California Poised to Extend Medicaid to Undocumented Immigrants

Ken Terry

May 23, 2019

California is now grappling with an issue that has broad ramifications for physicians across the country: how to give undocumented immigrants access to healthcare.

In the coming weeks, the California legislature will decide whether to adopt Gov. Gavin Newsom's plan to extend Medi-Cal (Medicaid) coverage to unauthorized immigrants aged 19 to 25 years.

The state legislators are also considering bills that would allow all undocumented adults whose income is below a certain level to enroll in Medi-Cal. Undocumented immigrant children and pregnant women are already eligible for Medi-Cal.

If California lawmakers adopt either of these approaches, their state would become the first in the country to provide Medicaid coverage to undocumented adults. Five other states and the District of Columbia cover unauthorized immigrant children.

Billions or Millions?

At a recent press conference, Newsom argued that it would be too expensive for the state to offer Medi-Cal coverage to all undocumented people. The cost would be about $3.4 billion per year, according to the Wall Street Journal.

In contrast, limiting the Medi-Cal expansion to individuals aged 19 to 25 would cost about $194 million, according to a summary of the governor's budget proposal. Federal matching funds are not available to pay for Medicaid coverage of undocumented immigrants.

Democratic State Senator Maria Elena Durazo has introduced a bill that would give all Californians with incomes lower than 138% of the federal poverty level access to Medi-Cal, regardless of immigration status.

The measure, which has the support of state immigration activists, cleared the Senate health committee by a vote of 7–1 in March. Similar legislation has been proposed in the State Assembly.

"In spite of their integral role in our state, undocumented Californians are, for the most part, left out of our health insurance system," Sen. Durazo said in a statement. "They can't get preventive screenings for serious health conditions like diabetes. They rely on emergency rooms and last-minute care."

Newsom's more limited plan is imbedded in his 2019–2020 budget proposal, which the legislature must act on by June 15. The proposed expansion of Medi-Cal to some undocumented adults is part of a broader package of healthcare reforms designed to move the state toward universal coverage.

Medi-Cal currently covers nearly a third of California's 39 million people, according to the state's Department of Health Care Services. In 2014, there were between 2.35 million and 2.65 million unauthorized immigrants in the Golden State, the Public Policy Institute of California estimates.

It is unclear how many undocumented immigrants already have some kind of healthcare insurance. Nationwide in 2017, the uninsured rate among nonelderly unauthorized immigrants was 47%, compared to 24% for noncitizens who were in the country lawfully and 10% for citizens, according to the Kaiser Family Foundation (KFF).

How Many Would Enroll?

The California Medical Association (CMA) favors legislation to extend Medi-Cal coverage to undocumented immigrants. In a statement provided to Medscape Medical News, association spokesman Anthony York said, "CMA is supportive of efforts to provide access to all Californians, particularly the remaining uninsured (about half of whom are undocumented). We view the governor's proposal as an important first step to increasing access to care to all California residents."

But there is uncertainty about how many undocumented immigrants would enroll in Medi-Cal if they could. The Trump administration's policy of deporting undocumented people for a variety of reasons could discourage these individuals from attracting attention to themselves. Moreover, family members who are in this country legally may also be discouraged from enrolling in Medicaid.

Under a rule proposed by the Trump administration in October 2018, officials could consider use of certain noncash programs, including Medicaid, when determining whether someone is a public charge and should therefore be denied a green card, according to KFF. These changes are expected to lead to decreases in Medicaid participation among immigrant families who are in the country legally, as well as their US-born children.

Republicans in Congress have cast a wary eye on California's Medi-Cal proposals, even though only state funds would be expended in covering the undocumented persons. Sen. Bill Cassidy (R-LA) has sponsored a bill, the Protect Medicaid Act, "to ensure the long-term integrity of Medicaid by preventing liberal states like California from forcing American citizens in other states to subsidize state programs that expand Medicaid benefits to illegal immigrants," Bloomberg News reports.

The legislation would require the US Department of Health and Human Services' Office of Inspector General to report on how states distinguish funding for undocumented Medicaid recipients from funding for all other enrollees.

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