Others May Follow California in Considering Coverage for Undocumented Immigrants

George Lauer
February 20, 2014
California Healthline

A bill introduced last week in the California Senate aimed at allowing undocumented immigrants to get health care through the state may be the first legislation of its kind in the country, but it probably won’t be the last. Stalled immigration talks in Washington, D.C., suggest that states will have to continue forging their own path.

SB 1005 proposed by Sen. Ricardo Lara (D-Long Beach) would establish a program to provide health coverage for more than two million Californians expected to be left without insurance through the Affordable Care Act. Many — but not all — are undocumented immigrants who are expressly denied coverage through the ACA.

“Other states are looking at this kind of legislation, although not to the degree California is so far,” said Jenny Rejeske, health policy analyst with the National Immigration Law Center.

“I think this is the natural next step — to be looking at ways to provide coverage for all those who are left out of the Affordable Care Act,” Rejeske said.

“I think it’s important to point out that it’s not just undocumented immigrants who are not going to get coverage through the ACA,” Rejeske said. According to private and government estimates, as many as 27 million may be left uninsured in 2016 after full implementation of the ACA. In California, estimates range to almost three million.

In an analysis of a Congressional Budget Office report in Health Affairs last summer, authors predicted most of the residual uninsured — about 80% — will be U.S. citizens.

“There’s this misconception that everyone who is legally in this country will be covered under the new law but that isn’t the case at all,” Rejeske said. “It makes perfect sense that states will be trying to figure out how to cover those left out.”

California’s ‘Come A Long Way Since Prop. 187’

In California, most estimates predict about one third — or as many as one million — of the state’s residually uninsured will be undocumented immigrants.

Last fall, the California Endowment, a health advocacy foundation, launched a statewide campaign to “start a conversation about what is essentially a public health gap,” according to Daniel Zingale, the foundation’s senior vice president.

“We’re thrilled that we’re going to be discussing this issue in the Legislature,” Zingale said this week. “This bill does embody the kind of conversation we were urging in our campaign.”

“California appears to be in the vanguard in accepting the truth about how it’s the morally and fiscally right thing to do to make sure everybody has health coverage,” Zingale said.

“Our state seems to have come a long way since Proposition 187. If you contrast this bill with what was going on here not that many years ago, we’ve made considerable progress,” Zingale said.

In 1994, California voters approved Prop. 187, which sought to establish a citizenship screening system that would exclude undocumented immigrants from state-run education and health care programs. California was in a national leadership role then as well, becoming the first state to pass legislation dealing with immigration, which was traditionally a federal issue. The new law was challenged in a lawsuit and found unconstitutional by a federal court. The state gave up appealing the ruling in 1999.

States Moving Forward With Little Federal Help

California and other states will continue dealing with immigration issues without much help from Washington, D.C. Immigration reform efforts have stalled yet again in Congress, leaving states in a sort of leadership limbo.

Health advocates point out that even if federal immigration reform proposals were moving forward, health coverage for undocumented immigrants still would be years in the future.

“Even if some kind of immigration reform bill passed in Congress tomorrow, the path to citizenship is over a decade long,” said Anthony Wright, executive director of Health Access, a California consumer advocacy group. “States have to do something about making sure people have coverage with or without new federal immigration laws.”

A few states have provisions dealing with coverage for specific undocumented immigrants.

“In some states like New York, Massachusetts, Illinois and Washington, there is coverage for undocumented kids through Medicaid,” Rejeske said. “In Washington, D.C., there is the D.C. Healthcare Alliance safety-net program that covers folks below the 138% [federal poverty] threshold. That’s probably the closest thing to what California is considering,” Rejeske said.

Using State Money Will Be Roadblock

Lara’s bill proposes to use state money to expand Medi-Cal eligibility to those at 138% of the federal poverty level and below — an annual income of about $15,000 or less for one person.

The bill also proposes creating an adjunct exchange run by Covered California officials to help low-income Californians — documented and undocumented — get subsidized coverage. The subsidies on this exchange would be paid for with state — not federal — money.

Lara estimates his plan would cost less than the estimated $1.4 billion the state spends providing emergency care to uninsured Californians.

Opposition to Lara’s plan will likely zero in on the proposal’s cost.

“Federal funding is key and that’s why we thought it was so important for the ACA to provide money and that’s why we think it’s so important for immigration reform legislation to include funding,” Rejeske said.

“Unfortunately, Congress does not agree and that’s why it’s so important for states to fill in the gaps. People don’t stop needing health care just because they’re excluded from coverage,” Rejeske said.

Rejeske and other advocates agree with Lara that spending the money for insurance coverage is better in the long run than spending it in hospital emergency departments.

“It will cost money up front to provide coverage but there are cost savings that offset that and besides, it’s the right thing to do,” Rejeske said.