Effect of citizenship documentation requirements on access to Medicaid for pregnant women

The Deficit Reduction Act (DRA) of 2005 mandated that Medicaid applicants provide proof of citizenship. We assessed the effect of these documentation requirements on the approximately 17,000 women who apply for pregnancy-related Medicaid coverage in Oregon each year. The primary research question was whether the requirements were associated with an increase in time between application and eligibility determination.

We obtained approximately 30,000 application records for December 2005 through March 2007 and used a straightforward pre-post design to compare time to determination for pregnant women nine months before and after DRA implementation. We calculated mean number of days from request to determination, as well as proportion of applicants not authorized within 7, 30, and 45 days, and used t-tests and Chi-square tests to assess statistical significance.

Time to determination increased from 18 to 22.6 days (25%) following DRA implementation (t=-21.92, p < 0.01). The proportion of applications not authorized within one week or within 30 days increased by 8% and 9%, respectively. The proportion still unauthorized after 45 days increased significantly upon DRA implementation, from 7% to 13% (Χ²=286.6, p < 0.01).

Implementation of citizenship documentation requirements was associated with a significant increase in time to eligibility determination for pregnant women. Since most women apply for coverage at about 5-8 weeks gestation, the added time for determination compromises their ability to obtain prenatal care within the first trimester. A follow-up study with the same sample is planned to determine whether the additional time to determination affected prenatal care initiation.