January 13, 2009 CONGRESSIONAL RECORD — SENATE S345 

subdivisions of the State, nonprofit organizations, colleges and universities, and private 

property owners for— 

(1) the restoration or rehabilitation, public 

use, and interpretation of sites and resources 

relating to Harriet Tubman; 

(2) the conduct of research, including archaeological research; 

(3) providing stewardship programs, education, signage, and other interpretive devices at the sites and resources for interpretive purposes; and 

(4)(A) the design and construction of the 

Visitor Center; and 

(B) the operation and maintenance of the 

Visitor Center. 

(f) INTERPRETATION.—The Secretary may 

provide interpretive tours to sites and resources located outside the boundary of the 

Historical Park in Caroline, Dorchester, and 

Talbot Counties, Maryland, relating to the 

life of Harriet Tubman and the Underground 

Railroad. 

(g) GENERAL MANAGEMENT PLAN.— 

(1) IN GENERAL.—Not later than 3 years 

after the date on which funds are made available to carry out this subsection, the Secretary, in coordination with the State of 

Maryland, political subdivisions of the 

State, and the United States Fish and Wildlife Service, shall complete a general management plan for the Historical Park in accordance with section 12(b) of Public Law 91– 

383 (16 U.S.C. 1a–7(b)). 

(2) COORDINATION.—The Secretary shall coordinate the preparation and implementation of the general management plan for the 

Historical Park with— 

(A) the Harriet Tubman National Historical Park in Auburn, New York; 

(B) the National Underground Railroad: 

Network to Freedom; 

(C) the Maryland Harriet Tubman Underground Railroad State Park; and 

(D) the Harriet Tubman Underground Railroad Byway in Dorchester and Caroline 

Counties, Maryland. 

(3) PRIORITY TREATMENT.—The general 

management plan for the Historical Park 

shall give priority to, with the concurrence 

of the owner of the property, the adequate 

protection of, interpretation of, public appreciation for, archaeological investigation 

of, and research on Stewart’s Canal, the 

Jacob Jackson home site, the Brodess Farm, 

the Ben Ross and Anthony Thompson properties on Harrisville Road, and the James 

Cook site, all of which are privately owned 

and located in the area identified as the 

‘‘Harriet Tubman Historic Area’’ on the map 

described in subsection (b)(1). 

(h) BLACKWATER NATIONAL WILDLIFE REFUGE.— 

(1) INTERAGENCY AGREEMENT.—The Secretary shall ensure that, not later than 1 

year after the date of enactment of this Act, 

the National Park Service and the United 

States Fish and Wildlife Service enter into 

an interagency agreement that— 

(A) promotes and mutually supports the 

compatible stewardship and interpretation of 

Harriet Tubman resources at the Blackwater 

National Wildlife Refuge; and 

(B) provides for the maximum level of cooperation between those Federal agencies to 

further the purposes of this Act. 

(2) EFFECT OF ACT.—Nothing in this Act 

modifies, alters, or amends the authorities of 

the United States Fish and Wildlife Service 

in the administration and management of 

the Blackwater National Wildlife Refuge. 

(i) DUTIES OF OTHER FEDERAL ENTITIES.— 

Any Federal entity conducting, supporting, 

permitting, or licensing activities directly 

affecting nationally significant land within 

the area identified as the ‘‘Harriet Tubman 

Historic Area’’ on the map described in subsection (b)(1) shall— 

(1) consult and cooperate with the Secretary with respect to the activities; 

(2) identify any alternatives with regard to 

the proposed activity affecting the Harriet 

Tubman Historic Area; and 

(3) to the maximum extent practicable, 

conduct, support, permit, or license the activities in a manner that the Secretary determines would not have an adverse effect on 

the Harriet Tubman Historic Area. 

SEC. 6. ADMINISTRATION. 

(a) IN GENERAL.—The Secretary shall administer the Harriet Tubman National Historical Park and the Harriet Tubman Underground Railroad National Historical Park in 

accordance with this Act and the laws generally applicable to units of the National 

Park System including— 

(1) the National Park Service Organic Act 

(16 U.S.C. 1 et seq.); and 

(2) the Act of August 21, 1935 (16 U.S.C. 461 

et seq.). 

(b) PARK REGULATIONS.—Notwithstanding 

subsection (a), regulations and policies applicable to units of the National Park System 

shall apply only to Federal land administered by the National Park Service that is 

located within the boundary of the Harriet 

Tubman Underground Railroad National Historical Park. 

SEC. 7. AUTHORIZATION OF APPROPRIATIONS. 

(a) IN GENERAL.—There are authorized to 

be appropriated such sums as are necessary 

to carry out this Act (other than subsection 

(b)), including the provision of National Park 

Service personnel and National Park Service 

management funds for the Harriet Tubman 

National Historical Park and the Harriet 

Tubman Underground Railroad National Historical Park. 

(b) GRANTS.—There are authorized to be 

appropriated not more than— 

(1) $11,000,000 to provide grants to the 

Church for— 

(A) historic preservation, rehabilitation, 

and restoration of resources within the 

boundary of the Harriet Tubman National 

Historical Park; and 

(B) the costs of design, construction, installation, and maintenance of exhibits and 

other interpretive devices authorized under 

section 4(d)(1)(B); 

(2) $11,000,000 for grants to the State of 

Maryland, political subdivisions of the State 

of Maryland, and nonprofit organizations for 

activities authorized under subsections (d)(1) 

and (e)(4)(A) of section 5; and 

(3) $200,000 for fiscal year 2010 and each fiscal year thereafter for competitive grants to 

historically Black colleges and universities, 

Predominately Black Institutions, and minority serving institutions for research into 

the life of Harriet Tubman and the AfricanAmerican experience during the years that 

coincide with the life of Harriet Tubman. 

(c) COST-SHARING REQUIREMENT.— 

(1) CHURCH AND VISITOR CENTER GRANTS.— 

The Federal share of the cost of activities 

provided grants under paragraph (1) or (2) of 

subsection (b) and any maintenance, construction, or utility costs incurred pursuant 

to a cooperative agreement entered into 

under section 4(d)(1)(A) or section 5(e) shall 

not be more than 50 percent. 

(2) HISTORICALLY BLACK COLLEGES AND UNIVERSITIES.—The Federal share of the cost of 

activities provided assistance under subsection (b)(3) shall be not more than 75 percent. 

(3) FORM OF NON-FEDERAL SHARE.—The nonFederal share required under this subsection 

may be in the form of in-kind contributions 

of goods or services fairly valued. 

By Mr. BINGAMAN (for himself 

and Mr. AKAKA): 

S. 228. A bill to amend title XIX of 

the Social Security Act to permit 

States, at their option, to require certain individuals to present satisfactory 

documentary evidence of proof of citizenship or nationality for purposes of 

eligibility for Medicaid, and for other 

purposes; to the Committee on Finance. 

Mr. BINGAMAN. Mr. President I rise 

today with my colleague Senator 

AKAKA to introduce legislation today 

designed to make several very important changes to current law to ensure 

that U.S. citizens receive the Medicaid 

to which they are entitled. 

Since July 1, 2006, most U.S. citizens 

and nationals applying for or renewing 

their Medicaid coverage face a new 

Federal requirement to provide documentation of their citizenship status. 

Recent reports indicate that tens-ofthousands of U.S. citizens, and in particular children, inappropriately are 

being denied Medicaid benefits simply 

because they don’t have access to 

newly required documentation. The articles below and report by the Center 

on Budget and Policy Priorities highlight this very serious problem. Hospitals, physicians, and pharmacies may 

not be willing to treat these individuals until they have a source of payment, but they cannot qualify for Medicaid until they produce a birth certificate and ID. 

This new Federal requirement was 

added to Medicaid by the Deficit Reduction Act of 2005, DRA, enacted February 8, 2006. The Tax Relief and 

Health Care Act of 2006, TRHCA, signed 

into law December 20, 2006, included 

some amendments to the DRA citizenship documentation requirement, primarily to exempt certain groups. Prior 

to enactment of the DRA, states were 

permitted to use their discretion in requiring such citizenship documentation. 

Under Section 6036 of the DRA, citizens applying for or renewing their 

Medicaid coverage must provide ‘‘satisfactory documentary evidence of citizenship or nationality.’’ The DRA 

specifies documents that are acceptable for this purpose and authorizes the 

HHS Secretary to designate additional 

acceptable documents. No Federal 

matching funds are available for services provided to individuals who declare they are citizens or nationals unless the state obtains satisfactory evidence of their citizenship or determines that they are subject to a statutory exemption. 

According to a CRS Report for Congress updated April 15, 2008, ‘‘Based on 

a recent survey by the Government Accountability Office, GAO, 22 of 44 states 

report declines in enrollment due to 

the new citizenship documentation requirement. Based on another survey by 

the Kaiser Commission on Medicaid 

and the Uninsured, 13 states report a 

significant negative impact on enrollment and another 24 states report a 

modest impact. Among seven states detailed in an earlier report from the 

Center on Budget and Policy Priorities, 

only Wisconsin has a data system that 


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S346 CONGRESSIONAL RECORD — SENATE January 13, 2009 

can identify denials and terminations 

due to a lack of citizenship documentation, and it reports that about 19,000 

people had their Medicaid eligibility 

denied or terminated for this reason 

between July 31, 2006, and March 1, 

2007.’’ 

A second wave study conducted from 

September 2007–March 2008 by the Department of Health Policy at the 

George Washington University School 

of Public Health published October 

2008, ‘‘Another distressing finding is 

the impact the citizenship documentation requirements appear to be having 

on SCHIP. Many states, for important 

reasons, use joint applications for both 

Medicaid and separate SCHIP programs. The effect, however, is to apply 

the citizenship documentation requirements to both programs, thereby delaying coverage for both groups of children.’’ 

‘‘Even if most or all of the reported 

Medicaid enrollment declines are due 

to the citizenship documentation requirement, a key question is whether 

the people who are being denied, terminated, or deterred from applying are 

U.S. citizens, rather than unauthorized 

aliens or other ineligible noncitizens. 

Of the 22 states reporting enrollment 

declines to GAO, a majority (16 states) 

attribute them to Medicaid coverage 

delays or losses for people who appear 

to be U.S. citizens.’’ 

It is important to note that citizenship documentation requirements do 

not affect Medicaid rules relating to 

immigrants—they apply to individuals 

claiming to be citizens. Most new legal 

immigrants are excluded from Medicaid during their first five years in the 

U.S. and undocumented immigrants remain eligible for Medicaid emergency 

services only. 

The legislation I am introducing 

would make several very important 

changes to current law to ensure that 

U.S. citizens receive the Medicaid to 

which they are entitled. 

First, the legislation would restore 

citizenship verification to a state option. Specifically, states would be permitted to determine when and to what 

extent citizenship verification is required of U.S. Citizens. States would 

also be permitted to utilize the standards most appropriate to the their population as long as such standards were 

no more stringent than those currently 

used by the Social Security Administration and includes native American 

tribal documents when appropriate. 

Second, the legislation would ensure 

that individuals are afforded a reasonable time period to provide citizenship 

documentation utilizing the same reasonable time period standard that is 

available to legal immigrants to provide satisfactory evidence of their immigration status. 

Third, the legislation protects children who are U.S. citizens by virtue of 

being born in the United States from 

being denied coverage after birth because of citizenship verification requirements. 

Fourth, the legislation also clarifies 

ambiguities in Federal law to ensure 

that these citizen children, regardless 

of the immigration status of their parents, are treated like all other low-income children born in the United 

States and are deemed eligible to receive Medicaid services for one year. 

Finally, the legislation also ensures 

that the thousands of citizen children 

and adults, who were erroneously denied Medicaid coverage, may receive 

retroactive Medicaid eligibility for 

coverage they were inappropriately denied because of citizenship verification 

requirements. 

I urge my colleagues in the Senate to 

support this critical legislation, which 

protects low-income U.S. citizens from 

being inappropriately denied Medicaid 

coverage because of lack of documentation. 

Mr. President, I ask unanimous consent that the text of the bill and letters of support be printed in the 

RECORD. 

There being no objection, the material was ordered to be printed in the 

RECORD, as follows: 

S. 228 

Be it enacted by the Senate and House of Representatives of the United States of America in 

Congress assembled, 

SECTION 1. STATE OPTION TO REQUIRE CERTAIN 

INDIVIDUALS TO PRESENT SATISFACTORY DOCUMENTARY EVIDENCE 

OF PROOF OF CITIZENSHIP OR NATIONALITY FOR PURPOSES OF ELIGIBILITY FOR MEDICAID. 

(a) IN GENERAL.—Section 1902(a)(46) of the 

Social Security Act (42 U.S.C. 1396a(a)(46)) is 

amended— 

(1) by inserting ‘‘(A)’’ after ‘‘(46)’’; 

(2) by adding ‘‘and’’ after the semicolon; 

and 

(3) by adding at the end the following new 

subparagraph: 

‘‘(B) at the option of the State and subject 

to section 1903(x), require that, with respect 

to an individual (other than an individual described in section 1903(x)(1)) who declares to 

be a citizen or national of the United States 

for purposes of establishing initial eligibility 

for medical assistance under this title (or, at 

State option, for purposes of renewing or redetermining such eligibility to the extent 

that such satisfactory documentary evidence 

of citizenship or nationality has not yet been 

presented), there is presented satisfactory 

documentary evidence of citizenship or nationality of the individual (using criteria determined by the State, which shall be no 

more restrictive than the criteria used by 

the Social Security Administration to determine citizenship, and which shall accept as 

such evidence a document issued by a federally-recognized Indian tribe evidencing membership or enrollment in, or affiliation with, 

such tribe (such as a tribal enrollment card 

or certificate of degree of Indian blood, and, 

with respect to those federally-recognized 

Indian tribes located within States having 

an international border whose membership 

includes individuals who are not citizens of 

the United States, such other forms of documentation (including tribal documentation, 

if appropriate) that the Secretary, after consulting with such tribes, determines to be 

satisfactory documentary evidence of citizenship or nationality for purposes of satisfying the requirement of this subparagraph));’’. 

(b) LIMITATION ON WAIVER AUTHORITY.— 

Notwithstanding any provision of section 

1115 of the Social Security Act (42 U.S.C. 

1315), or any other provision of law, the Secretary of Health and Human Services may 

not waive the requirements of section 

1902(a)(46)(B) of such Act (42 U.S.C. 

1396a(a)(46)(B)) with respect to a State. 

(c) CONFORMING AMENDMENTS.—Section 

1903 of such Act (42 U.S.C. 1396b) is amended— 

(1) in subsection (i)— 

(A) in paragraph (20), by adding ‘‘or’’ after 

the semicolon; 

(B) in paragraph (21), by striking ‘‘; or’’ and 

inserting a period; and 

(C) by striking paragraph (22); and 

(2) in subsection (x)— 

(A) by striking paragraphs (1) and (3); 

(B) by redesignating paragraph (2) as paragraph (1); 

(C) in paragraph (1), as so redesignated, by 

striking ‘‘paragraph (1)’’ and inserting ‘‘section 1902(a)(46)(B)’’; and 

(D) by adding at the end the following new 

paragraph: 

‘‘(2) In the case of an individual declaring 

to be a citizen or national of the United 

States with respect to whom a State requires 

the presentation of satisfactory documentary evidence of citizenship or nationality 

under section 1902(a)(46)(B), the individual 

shall be provided at least the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality 

under this subsection as is provided under 

clauses (i) and (ii) of section 1137(d)(4)(A) to 

an individual for the submittal to the State 

of evidence indicating a satisfactory immigration status.’’. 

SEC. 2. CLARIFICATION OF RULES FOR CHILDREN BORN IN THE UNITED STATES 

TO MOTHERS ELIGIBLE FOR MEDICAID. 

Section 1903(x) of such Act (42 U.S.C. 

1396b(x)), as amended by section 1(c)(2), is 

amended— 

(1) in paragraph (1)— 

(A) in subparagraph (C), by striking ‘‘or’’ 

at the end; 

(B) by redesignating subparagraph (D) as 

subparagraph (E); and 

(C) by inserting after subparagraph (C) the 

following new subparagraph: 

‘‘(D) pursuant to the application of section 

1902(e)(4) (and, in the case of an individual 

who is eligible for medical assistance on 

such basis, the individual shall be deemed to 

have provided satisfactory documentary evidence of citizenship or nationality and shall 

not be required to provide further documentary evidence on any date that occurs during 

or after the period in which the individual is 

eligible for medical assistance on such 

basis); or’’; and 

(2) by adding at the end the following new 

paragraph: 

‘‘(3) Nothing in subparagraph (A) or (B) of 

section 1902(a)(46), the preceding paragraphs 

of this subsection, or the Deficit Reduction 

Act of 2005, including section 6036 of such 

Act, shall be construed as changing the requirement of section 1902(e)(4) that a child 

born in the United States to an alien mother 

for whom medical assistance for the delivery 

of such child is available as treatment of an 

emergency medical condition pursuant to 

subsection (v) shall be deemed eligible for 

medical assistance during the first year of 

such child’s life.’’. 

SEC. 3. EFFECTIVE DATE. 

(a) RETROACTIVE APPLICATION.—The 

amendments made by this Act shall take effect as if included in the enactment of the 

Deficit Reduction Act of 2005 (Public Law 

109–171; 120 Stat. 4). 

(b) RESTORATION OF ELIGIBILITY.—In the 

case of an individual who, during the period 

that began on July 1, 2006, and ends on the 

date of enactment of this Act, was determined to be ineligible for medical assistance 


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January 13, 2009 CONGRESSIONAL RECORD — SENATE S347 

under a State Medicaid program solely as a 

result of the application of subsections (i)(22) 

and (x) of section 1903 of the Social Security 

Act (as in effect during such period), but who 

would have been determined eligible for such 

assistance if such subsections, as amended 

by sections 1 and 2, had applied to the individual, a State may deem the individual to 

be eligible for such assistance as of the date 

that the individual was determined to be ineligible for such medical assistance on such 

basis. 

[From the New York Times, June 5, 2006] 

MEDICAID RULES TOUGHENED ON PROOF OF

CITIZENSHIP

(By Robert Pear) 

WASHINGTON, June 4.—The Bush administration plans this week to issue strict standards requiring more than 50 million low-income people on Medicaid to prove they are 

United States citizens by showing passports 

or birth certificates and a limited number of 

other documents. 

The new standards follow a tussle with 

Congress. Federal health officials had considered giving states broad discretion to accept affidavits in place of official documents. 

But House Republicans complained, and the 

administration backed off, allowing affidavits ‘‘only in rare circumstances.’’ 

The requirements, which take effect July 

1, carry out a law signed by President Bush 

on Feb. 8. 

They vividly illustrate how concern about 

illegal immigration is affecting domestic social welfare policy. The purpose of the law 

was to conserve federal money for citizens, 

reducing the need for states to cut Medicaid 

benefits or limit eligibility. 

Gov. Rick Perry of Texas won enthusiastic 

applause at a state Republican convention 

on Friday when he vowed to increase border 

security and said, ‘‘Texas will start requiring 

every Medicaid applicant to verify that they 

are in the country legally in order to receive 

benefits.’’ 

But officials in some other states and advocates for the poor said the new requirements could cause hardship for children, 

older Americans and poor people born at 

home in rural areas who never received birth 

certificates. Children account for about half 

of Medicaid recipients. People 65 and older 

account for about 10 percent. 

Jennifer M. Ng’andu, a health policy specialist at the National Council of La Raza, a 

Hispanic rights group, said, ‘‘The documentation requirements will cause confusion 

about eligibility and will put up barriers to 

enrollment.’’ 

In general, Medicaid is available only to 

United States citizens and to certain ‘‘qualified aliens.’’ Before the new standards, in 

many states, people who declared they were 

citizens did not have to support the claim. 

But in a letter being sent this week to 

state officials, the Bush administration says, 

‘‘Self-attestation of citizenship and identity 

is no longer an acceptable practice.’’ 

In the law, Congress listed examples of 

documents that could be used to show citizenship, and it said the secretary of health 

and human services could ‘‘by regulation’’ 

specify other acceptable documents. 

The main proponents of the new requirements were two Republican House members 

from Georgia, Representatives Charlie Norwood and Nathan Deal. 

John E. Stone, a spokesman for Mr. Norwood, said Sunday: ‘‘Charlie provided feedback to the administration in the last two 

weeks to make sure the regulations would 

not undermine the intent of the law. Obviously you need some flexibility so that a 92– 

year-old woman with Alzheimer’s does not 

get kicked off Medicaid. What’s unacceptable 

is for people to claim benefits or sign affidavits swearing they are citizens without any 

verification.’’ 

In an interview Sunday, Dr. Mark B. 

McClellan, administrator of the Centers for 

Medicare and Medicaid Services, said, ‘‘We 

want to provide an effective way to document citizenship without placing excessive 

burdens on states or beneficiaries.’’ 

In the letter to state Medicaid directors, 

the administration says, ‘‘An applicant or 

recipient who fails to cooperate with the 

state in presenting documentary evidence of 

citizenship may be denied or terminated’’ 

from the program. 

The requirements will be enforced when a 

person applies for Medicaid or when eligibility is first recertified on or after July 1. In 

general, applicants and recipients will have 

45 days to provide documents. People with 

disabilities will have 90 days. 

States typically redetermine eligibility 

every 3 to 12 months. ‘‘Once citizenship has 

been proved, it need not be documented 

again’’ because it does not normally change, 

the administration said. 

But the guidelines include a significant 

ambiguity: ‘‘An individual who is already enrolled in Medicaid will remain eligible if he 

or she showed a good-faith effort to present 

satisfactory evidence of citizenship and identity, even if this effort takes longer than 45 

days.’’ The administration says that ‘‘beneficiaries will not lose benefits as long as they 

are undertaking a good-faith effort to provide documentation.’’ 

States have a strong incentive to enforce 

the requirements. If they fail to do so, they 

can lose federal Medicaid money. 

The guidelines say states should help people document citizenship, especially if they 

are homeless, mentally impaired or physically incapacitated and have no one to act 

on their behalf. 

The guidelines list four categories of documents that can be used as evidence of citizenship, from the most reliable to the least 

trustworthy. The best evidence, they say, is 

a United States passport or a certificate of 

naturalization. The next category includes 

state and local birth certificates and State 

Department documents issued to children 

born abroad to United States citizens. 

The third category consists of nongovernment documents showing place of birth. 

These include medical records from doctors, 

hospitals and clinics; nursing home admission papers; and records from life and health 

insurance companies. 

The fourth category includes affidavits, 

which can be used ‘‘only in rare circumstances when the state is unable to secure evidence of citizenship’’ from other 

sources. 

‘‘An affidavit must be supplied by at least 

two individuals, one of whom is not related 

to the applicant or recipient,’’ the guidelines 

say. ‘‘Each must attest to having personal 

knowledge of the events establishing the applicant’s or recipient’s claim of citizenship. 

The individuals making the affidavit must 

be able to provide proof of their own citizenship and identity.’’ 

People signing affidavits may also be 

asked ‘‘why documentary evidence of citizenship does not exist or cannot be readily 

obtained.’’ 

[From the Birmingham News, Dec. 4, 2006] 

MEDICAID RULES PUT PINCH ON POOR, LACK

OF PROOF NEEDED FOR PLAN KEEPS MANY

FROM HELP

(By Kim Chandler) 

The four children in her office needed immunizations. But because their mother did 

not have their original birth certificates, and 

couldn’t buy a copy, the family could not enroll in Medicaid, Dr. Marsha Raulerson said. 

The children did not get their shots. 

During September and October, 1,600 lowincome people, many of them children, were 

rejected by Alabama’s Medicaid program because of tougher federal rules. They require 

applicants to show an original birth certificate or a copy purchased from the state 

Health Department with a raised seal, plus a 

driver’s license or other proof of citizenship 

and identity when signing up for Medicaid 

benefits. 

Many more people eventually could lose 

benefits if they can’t produce the necessary 

documents. 

The new rules took effect July 1 and are 

part of the 2005 Deficit Reduction Act. Congress approved the law because of concern 

that illegal immigrants were signing up for 

Medicaid en masse. Instead of curbing widespread fraud, advocates argue, the new rules 

deter poor U.S. citizens from getting health 

coverage. 

‘‘Under the best of circumstances, many 

people would be surprised to have to produce 

documentation of their citizenship,’’ said 

Jim Carnes of Alabama Arise, an advocacy 

group for the poor. 

Alabama Medicaid Commissioner Carol 

Herrmann-Steckel said the state is working 

hard to keep people on the Medicaid rolls. 

Unlike some other states, Alabama is not 

kicking current Medicaid recipients off the 

program if they do not possess the necessary 

documents. Under a provision called ‘‘reasonable assurance,’’ current Medicaid recipients are allowed to temporarily re-enroll. 

Medicaid beneficiaries must re-enroll every 

year. 

‘‘We are doing everything we can to verify 

citizenship. We want to be fair to the Alabamians who are on Medicaid,’’ HerrmannSteckel said. However, federal government 

officials have not said how long the ‘‘reasonable assurance’’ period could last. The number of people who could lose Medicaid benefits would be ‘‘significant.’’ HerrmannSteckel said. 

Medicaid is a joint federal-state health 

care program for the poor and disabled, and 

it is a major provider of medical care in Alabama. Medicaid pays for the health care of 

nearly 1 million Alabamians, about 20 percent of the state’s population, HerrmannSteckel said. 

Advocates fear many poor people can no 

longer enroll in Medicaid because they cannot locate their birth certificate, or afford to 

buy a copy, and do not have the required 

proof of citizenship such as a photo ID. 

The cost of obtaining a birth certificate is 

a challenge for many low-income people, 

Carnes said, as is transportation to present 

the documents. The state Department of 

Public Health charges $12 to search for a 

birth certificate. 

There is currently no way to tell if the 

1,600 who were denied coverage were illegal 

immigrants or U.S. citizens without the 

proper documents. But anecdotal evidence 

from Medicaid workers suggests some were 

just poor American parents. Medicaid workers asked people who had been denied coverage why they didn’t have the proper paperwork. 

‘‘By and large the reason was, ‘I can’t afford to buy four birth certificates,’’’ said Lee 

Rawlinson, deputy Medicaid commissioner 

for beneficiary services. 

Herrmann-Steckel said the state is doing 

everything possible to help Medicaid-eligible 

people obtain the documents. 

The Department of Public Health has 

agreed to begin faxing Medicaid officials copies of birth certificates as a last resort for 

applicants who can’t obtain their own. The 

two agencies will split the cost. 

Transportation also is a problem for some 

families, Carnes said. While people previously could renew their Medicaid status by 


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S348 CONGRESSIONAL RECORD — SENATE January 13, 2009 

mail, the new rules require a trip to see a 

Medicaid eligibility worker in person. 

‘‘There are all sorts of barriers, particularly for people without transportation and 

who may not have had a documented birth to 

begin with,’’ Carnes said. 

Raulerson said she cares for a family in 

Monroe County that once had Medicaid benefits but, without a car, has not been able to 

renew their coverage. 

Medicaid officials say they don’t know how 

many Alabamians have lost their Medicaid 

benefits because they couldn’t, or didn’t, 

visit an eligibility worker. 

The Alabama Medicaid Agency is also 

working with other state agencies, such as 

the Department of Mental Health and Mental Retardation, to see if they’ve already 

verified a person’s citizenship, she said. 

People who also receive Medicare, the 

health care program for seniors, or Supplemental Security Income for a disability were 

exempted from the requirements after state 

Medicaid officials from across the country 

complained that would be too burdensome. 

Other states are struggling to comply as 

well. 

California has yet to implement the new 

federal rules. Vermont and other states are 

phasing in the regulations. While the law 

was designed to cut down on Medicaid fraud 

by illegal immigrants, Herrmann-Steckel 

said she does not believe Alabama has a 

widespread problem of illegal aliens receiving Medicaid. 

NEW MEDICAID RULES COULD COST STATE

MILLIONS

(By John Hanna) 

The state could face millions of dollars in 

additional costs because of federal rules requiring Medicaid recipients to verify their 

citizenship, Gov. Kathleen Sebelius said 

Wednesday. 

Sebelius said she’s worried the state will 

have to pick up the full cost of caring for 

some poor, frail and elderly Kansans who are 

living in nursing homes, instead of sharing 

the cost with the federal government. Also, 

she said, she will propose adding state employees to verify the citizenship status of 

Medicaid recipients and applicants. 

The governor told reporters she hopes Congress reviews the issue and other attempts to 

prevent illegal immigrants from obtaining 

social services or using driver’s licenses as 

identification. 

‘‘There was no input from the states on 

how realistic these were or what the cost 

was,’’ Sebelius said during a brief news conference following an unrelated meeting. 

Under Medicaid requirements that took effect July 1, recipients must provide either a 

passport or two other documents, such as a 

birth certificate and a driver’s license, to 

verify citizenship. 

While the measure is targeted at illegal 

immigrants, some advocates for the needy 

have worried that citizens will either lose or 

be denied services because they have trouble 

finding the necessary documents. 

State officials say the number of Kansans 

covered by Medicaid dropped almost 7 percent since July 1, down to 253,000 from 

271,000. They believe much of the decline can 

be attributed to the new requirements. 

Typically, every $1 the state spends on 

Medicaid is matched by about $1.50 from the 

federal government. If someone loses their 

coverage, then the state faces paying the entire bill for their services, Sebelius said. 

‘‘You’re at 100 percent state dollars or push 

them out the door,’’ she said. 

Also, Sebelius said, the state needs to 

‘‘ramp up’’ its staffing to handle the additional verification work. The governor is 

working on the budget proposal she’ll submit 

to the 2007 Legislature, which convenes Jan. 

8. 

‘‘We’re certainly going to put some of 

them in place,’’ she said. ‘‘We’re trying to 

make a careful analysis of how many we 

need.’’ 

She said that if the state refuses to comply 

with the law, it could face the loss of all federal health care dollars. 

‘‘We don’t have a lot of latitude to say 

we’re not going to do this,’’ she said. ‘‘There 

are literally hundreds of millions of dollars 

at stake.’’ 

Meanwhile, Sebelius expressed concern 

about a federal law on driver’s licenses 

passed last year. 

Starting in 2008, federal agencies won’t 

treat a state’s licenses as valid ID unless a 

state requires license applicants to document that they’re living in the United States 

legally. Lack of ID could prevent someone 

from entering a federal building or boarding 

a plane. 

Sebelius said the law will require local 

driver’s licenses offices to certify that someone has the proper documentation and to 

store the information. 

‘‘Exactly how that’s going to happen, we’re 

not quite sure,’’ Sebelius said. ‘‘We don’t basically have any of the equipment that’s required to do that in any of the rural areas.’’ 

THOUSANDS IN KANSAS OFF MEDICAID

FOLLOWING CITIZENSHIP RULES

Thousands of low-income Kansans have 

lost or been denied state health care coverage because of new rules requiring them to 

prove they are American citizens, state officials say. 

Since the federally mandated rules took effect July 1, the number of Medicaid recipients in Kansas has decreased by about 18,000, 

to 253,000. While officials can’t determine exactly how much of the 7 percent drop can be 

attributed to the new rules, they believe 

much of it can. 

‘‘The impact to the consumer has been severe,’’ said John Anzivino, a vice president 

for MAXIMUS, a Reston, Va., company that 

helps administer the joint federal-state Medicaid program in Kansas. ‘‘From our perspective, this has possibly been the most dramatic change and challenge to the Medicaid 

program since its inception.’’ 

The new rules were included in last year’s 

federal deficit reduction law and were designed to prevent illegal immigrants from 

enrolling in the state programs providing 

health coverage. 

But consumer advocates said many vulnerable people who legitimately were eligible 

for assistance would lose coverage because 

they couldn’t produce the necessary documentation. 

‘‘We expect that many of these that have 

lost coverage will regain coverage once they 

have gathered and provided the necessary 

documentation,’’ Marcia Nielsen, executive 

director of the Kansas Health Policy Authority, told the Lawrence Journal-World. ‘‘They 

will, however, experience a gap in coverage 

that could prove to be significant for some.’’ 

Medicaid applicants can prove their citizenship by providing a passport. Or they can 

provide other documents that verify both 

their citizenship, such as a birth certificate, 

and their identities, such as a driver’s license. 

Anzivino said most people seeking benefits 

don’t have a passport and are left scrambling 

to find birth certificates and other documents: 

The number of calls each month to a Kansas Medicaid clearinghouse has more than 

doubled to 49,000 from 23,000, official said. 

Meanwhile, Rep. Dennis Moore, a Democrat whose district is centered on the state’s 

portion of the Kansas City area, said federal 

officials were aware of states’ problems with 

the new rules and probably would work on it 

when the new Congress takes office in January. 

f 

SUBMITTED RESOLUTIONS 

SENATE RESOLUTION 13—CONGRATULATING THE UNIVERSITY 

OF FLORIDA FOOTBALL TEAM 

FOR WINNING THE 2008 BOWL 

CHAMPIONSHIP SERIES (BCS) NATIONAL CHAMPIONSHIP 

Mr. NELSON of Florida (for himself 

and Mr. MARTINEZ) submitted the following resolution; which was referred 

to the Committee on the Judiciary: 

S. RES. 13 

Whereas on January 8, 2009, before a crowd 

of more than 78,000 fans in Miami, Florida, 

the University of Florida Gators won the 2008 

Bowl Championship Series (BCS) national 

title with a stunning 24–14 triumph over the 

University of Oklahoma Sooners; 

Whereas the University of Florida is one of 

the premier academic institutions in the 

State of Florida; 

Whereas the University of Florida Gators 

captured the Southeastern Conference championship title on December 6, 2008; 

Whereas University of Florida football 

Head Coach Urban Meyer has won 2 BCS national championship games in the past 3 

years; 

Whereas University of Florida quarterback 

Tim Tebow was named the Most Outstanding 

Player of the BCS national title; 

Whereas Tim Tebow won the Maxwell 

Award for the second time in 2 years; 

Whereas the University of Florida defense 

held the University of Oklahoma to only 363 

yards of offense in the BCS championship 

game; 

Whereas the Gators finished 2008 ranked 

first in the Associated Press Poll and first in 

the Coaches Poll; 

Whereas the Gators finished the 2008 season with a record of 13–1; 

Whereas the University of Florida student 

athletes are among the most talented in the 

Nation; 

Whereas University of Florida fans worldwide supported and encouraged the Gators 

throughout the football season; 

Whereas University of Florida President J. 

Bernard Machen and Athletic Director Jeremy N. Foley have shown great leadership in 

bringing success and glory to the University 

of Florida; and 

Whereas the University of Florida students, faculty, alumni, and all Gator fans are 

deeply committed to bringing pride to the 

University of Florida and the entire State of 

Florida: Now, therefore, be it 

Resolved, That the Senate— 

(1) congratulates the University of Florida 

Gators for winning the 2008 Bowl Championship Series (BCS) national championship; 

(2) recognizes the achievements of the 

players, coaches, students, and staff whose 

hard work and dedication helped the University of Florida Gators win the championship; 

and 

(3) respectfully requests the Secretary of 

the Senate to transmit an enrolled copy of 

this resolution to— 

(A) the University of Florida for appropriate display; 

(B) President of the University of Florida, 

J. Bernard Machen; 

(C) Athletic Director of the University of 

Florida, Jeremy N. Foley; and 


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