Maternal and Child Health Journal

, Volume 15, Issue 6, pp 753–758 | Cite as

The Impact of Citizenship Documentation Requirements on Access to Medicaid for Pregnant Women in Oregon

  • Joanna Bauer
  • Lisa Angus
  • Nurit Fischler
  • Kenneth D. Rosenberg
  • Teresa F. Gipson
  • Jennifer DeVoe


The federal Deficit Reduction Act of 2005 mandated citizenship documentation from all Medicaid applicants as a condition of eligibility and was implemented in Oregon on September 1, 2006. We assessed whether new citizenship documentation requirements were associated with delays in Medicaid authorization for newly pregnant eligible applicants during the first nine months of DRA implementation in Oregon. We conducted a pre-post analysis of administrative records to compare the length of time between Medicaid application and authorization for all newly pregnant, Medicaid-eligible applicants in Oregon (n = 29,284), nine months before and after September 1, 2006. We compared mean days from application to authorization (McNemar’s), and proportion of eligible applicants who waited over 7, 30 and 45 days to be authorized (Pearson’s coefficient). The mean number of days women waited for authorization increased from 18 days in the 9 months before DRA implementation to 22.6 days in the post-implementation 9 month period (P ≤ .001). The proportion of eligible applicants who waited 7, 30 and 45 days increased significantly following DRA implementation (P ≤ .001). The proportion of eligible applicants who were not authorized within the standard 45-day period increased from 6.9 to 12.5% following the DRA. Implementation of new citizenship documentation requirements was associated with significant delays in Medicaid authorization for eligible pregnant women in Oregon. Such delays in gaining insurance coverage can detrimentally affect access to early prenatal care initiation among a vulnerable population known to be at higher risk for certain preventable pregnancy-related complications.


Prenatal Care Eligible Woman Social Security Administration Medicaid Coverage Medicaid Eligibility 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The Oregon Department of Children Adolescents and Families provided the dataset used for this analysis and assistance with data coding. Dr. DeVoe’s time on this project was supported by grant number K08-HS16181 from the Agency for Healthcare Research and Quality (AHRQ). Ms. Bauer received a stipend from the Human Resources Services Association (HRSA) Maternal Child Health Bureau through the Graduate Student Internship Program to complete research with the Oregon Office of Family Health. The authors report no conflict of interest within the last three years. There was no financial support provided by the NIH, Wellcome Trust, or HHMI for this research. These findings were presented at the 2009 American Public Health Association Conference Maternal Child Health poster session, November 11, 2009. No funding for this research was received from the National Institutes of Health (NIH), Wellcome Trust, Howard Hughes Medical Institute or other grant-making institutions.


  1. 1.
    Deficit Reduction Act of 2005, Pub. L. No. 109-171, 120 Stat. 4 (8 February 2006).Google Scholar
  2. 2.
    Self-declaration of U.S. Citizenship for Medicaid, Department of Health and Human Services Office of Inspector General. July 2005. Accessed July 3, 2008.
  3. 3.
    Haber, S. G., Khatutsky, G., & Mitchell, J. B. (2000). Covering uninsured adults through Medicaid: Lessons from the Oregon Health Plan. Health Care Financing Review, 22, 119–135.PubMedGoogle Scholar
  4. 4.
    Ross, D. (2007). New Medicaid citizenship documentation requirement is taking a toll: states report enrollment is down and administrative costs are up. Center on Budget and Policy Priorities. March 2007. Accessed August 15, 2007.
  5. 5.
    New Medicaid citizenship documentation requirement: A brief overview. Center on Budget and Policy Priorities: 2006. Accessed August 27, 2009.
  6. 6.
    States reported that citizenship documentation requirement resulted in enrollment declines for eligible citizens and posed administrative burdens. Government Accountability Office Government Accountability Office (GAO): June 2007. Available at: Accessed August 17, 2007.
  7. 7.
    Headed for a crunch: An update on Medicaid spending, coverage and policy heading into an economic downturn. Results from a 50-state Medicaid budget survey for State Fiscal Years 2008 and 2009. Kaiser Commission on Medicaid and the Uninsured: September 2008. Accessed October 19, 2008.
  8. 8.
    Oregon Department of Human Services, Annual Performance Progress Report FY 2006-07. September 30, 2007.
  9. 9.
    Implementation of the U.S. Deficit Reduction Act of 2005 in Oregon and its impacts on Oregon Health Plan clients: An overview of the effects of the new identity and citizenship documentation requirements during the first six months of implementation, September 1, 2006February 28, 2007. Oregon Department of Health Services. Accessed July 3, 2008.
  10. 10.
    Moos, M. K. (2006). Prenatal care: Limitations and opportunities. Journal of Obstetric, Gynecologic, & Neonatal, 35(2), 278–285.CrossRefGoogle Scholar
  11. 11.
    Vintzileos, A., et al. (2002). The impact of prenatal care on preterm births in the presence and absence of antenatal high-risk conditions. American Journal of Obstetrics and Gynecology, 187(5), 1254–1257.PubMedCrossRefGoogle Scholar
  12. 12.
    Poon, L., et al. (2009). First-trimester prediction of hypertensive disorders in pregnancy. Hypertension, 53, 812–818.PubMedCrossRefGoogle Scholar
  13. 13.
    Baldwin, L. M., et al. (1998). The effect of expanding Medicaid prenatal services on birth outcomes. American Journal of Public Health, 88(11), 1623–1629.PubMedCrossRefGoogle Scholar
  14. 14.
    Ricketts, S., Murray, E., & Schwalberg, R. (2005). Reduction low birthweight by resolving risks: Results from Colorado’s Prenatal Plus Program. American Journal of Public Health, 95(11), 1952–1957.PubMedCrossRefGoogle Scholar
  15. 15.
    Egerter, S., Braveman, P., & Marchi, K. (2002). The timing of insurance coverage and use of prenatal care among low-income women. American Journal of Public Health, 92(3), 423–427.PubMedCrossRefGoogle Scholar
  16. 16.
    Adams, E. K., et al. (2005). Welfare reform, insurance, coverage pre-pregnancy, and timely enrollment: An eight-state study. Inquiry, 42(3), 129–144.PubMedGoogle Scholar
  17. 17.
    Rosenberg, D., et al. (2007). Prenatal care initiation among very low-income women in the aftermath of welfare reform: Does pre-pregnancy Medicaid coverage made a difference? Maternal and Child Health Journal, 11(1), 11–17.PubMedCrossRefGoogle Scholar
  18. 18.
    Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Kaiser Commission on Medicaid and the Uninsured. February 2009. Accessed February 17, 2009.
  19. 19.
    Ross, D. (2010). New citizenship documentation option for Medicaid and CHIP is up and running. Center on Budget and Policy Priorities. April, 2010. Accessed May 31, 2010.
  20. 20.
    21. The Patient Protection and Portability Care Act of 2010 (PPCA). H.R. 3590.Google Scholar
  21. 21.
    Holohan, J., & Headen, I. (2010). Medicaid coverage and spending in health reform: National and state-by-state results for adults at or below 133% FPL. May, 2010. Kaiser Commission on Medicaid and the Uninsured. Accessed June 3, 2010.

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Joanna Bauer
    • 1
  • Lisa Angus
    • 2
  • Nurit Fischler
    • 3
  • Kenneth D. Rosenberg
    • 3
  • Teresa F. Gipson
    • 4
  • Jennifer DeVoe
    • 4
  1. 1.San FranciscoUSA
  2. 2.Oregon Health Policy & ResearchSalemORUSA
  3. 3.Oregon Public Health DivisionOffice of Family HealthPortlandUSA
  4. 4.Department of Family MedicineOregon Health & Science UniversityPortlandUSA

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