Document Type


Publication Date



George Washington University, School of Public Health and Health Services, Department of Health Policy


Geiger Gibson/RCHN Community Health Foundation Research Collaborative Policy Research Brief No. 6


Community Health Centers; Health Reform; Health Homes


This report represents a "second wave" follow-up to a "first wave" study whose purpose was to measure the effects of the Deficit Reduction Act's citizenship documentation requirements on health centers and their patients. The earlier study, conducted six months after implementation, found that the law had a widespread impact, including delayed applications, interrupted enrollment, disruptions in care, and at least anecdotal evidence of a growth in the number of uninsured patients as a result of the denial or loss of Medicaid coverage. This "second wave" survey underscores the existence of serious, ongoing problems more than a year after implementation. Specifically, the second wave survey finds that:

  • Three-quarters of all health centers continue to experience significant problems with citizenship documentation barriers for one or more patient groups; among health centers experiencing problems, the situation appears to be worsening rather than lessening on key measures.
  • Documentation requirements appear to have particularly affected several specific patient categories, including pregnant women, children, patients new to the service area, and newborns.
  • About one-third of health centers report a longer and more difficult application and enrollment process.
  • Nearly one-half of health centers continue to report that Medicaid application and enrollment disruptions and delays continue to affect their ability to arrange for specialty care and many affected centers report increased costs associated with helping patients with application and enrollment problems.
  • Although regulatory changes issued in 2007 were intended to address the problem, a significant number of health centers continue to report enrollment delays affecting newborns.
  • Despite the fact that the DRA did not modify the State Children’s Health Insurance Program (SCHIP) when administered as a separate program, fully one-third of health centers located in states with separate SCHIP programs, and 45 percent of respondents in states with combination programs (Medicaid expansions plus a separate SCHIP expansion), reported that citizenship documentation requirements are being applied to SCHIP applicants as well.

These findings suggest that changes implemented in the final rules have done little to ease burdens associated with the DRA’s citizenship documentation requirements, and that the law's greatest impact is falling on low income children and pregnant women and the health care providers that serve them.

Open Access