Duluth. But that won’t 

happen if we don’t adopt rational policies regarding immigration and healthcare that take 

full account of the benefits actually derived from a diverse and indeed a global 

population. 

 MR. DEAL. Thank you, Senator. 

 [Applause.] 

 MR. DEAL. I will ask the audience to cooperate. I left my gavel at 

home today, but I still have my knuckles to rap. So please cooperate 

with us. This is an important hearing and there obviously are differences 

of opinion. 

 I will begin the questioning, followed by my colleagues. If you will 

set the timer, we will have 5 minutes in which to--you want to do 10 

minutes? Okay, 10 minutes. 

 First of all, Senator Thompson, I want to agree with you that 

diversity works. But diversity in this country has always been founded 

on the rule of law, as you are very well aware. What at least some of us 

are saying here today, is that diversity, as long as it conforms to the law, 

is a very good thing. The problem we have is the presentation you have 

made, as I would characterize it, is that the facts are sometimes stubborn 

things, but the law is also sometimes a stubborn thing. So sometimes the 

easiest thing to do is to ignore the law. Many of the examples that you 
90

cited in your testimony are examples where we have just ignored the law 

and nobody has done anything about it. 

 So let me just put it in a very simple question to you then. Do you 

believe that taxpayers should pay for all healthcare that may be required, 

emergency and non-emergency, for anybody who is on American soil, 

regardless of their legal status? 

 MR. THOMPSON. What I believe is that we have a healthcare crisis. 

And in my district, it is more about the fact that-- 

 [Audience comment.] 

 MR. THOMPSON. It is more about the fact that most--and my district 

has a high percentage, probably the highest percentage, of uninsured I 

am told of any district in the State. And that is because the jobs in my 

district do not offer health insurance. They are in construction, they are 

in service industries. That is true whether they are in hotels, they are in 

restaurants, they are in places--the best corporate citizen I have got is 

probably Starbucks. So that is true for legal and illegal. And so there is 

a problem there with a healthcare crisis. 

 What I did say in my testimony is that we need to be reasonable in 

what type of documentation we ask them to require, how long we give 

people to require it, and what presumptions go on. The courthouse in 

Carnesville burned I think in--it was before I was born, but after my 

mom was born. My own mom cannot obtain an original birth certificate 

and so by the definitions that are being set up, she would have trouble--

and she is an American citizen as near as I can remember-- 

 MR. DEAL. You all better watch out. 

 [Laughter.] 

 MR. THOMPSON. She would have trouble under the rules that are 

being set up. And that is why I have urged folks to adopt practical 

solutions to real world problems like the Senate Bill. 

 MR. DEAL. Let me say to you that I think you will be pleased when 

you hear the second panel’s testimony with regard to that issue. I think 

you will find that the four States, including Georgia, that are now 

requiring and have required even before the Federal requirement went 

into place, that those problems are virtually non-existent. It is not one of 

those things that somebody says my birth certificate burned up 

somewhere, go home until you find it. State authorities, and I am sure 

you will hear from Mr. Ortiz who is head of our facility here in the State, 

that they are cooperative in getting those. I think those are strawman 

type arguments, quite frankly. I do not think they are realistic. I think 

that the facts do not sustain that. 

 Let me move to another area of your testimony that I think is 

certainly relevant, because part of the thrust of what we are talking about 

here today is part of what we have already done as we have all alluded to 
91

in the Deficit Reduction Act of requiring citizenship verification as an 

eligibility requirement for Medicaid. As all of you have indicated, the 

State of Georgia, even before we did that, had already taken that step. 

 But also part of what these hearings are, and there are hearings by 

various other committees across the country, looking and comparing and 

contrasting the Senate-passed version of the immigration reform bill and 

the House-passed version of the immigration reform bill. And you 

alluded, Senator Thompson, appropriately I think, to one of those 

distinctions. And that is there are really two big distinctions, if we want 

to simplify it. 

 And that first one is a guest worker program that is included in the 

Senate bill that is not in the House and an amnesty provision that is--or at 

least five different versions of amnesty--that are included in the Senate 

bill that there are none in the House bill. 

 Now one of your statements that caught my attention was the quote 

that I believe you quoted from another source. I cannot put my finger on 

it right now. 

 MR. THOMPSON. Center for Budget and Policy. 

 MR. DEAL. Yes, Center for Budget and Policy Priorities, in which 

they made the quote about the Senate immigration bill with a guest 

worker program expanding the number of family-sponsored and 

employment-based admissions, and it goes on to say they think that that 

is a good idea. 

 I asked this question to the panel that Congressman Norwood had in 

a hearing in Gainesville yesterday, and that is, for people to come into 

this country legally, we have sponsorship programs where someone can 

sponsor an individual to come in. Part of the 1996 Immigration Reform 

Act said that if you are a sponsor of an immigrant coming into this 

country, then you will have the responsibility of saying they will not 

become a charge upon the public services of the State or the Federal 

government. I asked the question if anyone had ever heard of a sponsor 

being held financially accountable for the expenses of an individual that 

they sponsored. 

 Have any of you gentlemen ever heard of that? 

 MR. CAGLE. No. 

 MR. ROGERS. No. 

 MR. THOMPSON. No. 

 MR. DEAL. You are in agreement with the panel yesterday. Nobody 

had ever heard of that. And that is what causes me some real concern, is 

if we are going to duplicate the language of an ineffective law in this new 

package that the Senate is proposing, I do not know how you would ever 

expect a hospital, for example, to know who the sponsor of an individual 

is, whether it be a private family type sponsorship or an employer-based 
92

sponsorship, to hold them accountable for expenses, here in this context 

talking about healthcare. 

 Do you have a good idea as to how that might work? 

 MR. THOMPSON. How you might? 

 MR. DEAL. How you might hold either an employer or a familybased sponsorship accountable for the expenses so that these individuals 

who now are presenting themselves either at the ER or the general 

hospital or doctors’ offices, do not become a charge upon public 

resources. 

 MR. THOMPSON. Well, I guess you are sort of calling for speculation 

and I am a lawyer, so I am probably good at doing that. 

 MR. DEAL. I am too and I know it when I see it. 

 [Laughter.] 

 MR. THOMPSON. Nor am I an expert. I do know that if you are 

legally here, you have certain documentation including a work 

authorization card. And again, I am not an expert from the Homeland 

Security Department, I am a State legislator from the Fifth District. But 

it would seem that you could somehow include in the documentation, the 

work authorization, who is responsible for what. 

 MR. DEAL. I think that is a very key element that we have to come to 

grips with some practical approaches to it. Either of you gentlemen have 

any suggestions? Because even though I personally do not think that the 

Senate version will ever pass the House of Representatives, at some 

point, the discussion will proceed to documentation. You know, how do 

you create a tamper-proof document, if you have an expanded guest 

worker program, how do you hold those who are the employer or 

sponsors of those individuals--how do you hold them accountable. 

 Did you all get into any of those kind of discussions at the State 

level? It probably was not necessary for you to do so. Senator Rogers? 

 MR. ROGERS. No, sir, Congressman Deal, we did not. And I think 

you hit on one of the multitude of problems with the Senate bill. I 

characterize it as not worth the paper it is printed on. Because it sets up a 

processing nightmare that could never be achieved. If we look at what 

we attempted to do in the 1986 amnesty and realize--and I think this is 

important for those in the audience to remember--that amnesty period 

just ended last year. It took 20 years to process three million. How long 

will it take us to process the 20 million that are here illegally today? No 

one knows. No one in this room may be alive at that point in time. 

 But it highlights again the processing problems that that bill contains 

and I think that the simple fact of the matter is, if you do not have the 

documentation on you, you cannot expect the taxpayers to pay for your 

medical care. If you want to pay for it out of your own pocket, have at it. 

But if you are expecting the taxpayers to pay for it, you have got to show 
93

up with the documentation. I cannot even go rent a video unless I have 

the proper documentation. So clearly I should not be allowed to ask 

some other taxpayer to pay for my medical care because I am not willing 

to do so myself. 

 MR. DEAL. Well, and I do think-- 

 [Applause.] 

 MR. DEAL. I do think that those are reasonable expectations that we 

have placed. 

 Part of any law--as you gentlemen know, you can pass laws, the 

important part sometimes is how they are implemented. And that has 

been the problem at the Federal level for many years, dating from 1986 

or even in some cases even beyond that. And the failure to implement 

the laws that either the Federal government or the State government 

passes. 

 So I think it is going to be important for all three of you to have the 

responsibility of oversight at the State level of implementing--making 

sure that the Federal changes we have made and the State changes you 

have made are actually implemented. As one of you alluded to, the 

Federal legislation delegates to the State the responsibility of verifying 

eligibility for programs like Medicaid. So I would ask and hope that you 

will all--I am sure you will--follow up to make sure that what all of us do 

are actually being carried out and implemented in the next year or so. 

 My time has expired and I will now recognize Ms. Solis for 10 

minutes. 

 MS. SOLIS. Thank you, Mr. Chairman. 

 First, I would like to just clarify that I do not believe anyone has 

proposed any legislation that I know of or that I am supporting that 

would actually repeal the provisions in the Medicaid plan, and that is to 

provide full services to U.S. citizens and to assist those that are in need 

of that service. I think all Americans, especially mothers and children 

that currently are uninsured, if they have to go through a bureaucracy to 

show proof of citizenship and maybe they, for example, just went 

through a flood like in Mississippi and Georgia, Katrina. What happens 

to those folks? Are you going to take their word that they are U.S. 

citizens or not? How are you going to verify that when every 

documentation is no longer in existence? That is number one. 

 Number two is I tend to agree with the statement that Mr. Rogers 

made regarding the State’s role here. Yes, the States have been burdened 

with a lot of these additional costs in healthcare and other services, but I 

really believe that one of the things that I would ask State elected 

officials to do is to hold their elected Federal representatives 

accountable. And I agree that over the last few years, in fact just this 

past session, the members on the other side of the aisle, agreed to cut 
94

back $28 billion in Medicaid for the next 10 years. You tell me how we 

are going to provide services for our elderly, for our disabled, and for 

those individuals that are unable to work that are U.S. citizens? How are 

we going to make up that revenue? Where are we going to cut from? 

 The other question I have is, we talk about law enforcement and 

incarceration, detaining of illegal immigrants. I have gone on record, as 

many Democrats have, to say that we need to beef up that particular 

fund. That we should not be asking our local municipalities, our local 

law enforcement officers, to have to dig into their budget to provide for 

Federal immigration enforcement. That is wrong. And this 

Administration and this particular Congress that is in control has not 

fully funded what I think are our first responders, the folks out in the 

field that really have been starved. And in Los Angeles County, we are 

faced with that dilemma right now. Our sheriff, Lee Baca, there has 

testified at many of these hearings regarding that particular issue. 

 Democrats, by the way, and I want to reiterate, had in the past 

proposed budget funding to fully fund more Border Patrol agents to the 

tune of, what was it I said earlier, at least 6000 more Border Patrol 

agents, to make sure that our borders were secure and that we do have 

adequate enforcement and that we do not burden our local law 

enforcement and local municipalities. So I agree that the Federal 

government needs to do more and I would ask that our elected officials 

do that. 

 Now I would like to go and ask some questions, please, to Senator 

Thompson. Senator Thompson, there are some in the room, and I 

believe across the country, that may think that legal and illegal 

immigrants are the source of our problems with respect to healthcare and 

the fact that rising costs continue to climb. While the number of 

uninsured increased--and I want to reiterate this--6 million people under 

this Administration that has been due primarily to loss of jobs and lack of 

job-based coverage. These are important issues that I think the public 

needs to be aware of, that in fact, we have more people that are not 

insured. And so you are going to have a system that is going to be 

burdened. You are going to see more people going to the trauma centers 

to use that type of healthcare service if they are not in any form available 

to get into a system that provides adequate coverage. There has not been 

enough local community clinics, in my opinion, that have actually been 

adequately funded. In many cases, in my own district, many have been 

closed. We need to do more for prevention so that we do not see these 

individuals reaching our trauma centers where the cost does tend to go 

up. But the focus there, in my opinion, is really about the uninsured, 

because many uninsured American citizens tend to over-utilize the 
95

trauma unit centers in our hospital system. And we have not adequately 

funded those hospitals and reimbursement rates for that type of service. 

 If we are asking for an unfunded mandate, I think that is wrong. I 

think the Federal government should do more to provide adequate 

coverage so people do not come up to our hospitals and use that very 

precious system or unit of service that is so vital. If someone has a head 

injury or is in a car accident or falls off their motorcycle and has a 

dangerous accident there, the first step is to go to the emergency unit of a 

hospital. The cost can be enormous and yes, in many cases, the States 

are saddled with that. And I agree that we need to have Federal 

government play a bigger role and to provide coverage for that. Later 

today, I am sure we are going to hear from the hospitals about that 

particular burden. 

 But I wanted to ask you, Senator Thompson, if you could give us 

some constructive ideas discussed in Georgia to help lower the number 

of uninsured children. You talked about your particular district having a 

high number, but that is not an unusual case. That is somewhat typical of 

many, many cities in our country. And if you could elaborate on that. 

 MR. THOMPSON. Well, I guess one of things that is a possibility here 

is an expansion of the SCHIP program or Peachcare, fully funding it out 

and maxing that out. We do not take advantage of every Federal dollar, 

we basically leave dollars on the table. And doing what Illinois has 

done, expanding healthcare to all minors also. And there is actually a 

proposal out there called Peachkid that would basically do that. That is 

going to be probably the subject of the election down here in Georgia, 

but that is one issue that is coming up. 

 I do think that in general what you commented about was a funding 

issue, and what we often see, especially at the local level, is that the fed 

does not want to pay for it, so they pass it off on the State. The State 

does not want to pay for it, so they pass it off on the county. And that 

results in my county hospital, Gwinnett Medical, having a huge deficit, 

and ultimately the taxpayer pays for this emergency room care. If there 

were in fact more clinics and more money spent on clinics, more money 

spent on preventive care, we would not in fact have this option. 

 I understand the desire to strike out at people you feel may have 

broken the law, but you are doing it in a way that is costing you actually 

more money, the current system is actually going to cost us more money 

and because a county can only raise money from property taxes, it is 

going to cost more money to those who can least afford it, people who 

are more sensitive to property tax increases, which are low-income 

people in their first home or elderly people. While I understand the 

impulse, it is not sound economics, what we are doing. 
96

 MS. SOLIS. I wanted to ask you if you could make a comparison 

between the Georgia law that just passed that would require 

documentation for Medicaid and what that would mean for you if the 

Federal government comes in and says well no, you have to follow along 

our lines. Would there be some dramatic changes that would affect 

costs, medical costs? 

 MR. THOMPSON. I do not have specific figures, but other than it 

basically passes the buck because it funnels people to the emergency 

rooms, that is my concern. And so then you are going to have--and my 

own Gwinnett Medical Center is already running a huge deficit for that. 

I do not have a specific answer for you about those costs, no. 

 MS. SOLIS. One of the questions that I had is that when we begin to 

ask for documentation, especially for individuals, even children in foster 

care, you talked a little bit about that. Many foster care children, for 

whatever reason, may not have appropriate documentation with them, 

because they were assigned by a court, State, to be put in a foster home. 

And those documentations are not available because the parents, the 

blood relatives, are not in say in a position to want to do that, to 

cooperate. What does that mean for American children that should be 

eligible for even foster care assistance? 

 MR. THOMPSON. Well obviously, I mean we were talking about a 

cumbersome system that is not going to work and is not worth the paper 

that it is printed on. That is what you are basically setting things up and 

you are also setting it up--for instance, most kids are in foster care 

because of some emergency and it is going to be harder to process them 

through, it is going to increase the trauma to those kids. Ultimately, I 

mean we can be both--on a personal level, it is going to increase the 

trauma to those kids, but on a government level, it is going to ultimately 

increase costs to us because it is going to require additional services later 

on the back end to correct the problems created on the front end. 

 MS. SOLIS. And Senator Thompson, the State’s children’s health 

insurance program that you talked about, SCHIP, the Federal partnership 

that provides insurance for children and families with Medicaid level 

income, needs to be reauthorized, as you know, next year. 

Unfortunately, Congress adds new funding to the program, we will see a 

$1.8 million child loss in healthcare coverage over the next few years 

and the States will face a $10-12 billion shortfall just to maintain that 

level of funding. How will your State deal with that crisis or that issue 

that you will be faced with? 

 MR. THOMPSON. Well, I mean unless Congress acts, Georgia is 

going to run out of money, it is just that simple. And Peachkids is 

probably--or Peachcare, sorry--has probably been, after the Hope 

Scholarship, the most popular program we have enacted in my lifetime, 
97

or at least in my voting lifetime. If that runs out of money, it is going to 

throw thousands of kids off healthcare and it is going to then result in 

more kids being in the emergency room, higher absentee rates in schools 

when kids have to stay home, it is going to result in lower test scores. I 

mean it is going to have a ripple effect that will be huge. Congress does 

in fact need to reauthorize this, absolutely. 

 MS. SOLIS. Thank you. 

 MR. DEAL. The gentlelady’s time has expired. Thank you. 

 Mr. Norwood is recognized for 10 minutes for questions. 

 MR. NORWOOD. Thank you very much, Mr. Chairman. It appears 

that it falls to me to sort of work on the record just a little bit so that we 

end up here getting some truths out. 

 I want to start by pointing out that the Congress I think did a very 

good job in limiting the growth in Medicaid referred to earlier as deep 

cuts, when in fact really it was simply slowing down the spending. But 

how we did it did not come out either. The way we did it was to make 

sure that millionaires could not get rid of their assets so they could be on 

long-term care. So that is the other part of the sentence that I am sure 

Ms. Solis would have gotten to the next round. 

 [Laughter.] 

 MR. NORWOOD. I want to begin sort of with my discussion saying 

that Senator Rogers, I think the United States Senate immigration bill is 

worse than you described. I think it is the worst piece of legislation that I 

have seen in Washington, D.C. in 12 years. Should that become law--

and it is not-- 

 [Applause.] 

 MR. NORWOOD. --it makes citizens out of the 20 million illegal 

immigrants that are here, immediately invites them to bring their families 

into this country and make citizens. We estimate that that will bring 

another 20 million new people to America over the next 20 years, and by 

the turn of the century, that will be another 100 million people have 

come into this country. 

 Now the reason I point that out is that the purpose of this hearing is 

to talk about the fact that illegal immigrants are getting on our social 

systems and it is busting the bank now. Senator Cagle, what do you 

think would happen in Georgia over the next century if that many more 

new people came into the country legally, were made citizens, and 

immediately could get onto our social programs? Can Georgia stand that 

kind of thing? 

 MR. CAGLE. Well, no, it certainly cannot. And when you look at 

Georgia today, I will tell you at the outset that there is--we believe in 

immigration and we believe that there is a right way and a wrong way to 
98

come to this country. And we cannot condone individuals that are 

coming here through illegal means. 

 When you look at Georgia today, you find that half of all births are 

being paid for by taxpayers of Georgia. We experienced a significant, 

$400 million, shortfall in Medicaid year after year until we made some 

real changes. When you look at really having an impact, it is only 

through eligibility and utilization to bring those costs into bear. We 

cannot continue to absorb these types of costs in Georgia. And Congress 

has got to act and it has got to act swiftly in order to preserve the future 

for our children. 

 MR. NORWOOD. Do you believe the first act should be to secure our 

border? 

 MR. CAGLE. There is no question. 

 MR. NORWOOD. Senator Rogers? 

 MR. ROGERS. That is your required duty and we all are anxiously 

awaiting that duty to be fulfilled. 

 MR. NORWOOD. Senator Thompson? 

 MR. THOMPSON. I believe you have to do both at the same time. 

 MR. NORWOOD. But you believe we need to secure our borders? 

 MR. THOMPSON. Absolutely. 

 MR. NORWOOD. And stop people from coming across our borders 

illegally. 

 MR. THOMPSON. Absolutely. 

 MR. NORWOOD. I am very happy to hear that. 

 By the way, in terms of correcting the record, you were talking about 

the SCHIP program. Georgia is a deficit State in SCHIP. We spend 

more in SCHIP monies than does the Federal government send us and 

allow us. Would you verify that, either one of you Senators? 

 MR. ROGERS. That is true. 

 MR. NORWOOD. And what you said was the opposite, and I am sure 

you did not mean to, but being a lawyer, you know-- 

 [Laughter.] 

 MR. NORWOOD. No offense, Mr. Chairman. 

 [Laughter.] 

 MR. NORWOOD. You made a comment, Mr. Thompson, and I quote, 

“you feel may have broken the law.” I presume you were talking to us or 

perhaps somebody on the panel, and you were saying that we feel they 

may be breaking the law by coming into our country, using bogus Social 

Security cards, et cetera, et cetera. Do you feel people who have come 

across our border from Saudi Arabia and India and Mexico, are they 

breaking our law, rather than “may be breaking”? Are they breaking our 

law? 
99

 MR. THOMPSON. I apologize, I do not know where I said “we feel” 

or “we may feel.” 

 MR. NORWOOD. You said “you feel,” you were talking to us--“you 

feel they may be breaking our law.” Are they or are they not? 

 MR. THOMPSON. If they are using false documentation, that is-- 

 MR. NORWOOD. Are they breaking our law by crossing our border 

illegally? Is that against the law? 

 Mr. Thompson. Yes, condemnation Okay, I just wanted to make 

sure. So it is not “may be breaking the law,” they are breaking the law. 

 MR. THOMPSON. Well, that depends. Some people do have legal 

documentation to come here. They may do other things when they get 

here-- 

 MR. NORWOOD. I am not talking about legal documentation, I am 

talking about people who slip across our border in the middle of the 

night. Turn on Fox News if you want to watch it. They are breaking the 

law. 

 [Laughter.] 

 MR. THOMPSON. And I appreciate your question, but I-- 

 MR. NORWOOD. No offense, you have said they are breaking the 

law, it is not “may.” 

 MR. THOMPSON. I have said that-- 

 MR. NORWOOD. Yes or no. 

 [Laughter.] 

 MR. THOMPSON. Congressman, if you will allow me to answer the 

question or we can-- 

 MR. NORWOOD. Yes or no would be great so I can go to some other 

questions. Do you believe people who cross our border without 

documents are breaking our laws? 

 MR. THOMPSON. That is against the law and that is not what I said. I 

said but having a false Social Security card does not necessarily mean 

they crossed the border illegally. 

 MR. NORWOOD. I did not say anything about that. 

 MR. THOMPSON. Well, that is what you are trying to insinuate. 

 MR. NORWOOD. I said that is another way they break the law. 

 MR. THOMPSON. I do also want that corrected for the record, Mr. 

Congressman. 

 MR. NORWOOD. All right, now Senator Rogers. 

 MR. ROGERS. Yes, sir, glad to answer a question. 

 MR. NORWOOD. We spend way too much money in Washington, 

very unwisely in my opinion. The difference is we get to print it. The 

problem is you do not get to print it over there in Atlanta, you have got to 

actually balance your budget. I want you to take just a minute again and 

talk about the budgetary limitations that we have in our State regarding 
100

all programs, but particularly we are talking about social programs here, 

and why is it so important that we deal with this problem of making sure 

we spend our dollars for American citizens who deserve the taxpayers’ 

dollars frankly, versus people who I think are criminals, who have come 

across our border, broken our laws using false documents, et cetera, et 

cetera. Would you do that budgetary thing just a minute for me? 

 MR. ROGERS. I will, sir, and I think what is clear, and sometimes I 

think in this great debate we lose focus of very simple facts. Congress is 

supposed to protect Americans, not people from other countries. 

Americans. 

 [Applause.] 

 MR. ROGERS. In Georgia, we are supposed to protect Georgians, not 

Alabamians, nor Floridians. So when I know there are 12,700 severely 

disabled children, elderly, frail people on a waiting list who already 

qualify for benefits and are being denied because we know that certain 

amounts of dollars go to people who are not eligible, then we have 

simply taken money from those who qualify, who are legal U.S. citizens 

and Georgia residents, and given it to people who are here illegally. That 

is not just a slap in the face to all of us, that is a direct slap in the face to 

the people who already legally qualify. 

 I want to follow up on something Congresswoman Solis said. She 

said she knows of no bill that seeks to repeal Medicaid provision. Well, 

of course not, if you make everybody legal, you do not need to repeal it, 

they will all get the benefit. 

 [Laughter.] 

 MR. ROGERS. The second thing-- 

 [Applause.] 

 MR. ROGERS. --I know Congressman Deal and Congressman 

Norwood were here in 1996, I do not know if Congresswoman Solis was, 

but in 1996, I want to correct something. Title 8, Chapter 14, Sections 

1611 and 1621, already declare exemptions for flood, as you brought up 

as an example. You do not have to have any documentation if you are 

injured in a flood or tornado or hurricane or anything, and for emergency 

foster care. So those exemptions are already built into the law. 

 Congressman Deal pointed out strawman arguments. I think 

oftentimes we get involved in these strawman arguments that are simply 

not part of what the law is. The law is very clear. If you have an 

emergency situation, whether it is a flood or foster care, you do not have 

to provide any documentation. 

 We are talking about people who are taking advantage of the system, 

who in many cases could pay for it out of their own pocket, but do not 

want to because they have the Government to pick up the tab for them. 
101

 MR. NORWOOD. I have got just a minute and, Senator Thompson, I 

need to ask you four or five questions. Please oblige me with yes or no 

and then I will maybe have time to get it all in. 

 How many people in your district? 

 MR. THOMPSON. One hundred fifty five thousand. 

 MR. NORWOOD. Yeah, 650,000 in mine and 8 million in Georgia. 

So I appreciate you trying to protect your district, but the rest of us also 

have to worry about the rest of the citizens and their attitude about this 

over the rest of the State. 

 Yes or no, please. Do you think enforcing our laws against civil 

violators is wrong? 

 MR. THOMPSON. No. 

 MR. NORWOOD. Do you believe that we should provide services to 

those who are illegally in the Nation even if it means there is less service 

for American citizens? 

 MR. THOMPSON. I think we need some comprehensive reform so 

that that does not happen, because that is-- 

 MR. NORWOOD. And the answer is yes or no? 

 MR. THOMPSON. That is a strawman choice and I am not going to 

play that game. 

 MR. NORWOOD. Well, you can refuse to answer. I just want to know 

if you-- 

 MR. THOMPSON. I have given you my answer, Mr. Norwood. 

 MR. NORWOOD. All right, so the answer is you do not. 

 You say that the people in your district-- 

 MR. THOMPSON. I disagree. 

 MR. NORWOOD. --are afraid to get health services because of actions 

of the legislature. Now I think that we are going to hear from hospital 

representatives later who are going to testify there is no shortage of folks 

seeking uncompensated care. Do you disagree? 

 MR. THOMPSON. My hospital runs a deficit, but it does not change 

the fact that there are people not going to the hospital who need--and not 

going to the doctor because of this. Again, you are setting up a false 

choice. 

 MR. NORWOOD. Well, I know these questions are hard. 

 Lastly, many are afraid to take their citizen children for care. You 

say that in your document. Many are afraid to take their citizen children 

for care. Would you be good enough to furnish proof to this Committee 

that that is true? 

 MR. THOMPSON. If you would like, I can submit an affidavit. 

 MR. NORWOOD. I do want you to do that because every ER doctor I 

have ever talked to in this State say they do not have any problems with 
102

the number of people coming in illegally using their emergency room. 

So proof would be greatly appreciated. 

 Sorry, Mr. Chairman, for going over. 

 MS. SOLIS. Mr. Chairman, before you excuse the panel, I would like 

to insert part of the Deficit Reduction Act of 2005 that was passed, the 

section, statute 120, Section 6036 “Improved Enforcement of 

Documentation Requirements,” which states nothing specifically about 

floods or foster children. I would like that--ask unanimous consent to 

have that entered into the record. 

 MR. ROGERS. It is a different title, it’s Title VIII, Chapter 14. 

 MR. DEAL. You may do so, but Senator Rogers was referring to the 

1996 Act, as I recall. 

 Yes, without objection, that may be included in the record. 

 [The information follows:] 

SEC. 6036. IMPROVED ENFORCEMENT OF DOCUMENTATION 

REQUIREMENTS. 

(a) In General- Section 1903 of the Social Security Act (42 U.S.C. 1396b) is 

amended-- 

(1) in subsection (i), as amended by section 104 of Public Law 109-91-- 

(A) by striking `or' at the end of paragraph (20); 

(B) by striking the period at the end of paragraph (21) and inserting `; or'; 

and 

(C) by inserting after paragraph (21) the following new paragraph: 

(22) with respect to amounts expended for medical assistance for an individual 

who declares under section 1137(d)(1)(A) to be a citizen or national of the 

United States for purposes of establishing eligibility for benefits under this title, 

unless the requirement of subsection (x) is met.'; and 

(2) by adding at the end the following new subsection: 

(x)(1) For purposes of subsection (i)(23), the requirement of this subsection is, with 

respect to an individual declaring to be a citizen or national of the United States, that, 

subject to paragraph (2), there is presented satisfactory documentary evidence of 

citizenship or nationality (as defined in paragraph (3)) of the individual. 

(2) The requirement of paragraph (1) shall not apply to an alien who is eligible for 

medical assistance under this title-- 

 (A) and is entitled to or enrolled for benefits under any part of title XVIII; 

(B) on the basis of receiving supplemental security income benefits under title 

XVI; or 

(C) on such other basis as the Secretary may specify under which satisfactory 

documentary evidence of citizenship or nationality had been previously 

presented. 

(3)(A) For purposes of this subsection, the term `satisfactory documentary evidence 

of citizenship or nationality' means-- 

(i) any document described in subparagraph (B); or 

(ii) a document described in subparagraph (C) and a document described in 

subparagraph (D). 

(B) The following are documents described in this subparagraph: 

(i) A United States passport. 

(ii) Form N-550 or N-570 (Certificate of Naturalization). 
103

(iii) Form N-560 or N-561 (Certificate of United States Citizenship). 

(iv) A valid State-issued driver's license or other identity document described in 

section 274A(b)(1)(D) of the Immigration and Nationality Act, but only if the 

State issuing the license or such document requires proof of United States 

citizenship before issuance of such license or document or obtains a social 

security number from the applicant and verifies before certification that such 

number is valid and assigned to the applicant who is a citizen. 

(v) Such other document as the Secretary may specify, by regulation, that 

provides proof of United States citizenship or nationality and that provides a 

reliable means of documentation of personal identity. 

(C) The following are documents described in this subparagraph: 

(i) A certificate of birth in the United States. 

(ii) Form FS-545 or Form DS-1350 (Certification of Birth Abroad). 

(iii) Form I-97 (United States Citizen Identification Card). 

(iv) Form FS-240 (Report of Birth Abroad of a Citizen of the United States). 

(v) Such other document (not described in subparagraph (B)(iv)) as the 

Secretary may specify that provides proof of United States citizenship or 

nationality. 

(D) The following are documents described in this subparagraph: 

(i) Any identity document described in section 274A(b)(1)(D) of the 

Immigration and Nationality Act. 

(ii) Any other documentation of personal identity of such other type as the 

Secretary finds, by regulation, provides a reliable means of identification. 

(E) A reference in this paragraph to a form includes a reference to any successor 

form. 

(b) Effective Date- The amendments made by subsection (a) shall apply to 

determinations of initial eligibility for medical assistance made on or after July 1, 2006, 

and to redeterminations of eligibility made on or after such date in the case of individuals 

for whom the requirement of section 1903(z) of the Social Security Act, as added by such 

amendments, was not previously met. 

(c) IMPLEMENTATION REQUIREMENT- As soon as practicable after the date of 

enactment of this Act, the Secretary of Health and Human Services shall establish an 

outreach program that is designed to educate individuals who are likely to be affected by 

the requirements of subsections (i)(23) and (x) of section 1903 of the Social Security Act 

(as added by subsection (a)) about such requirements and how they may be satisfied. 

 MR. DEAL. And without objection, Senator Thompson, you may be 

allowed to submit further evidence to substantiate the statements that 

have been referred to. 

 Gentlemen, thank you very much for your service and thank you for 

being with us today. 

 [Applause.] 

 MR. DEAL. If the second panel will please take their seats. I am 

pleased to introduce our second panel and we do need to move along as 

expeditiously as possible since we have three panels here today. I am 

pleased to introduce the second panel of Ms. Jean Sheil, who is the 

Director of Family and Children’s Health Program, Center for Medicaid 

and State Operations, Centers for Medicare & Medicaid Services in 

Washington, D.C.; Dr. Alison Siskin, who is a specialist in immigration 
104

legislation, Domestic Social Policy Division of the Congressional 

Research Service; and Mr. Abel C. Ortiz, who is Health and Human 

Services Policy Advisor, office of Governor Sonny Perdue of the State of 

Georgia. 

 Ladies and gentlemen, we are pleased to have you here and Ms. 

Sheil, we will begin with your testimony. You have 5 minutes. 

STATEMENTS OF JEAN SHEIL, DIRECTOR, FAMILY AND 

CHILDREN’S HEALTH PROGRAM, CENTER FOR 

MEDICAID AND STATE OPERATIONS, CENTERS FOR 

MEDICARE & MEDICAID SERVICES; DR. ALISON 

SISKIN, SPECIALIST IN IMMIGRATION LEGISLATION, 

DOMESTIC SOCIAL POLICY DIVISION, 

CONGRESSIONAL RESEARCH SERVICE; AND ABEL C. 

ORTIZ, HEALTH AND HUMAN SERVICES POLICY 

ADVISOR, OFFICE OF THE GOVERNOR, STATE OF 

GEORGIA 

 

 MS. SHEIL. Thank you, Mr. Chairman, Chairman Deal, Dr. 

Norwood, and Ms. Solis, thank you for inviting me to speak with you 

today about Section 6036 of the Deficit Reduction Act entitled 

“Improved Enforcement of Documentation Requirements.” 

 Medicaid is a partnership between the Federal government and the 

States. 

 MR. DEAL. Could you speak into the mic? 

 MS. SHEIL. Yes, sir. Is that better? 

 MR. DEAL. Yes. 

 MS. SHEIL. Okay. Medicaid is a partnership between the Federal 

government and the States. While the Federal government provides 

financial matching payments to the States, each State is responsible for 

overseeing its Medicaid program and each State pays a portion of its cost 

through a statutorily determined matching rate, currently ranging 

between 50 and approximately 76 percent. The Centers for Medicare & 

Medicaid Services, CMS, which oversees the Federal responsibility for 

Medicaid, ensures States enforce Medicaid eligibility requirements. 

Recently, CMS issued guidance and an interim final regulation to the 

States as part of the implementation of the Deficit Reduction Act which 

requires Medicaid applicants who declare they are citizens to document 

their citizenship and identity. 

 The Personal Responsibility and Work Opportunity Reconciliation 

Act of 1996, also known as PRWORA, significantly changed the 

eligibility of non-citizens for Federal means-tested public benefits, 

including Medicaid and subsequently the State Children’s Health 
105

Insurance Program, SCHIP. This change, however, did not alter 

eligibility for undocumented and non-immigrant aliens, who generally 

remain ineligible for non-emergency Federal benefits. 

 Under PRWORA, States are required to provide Medicaid to certain 

qualified aliens who otherwise meet the eligibility criteria of the State’s 

Medicaid program, unless subject to a 5-year bar. The 5-year bar applies 

only to qualified aliens who entered the United States on or after August 

22, 1996, with some exceptions. 

 However, the 5-year bar and other eligibility restrictions do not apply 

to aliens who are applying only for treatment of an emergency medical 

condition. Thus, all aliens, both qualified and non-qualified, including 

undocumented immigrants, may be eligible for treatment of an 

emergency medical condition, provided they otherwise meet the 

eligibility criteria, such as income level, for example, for the State’s 

Medicaid program. 

 American citizenship or legal immigration status have, for many 

years, been a requirement for Medicaid eligibility. However, as Dr. 

Norwood indicated, previously in many States, applicants could assert 

their citizenship status by merely checking a box on a form. The Deficit 

Reduction Act now holds States financially responsible for Medicaid 

expenditures for individuals claiming to be U.S. citizens unless such 

individuals provide actual documentary evidence supporting their 

citizenship and identity. This new requirement applies to new 

applications for Medicaid eligibility and redeterminations effective July 

1. 

 In order to give States some initial guidance on the implementation 

of this provision, on June 9, CMS issued a State Medicaid Director 

Letter. On July 12, the Department published an interim final regulation 

for States to implement this new requirement. Comments on the interim 

final rule were due last Friday, August 11. 

 The law requires that a person provide evidence of both citizenship 

and identity. In some cases, a single document will be enough to 

establish both citizenship and identity. However, if secondary 

documentation is used to establish citizenship, such as a birth certificate, 

the individual will also need evidence of his or her identity. Once 

citizenship has been proven, it need not be documented again with each 

eligibility renewal unless later evidence raises a question. 

 The interim regulation provides a broad array of documents that are 

acceptable evidence of citizenship and identity. Individuals who receive 

Medicare and individuals who are on Supplemental Security Income are 

exempt from these documentation requirements. 

 At the time of application or redetermination, the State must give an 

applicant reasonable opportunity to present documents establishing U.S. 
106

citizenship or nationality and identity. An individual who is already 

enrolled in Medicaid will remain eligible if he or she puts forth a goodfaith effort to present satisfactory evidence of citizenship and identity. 

Applicants who, despite their good-faith effort, are unable to present 

documentation should be assisted by the State in securing these 

documents. CMS encourages States to use automated capabilities to 

verify citizenship and identity of Medicaid applicants. We specifically 

asked for public comment in the regulation on whether there are other 

electronic data systems that should be identified to assist States in 

determining an individual’s citizenship or identity. 

 As with other Medicaid program requirements, States must 

implement an effective process for assuring compliance with 

documentation of citizenship in order to obtain Federal matching funds, 

and effective compliance will be part of Medicaid program integrity 

monitoring. When future automated capabilities to verify citizenship and 

identity of Medicaid applicants become available, States will also be 

required to match for individuals who used less reliable documents to 

verify citizenship and identity. States will receive the normal 50 percent 

match for administrative expenses related to implementation of the new 

law. 

 The law also requires that the Secretary develop, as soon as 

practicable, an outreach program which is intended to educate 

individuals who are likely to be affected by the requirements of this 

provision of the law. CMS has already conducted numerous 

teleconferences with States and other organizations interested in this 

provision. Fact sheets, posters, brochures are also available on our CMS 

website. In addition, we are developing an outreach plan that provides 

strategic direction and coordination for an integrated education and 

outreach program to inform States, Medicaid recipients, and others of 

these new documentation requirements. The plan will ensure that all 

stakeholders know of the new requirements, understand the documents 

which satisfy these requirements and assist the streamlined 

implementation by States, and ensure continued uninterrupted access to 

Medicaid for citizens. 

 Thank you again for this opportunity to speak with you on these new 

Medicaid program requirements. 

 MR. DEAL. Thank you. Dr. Siskin. 

 [The prepared statement of Ms. Sheil follows:] 
107

PREPARED STATEMENT OF JENA SHEIL, DIRECTOR, FAMILY AND CHILDREN’S HEALTH 

PROGRAM, CENTER FOR MEDICAID AND STATE OPERATIONS, CENTERS FOR MEDICARE &

MEDICAID SERVICES

Thank you for inviting me to speak with you about the impact of undocumented 

immigrants on the Medicaid program and the health care delivery system and express the 

Administration’s support for comprehensive immigration reform that increases border 

security, establishes a robust interior enforcement program, creates a temporary worker 

program, and addresses the problem of the estimated 11 to 12 million illegal immigrants 

already in the country. 

Medicaid is a partnership between the Federal government and the states. While the 

Federal government provides financial matching payments to the states, each state is 

responsible for overseeing its Medicaid program, and each state pays a portion of its cost 

through a statutorily determined matching rate, currently ranging between 50 and 

approximately 76 percent. The Centers for Medicare & Medicaid Services (CMS), which 

oversees the Federal responsibility for Medicaid, ensures states enforce Medicaid 

eligibility requirements. Recently, CMS issued guidance and an interim final regulation 

to the states as part of the implementation of the Deficit Reduction Act of 2005 (DRA), 

which requires Medicaid applicants who declare they are citizens to document their 

citizenship and identity. 

CMS, in regards to the broader health care system, also enforces regulations that 

require hospitals to medically screen and provide stabilizing treatment or an appropriate 

transfer to any person seeking emergency care, regardless of payment method or 

citizenship status. 

Immigrants and Medicaid Eligibility 

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 

(PRWORA) significantly changed the eligibility of non-citizens for Federal means-tested 

public benefits, including Medicaid and subsequently the State Children’s Health 

Insurance Program (SCHIP). This change, however, did not alter eligibility for 

undocumented and nonimmigrant aliens, who generally remain ineligible for nonemergency Federal benefits. As a general rule, only “qualified aliens” may be eligible for 

Medicaid and SCHIP coverage. Qualified aliens include aliens lawfully admitted for 

permanent residence under the Immigration and Nationality Act. Refugees, those granted 

asylum, and victims of a severe form of trafficking (as certified by the Office of Refugee 

Resettlement of the Department of Health and Human Services) among several other 

categories also may be considered qualified aliens. 

 Under PRWORA, states are required to provide Medicaid to certain qualified aliens 

who otherwise meet the eligibility criteria of the state’s Medicaid program, unless subject 

to a five-year bar. This five-year bar applies only to qualified aliens who entered the 

United States on or after August 22, 1996 with some exceptions. Typically the bar 

applies to lawful permanent residents and aliens granted parole for at least one year. 

Some qualified aliens are exempt from the five-year bar, including refugees, those 

granted asylum, and trafficking victims, among others. A qualified alien who is 

honorably discharged from the military; on active duty in the U.S. military; or the spouse 

(including a surviving spouse who has not remarried) or unmarried dependent child of an 

honorably discharged veteran or individual on active duty in the U.S. military also is 

exempt from the five-year bar. 

However, the five-year bar and other eligibility restrictions do not apply to aliens 

who are applying only for treatment of an emergency medical condition. Thus, all aliens 

– both qualified and non-qualified aliens (including undocumented immigrants) – may be 

eligible for treatment of an emergency medical condition, provided they otherwise meet 
108

the eligibility criteria (such as income level, for example) for the state’s Medicaid 

program. 

CMS Issues Guidance on Citizenship and Identity Documentation for Medicaid 

Eligibility 

American citizenship or legal immigration status have, for many years, been a 

requirement for Medicaid eligibility. However, previously, in many states applicants 

could assert their citizenship status by merely checking a box on a form. (A number of 

states have long required their applicants to document citizenship, including New York, 

New Hampshire and Montana.) The DRA now holds states financially responsible for 

Medicaid expenditures for individuals claiming to be United States citizens unless such 

individuals provide actual documentary evidence supporting their citizenship and 

identity. This new requirement applies to new applications for Medicaid eligibility and 

re-determinations beginning July 1, 2006. 

In order to give states some initial guidance on the implementation of this provision, 

on June 9, 2006 CMS issued a State Medicaid Director letter. On July 12, 2006 the 

Department published an interim final regulation for states to implement this new 

requirement. Comments on the interim final rule are due on August 11, 2006. We expect 

to publish a final rule shortly. 

The law requires that a person provide evidence of both citizenship and identity. In 

some cases, a single document will be enough to establish both citizenship and identity, 

such as a U.S. passport. However, if secondary documentation is used to establish 

citizenship, such as a birth certificate, the individual will also need evidence of his or her 

identity. Once citizenship has been proven, it need not be documented again with each 

eligibility renewal unless later evidence raises a question.

The law specifies certain forms of acceptable evidence of citizenship and identity 

and provides for the use of additional forms of documentation as established by Federal 

regulations, when appropriate. If an applicant or recipient presents evidence from the 

listing of primary documentation, such as a U.S. passport, certificate of naturalization, or 

a certificate of U.S. citizenship, no other information is required. When such evidence 

cannot be obtained, our regulations require the states to look to the next tier of acceptable 

forms of evidence. However, a state must first seek documents from the primary list 

before looking to the secondary or tertiary lists. Because individuals who receive 

Medicare and individuals who are on Supplemental Security Income (SSI) in a state 

using SSI for Medicaid eligibility purposes already have met certain documentation 

requirements, the regulation does not include new documentation requirements for these 

groups. This exemption reflects the special treatment of these groups in the statute. 

At the time of application or re-determination, the state must give an applicant or 

recipient a “reasonable opportunity” to present documents establishing U.S. citizenship or 

nationality and identity. An individual who is already enrolled in Medicaid will remain 

eligible if he/she puts forth a good faith effort to present satisfactory evidence of 

citizenship and identity. Applicants who despite their good faith effort are unable to 

present documentation should be assisted by the state in securing these documents. 

States may use data matches with the State Data Exchange (SDX) or vital statistics 

agencies in place of a birth certificate to assist applicants or recipients to meet the 

requirements of the law. As a check against fraud, states are also required to use 

currently available capabilities to conduct a match of the applicant’s name against the 

corresponding Social Security number that was provided. In addition the Federal 

government encourages states to use automated capabilities to verify citizenship and 

identity of Medicaid applicants. We specifically asked for public comment on whether 

there are other electronic data systems that should be identified to assist states in 

determining an individual’s citizenship or identity. 
109

As with other Medicaid program requirements, states must implement an effective 

process for assuring compliance with documentation of citizenship in order to obtain 

federal matching funds, and effective compliance will be part of Medicaid program 

integrity monitoring. In particular, audit processes will track the extent to which states 

rely on lower categories of documentation with the expectation that such categories 

would be used relatively infrequently and less often over time, as State processes and 

beneficiary documentation improve. When future automated capabilities to verify 

citizenship and identity of Medicaid applicants becomes available, states also will be 

required to match for individuals who used third or fourth tier documents to verify 

citizenship and identity. In the meantime, states must ensure that all case records within 

this category are identified so that they may be made available to conduct these 

automated matches. States will receive the normal 50 percent match for administrative 

expenses related to implementation of the new law. 

The law also requires that the Secretary develop an outreach program which is 

intended to educate individuals who are likely to be affected by the requirements of this 

provision of the law. CMS has already conducted numerous teleconferences with states 

and other organizations interested in this provision. In addition, we are developing an 

outreach plan that provides strategic direction and coordination for an integrated 

education and outreach program to inform states, Medicaid recipients, and others of these 

new documentation requirements. This initiative will be implemented to promote active 

and informed involvement by states and people with Medicaid in providing beneficiaries 

the necessary information about the new documentation requirements. The plan will 

ensure that all stakeholders know of the new requirements, understand the documents 

which satisfy these requirements, assist the streamlined implementation by states, and 

ensure continued uninterrupted access to Medicaid for citizens. 

EMTALA 

Regarding the broader health care system, CMS enforces the 1986 Emergency 

Medical Treatment and Labor Act (EMTALA). Under EMTALA, hospitals have 

obligations to any individual, regardless of citizenship, who requests treatment for a 

medical condition. EMTALA was designed to ensure that people will receive 

appropriate screening and emergency treatment regardless of their ability to pay. 

CMS’ regulations implementing EMTALA require that hospitals with dedicated 

emergency departments provide an appropriate medical screening examination to any 

person who comes to the hospital emergency department and requests treatment or 

examination of a medical condition. They also require that these hospitals provide an 

appropriate medical screening examination to any person who presents himself on 

hospital property requesting evaluation or treatment of an emergency medical condition. 

In both cases, a request may be made by another individual on behalf of the person for 

whom examination or treatment is sought, or a request can be considered to have been 

made if a prudent layperson believes that based on the behavior of the individual an 

emergency medical condition exists. If the examination reveals an emergency medical 

condition, the hospital must also provide either necessary stabilizing treatment or arrange 

for an appropriate transfer to another medical facility. 

EMTALA applies to all Medicare-participating hospitals with dedicated emergency 

departments and applies to all individuals regardless of immigration status who present 

themselves requesting examination or treatment of a medical condition. Hospitals with 

specialized capabilities have a responsibility under EMTALA to accept appropriate 

transfers regardless of whether the hospital has a dedicated emergency department. A 

hospital that violates EMTALA may have its ability to participate in Medicare terminated 

and may be subject to civil penalties of up to $50,000 per violation. An individual who 

has suffered personal harm and any hospital to which a patient has been improperly 
110

transferred and that has suffered a financial loss as a result of the transfer are also 

provided a private right of action against a hospital that violates EMTALA. 

Hospitals also are required to maintain lists of physicians who are on call for duty 

after the initial examination to provide necessary stabilizing treatment. Hospitals have 

discretion to develop their on-call lists in a way that best meets the needs of their patients 

requiring services required under EMTALA. 

Under CMS’ regulations, EMTALA does not apply after an individual has been 

admitted for inpatient hospital services, as long as the admission is made in good faith 

and not in an attempt to avoid the EMTALA requirements. 

Section 945 of the MMA required the Secretary of Health and Human Services to 

establish a technical advisory group (TAG) to review EMTALA policy, including the 

regulations and interpretive guidance outlining hospitals’ responsibilities under 

EMTALA. This TAG, which includes hospital, physician and patient representatives, 

has already met 4 times. The TAG will complete its deliberations and submit a report of 

its findings and recommendations to the Secretary by October 2008. 

Conclusion 

Thank you again for this opportunity to discuss the impact of undocumented 

immigrants on Medicaid and the health care system. I would also like to take this 

opportunity to once again express the Administration’s support for comprehensive 

immigration reform. I would be happy to answer any questions you might have. 

 MS. SISKIN. Thank you. Thank you, Chairman Deal, 

Congresswoman Solis, and Congressman Norwood for the invitation to 

appear before you today. I am Alison Siskin, a specialist in immigration 

legislation at the Congressional Research Service. 

 As discussed previously, currently, non-citizen eligibility for Federal 

Medicaid benefits largely depend on their immigration status and 

whether they arrived or were on the program’s rolls before August 22, 

1996, the enactment date of the Welfare Reform Act. Nonetheless, all 

aliens, regardless of status, who otherwise meet the eligibility 

requirements for Medicaid are eligible for emergency Medicaid. 

Unauthorized aliens are ineligible for full Medicaid but may qualify for 

emergency Medicaid. 

 Due to the eligibility of non-citizens for emergency Medicaid, many 

have questioned the impact of non-citizens on emergency departments. 

Although some have pointed to unauthorized aliens as a key contributor 

to the problem of emergency departments, the reality is more 

complicated. According to research, use of emergency rooms varies 

significantly across communities and studies have found that 

communities with more non-citizen residents generally have lower rates 

of emergency department use than communities with fewer non-citizen 

residents. 

 In 2003, Congress enacted the Medicare Prescription Drug 

Improvement and Modernization Act, which contains a provision, 

Section 1011, that provides reimbursement to States for emergency care 

afforded to unauthorized aliens. For each fiscal year, fiscal year 2005 
111

through fiscal year 2008, the provision appropriates $250 million, which 

is used to pay local governments, hospitals, and other providers for the 

cost of furnishing emergency health services to unauthorized aliens. 

 In February 2006, as we have discussed, Congress enacted the 

Deficit Reduction Act. Prior to the Deficit Reduction Act, as a condition 

of an individual’s eligibility for full Medicaid benefits, States were 

required to obtain a written declaration under penalty of perjury stating 

whether the individual is a U.S. citizen. States were only required to 

obtain documentary evidence for an individual who declared that they 

were not citizens or nationals. 

 As a result of the changes made by Section 6036 of the Deficit 

Reduction Act, States now must obtain documentary evidence of both 

citizenship and identity from individuals who declare that they are U.S. 

citizens or nationals in order to receive Federal reimbursement for 

Medicaid services provided to these individuals. This requirement 

applies to initial determinations and redeterminations of eligibility made 

on or after July 1, 2006. The requirement does not change the Medicaid 

documentation requirement or rules for non-citizens. 

 At least three States have said that they will postpone 

implementation of the citizen documentation requirements because they 

need more time to prepare new policy guidelines, train eligibility 

workers, and advise Medicaid beneficiaries. Two lawsuits have also 

been filed to challenge these requirements. 

 With the restriction for non-citizens on Medicaid eligibility, one 

question that arises is the extent to which non-citizens have private 

insurance. The literature has consistently found that non-citizens have 

higher uninsurance rates than native born and naturalized U.S. citizens 

and these differences remain when controlling for factors such as 

poverty, education, and labor force participation. However, there is no 

consensus on the impact of non-citizens on the overall U.S. uninsured 

population. For example, one report for that non-citizens accounted for 

59 percent of the increase in the uninsured population from 1994 to 

2003. 

 Nonetheless, another commission study found that the impact of 

non-citizens on the uninsured population depended on which years were 

analyzed and grouped together, concluding that immigration trends are 

not responsible, in large part, for the increase in the number of uninsured. 

 Due to high uninsurance rates among unauthorized aliens and their 

ineligibility for Medicaid, several studies have focused on the healthrelated cost of unauthorized aliens. 

 Since it is extremely difficult to get accurate data on unauthorized 

aliens, many studies make assumptions about the number of 

unauthorized aliens and their service usage. Some of these studies 
112

survey immigrant communities and ask immigrant status, while others 

ask local agencies to estimate the cost of services provided to the 

unauthorized aliens, or others use proxies such as those who provide a 

false Social Security number, to determine who is an unauthorized alien. 

Each of these methods has strengths and weaknesses, and none provides 

a reliable estimate upon which researchers agree. 

 A 2004 study by the Government Accountability Office, GAO, 

concluded that since hospitals do not generally collect information on 

patients’ immigration status, an accurate assessment of the impact of 

unauthorized aliens on hospitals’ uncompensated care costs remain 

elusive. Over 95 percent of the hospitals which responded to the GAO 

survey used a lack of a Social Security number as the only method to 

identify unauthorized aliens. It is unclear whether this method over or 

under-estimates the amount of care provided to unauthorized aliens. 

 The GAO study also reviewed the reported Medicaid spending for 

the 10 States with the highest estimated unauthorized population and 

found that emergency Medicaid expenditures for the 10 States have 

increased over the past several years but remain less than 3 percent of 

each State’s total Medicaid expenditures. Nonetheless, the study found 

that between 2000 and 2002, in 9 of the 10 States reviewed, the State’s 

emergency Medicaid expenditures grew faster than the total Medicaid 

expenditures. 

 In sum, it is unclear what the true impact of unauthorized aliens is on 

Medicaid and the health delivery system. 

 Thank you once again for your invitation to be here today and I am 

at your disposal for any questions. 

 MR. DEAL. Thank you. Mr. Ortiz. 

 [The prepared statement of Dr. Siskin follows:] 

PREPARED STATEMENT OF DR. ALISON SISKIN, SPECIALIST IN IMMIGRATION LEGISLATION,

DOMESTIC SOCIAL POLICY DIVISION, CONGRESSIONAL RESEARCH SERVICE

Thank you Chairman Deal, Ranking Member Brown, and Distinguished Members of 

the Committee for the invitation to appear before you today to speak about the financial 

impact of unauthorized aliens on Medicaid and Health Delivery Systems. I am Alison 

Siskin, a Specialist in Immigration Legislation at the Congressional Research Service. 

My testimony today will focus on a discussion of the Medicaid eligibility of noncitizens, 

and two recent legislative initiatives, one to reimburse providers for the cost of 

uncompensated care provided to unauthorized aliens, and the other to require certain 

documentation for those applying for Medicaid. My testimony will conclude with a 

discussion of studies on uninsurance rates for noncitizens, and estimates of the 

uncompensated cost of providing health care for unauthorized aliens. 

Currently, noncitizens’ eligibility for federal Medicaid benefits largely depends on 

their immigration status and whether they arrived (or were on a program’s rolls) before 

August 22, 1996, the enactment date of the Personal Responsibility and Work 

Opportunity Reconciliation Act (PRWORA). Legal permanent residents (LPRs) entering 
113

after August 22, 1996, are barred from Medicaid for five years, after which coverage 

becomes a state option. States have the option to use state funds to provide medical 

coverage for LPRs within five years of their arrival in the United States. Refugees and 

asylees are eligible for Medicaid for seven years after arrival. After the seven years, they 

may be eligible for Medicaid at the state’s option. LPRs with a substantial (10-year) U.S. 

work history or a military connection are eligible for Medicaid without regard to the 5-

year bar. LPRs receiving Supplemental Security Income (SSI) on or after August 22, 

1996 are eligible for Medicaid since Medicaid coverage is required for all SSI recipients. 

Finally, in the case of LPRs sponsored for admission after 1997, the income and 

resources of their sponsor are “deemed” available to them when judging their eligibility. 

Nonetheless, all aliens regardless of status who otherwise meet the eligibility 

requirements for Medicaid are eligible for emergency Medicaid. Thus, unauthorized 

aliens are ineligible for Medicaid, but may qualify for emergency Medicaid. 

 Emergency Medicaid covers unauthorized aliens, nonimmigrants, and LPRs within 

the first five years of arrival for emergency conditions if they meet the other eligibility 

requirements of the program. Under the Emergency Medical Treatment and Active 

Labor Act, all Medicare-participating hospitals with emergency departments treat all 

medically unstable patients and women in active labor regardless of their ability to pay. 

Unauthorized aliens who are otherwise eligible for Medicaid except for their illegal status 

may receive “medical assistance under Title XIX of the Social Security Act ... for care 

and emergency services that are necessary for the treatment of an emergency medical 

condition (as defined in Section 1903(v)(3) of such Act) of the alien involved and are not 

related to an organ transplant procedure.” This language from the Personal 

Responsibility and Work Opportunity Reconciliation Act of 1996 restates and carries 

forward a provision which had been enacted 10 years previously as an amendment to the 

Medicaid provisions of the Social Security Act. 

Section 1903(v)(3) defines “emergency medical condition” as: 

a medical condition (including emergency labor and delivery) manifesting itself by 

acute symptoms of sufficient severity (including severe pain) such that the absence 

of immediate medical attention could reasonably be expected to result in — (A) 

placing the patient’s health in serious jeopardy, (B) serious impairment to bodily 

functions, or (C) serious dysfunction of any bodily organ or part. 

Like other Medicaid recipients, unauthorized aliens must demonstrate that they are 

state residents, and many are not (or are unable or unwilling to prove that they are). This 

is particularly true of unauthorized aliens requiring emergency hospital care during 

attempted illegal entries. To be eligible for emergency Medicaid, unauthorized aliens 

must also be poor and either aged, disabled, or members of a family with children. 

Working age single males, for example, are generally not eligible for any form of 

Medicaid regardless of their financial status or residence. 

Due to the eligibility of noncitizens for emergency Medicaid, many have questioned 

the impact of noncitizens on emergency departments. Although some have pointed to 

unauthorized aliens as a key contributor to problems of emergency departments, the 

reality is more complicated. According to research, use of emergency care varies 

significantly across communities, and contrary to popular perception, studies have found 

that communities with more noncitizen (alien) residents generally have lower rates of 

emergency department use than communities with fewer noncitizen residents. (For 

example see, Peter J. Cunningham, “What Accounts for Differences in the Use of 

Hospital Emergency Departments Across U.S. Communities,” Health Affairs-Web 

Exclusive, Jul. 18, 2006, pp. W324-W336. ) 
114

In 2003, Congress enacted The Medicare Prescription Drug, Improvement and 

Modernization Act of 2003 (P.L. 108-173), which contains a provision (known as section 

1011) that provides reimbursement to states for emergency care afforded to unauthorized 

aliens. For each fiscal year, FY2005-FY2008, the provision appropriates $250 million of 

which: 

• $167 million is allotted to states based on the percentage of unauthorized aliens 

residing in the state compared to the total number of unauthorized aliens in the 

United States; and 

• $83 million is allocated to the six states with the highest percentage of 

unauthorized alien apprehensions for the fiscal year, based on the percentage of 

apprehensions in the state compared to the number of apprehensions for all 

such states. 

P.L. 108-173 directs the Secretary of Health and Human Services (HHS) to pay 

local governments, hospitals, or other providers located in the state (including providers 

of services rendered through an Indian Health Service facility) for the costs of furnishing 

emergency health care services to unauthorized aliens during that fiscal year. Advanced 

payments will be made quarterly based on the applicants’ projected expenditures. 

 In February 2006, Congress passed the Deficit Reduction Act (DRA, P.L. 109-171) 

which contains a provision requiring certain documentation for those applying for 

Medicaid who claim U.S. citizenship. Prior to the DRA, as a condition of an 

individual’s eligibility for full Medicaid benefits, states were required to obtain a written 

declaration, under penalty of perjury, stating whether the individual is a citizen or 

national of the United States. States were only required to obtain documentary evidence 

from individuals who declared that they were not citizens or nationals. 

In July 2005, the Inspector General (IG) for the Department of Health and Human 

Services released a report entitled, Self-Declaration of U.S. Citizenship for Medicaid. 

The report found that as of 2004, 47 states allowed self-declaration of U.S. citizenship for 

determinations of Medicaid eligibility, but 44 of those states required documentary 

evidence of citizenship if the statement seems questionable. Montana, New Hampshire, 

New York, and Texas did not permit self-declaration of citizenship for determinations of 

Medicaid eligibility. In addition, the report found that 27 states did not verify the 

accuracy of U.S. citizenship statements as part of their post-eligibility quality control. 

While the IG noted that Centers for Medicare and Medicaid Services (CMS) had 

encouraged self-declaration in an effort to simplify and accelerate the Medicaid 

application process which resulted in rapid enrollment, self-declaration also could have 

lead to inaccurate eligibility determinations for those who provide false citizenship 

statements. Nonetheless, the report failed to identify the extent to which current 

Medicaid beneficiaries were ineligible based on citizenship or the extent to which eligible 

individuals failed to apply for Medicaid in states that require proof of U.S. citizenship as 

a condition of eligibility. 

As a result of changes made by §6036 of DRA, states now must obtain documentary 

evidence of both citizenship and identity from individuals who declare that they are 

citizens or nationals of the U.S. (with certain exceptions) in order to receive federal 

reimbursement for Medicaid services provided to these individuals. This requirement 

applies to initial determinations and redeterminations of Medicaid eligibility made on or 

after July 1, 2006. The requirement does not change Medicaid documentation (or other) 

rules for noncitizens. 

The CMS provided states with initial guidance on the Medicaid citizenship 

documentation provision in DRA on June 9, 2006. An interim final rule (the contents of 

which differ from CMS’s initial guidance) was published in the Federal Register on July 

12, 2006. The interim rule explains who is exempt from the documentation provision, 
115

what types of documents and data matches may be used to prove citizenship (or 

nationality) and identity, and how states must comply with the new requirement. 

At least three states (Ohio, California, and North Carolina) have said that they will 

postpone implementation of the Medicaid citizenship documentation requirement because 

they need more time to prepare new policy guidelines, train eligibility workers, and 

advise Medicaid beneficiaries. Two lawsuits have also been filed to challenge the 

requirement. In addition, according to a Medicaid official in Tennessee, the directions 

given to their Medicaid directors to implement DRA §6036 are almost identical to those 

in the federal letter sent to the states from CMS on how to implement the provision. The 

state did not have time to develop their own guidance as the CMS letter was sent several 

days after the provision was supposed to be implemented. The official noted that the 

provision has proven difficult to implement for children, especially those who are not yet 

school-aged. 

With the restrictions for noncitizens on Medicaid eligibility, one question that arises 

is the extent to which noncitizens have private insurance. The literature has consistently 

found that noncitizens have higher uninsurance rates than native born and naturalized 

U.S. citizens, and these differences remain when controlling for factors such as poverty, 

education and labor force participation. For example, a Kaiser Commission study found 

that in 2003, 47% of noncitizens lacked health insurance compared to 15% of native born 

citizens. In addition, another Kaiser Commission study found that in 2003, 26% of low 

income children with noncitizen parents lacked health insurance while only 16% of low 

income children with citizen parents lacked health insurance. These findings are similar 

to a CRS study which used data from 2001, and found that noncitizens were three times 

more likely to be uninsured than U.S. citizens and naturalized foreign born individuals. 

Forty-four percent of noncitizens were uninsured compared to 17% of naturalized U.S. 

citizens and 12% of native born U.S. citizens. 

Although there appears to be general agreement that noncitizens are more likely than 

U.S. citizens to lack health insurance, there is not a consensus on the impact of 

noncitizens on the overall U.S. uninsured population. For example, a report by the 

Employee Benefits Research Institute (EBRI) found that noncitizens accounted for 59% 

of the increase in the uninsured population from 1994 to 2003. Similarly, another study 

found that by applying the uninsurance rates of unauthorized aliens in Los Angeles 

County to the entire country, unauthorized aliens accounted for one-third of the increase 

in the number of uninsured adults in the United States between 1980 and 2000. 

Nonetheless, a Kaiser Commission study found that the impact of noncitizens on the 

uninsured population depended on which years were analyzed and grouped together. The 

Kaiser Commission study analyzed the uninsured population during three periods: 1994-

1998; 1998-2000; and 2000-2003. The Kaiser Commission study found that when 

combining the data from 1998 through 2003, almost two-thirds of the increase in the 

uninsured population was due to noncitizens, but the result was largely driven by the 

reduction in the number of uninsured U.S. citizens between 1998 and 2000. In contrast, 

the report noted that in the 1994 to 1998 and 2000 to 2003 periods, most of the growth in 

the uninsured population was due to native born U.S. citizens. Seventy-four percent of 

the growth in the uninsured population between 1994 to 1998 was due to native born U.S. 

citizens while 10% was due to noncitizens. Likewise, between 2000 and 2003, 24% of 

the growth in the uninsured population was due to noncitizens, while 71% of the growth 

could be attributed to native born U.S. citizens. The Kaiser Commission study concluded 

that immigration trends are not responsible, in large part, for the increase in the number 

of uninsured. In addition, the researchers noted that, mostly due to the fact that 

noncitizens comprise a much smaller proportion of the population than U.S. citizens, 

noncitizens would have to fare dramatically worse than citizens to be responsible for the 

majority of the change in the uninsured population. 
116

Due to high uninsurance rates among unauthorized aliens and their ineligibility for 

Medicaid, several studies have focused on the health-related costs of unauthorized aliens 

on state and local governments, and health care providers. It is very difficult to 

enumerate a population which is trying to avoid detection by the government. The main 

sources of socioeconomic information in the United States, the Current Population 

Survey (CPS), the Decennial Census of the Population (Census), and the American 

Community Survey, collected by the Census Bureau, ask citizenship status, but not 

immigration status. Thus, it is not possible to use these data sources in calculating the 

healthcare cost of unauthorized aliens. 

Since it is extremely difficult to get accurate data on unauthorized aliens, many 

studies make assumptions about the number of unauthorized aliens, their service usage, 

and their revenue contributions. As a result, many studies which attempt to estimate the 

cost of health care for unauthorized aliens in the United States focus on limited 

geographic regions (e.g., border communities, states, or cities). Some of these studies 

survey immigrant communities and ask immigration status, while others ask for local 

agencies to estimate the cost of services provided to unauthorized aliens. Other studies 

use proxies, such as those who provided a false Social Security number, to determine 

who is an unauthorized alien. Each of these methods has strengths and weaknesses, and 

none provides a reliable estimate upon which researchers agree. 

The following is a discussion of selected studies which estimate the cost of health 

care provided to unauthorized aliens. I have focused on studies completed during the 

previous 10 years. In addition, this is not an exhaustive review of the literature on the 

cost of health care for unauthorized aliens in the United States. 

GAO Study (2004). In May 2004, the Government Accountability Office (GAO) 

released a study entitled Undocumented Aliens: Questions Persist about Their Impact on 

Hospitals’ Uncompensated Care Costs. The study concluded that since hospitals do not 

generally collect information on patients’ immigration status, an accurate assessment of 

the impact of unauthorized aliens on hospitals’ uncompensated care costs “remains 

elusive.” GAO surveyed 503 hospitals, but as a result of the low response rate to the 

survey, was unable to determine the cost of uncompensated care provided to 

unauthorized aliens. In addition, over 95% of the hospitals which responded to the 

survey used the lack of a Social Security number as the only method to identify 

unauthorized aliens. It is unclear whether this method over or under estimates the 

amount of care provided to unauthorized aliens. 

The GAO study also reviewed the reported Medicaid spending for the 10 states with 

the highest estimated unauthorized populations: Arizona, California, Florida, Georgia, 

Illinois, New Jersey, New Mexico, New York, North Carolina, and Texas. Although 

states are not required to report to CMS the amount of Medicaid expenditures for 

unauthorized aliens, several states provided data or suggested to GAO that most of their 

emergency Medicaid expenditures were for services provided to unauthorized aliens. In 

addition, five of the states reported that more than half of emergency Medicaid 

expenditures were for labor and delivery services. 

GAO found that emergency Medicaid expenditures for the 10 states have increased 

over the past several years but remain a small proportion, less than three percent, of each 

state’s total Medicaid expenditures. Nonetheless, the study found that, between FY2000 

and FY2002, in nine of the 10 states reviewed, the state’s emergency Medicaid 

expenditures grew faster than the total Medicaid expenditures. 

Impact of Illegal Immigration on Mississippi (2006). The Mississippi Office of 

the State Auditor estimated that $35 million of $504.6 million spent for uninsured 

healthcare services in 2004 may be due to unauthorized aliens. This number was 

estimated by using a finding from the RAND Corporation that 68% of unauthorized alien 

adults lacked health insurance. Importantly, the report noted that “because no data 
117

regarding immigration status is collected, it is difficult to determine the accuracy of this 

estimate...” 

Impact of Illegal Immigration on Minnesota (2005). The Office of Strategic 

Planning and Results Management for the State of Minnesota reported that in FY2005, 

unauthorized aliens cost Minnesota health assistance programs approximately $35.5 

million, of which approximately $17.3 million was paid by the state. The cost included: 

• $16.3 million, for Minnesota Emergency Medical Assistance, which covers all 

emergency services including labor and delivery, of which the state and the federal 

governments each paid 50% ($8.15 million). 

• $15.5 million for Minnesota State Children’s Health Insurance Program (SCHIP) 

which covers medical costs for pregnant women without other health insurance 

through the month of birth. The state paid 35% of the costs ($5.4 million) while the 

federal government paid 65% of the costs ($10.1 million). 

• $3.7 million for Minnesota Medical Assistance program’s state noncitizen pregnant 

women fund, all of which was paid by the state. 

The High Cost of Cheap Labor: Illegal Immigration and the Federal Budget 

(2004). This study released by the Center for Immigration Studies uses the March 

Current Population Survey (CPS) and the decennial census, and relies on the 

methodology used in two other respected studies of the fiscal effects of immigration: (1) 

The New Americans (1997) by the National Research Council (NRC); and (2) Immigrants 

in New York: Their Legal Status, Incomes and Taxes (1998) by researchers at the Urban 

Institute. Unauthorized aliens are estimated by using socioeconomic characteristics to 

assign a probability to each respondent that the respondent is an unauthorized alien. The 

study uses households as the unit of analysis arguing, as in the NRC study, that the 

household is the primary unit through which taxes are paid and services used. It is 

important to note that although the head of the household is an unauthorized alien, it is 

possible that others in the household are legally present, or United States citizens. 

The study noted that ascertaining the cost of unauthorized alien households presents 

complex fiscal questions, and estimated that on average, each household headed by 

unauthorized aliens cost the federal treasury $658 for Medicaid (including SCHIP) and 

$591 for medical care for the uninsured in FY2002. In comparison, the study estimated 

that in FY2002, legal alien headed-households, on average, cost the federal treasury 

$1,232 for Medicaid (including SCHIP) and $123 for medical care for the uninsured. 

Care for the Uninsured Non-citizens: A Growing Burden on Florida’s Hospitals 

(2003). Using case studies of 700 unauthorized aliens from 39 hospitals/health systems 

representing 56 hospitals or 26% of the acute care hospitals in Florida, the Florida 

Hospital Association reported that these 39 hospitals/health systems spent $40.2 million 

on care for unauthorized aliens. Three-quarters of the unauthorized alien patients 

incurred charges below $50,000, while 32 unauthorized alien patients incurred charges in 

excess of $250,000 each, totaling more than $21.4 million. 

Medical Emergency: Costs of Uncompensated Care in Southwest Border 

Counties (2002). In 2002, the United States/Mexico Border Counties Coalition released 

a study entitled Medical Emergency: Costs of Uncompensated Care in Southwest Border 

Counties. The survey conducted statistical modeling by identifying sets of non-border 

communities that “capture essential characteristics of each border community with 

respect to the demand for emergency medical services.” The researchers note the 

complexity of matching border communities with other communities, as the counties on 

the U.S./Mexico border are unique on many important dimensions, and this complexity 

may have impacted the results. The researchers then performed a linear regression, and 

assumed the differences between the border communities and the similar non-border 

communities could be attributed to unauthorized aliens. The study concluded that in 
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2000, $189.6 million was spent by hospitals in the Southwest border communities to 

provide uncompensated care to unauthorized aliens. 

Health Care for Unauthorized Immigrants: Who Pays? (2001). The House 

Research Organization for the Texas House of Representatives asserted that the Harris 

County Hospital District estimated that between 1999 and 2001 it spent $330 million on 

health care for unauthorized aliens, of which $105 million was reimbursed by the federal 

government. The study failed to provide methodology for the estimate, and as a result, it 

is impossible to assess the validity of the estimate. 

In sum, it is unclear what the true impact of noncitizens is on Medicaid and the health 

delivery system. Although noncitizens are more likely than citizens to be uninsured, it is 

not known to what extent noncitizens affect the overall uninsurance rate for the U.S. 

Thank you once again for your invitation to be here today, and I am at your disposal 

for any questions you may have. 

 MR. ORTIZ. Thank you, Chairman Deal and members of the Energy 

and Commerce Committee for holding this field hearing today in Dalton, 

Georgia. I appreciate your leadership on this issue and am grateful to 

testify about Georgia’s experience in implementing the Medicaid 

Citizenship Provisions of the DRA. 

 Medicaid has grown to become the second largest budget item in the 

State of Georgia, only behind public education. The people of Georgia 

have been very clear that they expect us to be good stewards of the 

State’s resources and to be fair and just in dedicating those resources to 

those most in need. 

 Therefore, last December, Governor Perdue instructed the Georgia 

Department of Human Resources, the State agency that administers 

Medicaid enrollment, to institute more stringent documentation 

requirements for both citizenship and income eligibility. 

 As of January 1, 2006, applicants for Georgia’s Family Medicaid 

program have been required to provide documents such as W-2 forms, 

pay stubs, or income tax returns before becoming eligible for benefits. 

The only exception to this policy is for pregnant women and their 

newborns, allowing them to receive immediate prenatal and postnatal 

care. 

 Federal law requires that taxpayer-funded benefits be limited to those 

who are lawfully in the United States and income verification 

requirements serve as an additional check for legal U.S. citizenship. As 

the Governor said in December, documentation verification reduces 

fraud in the taxpayer-funded healthcare system and ensures that 

Medicaid recipients are legal residents entitled to public assistance. 

 Since implementation, we have seen a sizable reductions in our 

caseload, which has been attributed to the combination of both more 

rigorous citizenship and income documentation requirements. This fact 

is strong evidence of fraud and abuse inherent under the previously 

allowed self-declaration prerequisite. 
119

 In January 2006, Congress passed the Deficit Reduction Act. This 

bill contains many of the Medicaid flexibilities that the Nation’s 

governors have been asking for and I would like thank the Committee 

and Congressman Barton and Chairman Deal for working with the 

governors on this process. 

 The DRA Improved Enforcement of Documentation Requirements 

contained requirements largely similar to those document verification 

regulations instituted in Georgia on January 1. 

 In the implementation of citizenship verification requirements, the 

Governor made it very clear that first, all new document requirements 

needed to be in compliance with Federal law and regulation; second, that 

our State eligibility workers were to be dedicated to diligently assist 

citizens and qualified aliens to obtain the documentation necessary for 

Medicaid eligibility. 

 When an applicant lacks the proper documentation, our practice is to 

hold the application open for the maximum time period allowed by CMS 

regulation. During that time, eligibility workers will assist applicants to 

produce the satisfactory documentation. 

 In Georgia, 3000 caseworkers across 159 counties determine 

Medicaid eligibility. They have been trained to integrate these new 

regulations into their daily work, while continuing to provide supportive 

assistance to Medicaid applicants. 

 To ensure the efficient and successful eligibility determination for 

qualified applicants, Georgia has taken full advantage of additional 

flexibilities allowed under the DRA, such as cross-matching of State 

vital statistics; not requiring verification if the individual has already 

been deemed eligible for SSI or Medicare; presumptive eligibility for 

pregnant women and deemed newborn eligibility. 

 One thing we have noticed is that our increased focus on eligibility 

documentation is enhancing accountability across our system. When we 

communicate well with our consumers, more of them come to our front 

door of our system with the documents in hand ready and able to prove 

citizenship and verify their income. If they do not have the 

documentation when they come to the front door, we work diligently to 

ensure that they have the documentation in hand when they are 

determined eligible. We see this as a service to the citizens of Georgia. 

 In conclusion, the United States is a great country with great 

benefits. Our expectations are that those we serve should be eligible and 

we have a responsibility to verify that eligibility. We stand ready in 

Georgia to get the right work done the right way. 

 Thank you again, Chairman Deal, for your time and continued 

leadership on this issue. 

 [The prepared statement of Abel C. Ortiz follows:] 
120

PREPARED STATEMENT OF ABEL C. ORTIZ, HEALTH AND HUMAN SERVICES POLICY 

ADVISOR, OFFICE OF THE GOVERNOR, STATE OF GEORGIA

Thank you, Chairman Deal, and Members of the Energy and Commerce Committee 

for holding this field hearing today in Dalton, Georgia. I appreciate your leadership on 

this issue and am grateful for the opportunity to testify regarding Georgia’s experiences 

implementing the Medicaid Citizenship Documentation Provisions of the Deficit 

Reduction Act (DRA). 

Medicaid has grown to become the second largest budget item in our state, behind 

only public education. The people of Georgia have been very clear that they expect us to 

be good stewards of the state’s resources, and to be fair and just in dedicating those 

resources to people most in need. 

Therefore, last December Governor Sonny Perdue instructed the Georgia 

Department of Human Resources, the state agency that administers Medicaid enrollment, 

to institute more stringent documentation requirements for both citizenship and income 

eligibility. 

As of January 1, 2006, applicants for Georgia’s Family Medicaid program have been 

required to provide documents such as W-2 forms, pay stubs, or income tax returns 

before becoming eligible for benefits. The only exception to the policy is for pregnant 

women and their newborns, allowing them to receive immediate prenatal and postnatal 

care. 

Federal law requires that taxpayer-funded benefits be limited to those who are 

lawfully in the United States and the income verification requirement serves as an 

additional check for legal U.S. citizenship. As the Governor said in December, document 

verification reduces “fraud in the taxpayer-funded healthcare system and ensure(s) that 

Medicaid recipients are legal residents entitled to public assistance.” 

Since implementation we have seen sizable reductions in our caseload which we 

attribute to the combination of more rigorous citizenship and income documentation 

requirements. This fact is strong evidence of fraud and abuse inherent under the 

previously allowed “self-declaration” prerequisite. 

In January 2006, Congress passed the Deficit Reduction Act (DRA). The bill 

contained many of the Medicaid flexibilities the Nation’s Governors have been asking for 

and I would like to thank the Committee, Chairman Barton and Chairman Deal for 

working with the Governors in that process. 

Section 6036 of the DRA, Improved Enforcement of Documentation Requirements, 

contained requirements largely similar to document verification regulations instituted in 

Georgia on January 1. 

In implementing the citizenship verification requirement, the Governors’ directions 

were clear: First, all new documentation requirements were to be in compliance with 

federal law and regulation and, second, our State Medicaid eligibility workers were 

directed to work diligently to assist any citizen or qualified alien in obtaining the 

documentation necessary for Medicaid eligibility. 

When an applicant lacks the proper documentation, our practice is to hold that 

application open for the maximum time period allowed by CMS regulations. During that 

time eligibility workers will assist the applicant to produce satisfactory documentation. 

In Georgia, 3,000 caseworkers, across 159 counties, determine Medicaid eligibility. 

They have been trained to integrate these new regulations into their daily work, while 

continuing to provide supportive assistance to Medicaid applicants. 

To ensure the efficient and successful eligibility determination for qualified 

applicants Georgia has taken full advantage of additional flexibilities allowed under the 

DRA, such as: 

• Cross-matching state vital statistics; 
121

• Not requiring verification if the individual has already been deemed eligible for 

SSI and Medicare; 

• Presumptive eligibility for pregnant women; 

• Deemed newborn eligibility. 

One thing we have noticed is that our increased focus on eligibility documentation is 

enhancing accountability throughout our system. When we communicate well with our 

customers, more of them are coming to the front door of our system with documentation 

in hand, ready and able to prove their citizenship and verify their income. If they don’t 

have the documentation when they come in the front door, we work diligently to insure 

that they have the documentation in hand when they are determined eligible. We see this 

as a service to citizens of Georgia. 

In conclusion, the United States is a great country with great benefits. Our 

expectations are that those we serve should be eligible and we have a responsibility to 

verify that eligibility. We stand ready in Georgia to get the right work done, the right 

way. 

Again, thank you Chairman Deal for your time and continued leadership on these 

important issues. 

 MR. DEAL. Well, thank you all for your testimony. I think I have 

agreement from my panel members up here that we are going to limit our 

question time to 5 minutes for each of you since we are running a little 

behind our schedule and we have another panel that is coming up. And I 

will begin that. 

 First of all, as you mentioned, Dr. Siskin, prior to the DRA, we had 

a system in place that said you had to certify, subject to perjury, that you 

were a citizen and, therefore, eligible--or other category--that you were 

eligible for participation in Medicaid. Are you or any of the panel 

members ever aware of anybody who has ever been prosecuted for 

falsely certifying that they were eligible? 

 MS. SHEIL. I am not. 

 MS. SISKIN. Nor am I. 

 MR. ORTIZ. I am not. 

 MR. DEAL. Well, that is similar to the answers I got on the other 

question which I am going to ask you now too. 

 Under the 1996 Immigration Reform Act, where we said that if you 

want to sponsor someone to come into this country, you assume 

responsibility as a sponsor and to be responsible for the cost so they do 

not become a drain on our social welfare system. Are any of you ever 

aware of anyone ever being charged as a sponsor and sent a bill for the 

cost of their person they sponsored? 

 MS. SISKIN. Not for public benefits. There have been cases where 

somebody who was sponsored sued their sponsor for not providing 

support, but no one has gone after somebody for a public benefit, as far 

as I know. 

 [Laughter.] 

 MR. ORTIZ. I am not aware of anybody. 
122

 MS. SHEIL. I am not aware that anybody has been charged; however, 

in the eligibility determination process, eligibility workers should be 

collecting information on the income and assets of the sponsor and 

considering that income in developing their eligibility. But I do not 

know to what extent that is being done. 

 MR. DEAL. Even if we are collecting that information, how do we 

then effectively communicate it to places like public hospitals where they 

are faced only with the option of charging it off as uncollectible debt? 

 MS. SISKIN. Well, in the last 2 years, supposedly it is now being 

captured electronically in the SAVE system. Prior to that, you would 

have had to fill out a form with the former INS and now the Department 

of Homeland Security, requesting information on an alien sponsor. But I 

am not sure the hospitals have access to the SAVE system. 

 MR. DEAL. That is the problem, is it not? We have problems 

communicating within our own agencies and we collect all this 

information, sometimes do not share it within our own agencies, as we 

have all heard the story, but we certainly have not shared it with the 

people who are on the front line, who are incurring the costs and have no 

one to send a bill to. 

 That ties in with my concern about the expanded guest worker 

provisions of the Senate bill where it appears on their terms would be to 

repeat this same process, which I think is totally ineffective. 

 Let me though follow up with the electronic verification. Senator 

Rogers mentioned it I believe and you all have alluded to it. 

 Mr. Ortiz, are you at the State level using the electronic verification 

system and what does that tie you in to? 

 MR. ORTIZ. We are using it and we use our cross matches with our 

State vital records and then we use it to cross match with Medicare and 

Social Security. 

 MR. DEAL. And that is on the documentation for certification of 

eligibility? 

 MR. ORTIZ. Yes, it is. 

 MR. DEAL. Okay. Is it working pretty well so far? 

 MR. ORTIZ. We have not had any reports of any slow down in 

processing. Our workers have just completed training last week, it has 

been ongoing and they just completed it last week and we have had no 

reports of any problems gaining that information through the electronic 

system. 

 MR. DEAL. Ms. Sheil, since you are going to be responsible for the 

implementation of the new DRA provisions, have you had any real 

concerns that have surfaced in using the proper verification and 

documentation that the law requires? 
123

 MS. SHEIL. We have had numerous phone calls and training sessions 

with our State agencies and they understand the policies. I continue to 

answer questions about the policies, so I think that implementation for 

the vast majority is going very well. 

 MR. DEAL. And your testimony, Mr. Ortiz, alludes to this, and says 

it I think rather plainly, quite frankly, that if someone comes in and asks 

for Medicaid certification and they do not have their documents, you 

work with them to try to obtain those documents, if they are validly 

presenting themselves; is that correct? 

 MR. ORTIZ. That is true. And that has actually been true for many, 

many years. I have experience both as a hospital social worker, an 

economic social worker, a social worker in a mental health clinic, and 

also as a foster care supervisor; and through my many years of being a 

social worker, it has always been the eligibility worker and other social 

workers outside the system who help applicants get that type of 

information, because it has always been needed. So this is an ongoing 

enhanced version of that. 

 MR. DEAL. Thank you. My time has expired. Ms. Solis. 

 MS. SOLIS. Thank you. 

 Ms. Siskin, thanks for joining us here today on such short notice and 

I am sure we will hear a lot more about immigrants and supposedly their 

responsibility for the problems we are facing with the Nation’s 

healthcare system. If I understand your testimony, the situation for me is 

not very clear and simple. For example, is it not true that looking at 

emergency department use by non-citizens, communities with higher 

numbers of non-citizen residents have lower rates of emergency 

department use than communities with more citizen residents? 

 MS. SISKIN. Yes, that is what the studies have found. 

 MS. SOLIS. And also, is it not true that communities with higher use 

of emergency departments also tend to have longer waiting periods for 

patients seeking medical appointments when sick? 

 MS. SISKIN. That I would have to check on for you. 

 MS. SOLIS. And is it not true that while immigrants tend to have 

higher rates of uninsurance than citizens, there is no clear consensus on 

the impact of non-citizens on the overall U.S. uninsured population? 

 MS. SISKIN. That is true, the studies are all over the place on the 

impact. 

 MS. SOLIS. And now looking at the use of government benefits by 

immigrants, can you tell me whether there is any reliable evidence or 

studies that have shown rampant fraudulent use of Medicaid services by 

those who are not eligible for it, by reason of citizenship? 

 MS. SISKIN. I have not seen any studies like that. In the CMS study-

-I am sorry, the Inspector General study from the Department of Health 
124

and Human Services that looked at this issue of self-declaration did not 

look at that issue. 

 MS. SOLIS. Thank you. My next question is for Ms. Sheil. I know 

that your agency is in the process of issuing a final rule on the Medicaid 

citizenship documentation requirements that passed Congress. And as 

you know, I along with 40 of my colleagues wrote a letter commenting 

on the rule and asking you to change some of the most egregious 

problems in the draft proposal. In addition, Ranking Member Dingell 

and Health Subcommittee Ranking Member Brown and Government 

Reform Committee Ranking Member Waxman also sent you similar 

comments. 

 And I would like to ask that both sets of my comments be placed into 

the record. 

 [The information follows:] 
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 The problem I see with the new requirement is that it really will wind 

up hurting many U.S. citizens and I think that is what some of us are 

trying to get to at this hearing today. 

 I understand that your boss, Dr. McClellan, already wrote in a letter 

to the Inspector General that States, and I quote, “States have little 

evidence that many non-eligible non-citizens are receiving Medicaid.” 

What we have as a result of this new law is more government 

bureaucracy to address a largely fictitious problem. In fact, as a result of 

the new government burden, estimates are that one to two million 
138

American citizens could lose their healthcare. When we already have 46 

million uninsured, and when we know that the uninsured and 

uncompensated are a major burden for our Nation’s health providers, we 

should not be taking action that would make more Americans lose their 

healthcare coverage. 

 First, the rule will delay, in my opinion, access to necessary 

healthcare. The rule says that a pregnant woman or a child, for example, 

who will meet all the requirements for eligibility but are waiting for their 

certified copy of their birth certificate to be mailed to them, cannot get 

their Medicaid coverage. Is that correct? 

 MS. SHEIL. Are you reading from a letter that Dr. McClellan wrote? 

 MS. SOLIS. No. 

 MS. SHEIL. This is your letter? Could you repeat the question, 

please? 

 MS. SOLIS. What I would like to know is if in fact, if a pregnant 

woman or a child, for example, who meets the requirements for 

eligibility but is waiting for the certified copy of a birth certificate to be 

mailed, would they be denied coverage? 

 MS. SHEIL. Applicants have 45 days from the date of application to 

present documentation. 

 MS. SOLIS. But if in fact they are found to be citizens after that time, 

they would still be denied? 

 MS. SHEIL. State agencies have 45 days from the date of application 

to make a determination of eligibility. 

 MS. SOLIS. So in a situation of an area like Georgia and victims of 

the Hurricane Katrina, how would that operate when most of the 

healthcare agencies there were flooded and many records are just not 

available? Mr. Ortiz. 

 MR. ORTIZ. When Hurricane Katrina hit Georgia, the only State that 

took in more evacuees than Georgia was Texas. What we did is we 

worked with CMS to establish presumptive eligibility. We also 

established links with the State of Louisiana and the State of Mississippi 

to verify with their drivers’ license bureau and with their vital statistics, 

to verify that when individuals came in and said I was born in Louisiana, 

then we could verify that electronically and CMS provided us the 

flexibility and a time period to get that documentation in, but there was 

no disruption in coverage. They were immediately eligible, it was called 

presumptive eligibility and the Federal government worked with us to 

make sure that nothing happened where there was a delay in payment or 

healthcare. 

 MS. SOLIS. The other question I have just to wrap up, and I know my 

time is already running out, is with respect to foster care children and the 

fact that again, we are asking for proof of citizenship. And as you know, 
139

the foster care system in many cases, a child jumps from one home to 

another, foster care is not always as stable as we would like and in many 

instances parents of foster care children do not want to provide proof of 

citizenship. What happens in a case for eligibility for that child if there 

is no documentation available? 

 MS. SHEIL. We believe that the State agencies have more 

information about foster children probably than any other children on the 

caseload. The requirement is not for Title IV-E, they get Title IV-E, it is 

for the Medicaid benefits. When they are found eligible for Title IV-E, 

they are made eligible automatically for Medicaid. The State agencies 

will consider them recipients and they will have, upon the first 

redetermination of eligibility, the responsibility to have collected 

information. So they will have a year to gather the information. The 

foster care workers will need to talk with the eligibility workers and they 

will use electronic means, they will be able to use matches with vital 

statistics, obtain birth certificates, just like any other type of case. 

 The policy that is outlined in the regulations provides very, very 

broad arrays of documents that may be used to document citizenship and 

identity. 

 MS. SOLIS. Just one last question with respect to Native Americans 

also. I understand that if they do not have adequate proof of citizenship 

for whatever reason, will they also be denied assistance? I mean that is a 

big issue right now that I think many people have questions about. 

 MS. SHEIL. The policy that we have outlined in the regulations, 

which is policy that basically has been a longstanding established policy 

used by the Social Security Administration with the types of documents 

that are listed. They have a broad array of ways of documenting 

satisfactorily your citizenship. Native Americans also can have birth 

certificates, we have utilized-- 

 MS. SOLIS. Some will not though. So what would you use then? 

 MS. SHEIL. There will be ample room for States to use cross matches 

with vital statistics agencies, they will be able to use some Native 

American documents we did list as acceptable documents. We do use 

Native American documents, they are allowed to prove identity. But the 

policy is sufficient to provide much flexibility in terms of the documents 

that may be used. 

 MS. SOLIS. Thank you. 

 MR. DEAL. Dr. Norwood. 

 MR. NORWOOD. Thank you very much, Mr. Chairman. 

 It is the time in the hearing at which I want to remind us that this 

hearing is not about immigrants, it is about illegal aliens. 

 I want to ask you, Dr. Siskin, if I may, are you here as a private 

citizen or an employee of CRS? 
140

 MS. SISKIN. An employee of CRS. 

 MR. NORWOOD. Okay. Does CRS make assumptions about illegal 

aliens in their studies? 

 MS. SISKIN. What do you mean by assumptions about illegal-- 

 MR. NORWOOD. You are the one that used assumptions all through 

your testimony. That is what I mean. 

 MS. SISKIN. We are very clear when we use census data or anything 

from the U.S. Census Bureau, that there is no way to determine who is an 

unauthorized alien. 

 MR. NORWOOD. So you do use assumptions? 

 MS. SISKIN. No, we would not say that those were unauthorized 

aliens, we would use the term non-citizen, meaning both legal and illegal 

aliens. 

 MR. NORWOOD. So other studies do use assumptions and you do 

not. 

 MS. SISKIN. Correct. 

 MR. NORWOOD. Ah-ha. I find that pretty interesting. 

 The Rand study, for example, that pointed out 65 percent of illegal 

aliens in this country do not have any kind of insurance, they account for 

about a third of the growth in non-insured people. Is that just an 

assumption? 

 MS. SISKIN. I would have to look at the study and see how they 

came up with that. I mean they may have extrapolated from an 

individual community but there is no census of the entire illegal 

population in this country. 

 MR. NORWOOD. Recently, Colorado State Emergency Medicaid 

Program estimated $30 million in hospital and physician delivery costs 

for about 6000 illegal alien mothers, an average of $5000 per baby. 

These 6000 births to illegal aliens represent 40 percent of the births paid 

for by Medicaid in Colorado. Is that an assumption? 

 MS. SISKIN. It would depend how they are determining who is an 

unauthorized alien. If they know for a fact that somebody is an 

unauthorized alien, but if they are using a proxy such as Social Security 

number or lack of Social Security number, it would be an assumption. 

 MR. NORWOOD. Do you not suppose that the State of Colorado 

would know? Mr. Ortiz, we would know in Georgia, would we not, sir? 

 MR. ORTIZ. We would look at our emergency Medicaid and know 

where they come in and the fact that they continue--one of the things 

when we talk about emergency room services, people are under the 

misconception that the billing stops at the emergency room. What tends 

to happen is it continues on when there is no emergency and you end up 

paying under emergency Medicaid for routine care and ongoing care. 
141

And so I think it is more of a problem than just the emergency room you 

mentioned. 

 MR. NORWOOD. Yes, it is. But we do know information like that. 

We may turn and look the other way or not want to admit it, but we do 

know those things happen. 

 Dr. Siskin, I am going to tell you honestly, I am upset with your 

testimony and plan to make a complaint to CRS about it. We can go into 

this when we get back to Washington, but I want you to know I really did 

not appreciate the viewpoint you all took at CMS, not looking, in my 

opinion, at the whole picture. 

 Now Ms. Sheil-- 

 MR. DEAL. You said CMS. 

 [Applause.] 

 MR. NORWOOD. I did not mean CMS, I beg your pardon--CRS. 

 Ms. Sheil, I want to tell you personally how much I appreciate the 

work you and Dennis Smith have been doing in an effort to try to get us 

to get this straightened out in this country so that only our own citizens 

receive the tax dollars that go into Medicare. I have worked with CMS 

for 12 years and it is always hard, it is always difficult, and I have great 

feelings about how well you all have handled this, how hard you have 

tried to work this out for the American citizen to make sure that we do 

not let anybody drop through the cracks because we are trying to zero in 

on not letting foreigners get into our social system. 

 Explain to me just a little bit briefly what has basically changed in 

the law that has caused us to come to this point to where Mr. Ortiz--who 

by the way is doing a great job for our Governor, thank you, sir--is 

changing how we do business in Georgia and obviously they are 

changing how they do business in Colorado. Just briefly explain to us 

what changes you see that we have made that have been most important. 

 MS. SHEIL. Well, the change is that we will now have to have 

documentation of citizenship and identity to protect the Medicaid 

program’s integrity. There are no changes as far as citizens having to 

declare their citizenship, they have always had to do that, this is just a 

documentation requirement. And we are now holding States financially 

responsible for implementing the provisions of the law. 

 MR. NORWOOD. And now finally doing oversight-- 

 MS. SHEIL. Correct. 

 MR. NORWOOD. --into making sure the States do. Mr. Ortiz, again, I 

know what all you have been doing for Governor Perdue and I want to 

tell you, we from Washington appreciate all of your help and all the good 

works that you are doing. 
142

 Very quickly, now that you are actually verifying citizenship, have 

you run into any particular problems, or has there been this great burden 

on the State of Georgia to try to narrow this down? 

 MR. ORTIZ. I think because the similar work has been done in the 

past for foster kids and you need to remember that Medicaid is a payer of 

last resort, so our eligibility workers already have to check SSI and 

Medicare before they make anybody eligible for Medicaid, so they are 

used to doing this type of work. So this is something that is just an 

enhancement to what they are already doing. And we see it as a 

necessary and responsible thing to do. 

 MR. NORWOOD. I see my time is up, Mr. Chairman. Thank you. 

 MR. DEAL. I want to thank the panel. We appreciate you being here 

today. 

 [Applause.] 

 MR. DEAL. I would like to ask the third panel if they would please 

come forward. 

 While our third panel is coming up, I want to express appreciation to 

the staff here at Northwest Georgia Trade and Convention Center for 

allowing us to hold this field hearing here in their facility today. You are 

very fortunate, we are all very fortunate here in the Dalton area, to have a 

facility of this type and the staff does a great job and I want to thank 

them all for their cooperation in facilitating this event today. 

 All right, we have the third and final panel and it will follow in the 

same distinguished fashion that the two that preceded it did. I will 

introduce them at this time. First of all, Mr. James E. Gardner, who is 

the President and Chief Executive Officer of Northeast Georgia Health 

Systems in Gainesville, Georgia; Mr. Charles Stewart, who is the Chief 

Executive Officer of Hutcheson Medical Center in Fort Oglethorpe, 

Georgia and Mr. Marty Michaels, who is Chair of the Georgia Chapter of 

the American Academy of Pediatricians and he is from Dalton, Georgia. 

 Gentlemen, thank you very much for being here and once again, I 

did not say it in the last panel, but your written testimony is a part of our 

record and we would ask you in your time of 5 minutes if you would 

summarize your testimony and Mr. Gardner, I will begin with you. 

STATEMENTS OF JAMES E. GARDNER, JR., PRESIDENT AND 

CHIEF EXECUTIVE OFFICER, NORTHEAST GEORGIA 

HEALTH SYSTEM, GAINESVILLE, GEORGIA; CHARLES 

STEWART, CHIEF EXECUTIVE OFFICER, HUTCHESON 

MEDICAL CENTER: AND DR. MARTY MICHAELS, 

CHAIR, GEORGIA CHAPTER, AMERICAN ACADEMY OF 

PEDIATRICS 
143

 MR. GARDNER. Mr. Chairman, members of the Committee, thank 

you for inviting me to be with you today. My name is Jim Gardner and I 

am President and Chief Executive Officer of Northeast Georgia Medical 

Center and Health System in Gainesville, Georgia. Very much like 

Dalton, Gainesville is a community with a large Hispanic population. 

Gainesville’s poultry and booming housing industry have attracted both 

legal and illegal immigrants to our community. 

 Before I get to the crux of my comments about how illegal 

immigration affects our medical facility, let me take a moment to defend 

the hard line that I am about to take. 

 At the Medical Center, I am surrounded by people who chose their 

professions because of a genuine and sincere desire to help people. We 

have a remarkable community of nurses and doctors who give of 

themselves completely and without prejudice to their patients. During 

hectic office hours, many of our community physicians volunteer to treat 

indigent patients through the Hall County Medical Society’s Health 

Access Initiative without compensation. After they have worked their 

more than full-time jobs, many of our employees and physicians 

volunteer at the local Good News Clinics where free medical and dental 

services are provided for uninsured people who have no resources to pay 

for services. We had many employees who volunteered for Katrina relief 

efforts during their families’ spring break, and countless employees and 

physicians used personal vacation time to travel the world on mission 

trips to use their medical skills in third world countries. 

 I am very proud of the dedication and compassion of the people I 

work with. I felt a need to say that, because in the current political 

climate, taking a position for any limitation on services to illegal 

immigrants is often painted with a broad brush as cruel and uncaring. 

That would be an unfair representation of the organization I serve and 

represent today. So I just wanted to get that clearly on the table before I 

begin to address how illegal immigration affects our healthcare facility. 

 In Hall County, the number of Hispanics has grown from 1 percent 

in 1980 to just over 24 percent today, according to the 2004 U.S. Census. 

Roughly one in four in Hall County is Hispanic. To identify how many 

illegal immigrants we have is difficult, as you have already heard. But at 

Northeast Georgia Medical Center and in physician offices all over the 

region, providers must cover the expense of bilingual staff to care for 

patients, and print out all forms and educational materials in two 

languages. In 2003, a local study “Healthy Hall” reported that 33 percent 

of all Latinos are uninsured, which represents 60 percent of the uninsured 

in Hall County. Uninsured patients face a huge burden on our health 

system and put our ability to care for the people in our region in 

jeopardy. 
144

 To the community, hospitals look like big business, with big money. 

In realty, our hospital must spend over a million dollars a day to provide 

the care our community needs. Even with our investment income, 

margins have declined in recent years, limiting our ability to care for the 

growing needs of the people of northeast Georgia. Recently, our 

organization made dramatic reductions, including the elimination of 

approximately 300 full time positions that have helped to stop that 

downward trend. However, with projections of continued illegal 

immigration and the inability of many area citizens to obtain health 

insurance, keeping our health system operating in the black remains a 

challenge. 

 The Deficit Reduction Act no longer allows for self-declaration of 

citizenship, but requires verification. This means that every Medicaid 

recipient must prove citizenship to be eligible for Medicaid benefits, but 

not to be eligible to receive emergency medical services. That is a very 

important distinction. The change in verifications only took place in 

July, but we are already seeing the impact on our operations and 

finances. 

 For the crux of my comments, I would like to share a true story of a 

young Latino woman, I will refer to as Maria, who came to our 

emergency room in the last month requesting dialysis. An illegal 

immigrant from Mexico, she had come directly to Gainesville at the 

request of her mother and sister, who both admitted they are living in the 

U.S. illegally. Mexico had requested upfront payment for the young 

woman’s dialysis--funds which the patient did not have. She was told 

that the same would be required in the U.S., but she decided to make the 

journey anyway because her sister had been receiving outpatient dialysis 

in the Gainesville community for the last 2 years. Maria was encouraged 

by her sister to leave Mexico and come to Gainesville for care in spite of 

the fact that the dialysis center had informed her that her care would be 

denied and that Maria should remain in Mexico for treatments. The 

dialysis center referenced is a private outpatient facility and is not owned 

or operated by Northeast Georgia Medical Center. At the time Maria’s 

request for service was made, this dialysis center had 56 patients, 11 of 

which were undocumented immigrants for whom they were receiving no 

reimbursement based on Georgia’s January 2006 implementation of the 

Federal Medicaid rules which excludes Medicaid coverage for chronic 

conditions for non-U.S. citizens. 

 Maria’s condition had become life-threatening by the time she 

arrived in Gainesville and presented in our emergency department for 

care. She had to be admitted by law, also by conscience, until her 

condition could be stabilized. Our staff worked for the next 8 days to 

locate an outpatient dialysis center that would accept her for follow-up 
145

treatment upon her discharge from the hospital. They were in a tough 

place. They were caring, compassionate people whose moral compass 

was spinning. They talked with the distraught mother and sisters, 

contacted the Emory transplant center, the Georgia Medical Foundation, 

three local dialysis centers and the Mexican Consulate trying to find a 

way to secure dialysis treatment for this young woman who would need 

to be dialyzed on average 3 times a week indefinitely. The hospital does 

not provide outpatient dialysis services and all local outpatient providers 

refused to accept this woman as a patient because she had no sources for 

payment that would even cover the cost of her treatments. 

 Maria was dialyzed six times while at our hospital, five of those 

times out of necessity while we waited to find an outpatient provider to 

accept her. The direct cost of her care to Northeast Georgia Medical 

Center was over $9,500, which did not include the time expended by 

case managers and staff on this young woman’s behalf. Medicare and 

Medicaid generally pays about $200 per procedure for basic dialysis 

services provided on an outpatient basis. 

 Based on a recommendation from the Mexican Consulate and with a 

discharge plan approved by her physician, the Health System worked 

with the patient and mother to arrange for the patient’s transport back to 

Mexico. The hospital recommended that the patient’s mother also 

accompany her to help coordinate the care needs. 

 Had Maria been discharged from the hospital without a resource for 

outpatient dialysis, she would have, most assuredly, returned to our 

emergency department or another emergency department within 2 to 3 

days in a life-threatening condition that would have resulted in her 

emergency re-admission to the hospital. 

 The young woman’s hospital care to stabilize her until she was safe 

to travel home cost our organization thousands of dollars which will not 

be reimbursed. The story, however, is heartbreaking. Similar stories 

could be told by staff of hospitals and care centers all over the country. 

 It will no doubt be a rough few years until word spreads that proof of 

citizenship will be required to receive benefits intended for U.S. citizens. 

Years of failing to require proof of citizenship has meant that illegal 

immigrants could come to the U.S. and receive free care, paid for with 

tax dollars, better care at no expense, becoming a magnet to draw the 

chronically sick to an already broken healthcare funding system. 

 To tell the truth, our moral compasses are still spinning. The nurses 

and doctors who cared for this woman will think of her often. Each of us 

has to make personal decisions about what we will do to help the people 

of Mexico and any other Nation that is not as fortunate as the United 

States, or for that matter the poor in our own country. Our Government 

must also make decisions about border control, foreign aid, trade 
146

agreements and ways to strengthen our ability to help our neighbors. But 

the primary purpose of the Medicaid program has always been to provide 

care for U.S. citizens, and without these serious reforms, the system 

simply is doomed to fail. 

 I appreciate the work of this committee to keep the Medicaid 

program viable for United States citizens in need. I respect the difficulty 

of our work and ask for your continued help in providing affordable 

healthcare for the people of our community. 

 Thank you and I stand ready to answer questions. 

 MR. DEAL. Thank you, Mr. Gardner. 

 [Applause.] 

 MR. DEAL. Mr. Stewart. 

 [The prepared statement of James E. Gardner, Jr. follows:] 

PREPARED STATEMENT OF JAMES E. GARDNER, JR., PRESIDENT AND CHIEF EXECUTIVE 

OFFICER, NORTHEAST GEORGIA HEALTH SYSTEM

Mr. Chairman, members of the Committee, thank you for inviting me to be with you 

today. My name is Jim Gardner, and I am president and chief executive officer at 

Northeast Georgia Medical Center and Health System in Gainesville, Georgia. Very 

much like Dalton, Gainesville is a community with a large Hispanic population. 

Gainesville’s poultry and booming housing industry have attracted both legal, and illegal 

immigrants to our community. 

 Before I get to the crux of my comments about how illegal immigration affects our 

medical facility, let me take a moment to defend the hard line that I am about to take. 

 At the Medical Center, I am surrounded by people who chose their professions 

because of a genuine, sincere desire to help people in need. We have a remarkable 

community of nurses and doctors who give of themselves completely and without 

prejudice to their patients. During their hectic office hours, many of our community 

physicians volunteer to treat indigent patients through the Hall County Medical Society’s 

Health Access Initiative without compensation. After they have worked their more-thanfulltime jobs, many of our employees and physicians volunteer at the local Good News 

Clinics where free medical and dental services are provided for uninsured people who 

have no resources to pay for services. We had many employees who volunteered for 

Katrina relief efforts during their families’ Spring Break, and countless employees and 

physicians use personal vacation time to travel the world on mission trips to use their 

medical skills in third world countries. 

 I am very proud of the dedication and compassion of the people I work with. I felt a 

need to say that, because in the current political climate, taking a position for any 

limitation on services to illegal immigrants is often painted with a broad brush as cruel 

and uncaring. That would be an unfair representation of the organization I serve and 

represent today. So I just wanted to get that clearly on the table before I began to address 

how illegal immigration affects our healthcare facility. 

 In Hall County, the number of Hispanics has grown from one percent in 1980 to just 

over 24 percent today, according to the 2004 U.S.Census. Roughly one in four people in 

Hall County is Hispanic. To identify exactly how many illegal immigrants we have is 

very difficult. But at Northeast Georgia Medical Center and in physician offices all over 

the region, providers must cover the expense of bilingual staff to care for patients, and 

print all forms and educational materials in two languages. In 2003, a local study 

“Healthy Hall” reported that 33 percent of all Latinos are uninsured, which represents 60 
147

percent of the uninsured in Hall County. Uninsured patients place a huge financial 

burden on our health system and put our ability to care for the people of our region in 

jeopardy. 

 To the community, hospitals look like big business, with big money. In reality, our 

hospital must spend over a million dollars a day to provide the care our community 

needs. Even with our investment income, margins have declined in recent years, limiting 

our ability to care for the needs of the people of northeast Georgia. Recently, our 

organization made dramatic cost reductions that have helped stop the downward trend. 

However, with projections of continued illegal immigration and the inability of many 

area citizens to obtain health insurance, keeping our health system operating in the black 

remains a challenge. 

 The Deficit Reduction Act no longer allows for self-declaration of citizenship, but 

requires verification. This means that every Medicaid recipient must prove citizenship to 

be eligible for Medicaid benefits, but not to be eligible to receive emergency medical 

services. The change in verification requirements only recently took effect July 1 but 

already we are seeing its impact on our operations and finances. 

Let me share the true story of a young Latino woman I will refer to as “Maria,” who 

came to our emergency room requesting dialysis. An illegal immigrant from Mexico, she 

had come directly to Gainesville at the request of her mother and sister, who both 

admitted they are living in the U.S. illegally. Mexico had requested upfront payment for 

the young woman’s dialysis – funds which the patient did not have. She was told that the 

same would be required in the U.S., but she decided to make the journey anyway because 

her sister has been receiving out-patient dialysis in the Gainesville community for the 

past two years. “Maria” was encouraged by her sister to leave Mexico and come to 

Gainesville for care in spite of the fact that the Dialysis Center had informed her that care 

here would be denied and that “Maria” should remain in Mexico for treatments. The 

Dialysis Center referenced is a private out-patient facility that is not owned or operated 

by Northeast Georgia Medical Center. At the time “Maria’s” request for services was 

made, this dialysis center had 56 patients, 11 of which were undocumented immigrants 

for whom they were receiving no reimbursement based on Georgia’s January 2006 

implementation of Federal Medicaid rules which excludes Medicaid coverage of chronic 

conditions for non U.S. citizens. . 

 Maria’s condition had become life-threatening by the time she arrived in Gainesville 

and presented in our emergency department for care. She had to be admitted by law, but 

also by conscience, until her condition could be stabilized. Our staff worked for the next 

eight days to locate an outpatient dialysis center that would accept her for follow-up 

treatment upon her discharge from the hospital. They were in a tough place: caring, 

compassionate people whose moral compasses were spinning. They talked with the 

distraught mother and sisters, contacted the Emory transplant center, The Georgia 

Medical Foundation, three local dialysis centers and the Mexican Consulate trying to find 

a way to secure dialysis treatment for this young woman who would need dialysis on 

average three times a week, indefinitely. The hospital does not provide outpatient 

dialysis services and all local outpatient providers refused to accept the young woman as 

a patient because she had no sources for payment that would even cover the cost of her 

treatments. 

 “Maria” was dialyzed 6 times while in our hospital—5 of those times out of 

necessity while we waited to find an outpatient provider to accept her. The direct cost of 

her care to Northeast Georgia Medical Center was over $9,500, which did not include the 

time expended by case managers and other staff on this young woman’s behalf. 

Medicare and Medicaid generally pays about $200 per procedure for basic dialysis 

services provided on an outpatient basis. 

Based on the recommendation from the Mexican Consulate and with a discharge 

plan approved by her physician, the Health System worked with the patient and mother to 
148

arrange for the patient’s transport back to Mexico. The hospital recommended that the 

patient’s mother accompany her to help coordinate the care she needs. 

Had “Maria” been discharged from the hospital without a resource for outpatient 

dialysis, she would have, most assuredly, returned to our emergency department or 

another nearby emergency department in 2-3 days in a life-threatening condition that 

would have resulted in her emergency re-admission to the hospital. 

 The young woman’s hospital care to stabilize her until she was safe to travel home 

cost our organization thousands of dollars which will not be reimbursed. The story is 

heartbreaking. Similar stories could be told by staff of hospitals and care centers all over 

the country. 

 It will no doubt be a rough few years, until word spreads that proof of citizenship 

will be required to receive benefits intended for U.S. citizens. Years of failing to require 

proof of citizenship has meant that illegal immigrants could come to the U.S. and receive 

free care, paid for through tax dollars. Better care, at no expense... a magnet to draw 

chronically sick people to our already broken healthcare funding system. 

 To tell you the truth, our moral compasses are still spinning. The nurses and doctors 

who cared for this young woman will think of her often. Each of us must make personal 

decisions about what we will do to help the people of Mexico and any other nation that is 

not as fortunate as the United States and for that matter the poor in our own country. Our 

government must also make decisions about border control, foreign aid, trade agreements 

and ways to strengthen our ability to help our neighbors. But the primary purpose of the 

Medicaid program has always been to provide care for U.S. citizens, and without these 

serious reforms, the system simply is doomed to fail. 

 The verification component of the deficit reduction act will only work if healthcare 

providers enforce the law, even though enforcement will often require tough actions. 

 I appreciate the work of this committee to keep the Medicaid program viable for 

United States citizens in need. I respect the difficulty of your work and ask for your 

continued help in providing affordable healthcare for the people of our community. 

Thank you. 

 MR. STEWART. Good morning, Mr. Chairman and members of the 

committee. My colleague Mr. Gardner spoke of the impact of illegal 

aliens on the Gainesville community and I am very pleased to be here 

today to discuss the impact that illegal immigration is having on the 

Medicaid program and our health delivery system as a whole. I also 

wish to thank you, Chairman Deal, members of the committee, members 

of the Georgia legislature, and others for taking time to come to Dalton 

to address this important issue. 

 Since 1953, Hutcheson Medical Center has been northwest Georgia’s 

community hospital. We are a 300-bed healthcare system with a 

commitment to provide access to quality, cost-effective healthcare to our 

growing population. 

 Being one of the largest community hospitals in Georgia, Hutcheson 

Medical Center has over 1,300 employees with more than 200 physicians 

and over 400 registered nurses and clinical staff. Our primary service 

area includes Catoosa, Dade, and Walker Counties with more than 

137,000 residents. 

 Let me begin by saying that I share the committee’s concern about 

the Nation’s need to secure our borders. As you are aware, 
149

undocumented aliens’ use of medical services had been a longstanding 

issue for hospitals. As required by Federal law--the Emergency Medical 

Treatment and Labor Act or EMTALA--hospitals participating in 

Medicare must provide emergency medical services for all patients who 

seek care, regardless of their ability to pay. Under EMTALA, hospitals 

must provide an appropriate medical screening examination for 

individuals who seek emergency care in a hospital emergency 

department. 

 If an individual is found to have an emergency medical condition, 

the hospital must treat and stabilize the medical condition, or transfer the 

patient under certain circumstances. Additionally, if an individual’s 

medical condition is not stable, the hospital may not transfer him or her 

unless the individual or someone acting on their behalf, requests the 

transfer, and the transfer is appropriate under EMTALA. Since hospitals 

are required to evaluate and treat all patients who seek care in hospital 

emergency departments, EMTALA, in effect, requires hospitals to 

provide free care for some patients, regardless of their condition or their 

citizenship status. This raises the concern that while we are treating the 

illegal immigrant population, how many Georgia citizens are not getting 

the quality treatment they require? 

 As Congressman Deal pointed out earlier, it costs approximately 

$340 to care for a non-emergency patient in the emergency department 

while it costs less than $75 to care for the same patient in a clinic. That 

means that over four people can be treated in a clinic for less money than 

one person can be seen in the emergency department. And, according to 

the Georgia Department of Community Health, 41.3 percent of ER visits 

were for non-emergencies on Mondays through Fridays from 8:00 a.m. 

until 5:00 p.m., which is when most physician offices and clinics are 

open. At Hutcheson Medical Center, we have seen our uncompensated 

care increase by a million and a half dollars just in this fiscal year alone. 

 Another issue the hospitals face in emergency departments is the 

growing number of births to illegal aliens. It is documented that in some 

States, more than half of emergency Medicaid expenditures were for 

labor and delivery services. Our current law provides that babies who 

are born on U.S. soil to illegal immigrants are to become immediately 

recognized as citizens; and thereby ultimately drive up the cost of 

healthcare, especially in those States with the highest estimated illegal 

populations, of which Georgia is a part. The question arises, how long 

are providers obligated to care for these newborns? 

 Additionally, there is concern that Title II, Sections 201 and 202 of 

H.R. 4437, if enacted, will place hospitals and caregivers at risk for 

violating provisions of the Immigration and Nationality Act. While I 

believe that it is not the intent of Congress to criminalize providers who 
150

are just trying to provide quality care to their patients, some of the 

language is broadly worded, and at the very least, creates a Catch 22 for 

hospitals and providers that seek reimbursement under Section 1011 of 

the Medicare Modernization Act. In order to receive reimbursement, 

they must acknowledge that they have rendered treatment to an 

individual who is an undocumented alien. 

 Thank you again for giving me the opportunity to comment on this 

very important issue. I appreciate all of your service to our country and 

our State, and I am available for questions as well. 

 MR. DEAL. Thank you. Dr. Michaels. 

 [The prepared statement of Charles Stewart follows:] 

PREPARED STATEMENT OF CHARLES STEWART, CHIEF EXECUTIVE OFFICER, HUTCHESON 

MEDICAL CENTER

Good Morning, Mr. Chairman and members of the committee, my name is Charles 

Stewart and I am the Chief Executive Officer of the Hutcheson Medical Center in Ft. 

Oglethorpe, Georgia. I am very pleased to be here today to discuss the impact that illegal 

immigration has on the Medicaid program and our health delivery system as a whole. I 

also wish to thank you, Chairman Deal, members of the Committee, members of the 

Georgia Legislature, and other witnesses for taking the time to come to Dalton to address 

this important issue. 

Since 1953, Hutcheson Medical Center has been Northwest Georgia’s community 

hospital. We are a 300-bed health care system with a commitment to provide access to 

quality, cost effective healthcare to our growing population. 

Being one of the largest community hospitals in Georgia, Hutcheson Medical Center 

has over 1300 employees, with more than 270 physicians and over 400 registered nurses 

and clinical staff. Our primary service area includes Catoosa, Dade and Walker counties 

with more than 137,000 residents. 

Let me begin by saying that I share the committee’s concerns about the nation’s 

need to secure its penetrable borders. As you are aware, undocumented aliens’ use of 

medical services has been a longstanding issue for hospitals. As required by federal law - 

the Emergency Medical Treatment and Labor Act (EMTALA) - hospitals participating in 

Medicare must provide emergency medical services for all patients who seek care, 

regardless of their ability to pay. Under EMTALA, hospitals must provide an appropriate 

medical screening examination for individuals who seek emergency care in a hospital 

emergency department. 

If an individual is found to have an emergency medical condition, the hospital must 

treat and stabilize the medical condition, or transfer the patient under certain 

circumstances. Additionally, if an individual’s medical condition is not stable, the 

hospital may not transfer him or her unless the individual, or someone acting on their 

behalf, requests the transfer, and the transfer is appropriate under EMTALA. Since 

hospitals are required to evaluate and treat all patients who seek care in hospital 

emergency departments, EMTALA in effect requires hospitals to provide free care for 

some patients regardless of their condition or their citizenship status. This raises the 

concern that while we are treating the illegal immigrant population, how many Georgia 

citizens are not getting the quality treatment they require? 

Meanwhile, it costs approximately $340 to care for a non-emergency patient in the 

emergency department while it costs less than $75 to care for the same patient in a clinic. 

That means over four people can be treated in a clinic for less money than one person can 
151

be seen in the emergency department. And, according to the Georgia Department of 

Community Health, 41.3% of ER visits were for non-emergencies on Mondays through 

Fridays from 8:00 a.m. until 5:00 p.m., which is when most physician offices and clinics 

are open. 

Another issue that hospitals face in emergency departments is the growing number 

of births to illegal aliens. It is documented that in some states, more than half of 

emergency Medicaid expenditures were for labor and delivery services. Our current law 

provides that babies who are born on U.S. soil to illegal immigrants are to become 

immediately recognized as citizens; and, thereby ultimately drive up the cost of 

healthcare, especially in those states with the highest estimated illegal populations of 

which Georgia is a part. The question arises how long are providers obligated to care for 

these newborns? 

Additionally, there is a concern that Title II, Sections 201 and 202 of H.R. 4437, if 

enacted, will place hospitals and caregivers at risk for violating provisions of the 

Immigration and Nationality Act (INA). While I believe that it is not the intent of 

Congress to criminalize providers who are just trying to provide quality care to their 

patients, some of the language is broadly worded, and at the very least, creates a “Catch 

22” for hospitals and providers that seek reimbursement under section 1011 of the 

Medicare Modernization Act: in order to receive reimbursement, they must acknowledge 

that they have rendered treatment to an individual who is an undocumented alien. 

Thank you, again, for giving me the opportunity to comment on this very important 

topic. I appreciate your service to our great Country and State, and am happy to answer 

any questions you or members of the Committee may have. 

 MR. MICHAELS. Thank you, Mr. Chairman. Stop me if I am not 

supposed to do this, but I would like to thank the Congressmen and 

Congresswoman on the panel, Chairperson Deal, I would like to thank 

you personally for the time that you have taken in talking with me over 

the last year about children’s healthcare issues and, Mr. Clark, I would 

like to thank you for the same. I have felt that I was listened to and I do 

feel that you are attuned to the important needs of children and I thank 

you for that and your leadership. 

 MR. DEAL. You can say that a long time. Thank you. 

 [Laughter.] 

 MR. MICHAELS. Congressman Norwood, I would like to thank you 

for your support on position issues with Steadfast, and I am glad to see 

that you are looking very well. 

 And Congresswoman Solis, I appreciate your advocacy for children, 

especially children of low-income families. So thank you for that. 

 I will be speaking today from my notes. This testimony is filed by 

the American Academy of Pediatrics. I will not be reading from this but 

this needs to be part of the official record because this states the official 

position of the American Academy of Pediatrics. 

 MR. DEAL. Without objection, that will be made part of the record. 

 MR. MICHAELS. Thank you, sir. 

 And my comments generally do reflect the opinion of the American 

Academy of Pediatrics, but there will be some personal comments that 

have not been discussed by the American Academy of Pediatrics, so this 
152

should not be construed as the official position of the American 

Academy. 

 My name is Martin Michaels, I am a primary care pediatrician. I am 

President of the Georgia Chapter of the American Academy of Pediatrics 

and I am the founding partner of Peachcare P.C., which is medium-sized 

general pediatric practice in Dalton, Georgia. I am grateful for the 

opportunity to testify to the Health Subcommittee today in Dalton. 

 I will be focusing my comments on the impact of illegal immigration 

on the Medicaid Program and our healthcare delivery system, as it relates 

to the healthcare and the health status of children of illegal immigrants 

who live in the United States. 

 The definition for children for me is ages 0 to 18 years, for today’s 

discussion. 

 A little bit about my practice and experience, I am a pediatrician who 

has practiced in northwest Georgia since 1984. When I began in 

practice, I had a lot more hair and the percent of children covered by 

Medicaid at that time in my practice was about 20 percent, and there was 

no SCHIP program at that time. There were very few immigrants in 

Dalton at that time. There was a large group of uninsured children and 

under-insured children and a minority of the children in my practice had 

a true medical home. 

 Early in my career, I saw first-hand the suboptimal outcomes and 

complications occurring because of the lack of medical home for a large 

number of children and the large majority of these children were 

Caucasian children, I had very few foreign born children in my practice 

at that time. 

 In our practice, we place a strong emphasis on providing a medical 

home for all our patients. A medical home is a place where the patient 

and family are known by the providers, where the families have a 

trusting relationship with the providers and comprehensive preventive 

and acute care is available in a timely and continuous way. A 

permanent, complete, ongoing medical record exists in the medical 

home. Parents preferentially seek care in their medical home rather than 

the ER for many reasons. 

 My practice accepts all children without regard for ability to pay. 

We have never used a collection agency and we never will. If a family 

calls and says they have good insurance or bad insurance, Medicaid, 

Peachcare or no insurance and no money, we will still see the child. 

 When looking at the issue of healthcare for children of immigrants, 

illegal and legal, it is important to remember that we are talking about 

individual families and individual children. This is not a faceless mass 

from any one country. I have seen immigrants in Dalton from every 

continent of the world except for Antarctica. Within the primarily 
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Spanish speaking population in Dalton, there is huge diversity. There are 

families from South America, Central America, Mexico, and Cuba. Each 

of these families is unique and different, just as each white and AfricanAmerican family is unique and different. 

 I want to talk a little bit about focusing on children. I am sure that no 

one on any of these panels, the three panels that have spoken, the panel 

of Congressmen and women, the folks in the audience--I do not think 

that anybody here wants to intentionally or unintentionally hurt children. 

I think either we have children, we have grandchildren, we have friends 

that have children, nieces, nephews--none of us wants to intentionally or 

unintentionally hurt a child. 

 Remember that children do not have a choice in what we are talking 

about today. They are innocent of wrongdoing and they find their 

healthcare availability subject to decisions made by adults, adult 

legislators, adult employers, and adult parents. Adult legislators make 

decisions about immigration policies, border entry, regulation, level of 

enforcement of policies in the interior of the Nation, in the workplace 

and in the community. Adult immigrants make decisions about whether 

to bend or break the rules. Adult employers make decisions about 

whether to bend or break the rules. 

 As a pediatrician, I have witnessed first-hand complications that 

occur when primary healthcare is not accessible to children, and it is my 

position that all children who reside in the United States should have 

equal access to quality healthcare directed by a medical home. This 

includes children of documented immigrants, some of whom were born 

in other countries and some who were born in the United States, and 

children of undocumented immigrants, some who were born in other 

countries and some who were born in the United States. Foster children, 

newborns, children affected by disasters such as Hurricane Katrina, 

Native American Indian children, all must have immediate presumptive 

eligibility upon application to avoid disastrous and expensive health 

outcomes due to lack of access to appropriate primary care. 

 I will say as a sidebar, one of the panelists mentioned that State 

agencies have more information than anyone else about foster children. 

But just to give you an example from the front lines, when a foster child 

comes to my office for the first time, I do not have immunization 

records, I do not know if that child is allergic to anything, I do not know 

if that child has seen a specialist, I have pretty much zilch. And it is a 

big problem. We are working on it in Georgia, the officials in Georgia 

are aware of this, it is not that it has not been talked about, but it has not 

gotten better. We have been talking about that for years. So if we think 

that they are going to be able to figure out documentation for eligibility 
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in a time efficient way, I would predict not. And I do not mean that in an 

ugly way, I just mean that in a practical way. 

 Also, any policies about documentation of citizenship must take into 

account the healthcare literacy level of the population served and must be 

geared at a low enough educational level that the clients can reasonably 

carry out the requirements of the policy. I have not heard anybody say 

anything about healthcare literacy today, but that is a term in the 

literature and you need to look at examples of different levels of 

healthcare literacy, what it takes to figure out a Social Security card, 

what it takes to get a birth certificate. These are levels of functioning 

that may be above the levels of many of the parents that I see. 

 When children do not have access to medical homes, the resulting 

costs are human health costs and suffering for the immigrant child, 

adverse health consequences for the community, not just for the child, 

but contractible diseases that the community is exposed to because of 

lack of primary care for the immigrant child, increased unreimbursed 

costs for hospitals and for physicians and other providers, increased taxes 

and increased healthcare premiums for the community because care 

outside of the medical home is very expensive. 

 I want to make a comment about virtual barriers to care. Virtual 

barriers to care must be avoided. These are roadblocks whose intent is to 

make it more difficult to get care to which an individual is otherwise 

legally entitled. Setting up virtual barriers to care for children is 

becoming rampant in my experience in our healthcare system and it is 

unethical. Requiring the parents of a newborn or foster child to bring in 

a birth certificate before they can get Medicaid benefits is a virtual 

barrier to care and one that will result in expensive medical 

complications and ER visits. 

 I want to talk a little bit about spending our limited healthcare 

dollars, and Mr. Deal and Mr. Clark, you and I have talked about this. I 

think you know that I understand it is not a bottomless pit of dollars that 

we have to spend, I understand that very clearly and I have made 

individual efforts to learn about that and how to cut those costs in a good 

way. There are economic, moral, and ethical aspects to how we spend 

our healthcare dollars. Our healthcare dollars are limited, they are 

precious, they must be used wisely and not wasted. 

 Children are not breaking the bank of Medicaid nationally or in 

Georgia. Seventy percent of the recipients of Medicaid are children, but 

they only account nationally for 30 percent of the cost. And in Georgia, 

that break is even bigger, as I understand it. 

 The other specific I want to share from Georgia is that between 2000 

and 2005, the cost of Medicaid and SCHIP for Georgia, combined State 

and Federal expenditures, increased from $3.5 billion in 2000 to $6.5 
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billion in 2005. That is an alarming looking number. But it is very 

important to remember that the number of enrollees went from 970,000 

in 2000 to 1.5 million in 2005, there was an increase of 150 percent in 

the number of enrollees. 

 And Mr. Norwood, just to go back to the comment about Georgia 

being a deficit State for Peachcare, I think it would be important to look 

and see if the deficit is really there in terms of members served per--

amount paid per member per year. Because I suspect that what happened 

there is we had such a huge increase in enrollment, and that was due to 

the leadership of the Department of Community Health in doing a great 

job of enrolling kids. Georgia back in 2000-2001 was the poster state for 

the SCHIP program, we were doing great. And I think Deanna Key at 

that time, who was the membership person at DCH, did an outstanding 

job and got kids signed up quickly that were eligible, and therefore, 

Georgia spent more money. But I think it is real important to look at the 

per member per year cost to make sure we are really a deficit state. I 

think other States received more money than they were supposed to and 

did not sign up as many kids, and I think they owe us some back, is the 

way I understand it. I may be wrong on that, but I think that is correct. 

 And in summary of that, I want to say that the increased per member 

per year in Georgia for kids between 2000 and 2005, per member per 

year, was 2.5 percent. The inflation rate I believe between 2000 and 

2005 averaged over 2.5 percent and I know of no other healthcare system 

that did not increase faster than the rate of inflation. If there is, I would 

like for somebody to tell me where that was. 

 So Georgia had a very successful, in my opinion, healthcare 

expenditure during those 5 years. Why? Because all those children in 

the Georgia program were assigned to a medical home. That is my 

opinion about why that increase was so low, and it was called Georgia 

Better Healthcare, it was a primary care case management system and 

kids could not be in the system without a primary care provider. 

 Creating barriers to access to care for children is neither moral or 

ethical. It will not save significant healthcare dollars. It will adversely 

affect the health of children who do not have access to care. It will 

adversely affect the health of our Dalton, Whitfield, Murray 

communities. It will adversely affect our State’s vital statistics. I am 

really sorry to say, Mr. Norwood and Mr. Deal, that our infant mortality 

rates and our neonatal mortality rates in Georgia are among the lowest in 

the country. We are number 44 and number 45 out of 50 States in 

neonatal mortality and infant mortality. And I am not saying that in an 

accusatory way, I am saying that we need to do something about that. 

The doctors have talked about that for many years, it is something that 

needs to improve. A lot of it has to do with socio-economic factors, but 
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the fact is not providing access to care for legal or illegal immigrants will 

put us down from 45, we may end up below Alabama and Mississippi, 

States that are at the bottom of the list. 

 To make things a little bit more upbeat, our immunization rate in 

Georgia is actually number four in the country, we are fourth in the 

country in fully immunized 3-year olds. Why? Because our Vaccine for 

Children program in Georgia covers uninsured and under-insured 

children. If we do not continue access to care for immigrants, illegal, 

legal, if we make those barriers to care there, our immunization rate is 

going to plummet and I think when industries look to see what State they 

want to locate in, they look at healthcare indicators and for children, in 

my experience, immunization rates, neonatal mortality, infant mortality 

are three top indicators that people look at. 

 MR. DEAL. Dr. Michaels, would you summarize for us, please, sir? 

 MR. MICHAELS. Yes, sir. How to save healthcare dollars. Wasting 

healthcare dollars is immoral. The right way to save money in the 

healthcare system is to study utilization and outcomes and how these two 

are linked. We must have excellent outcomes for all children, we must 

find the most cost-effective way to reach those outcomes, identify best 

practices, and then require mandatory non-onerous, non-punitive review 

of profiling in practice patterns by practicing providers and require 

mandatory non-punitive education about cost-effective ways to achieve 

the best outcomes. This type of model could be called PFE, Pay for 

Education, and it can be implemented in a more fair way than Pay for 

Performance. 

 Medical homes save healthcare dollars. All children residing in the 

United States should receive care in a medical home. Practical 

examples, to minimize ER visits. Our practice, which is a medical home, 

pays $24,000 a year for a 24-hour telephone triage system, so our 

patients do not go to the ER before they call that number. They go 

through a very safe protocol which is handled over the phone by a 

registered nurse. And if they are told to go to the ER, they go. If they 

are told to give Tylenol and see us in the morning, they do that. Our 

low-income families abide by those suggestions. And that is a 

suggestion I have about EMTALA. I would suggest the Federal 

government figure out a way to require telephone triage of children 

through a safe pediatric telephone triage system such as that of Dr. 

Barton Schmidt in Colorado. 

 In summary, the recommendations of the American Academy of 

Pediatrics--and this will just take 45 seconds I think to sum up. Our 

mission statement is to attain optimal physical, mental, and social health 

and well being for all infants, children, adolescents, and young adults. 

Thereby, the official recommendations of the American Academy of 
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Pediatrics are that CMS should confirm with the States that newborns are 

considered eligible for Medicaid coverage. 

 Paperwork should not delay payment for services provided to 

newborns. Eligibility for newborns should be presumptive. 

 The deemed sponsor rule should be changed so that immigrant 

children are not denied access to insurance and, by extension, quality 

healthcare. 

 Community resources should be pooled to address unpaid care 

provided by pediatricians to immigrant children. 

 Outreach efforts to enroll children who do qualify for Medicaid and 

SCHIP but who are not currently enrolled should be expanded. 

 Payment policies should encourage the establishment of a medical 

home for all children residing in the United States. The medical home, 

since it saves dollars in decreased referrals, ER use, and hospitalization, 

should be recognized as a scorable element in the healthcare budget 

process. And a case management fee is one mechanism to have a 

payment policy that will encourage the establishment of a medical home. 

 Finally in 15 seconds, the Marty Michaels recommendations which 

are not the official position of the American Academy of Pediatrics are: 

 That all children residing in the United States should have a medical 

home. 

 Cost savings should be achieved by finding ways to spend healthcare 

dollars effectively through improved utilization and outcomes derived 

from a Pay for Education model. 

 And lastly, policies regarding documentation of citizenship should 

not create virtual barriers to healthcare for children. 

 Thank you to the Committee and the community for listening; thank 

you all in advance for working proactively to develop policies that 

ensure that all children residing in the United States have a medical home 

and access to needed preventive and acute healthcare. Together we can 

provide appropriate care for all children residing in the United States 

while preserving precious United States healthcare dollars. 

 [Applause.] 

 [The prepared statement of Marty Michaels follows:] 

PREPARED STATEMENT OF DR. MARTY MICHAELS, CHAIR, GEORGIA CHAPTER, AMERICAN 

ACADEMY OF PEDIATRICS

The American Academy of Pediatrics (AAP) is an organization of 60,000 primary 

care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists, who 

are deeply committed to protecting the health of children, adolescents and young adults in 

the United States. Our testimony in today’s Hearing, “Examining the Impact of Illegal 

Immigration on the Medicaid Program and Our Healthcare Delivery System,” will focus 

on children, the innocent victims of illegal immigration. 
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Children, whether they are undocumented or not, need care in our communities. 

Most immigrant children’s care should be preventive, but too often, that care is foregone. 

Comprehensive, coordinated, and continuous health services provided within a medical 

home should be integral to all efforts on behalf of immigrant children. Children need and 

deserve access to care, and communities benefit when they receive it. 

Unfortunately, immigrant children often do not receive the care they need because 

of federal, state and local laws limiting payment for their care, or a generalized belief that 

if children seek care, their families or loved ones may become the target of law 

enforcement. 

AAP believes that barriers to access, such as the recent promulgation of rules by the 

Centers for Medicare and Medicaid Services requiring Medicaid recipients to document 

citizenship and identification, will harm the health of the children in our country and the 

communities they live in. 

Immigrant Children

One in every five American children is a member of an immigrant family. About 

one-third of the nation’s low-income, uninsured children live in immigrant families. 

Children of immigrants, often racial or ethnic minorities, experience significant health 

disparities. These disparities arise because of complex and often poorly understood 

factors, many of which are worsened by the circumstances of their lives. Although these 

children have similar challenges with regard to poverty, housing, and food, significant 

physical, mental, and social health issues may exist that are unique to each individual 

child. 

Children of immigrants are more likely to be uninsured and less likely to gain access 

to health care services than children in native families. Socioeconomic, financial, 

geographic, linguistic, legal, cultural, and medical barriers often limit these families from 

accessing even basic health care services. Once care is available, communication barriers 

often result in immigrant children receiving lower-quality services. Many immigrant 

families also have varied immigration statuses that confer different legal rights and affect 

the extent to which these families are eligible for public programs such as SCHIP, the 

State Children’s Health Insurance Program, and Medicaid. Thus, the immigration status 

of children in the same family may differ. As a result, a foreign-born child may be 

ineligible for insurance coverage, while his or her younger, U.S.-born sibling is eligible 

as a native citizen. 

Each immigrant’s experience is unique and complex but certain overarching health 

issues are common in caring for immigrant families. Immigration imposes unique

stresses on children and families, including: 

• depression, grief, or anxiety associated with migration and acculturation;

• separation from support systems;

• inadequate language skills in a society that is not tolerant of linguistic 

differences;

• disparities in social, professional, and economic status between the country of 

origin and the United States; and

• traumatic events, such as war or persecution, that may have occurred in their 

native country. 

The health of immigrant children not only impacts the child, it impacts the entire 

community. Preventive care commonly provided to children born in the United States 

will often not be available to children of immigrants. Left untreated, the health issues 

caused by this lack of prevention cause immigrant families to seek care for their children 

in emergency settings. Children commonly present with worse health status in the 

emergency room than if they had received preventive care. 
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Beyond the health status of the child, communities should also care about the health 

of the children who live in them because immigrant children may have diseases that are 

rarely diagnosed in the United States. Left untreated, these diseases may be passed on to 

the communities in which immigrant children reside. In addition, many foreign-born 

children have not been immunized adequately or lack documents verifying their 

immunization status. Dental problems are also common among immigrant children. 

The measles vaccine is an example of the importance of prevention for 

communities. Measles is a highly infectious viral disease that can cause a rash, fever, 

diarrhea and, in severe cases, pneumonia, encephalitis and even death. Worldwide, it 

infects some 30 million people and causes more than 450,000 deaths a year. In the 

United States, measles was once a common childhood disease, but it had been largely 

eliminated by 2000. Nevertheless, an outbreak of measles occurred in Indiana last year. 

A 17-year-old unvaccinated girl who visited an orphanage in Romania on a church 

mission picked up the virus there. 

When the girl returned, she attended a gathering of some 500 church members that 

included many other unvaccinated children. By the time the outbreak had run its course, 

34 people had become ill. Three were hospitalized, including one with life-threatening 

complications. Clearly, communities should care about the health of those who reside in 

them.

Federal and State Health Programs for Immigrants

One of the most important risk factors for lack of health coverage is a child’s family 

immigration status. Some children in the United States are ineligible for Medicaid and 

SCHIP because of immigrant eligibility restrictions. Many others are eligible but not 

enrolled because their families encounter language barriers to enrollment, are confused 

about program rules and eligibility status, or are worried about repercussions if they use 

public benefits. 

The vast majority of immigrant children meet the income requirements for eligibility 

for Medicaid or the State Children’s Health Insurance Program (SCHIP), but for various 

reasons are not enrolled. Medicaid and SCHIP are not available to most immigrant 

children because of eligibility restrictions imposed by various federal laws. Two 

examples include the sponsor deeming rule and the recently promulgated citizenship and 

identification documentation requirements. 

While qualified immigrants can become eligible to receive federal benefits after five 

years of U.S. residency, secondary rules often interfere with their access to benefits, such 

as the “sponsor deeming” rule. Current law requires that people who immigrate through 

family “sponsors” may have their sponsors’ income counted in determining eligibility. 

This rule applies even if the sponsor lives in a separate household and does not actually 

contribute to the immigrant’s financial support. Sponsor deeming has made a majority of 

low-income immigrants ineligible for benefits, even after five years have passed. 

Moreover, if an immigrant uses certain benefits, including Medicaid and SCHIP, his or 

her sponsor can be required to repay the government for the value of the benefits used 

until the immigrant becomes a citizen or has had approximately 10 years of employment 

in the United States. Together, these requirements impose significant barriers to securing 

health coverage, even when immigrant children are otherwise eligible. 

Immigrant children who used to qualify based on certifications as to their immigrant 

status now may not qualify because of changes contained in the Deficit Reduction Act. 

These changes require that Medicaid applicants, who would otherwise qualify, must now 

also provide documentation such as a passport or original birth certificate to verify their 

citizenship status and identity. While designed to weed out fraud and abuse from the 

system, AAP has already received information that the rule has limited access to care for 

poor children who would otherwise qualify for Medicaid. An extreme example of this 
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can be found in new rules denying coverage for children born in the United States to 

undocumented mothers. 

According to these new rules, newborns may not be eligible for Medicaid until 

strenuous documentation requirements have been satisfied. Hospital records may not be 

used in most cases to prove that children are citizens, even though the child was born in 

the hospital providing care and are, by definition, citizens. Thus, care for some citizen 

newborns may not be paid for by Medicaid because paperwork documenting their status 

is not yet available. Pediatricians treating these citizen newborns whether they are lowbirthweight, have post-partum complications, or simply need well-baby care, may not be 

paid. This result is completely unnecessary because the child will eventually qualify for 

Medicaid benefits as a result of where he or she was born. 

Recommendations

Lawmakers should be aware of and sensitive to the onerous financial, educational, 

geographic, linguistic, and cultural barriers that interfere with achieving optimal health 

statusfor immigrant children. This awareness should translate into: 

• CMS confirming with states that newborns are presumed eligible for Medicaid 

coverage. Paperwork should not delay payment for services provided to 

resident newborns. 

• The deemed sponsor rule should be changed so that immigrant children are not 

denied access to insurance, and by extension, quality health care. 

• The pooling of community resources to address unpaid-for care provided by 

pediatricians to immigrant children. Undocumented children receive care from 

pediatricians. Communities benefit from the provision of this care. 

Communities should not expect pediatricians alone to provide the resources 

needed to furnish this care. 

• Encouraging payment policies to support the establishment of a medical home 

for all children residing in the United States. Comprehensive, coordinated, and 

continuous health services provided within a medical home should be integral to 

all efforts on behalf of immigrant children. In addition, the establishment of a 

medical home should be a “scorable element” for children, as the medical home 

will have the effect of providing care for children away from the emergency 

room in many instances. 

• Outreach efforts for children who are potentially eligible for Medicaid and 

SCHIP but not enrolled, simplified enrollment for both programs, and state 

funding for those who are not eligible for Medicaid or SCHIP. The Medicaid 

reciprocity model, which allows Medicaid recipients in one state to qualify for 

services in another state without reestablishing eligibility, is an example of a 

model that enables underserved families to access health benefits more easily. 

In closing, the American Academy of Pediatrics seeks to ensure that Congress keeps 

in mind the children we care for as it considers restructuring immigration law. 

Pediatricians and a host of other health professionals provide care to children throughout 

the United States. We must not compromise children’s health in the name of reform. 

 MR. DEAL. Thank you, thank you all. 

 My observation is that all three of you have established the primary 

reason why we should secure our borders. And that is, you are having to 

deal with the effects of our not doing so. And Dr. Michaels, certainly the 

empathy that you display for your patients and for children in general is 

exemplary. 
161

 But we should not be putting you in that position and we should not 

be putting the hospitals in the position of having to determine whether 

somebody is legal, illegal, et cetera. The security of our border will go a 

long way toward relieving that burden that is being placed on you. 

 And since we have come so close to other legislative issues that are 

not really the thrust of this hearing, let me mention a few. You 

mentioned about immunization records. Hopefully, the Health IT bill 

that we have all worked on, and hopefully we will see finalized, will go a 

long way toward providing that seamless flow of information. And the 

other general category that is not directly involved here and that is a bill 

that I am the sponsor of of terminating birthright citizenship because 

that-- 

 [Applause.] 

 MR. DEAL. --is part of the reason that many of these expenditures 

that you are talking about actually come about. The case of Maria is an 

example of just the lack of security at the border and you are put in a 

very delicate and difficult position, are you not, Mr. Gardner? 

 MR. GARDNER. Absolutely. And I think the challenge for healthcare 

folks--and you touched on it, Congressman Deal, is that this is not the 

business that we got into. It is about taking care of patients. And to have 

that very difficult choice of literally sometimes losing tens or hundreds 

of thousands of dollars, depending on what the case is trying to do the 

right thing versus the practicality of--for every $50,000 that the hospital 

loses, it translates into one full time job that has to be eliminated. And 

that is the balance that goes on every day. 

 MR. DEAL. Well, you alluded to some other things too, and that is 

the cost factor of those who present themselves in your emergency rooms 

and I think Mr. Stewart also alluded to the EMTALA law. I know Dr. 

Norwood and I have both been very conscious of the fact that we need to 

revisit that to try to give you some relief. We tried to build in some 

provisions in the Deficit Reduction Act that would give you some 

liability protections for making decisions to defer from your ERs to 

alternative sites. Unfortunately some of that language did not survive, 

but it is a constant concern. 

 The other thing is when you have someone who presents themselves 

in your hospital, whether it be through ER or in other methods of 

presentation, and they do not have any insurance and they do not have, or 

say they do not have the ability to pay out of their pocket for the cost of 

their care; am I not correct that what that does is it drives up the cost of 

care for other people, either those who have insurance, because you have 

to reflect that in the charges that you make, and insurance companies 

have to reflect that in their premiums, or it is reflected to the general 

population in some form or fashion for those who are fortunate enough to 
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get subsidized assistance for indigent care, and I know that not all of you 

have that ability to get that money. But does it not just shift this cost? 

 MR. GARDNER. You know, without question, there is actually an 

explicit tax, I would argue, on top of all insurance premiums, whatever 

the true cost of insurance would be, and I cannot estimate that exact 

premium to you. But you know, for instance if you just take a look at 

Northeast Georgia Medical Center, our bad debt this year is going to be 

approximately $30 million on a budget of about $400 million. So that 

has to come from somewhere, that $30 million is transferred somewhere 

else in the system in terms of increased rates. And in fairness to the 

insurance companies they have to be able to remain solvent also. 

 So ultimately it is passed back to those of us that have health 

insurance. 

 MR. DEAL. And it is a Catch 22 because as they pass those costs 

back, it raises the cost of insurance and, therefore, you have more people 

who cannot afford to buy that insurance and more who fall into the 

uninsured category. 

 MR. GARDNER. There is the dilemma. 

 MR. DEAL. One quick last question, and you may not have the 

information, but I would like to ask it. Do either of you hospital 

administrators have any information as to the number of children born in 

your facilities that were born to parents who are illegally in our country? 

 MR. STEWART. I do not know that we have that information 

available. 

 MR. GARDNER. We do not have that information available either. 

But I can tell you we did 4,200 deliveries last year and it is reflective of 

our community in terms of the numbers of individuals to various 

demographic factors of our community. 

 MR. DEAL. Thank you. Ms. Solis. 

 MS. SOLIS. Yes, I just wanted to make a brief comment. Mr. 

Gardner, you said that your individual that you pointed out, Maria, had 

six dialysis treatments totaling $9,500. That is about $1583 per 

treatment. But you also are saying that Medicare and Medicaid only 

pays to reimburse for $200 for treatment. So is Medicare underpaying 

the dialysis by $1300? 

 MR. GARDNER. I do not know that I can address that. 

 MS. SOLIS. Or are you overcharging the uninsured women then? 

 MR. GARDNER. No, this lady had a very-- 

 MS. SOLIS. Thank you. 

 MR. GARDNER. --she had a very complicated stay within the ICU for 

about 8 days. Slightly more expensive than a dialysis treatment. 

 MS. SOLIS. Thank you. Mr. Michaels, I really appreciate the fact 

that you came and were very objective and honest about what your 
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services are. And with respect to the SCHIP program, I know in the 

State of California and many cases in other States, we turn back money, 

we have not really fully utilized and really done a good job as the State 

of Georgia has. So I commend the State of Georgia and obviously your 

work for doing that. Perhaps there is a way we could negotiate through 

the Congress so that States like yours that are actually on the increase 

because you have a higher number of uninsured that are now-- 

 MR. MICHAELS. We would go for that. 

 MS. SOLIS. --we can work on that. That is something that I would 

agree with. I mean children need to be covered. 

 And I wanted to ask you what the costs are for a child that does not 

receive say prenatal healthcare and what additional costs would be 

assumed by the State if prenatal care were denied for children who were 

born here but parents were undocumented? 

 MR. MICHAELS. Yeah. Well, the cost of neonatal ICU is one of the 

most exorbitant in pediatrics and if you look at the private sector, HMOs, 

when they do not make money, one of the big reasons they do not is they 

had higher than anticipated neonatal ICU charges for that quarter. So the 

big risk with lack of prenatal care is complications that lead to prolonged 

ICU stays for newborns--extreme prematurity, you can have a baby born 

25-26 weeks, that bill can probably be a million dollars, I do not know. 

You can tell me on that. Hundreds of thousands anyway for sure, 

because they can have lots of complications and need a ventilator for 

several months and they can have all kinds of surgical complications. So 

high risks of prematurity and other complications, you will have a higher 

mortality rate for newborns, higher stillbirth rate, and a lot higher 

expense due to intensive care costs. 

 MS. SOLIS. One other question I had was you talked about foster 

care and not being able to receive adequate information for 

immunization, basic things that should be made available. We heard 

earlier from the other panel that that was not the case, that they are able 

to get that information and they can collaborate. Could you please allude 

to me, am I getting something wrong here? 

 MR. MICHAELS. Well, I guess it is one of those things where there is 

probably some theoretical--I do not know all the details of what the 

caseworkers are doing when they do the intake, but all I can tell you 

from a practical standpoint, most of the time, every day--well, we see 

foster kids every day in our office and when we see a new foster child, I 

generally do not have any medical records at all at that visit. I generally 

do not have the immunization records, I generally do not have allergies, 

any of those things. 

 MS. SOLIS. Generally what would the time frame be for you to 

receive that information? Does it vary, is it more than a year? 
164

 MR. MICHAELS. It can really vary, because these kids--they are put 

in foster care here but they may have lived in south Georgia prior to that. 

We do have an immunization registry in Georgia, so that problem that 

we alluded to hopefully will be improving over time, but it is not fully in 

use by all parties yet. 

 MS. SOLIS. One of the other questions I had was regarding the 

EMTALA law and what would happen if there were restrictions on that. 

If, for example, women who were undocumented were removed from 

assistance, what would happen to the State of Georgia? 

 MR. MICHAELS. You are talking about pregnant women? 

 MS. SOLIS. Uh-huh. 

 MR. MICHAELS. If pregnant women came in and EMTALA had 

been relaxed and the hospital was not obliged to treat those women, you 

would have a lot of complications. You could have mortality, a woman 

could die of a ruptured placenta and just bleed and the baby and the 

mother could die, there could be infection and sepsis which are lifethreatening for the baby and for the mother as well. 

 MS. SOLIS. Do you honestly believe that by taking away that service, 

that people are going to have less pregnancies? 

 MR. MICHAELS. No. 

 MS. SOLIS. One last question. With respect to your particular 

caseload of individuals, what would you say--when you get into a 

situation of providing service, do you have a rough estimate of what the 

legal and illegal are? 

 MR. MICHAELS. I really do not know because I do not ask, first of 

all. I do not think providers should be in the position of asking because 

that disrupts the trust of the medical home. 

 MS. SOLIS. How would you feel if you were, according to the 

Sensenbrenner Bill, held liable, there would be penalties against you for 

servicing undocumented? How would you--what kind of atmosphere 

would that place in your home setting or your hospital setting? 

 MR. MICHAELS. It would place us in terrible conflict, but I am 

confident that Congress will not do that to the providers. 

 MS. SOLIS. Okay, thank you. That concludes my questions. 

 [Applause.] 

 MR. DEAL. Dr. Norwood. 

 MR. NORWOOD. Thank you, Mr. Chairman. 

 Mr. Gardner, according to the United States Senate immigration bill, 

the Reid-Kennedy-McCain-Hagel Bill, we would increase the number of 

citizens in this country somewhere in the neighborhood of 66 million 

new people in the next 20 years. I think I know Georgia pretty well, we 

have got 159 counties, we have got rural hospitals in every county, 

sometimes maybe even two. What is that going to do to hospitals like 
165

yours, either one of you, Mr. Stewart or Mr. Gardner, if we have that 

kind of influx of new people into the country over the next 20 years? 

 MR. GARDNER. Congressman, I think it is a bit of a complicated 

answer, but you know, undoubtedly the cost of healthcare is going to 

continue to go up. Right now, Northeast Georgia, we have the third 

busiest emergency room in the State of Georgia with about 105,000 visits 

per year. So if you just extrapolate, look at the population and how many 

folks are coming, it is just going to make an already unmanageable 

situation that much more difficult. 

 MR. NORWOOD. Well, the Rand study says most of these people will 

not have any type of healthcare insurance. So if you are in a position 

now that you are having to cost shift over because you are spending so 

many dollars, and you said what, a million a day? 

 MR. GARDNER. A million a day. 

 MR. NORWOOD. Something to that effect. What is going to happen 

when it goes to three million a day? At what point do you close? 

 MR. GARDNER. What I am concerned about right now is our 

uncompensated care and bad debt has gone from $20 million to $30 

million in the last 4 years. That rate of growth is what is not sustainable. 

We have literally since 1984 given away in excess of a quarter billion 

dollars of free care at Northeast Georgia Healthcare System. We cannot 

do it. 

 MR. NORWOOD. Why do you not just cost shift that over to the 

Americans who have healthcare insurance, make us pay for it? 

 MR. GARDNER. Well, you know what the answer to that is, it is a 

Catch 22 because then fewer individuals continue to buy health 

insurance, the business community cannot pay for health insurance and 

we end up just exacerbating an already difficult problem. 

 MR. NORWOOD. Well, then, cost shift it over to Medicare, make 

them pay more. 

 MR. GARDNER. Well, Congressman, I think the answer to that is the 

DRA and there is no place to cost shift any more. 

 MR. NORWOOD. That is exactly my point I am trying to get to. We 

are at the end of the road shifting these costs over to other people. 

 [Applause.] 

 MR. NORWOOD. What is going to happen with this 66 million, 

maybe 100 million new patients that we are going to see in this country 

in regards to tuberculosis or meningitis or measles? The communicable 

diseases that we do a pretty good job of in this country, but not 

necessarily around the world, what is going to happen to you with those? 

Is that going to go up? 

 MR. GARDNER. I think it is fair to say-- 

 MR. NORWOOD. Speculate, I know you cannot-- 
166

 MR. GARDNER. I am a hospital administrator, I am not a physician, 

but the numbers and history would tell you that as the population 

increases, the incidence of disease goes up. 

 MR. NORWOOD. That is the point. 

 Well, one last thing. You do not know actually for sure how much 

uncompensated care you have to extend, do you, on illegal aliens? You 

do not know that number, do you? 

 MR. GARDNER. No, we sure do not. 

 MR. NORWOOD. Is that because you do not ask citizenship status? 

Just to put together the information. 

 MR. GARDNER. Frankly, we do not ask, it is a very uncomfortable 

situation for providers, just being honest with you. 

 MR. NORWOOD. You do not ask people to pay you, do you? Are 

you uncomfortable asking other people to pay you? 

 [Laughter.] 

 MR. NORWOOD. Now wait a minute, Doc, I know you do not, but I 

know the hospital does. Are you uncomfortable asking me to pay you if 

I come to your hospital? 

 MR. GARDNER. You would be surprised, but in our organization up 

until probably a couple of years ago, it was relatively lax in terms of 

requesting payment. As the situation has worsened, we have become 

more appropriately inquisitive about payment. 

 MR. NORWOOD. As they have all over the State, but that is not new. 

I have been in healthcare awhile too. Hospitals want their money, but 

you refuse to ask somebody if they are a citizen of this country or not? 

Because you know as well as I do sitting here, now you can laugh it off 

all you want to, but that is going to determine whether you get paid. It is 

going to determine whether that person pays you or whether 

Congressman Deal pays you. That is what that question is going to 

determine. Why do you guys not ask and why does the American 

Hospital Association find that so difficult when they are right on the 

money when they want me to pay them? 

 MR. GARDNER. You know, again, it is not why we went into 

healthcare in the first place. And having to act as an immigration traffic 

cop does not come comfortably to us. But the situation is such that that 

is unfortunately the world that we are probably going to live in, we are 

going to do what is required. 

 MR. NORWOOD. You are going to do that or close. And I have got 

25 counties and I have got small rural hospitals all over the place that are 

going to shut down because of all this; because they cannot stand a 

million dollars a day. You happen to be big enough maybe you can 

offset it, but most of Georgia’s rural hospitals simply cannot continue 

with this. 
167

 Let us talk just real quickly about birthright citizenship. To my 

knowledge, there is not one Nation, at least western nation, that allows 

birthright citizenship besides the United States. Now I noticed when that 

subject came up a minute ago, three or four people in this room were just 

adamantly against us doing away with that, just shaking their head all 

over the place. We have got to have birthright citizenship. 

 But the rest of the world is not doing that. I wonder why they are not 

doing that kind of thing? Mexico does not do that. Why do we not 

follow their lead? Why do we not do like they do? They do not allow 

you to be born in Mexico and immediately become a citizen. Why is it 

people from Mexico who come here want us to do the absolute opposite? 

 Last quick question. Doctor, how many Medicaid patients in your 

practice? 

 MR. MICHAELS. We have about 5,500. 

 MR. NORWOOD. What percent might that be? 

 MR. MICHAELS. About 75 percent of the folks we see are on 

Medicaid or SCHIP. 

 MR. NORWOOD. Do you have any idea in your practice how many of 

those Medicaid patients might be illegal aliens? 

 MR. MICHAELS. I do not know. You know, most of our Medicaid 

patients are young age, so most of them were born here in the United 

States, so by definition of the current situation, I think they are citizens. 

 MR. NORWOOD. So let me maybe phrase it another way. Do you 

know the percentage of those that might be parents of illegal aliens? 

 MR. MICHAELS. I have no idea. 

 MR. NORWOOD. Yeah, you are not interested in knowing? 

 MR. MICHAELS. Well, because the Hippocratic Oath that I took in 

medical school when I graduated said “Do no harm.” And the medical 

home-- 

 [Applause.] 

 MR. MICHAELS. --is a critical concept for me in my provision of care 

to patients and is based on a trusting relationship between the parents and 

provider. 

 MR. NORWOOD. I understand. 

 MR. MICHAELS. and if I ask them that question, the trust is totally 

eroded. They will not come back. 

 MR. NORWOOD. I understand. But the Hippocratic Oath says “Do 

no harm,” and we are doing a tremendous harm to this country, to the 

medical system and the citizens of this Nation-- 

 [Applause.] 

 MR. NORWOOD. --by not dealing with this upfront and being honest 

with ourselves and being honest with people who are crossing our 

borders illegally. We have to face this problem and deal with it. 
168

 Sorry, Mr. Chairman, I went over. Thank you very much. 

 MR. DEAL. Well, I want to thank this panel as well and this 

concludes this hearing. I think whether there is agreement or 

disagreement on the issues that have been discussed here, I think it does 

illustrate the difficulty that the issue of illegal immigration has created in 

our country and by the consequence of that, the difficulty of Congress 

arriving at a reasonable and fair solution to it. 

 We appreciate the testimony of all the witnesses. We thank the 

audience for your participation, and with that this field hearing is 

adjourned. 

 [Whereupon, at 12:55 p.m., the Committee was adjourned.] 

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