June 2010

Document Type


Degree Name



Dept. of Public Health and Preventive Medicine


Oregon Health & Science University


Background: As part of the Deficit Reduction Act (DRA) of 2005, all states became required to verify that Medicaid beneficiaries are U.S. citizens. Since the policy was implemented in 2006, three quarters of states have reported significant declines in Medicaid enrollment and observational studies have reported increased administrative burdens. Although the magnitude of disenrollment following implementation has been published widely, no study has yet examined the characteristics of affected children, the potential for this type of denial to lead to significant insurance gaps, or the resulting impact of this policy on access to health care. Because public insurance is held by over 30% of American children and because the risks of insurance gaps among this population are well known, a thorough understanding of the impacts of this policy will be essential to inform future policy. Research Questions: (1) What individual characteristics are associated with children’s Medicaid denial for inability to document citizenship? (2) Is denial for this reason associated with a subsequent six month gap in health insurance? (3) Is denial for inability to document citizenship associated with having poor access to health care? And, can having insurance coverage and/or a usual source of care attenuate the effect of Medicaid denial on access to health care? Methods: We used data from the 2007 OHP Disenrollment Study, which identified a random cohort of children who applied to Oregon’s Medicaid program over a three month period shortly after implementation of the 2005 DRA. Parents of selected children completed a previously validated mail survey focusing on access and utilization of health care over the previous six months since their child’s application. Data were weighted to reflect the population of interest and to account for survey non response. We performed a complete descriptive analysis as well as multivariable logistic regression modeling to examine each of the three research questions. Results: 394 children participated in the survey. This number was weighted to reflect a full population of 104,375 children who applied for Medicaid in Oregon during the sampling window. Children denied for inability to document citizenship were more likely than children denied for other reasons to come from a low income household (OR=p=0.0005), have a chronic disease (p=0.0234), and/or to have previously applied for Medicaid (p<0.0001); but they did not differ from others in their race, ethnicity, preferred language, or birthplace. More than a third of children denied for inability to document citizenship had a six month gap in health insurance following their denial, making them just as likely to have a gap as children denied for other reasons. Compared to accepted children, both groups of denied children were significantly more likely to have unmet health care needs, an association that was attenuated when both health insurance and usual source of care were accounted for. Conclusions: Children affected by the new citizenship documentation requirement for Medicaid are medically and socially vulnerable citizen children. Since being denied, these children have suffered significant gaps in health insurance and resulting unmet health care needs. In the interest of child health, we must either reconsider such regressive laws or streamline the process to avoid these enrollment barriers.




School of Medicine



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