All Renell Francine Ray needed to stay on Medicaid was an original birth certificate and a valid state ID card that would prove she was a U.S. citizen and Maryland resident.
Producing those documents might have seemed simple enough to Congress when it decided to require them as a way to block illegal immigrants from using the nation's health insurer of last resort.
But in the world of bureaucrats and paperwork, Ray became entangled in a maddening Catch-22: To obtain her original birth certificate from Virginia, she needed a valid state ID; to obtain a valid state ID, she was told, she would need her original birth certificate.
As a result Ray, a diabetic suffering from gout and arthritis, has been struggling for months to get on Medicaid, one of thousands of Marylanders who have failed to qualify for the program since the new law went into effect last summer.
"I'm to the point where I'm frustrated, I'm really frustrated," said Ray, a Baltimore resident who is on five different medications.
"I don't think you should have to go through things like this."
Across the country, advocates and health officials say, hundreds of thousands of poor people who may be eligible for Medicaid have gone without it at least temporarily, having to scramble to get paperwork to prove where they were born and where they live.
"It's affecting so many legal citizens, so many people who were born and raised here, and they can't get it because these documents are just as difficult for them to get as anybody else," said Sadie A. Matarazzo, a social worker with Baltimore HealthCare Access Inc., which works with some of the city's Medicaid recipients.
Generally, very low-income U.S. citizens and legal immigrants with at least five years' residency are eligible for Medicaid, a federally subsidized health insurance program for the poor. Single adults without young children like Ray are generally not eligible unless they are deemed "medically needy," in which case they can qualify in Maryland if they earn roughly $20,000 a year or less.
Until last year, states, which administer the program, allowed people to simply declare their legal status, and no citizenship documents were necessary.
But Congress, concerned that illegal immigrants had easy access to the taxpayer-financed program, passed a law last year requiring states to get documentary proof of Medicaid applicants' legal status.
Supporters argue that it's only fair to ensure that those receiving government help are legally entitled to it, that in the past, any illegal immigrant could sign up rather easily for government-funded care.
But many states are finding that the law is also a barrier to tens of thousands, and likely hundreds of thousands, of poor citizens on their rolls.
That includes many children, for whom parents must track down the required paperwork.
"It's a large number of people, and the state officials are saying that most, if not almost all, of these people are U.S. citizens," said Donna Cohen Ross, who has researched the issue for the Washington D.C.-based Center on Budget and Policy Priorities.
Maryland health officials have worked to match up the state's half-million Medicaid recipients with state birth records in an effort that, though costly and time-consuming, has avoided unnecessarily rejecting tens of thousands of applications from lifelong Marylanders.
State officials have not kept track of how many people are losing Medicaid coverage because of the new law - or its effect on children.
The U.S.-born children of legal immigrants may be particularly vulnerable to the new rules, according to CASA of Maryland, an immigrant advocacy group that says some parents have reported difficulty getting local health officials to accept their children's birth certificates.
Maryland has experienced a 15 percent increase in the total number of people dropped for failing to file all the necessary forms - nearly 17,000 more people losing coverage from August to April over the same period a year earlier.
That has contributed to a drop in Medicaid enrollment of 6,500 people, to 501,500 people, since the new requirements went into effect last summer through May - a pattern similar to that of many other states when officials have expected increases in enrollment instead.
State and local health officials say that many of those who lost coverage failed to meet the new documentation requirements. A "high percentage" of those are probably citizens, said Charles E. Lehman, executive director of Office of Operations, Eligibility and Pharmacy at the state's Department of Health and Mental Hygiene.
Eventually, officials hope, many of those people will find their way back onto the Medicaid rolls, but it can take time to get documents in order.
Immigrant advocates say that all these difficulties are arising from legislation that wasn't necessary.
"It's certainly an example of a way that anti-immigrant fervor was manipulated to address a problem that didn't exist," says Kim Propeack, advocacy director for CASA of Maryland.
Sen. Jeff Bingaman, a New Mexico Democrat, has sponsored a bill that would essentially overturn the new restriction, allowing states again to accept applicants' self-declarations. His measure is expected to be offered as an amendment to a larger health care bill this year, but it's unclear whether Congress would approve a change when immigration is still a major issue heading into the 2008 election.
Lehman, whose office spent nearly $12 million last year complying with the new law, supports a change, saying he doubts that there are a large number of illegal immigrants on Medicaid in Maryland.
"We don't think it was as big a problem as they thought it was to begin with," Lehman said. "We could find ways to ensure that citizens were eligible much more cost-effectively and without denying people access to care when they needed it, so we'd like to have the flexibility."
Without more flexibility, the standards for proving citizenship can be tough to meet. The best document to prove eligibility, for example, is a U.S. passport, but many poor people don't have passports, and they cannot be obtained quickly.
Most people qualify by providing an original birth certificate and a valid state identification card - within reach for most, but sometimes not without help from a social worker, and not without weeks or months of delay.
Then there are the complicated cases. Matarazzo, who worked with Ray, had another client whose birth certificate didn't exist.
"He was born at City Hospital back when it was City Hospital, and he didn't have a birth certificate, and he kept applying for assistance and they kept saying no, no, no," she said.
It took 6 1/2 months to get officials to accept his paperwork for Medicaid.
In Renell Ray's case, one complication compounded another. She was born in Hopewell, Va., in 1954. If she had been born in Maryland, officials in Annapolis could have cross-checked her application with state records, and she would have qualified for Medicaid with little difficulty.
Ray moved to West Baltimore 50 years ago and has been a part of the community ever since.
She dropped out of Douglas Senior High School while pregnant with her only child, a daughter who has since given her eight grandchildren. She worked in odd jobs for various employers over the years, but she readily admits that with her health issues, she'd rather not work anymore - and she currently doesn't, getting by on food stamps and the generosity of relatives.
In addition to diabetes that sometimes causes her extremities to swell, Ray has gout in one knee and arthritis in both, she said, and a raft of medications to treat them. She is in poor physical shape, and, she said, suffered a heart attack in 1989, while in her mid-30s.
She can recite every school she has attended and every address she has lived at in the city, including eight different places along North Fulton Avenue alone. She used to have a valid state ID card in the 1980s, when she worked regularly in times of better health. In more recent years, she has been on welfare, and in and out of the criminal justice system. She is currently on probation for a felony conviction of possessing drugs with the intent to distribute them.
The system knows Renell Ray well: It has her picture, her signature, her records. But that didn't work in her favor at first.
Forced early this year by the new law to get her documents, she found that the state of Virginia needed her to produce an official government ID, with photograph, to get her birth certificate. She also learned that the Maryland Motor Vehicles Administration wanted an original birth certificate to give her an ID card.
Ray could have sidestepped this issue by traveling to Virginia in person to request the birth certificate, but, she said, that would have violated the terms of her probation. She then said she tried to ask for a photo identification from the same Maryland justice system that had recently processed her, but failed there as well.
"I just couldn't believe it," Ray said. "I was at my wit's end."
Then, in March, Ray found Matarazzo through another nonprofit, Universal Counseling, that has been temporarily helping her get the insulin and other medicines she needs while off government assistance.
Eventually, with Matarazzo making telephone calls up the chain of command, they found that, because Ray previously had a valid state ID, she needed only a photocopy of her birth certificate, along with other documents proving she lived in Maryland, to get her new ID card.
On the morning of May 23, having already made several frustrating trips to the MVA office near Mondawmin Mall, Ray walked in again and, after finding the right employee to talk to, walked out minutes later with her ID card.
Matarazzo has since sent in a copy of that ID, along with other paperwork, to an online records company to get Ray's birth certificate. But the company said Ray needs to supply yet more information, Matarazzo said, before she can finally get the last vital piece she needs to get on Medicaid.
Once she has an original birth certificate in hand, Ray should be back on Medicaid within one to three months, after at least six months of wading through the new restrictions.
"It's a struggle. You've got to be willing once you put your foot forward, to finish the struggle," Ray said. "And I'm determined to get this."