Documenting citizenship in Medicaid: the struggle between ideology and evidence.

In 2006 Congress passed, and the Centers for Medicare and Medicaid Services (CMS) rapidly issued, regulations requiring states to obtain proof of citizenship from citizens who had applied for Medicaid. This policy was framed as reducing fraud by illegal aliens to preserve benefits for citizens. In fact, evidence indicates there was no significant problem of fraud by immigrants, and the major effect of the policy was to reduce coverage of eligible citizens. This article addresses the reasons why Congress developed this policy and why CMS acted with uncharacteristic haste to implement these counterproductive policies. We note the importance of the policy's symbolic framing--that is, as establishing sanctions against illegal immigration--in congressional passage during a period of rising nativism in Congress and the nation. The regulatory actions reflected the ideological preferences of political appointees and an increasingly adversarial relationship between CMS and state agencies during this period. These haphazard regulatory actions made the policies more convoluted and likely led more eligible citizens to lose coverage. In 2009, Congress amended the law to modify implementation. These issues have continued to persist in the recent debate on national health care reform.

Limited take-up of health coverage tax credits: a challenge to future tax credit design.

The Trade Act of 2002 created federal tax credits to subsidize health coverage for certain early retirees and workers displaced by international trade. Though small, this program offers the opportunity to learn how to design future tax credits for larger groups of uninsured. During September 2004, the most recent month for which there are data about all forms of Trade Act credits, roughly 22 percent of eligible individuals received credits. The authors find that health insurance tax credits are more likely to reach their target populations if such credits: 1) limit premium costs for the low-income uninsured and do not require full premium payments while applications are pending; 2) provide access to coverage that beneficiaries value, including care for preexisting conditions; 3) are combined with outreach that uses easily understandable, multilingual materials and proactive enrollment efforts; and 4) feature a simple application process involving one form filed with one agency.