More than 50 million Medicaid recipients will soon have to produce birth certificates, passports or other documents to prove that they are United States citizens, and everyone who applies for coverage after June 30 will have to show similar documents under a new federal law.
The requirement is meant to stop the "theft of Medicaid benefits by illegal aliens," in the words of Representative Charlie Norwood, Republican of Georgia, a principal author of the provision, which was signed into law by President Bush on Feb. 8.
In enforcing the new requirement, federal and state officials must take account of passions stirred by weeks of national debate over immigration policy.
State officials worry that many blacks, American Indians and other poor people will be unable to come up with the documents needed to prove citizenship.
In addition, hospital executives said they were concerned that the law could increase their costs, by reducing the number of patients with insurance.
The new requirement takes effect on July 1.
The Congressional Budget Office estimates that it will save the federal government $220 million over five years and $735 million over 10 years.
Most of them will be illegal immigrants, it said, but some will be citizens unable to produce the necessary documents.
Some Medicaid experts put the numbers much higher, saying that millions of citizens could find their health benefits in jeopardy.
Hospitals and nursing homes are expressing concern.
In a draft letter providing guidance to state officials, the Bush administration says, "An applicant or recipient who does not cooperate with the requirement to present documentary evidence of citizenship may be denied eligibility or terminated" from Medicaid.
Representative John Lewis, Democrat of Georgia, said: "Many older Americans do not have birth certificates because their parents did not have access to hospitals, and so they were born at home.
In the last century, all over the South, because of segregation and racial discrimination, many hospitals would not take minorities."
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