More on medicaid and birth certificates

by rcentor on March 18, 2006

As expected, my post on Medicaid received an interesting variety of responses. I believe that those who think that requiiring birth certificates or passports have not thought through the issue carefully. I will try to make the argument in a logical fashion.

We will assume that some illegal aliens receive Medicaid and that we would like to prevent this (some would argue this assumption, but I find this a reasonable place to start).

One can consider birth certificate or passport a diagnostic test of citizenship. Like all diagnostic tests, we will have false positives and false negatives. Many illegal aliens have fake birth certificates (and if not, this requirement will create a business to make them). Some of these birth certificates will pass muster. Similarly, some will have fake passports.

At the same time, many true citizens will not be able to access either a birth certificate or a passport – i.e., false negatives.

What we must ask is whether we should penalize the false negatives in a zealous attempt to limit Medicaid for illegal aliens. This law attacks the most vulnerable in our society, and adds great bureaucratic costs for everyone.

The idea of requiring proof of citizenship seems like a good one on the surface, but on further reflection I believe the costs greatly outweigh the benefits.

Who suffers from this law? Some patients suffer, but when patients are sick hospitals still care for them. So hospitals will suffer financially. Patients will suffer, because we know that the lack of Medicaid will decrease the likelihood that patients receive prevention, increasing their subsequent hospital costs.

We (the taxpayers) end up paying either way. This law does not save money, it only sounds good on the surface.

As usual, this law has unintended consequences. I challenge those who think this law a good idea, to work through the implications of the law. If you still think that the law is useful, please explain it in logical and economic terms.

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{ 12 comments… read them below or add one }

Daniel Newby March 18, 2006 at 6:02 pm

“This law attacks the most vulnerable in our society, …”

Attack? Since when is refraining from giving a gift an “attack”?

“Some patients suffer, but when patients are sick hospitals still care for them. So hospitals will suffer financially.”

Good. By moving the costs as close as possible to the ultimate payer, proper solutions become possible. Nothing will ever improve as long as the cost is a tiny fraction of the total budget of an untouchable Congress 5000 miles away.

ron March 18, 2006 at 6:10 pm

Here’s the logical and economic argument.

Illegal aliens are here against the law. It is time to control our borders.

If someone is here illegally, send that person back where that person came from.

If that person’s illegal status is revealed via the schools, through health care, a police arrest, all is fine with me.

Now, explain in logical and economic terms, what part of that you don’t understand or find objectionable yourself.

False positives, false negatives. Give me a break. This is not a medical test. This is about controlling who enters this country. Blacks suffering because they don’t have birth certificates. Oh yeah. A black man with an Alabama accent can’t produce a birth certificate and the authorities are going to assume he’s a Kenyan and ship him back to Africa. Do you realize how ridiculous you sound?

Right now, a John Doe entering a hospital anywhere in the USA is going to get the medical care needed on the emergent basis, and the insurance gets sorted out later. Medicaid smetimes gets effected after the fact. It can often take a month or more to get all that done anyway. Now legal residence status will be one of the variables. Big deal.

Moof March 18, 2006 at 6:22 pm

Dr. Centor, I understand your logic. Only last summer I had a problem with not being able to get a copy of my birth certificate in a timely manner for a college application.

Also – the poorest and most indigent will the be ones affected, since they’re most likely to not have their paper work, and find it the most difficult to acquire it.

However, with medicine being the way it is today, we really do need to stem the abuse by people who come into the country in order to sponge, and end up making it all the more difficult for the rest of us – including (and especially) our own poorest countrymen.

Can you suggest a better way to deal with the issue?

Cricket March 18, 2006 at 7:00 pm

I think a better way to start would be eliminating the “automatic citizenship status” for babies born here in the United States. Here in Southern California, Mexican Nationals cross our borders illegally before the birth to have the child in a U.S. hospital…thus creating an “instant citizen” with all the perks that come with that.

I realize that it is unfair to harshly burden the poor and uneducated for the sole sake of justice for illegals, but something has to be done. Many of those mentioned above, also come here before birth for the free prenatal care they recieve at health care clinics sponsored with Federal and State funds. They also take advantage of Fedreal food give away programs. They do not have driver’s licenses…only consulate cards. I see it with my own two eyes on a weekly basis.

Just to mention…there are no easy answers.

tina March 18, 2006 at 7:49 pm

Db, you are so analytical! in a good way I mean but it is kind of funny. We al get our hackles up over this and you discuss it in statistical terms. We need to put your pic next to the definition of rational in the dictionary.

I am not so rational-oh the enotions!-however if I was pregnent and I lived in Mexico I would cross the border in an instant to give my kid a better life.

ron March 18, 2006 at 8:33 pm

Cricket, I think the term you allude to is “anchor babies” as in the baby of that family, otherwise in the USA illegally, is now “anchoring” that illegal family in the USA.

The answer to that, as I understand it, lies in the 14th Amendment of the US Constitution, reading in part:

“All persons born or naturalized in the United States, AND SUBJECT TO THE JURISDICTION THEREOF, are citizens of the United States and the State wherein they reside.”

Emphasis mine.

Foreign nationals employed in the diplomatic corps of their native country. They have a kid in the USA. They are not US citizens. We don’t draft their kid into our army. The child was born in the USA but not subject to our jurisdiction.

“Subject to its jurisdiction” excluded from its operation children of ministers, consuls, and citizens of foreign states born within the United States.

The way I read the 14th amendment and its subsequent interpretation, a family here illegally, they have a child in the USA, they are certainly entitled to good medical care out of ordinary humanitarian concern. But when the medical issues of the childbirth have been addressed, the baby AND the family go back home where they came from. They are **NOT** US citizens. They are subject to the jurisdiction of their home country.

An illustration. Here’s a site dedicated to opposition to the death penalty:
http://www.deathpenaltyinfo.org/article.php?did=198&scid=31
They remind us that Mexican citizens who commit capital crimes in the USA and face the death penalty, we may be violating their rights because the Mexican consulate needs to be involved in the process. The World Court seems to agree.

You see, these criminals who committed capital crimes in the USA, they are still subject to the jurisdiction of their home country.

Fine with me. Let’s recognize that nationals of foreign countries here illegally are subject to the jurisdiction of their home countries, AS ARE THEIR CHILDREN. They can’t have it both ways.

Tara March 19, 2006 at 6:56 am

Once again you have made some good points. However- Because I am uninsured I must use a county hospital that is so overwhelmed that it loses the patients its there for. I have had biopys lost and had to be redone, infections overlooked, and trying to get appointments at the specialist I need takes months or they dont call back at all! When I call the clinic they tell me to go to the ER. The ER cannot do anything for me and this is such a waste of taxpayer money. I had insurance until about 4 months ago. As of right now I cannot get treated because of so many people using the same dept. I ended up getting on Parkland Plus. But I had to have all my bills, my last 4 pay stubs, a letter from my employer, birth certificates for all 3 kids and a copy of my taxes. This has been going on since Jan. In dec I was a healthy energetic 41 yo. Today I cant even make it to the store, muchless spend a fun afternoon with my children. I gave up going to the hospital after the 3 times they sent me because they didnt want to make room for me in the Oncology Clinic. I have watched my hemoglobins go from 46 to 16 to 14 to 13 and I have been bleeding for 3 weeks straight. Am I bitter? You betcha. By the time someone at Parkland finally does something , my parents and children will already be sitting Shiva. I have fought to get on Mediaid. I have worked from the time I was 14 and I think I deserve to be able to get some help from my govt. Sorry about the long tirade. Im just tired of people who are here illegaly getting money, food and free good medical care and I cant seem to find a foot hold. The last time I checked the place where I was born is in the US and I am a citizen that keeps getting overlooked. This isnt about Doctors, this is about our nation looking after its own.

Renee March 19, 2006 at 9:23 am

Ron said, “A black man with an Alabama accent can’t produce a birth certificate and the authorities are going to assume he’s a Kenyan and ship him back to Africa.”

That might work if the county Medicaid office actually has a face-to-face meeting with the black man. But, the way these new federal regulations are written, the Medicaid office must base their decisions on documents, not on the lack of a foreign accent.

Here’s a scenario for you – if my grandfather were still alive, he’s be in his late 90′s. If you listened to him talk, he sounded like an American, no accent. BUT – he came to this country from Russia in 1910, when he was 3 years old, as a legal immigrant Still, no US birth certificate. And no US passport either, since he and my grandmother never took vacations. I think it’s unlikely he became a naturalized citizen; he never spoke of this, and may not have realized he should do so. If you asked him if he was an American, he’d have said, “Yes, I own my own home, and I pay taxes. I’ve lived here all my life.”

What does this have to do with Medicaid? It’s relevant because some portion of elderly residents of nursing homes have to go on Medicaid, once they spend down all their assets. Now, a person like my grandfather, if this were his situation, would not be able to provide proof of citizenship. At my father’s nursing home, there are plenty of people in their 90′s, who may not realize that, technically, they are not citizens. Or, if they became citizens, can’t produce their citizenship papers, because the papers are lost, or the resident’s memory is so bad, they can’t remember where the papers are. Some of these people are already on Medicaid. Should they now be thrown off of it?

ron March 19, 2006 at 3:47 pm

**sigh, shakes head……..

do you really think this is about a 90-year-old Russian?

Someone in the USA legally, maybe the birth certificate was lost in the seige of Leningrad. The person in the USA legally to begin with, and therefore has a long paper trail of activities consistent with legal status.

The elderly man is interested in receiving the government benefits. The family is interested in seeing to it that grandfather receives the government benefits. The nursing home wants to be paid. You think the parties involved will not be motivated to come up with documentation satisfactory to the local Medicaid office? You think that won’t be possible?

You can’t tell the difference between uncle Pashya in the nursing home and the obvious illegals in the ER, five different Mexican guys presenting with the same ID card on different days?

By the way, I have the same 90-year-old relatives, same immigrants, just a different country, one of whom did spend a little time behind bars waiting for some paperwork glitch to be settled. I understand the concept. Working in an agricultural area in the West, I daresay I see a few more illegals than might be seen in a VA hospital.

It is remarkable the difference in opinion on this matter, between those who do and do not have to actually deal with the problems created by the people here illegally.

CHenry March 19, 2006 at 10:59 pm

I see no contradiction in forcing the illegal entrant family back to their home country with their U.S.-born “anchor” baby. That policy wouldn’t even require reneging the citizenship by birthright status; the child has to return once of majority age and claim it, and if able to satisfy proof of citizenship here thereafter be subject to U.S. laws, including selective service registration and everything else expected of U.S.-born citizens. Being born here doesn’t convey to me the right to nominate residency rights to anyone else, even a parent needed to care for me.

rwlee March 21, 2006 at 6:08 pm

Ron, the anchorbaby IS a U.S. citizen. They are subject to the jurisdiction of the United States despite the fact that consultation with their embassy is presumptively required. Many European countries once had similar provisions, but most have had them repealed, including the U.K. and Australia, after they witnessed similar abuses. I say “abuses” because the 14th Amendment was enacted in the mid-to-late 1800s to redress citizenship issues faced slaves. While it can be argued that our current situation is not what the authors intended, at this point, the court cases — and plain language of the amendment — are clear and consistent.

Your stated exception is that of diplomats of foreign countries, which, as you alluded, are NOT subject to the jurisdiction of the U.S. That doctrine is known as “diplomatic immunity” and has been the subject of controversy from time to time … also due to abuses.

ron March 21, 2006 at 10:30 pm

rwlee, I would agree with you in that that’s how the “anchor baby” is treated now (pursuant to the Wong Kim Ark case). My opinion, FWIW, is this was not the intent of those who wrote the 14th Amendment, not is it the intent from a plain reading of the Amendment. There is something more to the phrase “subject to the jurisdiction” beyond the laws. Of course they have to drive on the right hand side of the road, obey local laws if they are physically in the USA. That’s not what was meant by the phrase, otherwise why put it in? The debates and statements of the people writing the Amendment are on record, and worth looking at.

The wording of the Constitution is actually not specific enough, and the exact terms to define citizen are listed in the US Code:

http://www4.law.cornell.edu/uscode/html/uscode08/usc_sec_08_00001401—-000-.html

And yes, that’s how we treat “anchor babies” now, by “birthright citizenship”. This has also been controversial, and was not recognized in the 19th century and a large part of the 20th century. Methinks it’s due for another round in the courts.

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