Think Tank

How Should California Deal With Health Coverage for Undocumented Immigrants?

As many as one million undocumented immigrants in California will remain ineligible for health coverage under the Affordable Care Act.

The California Endowment last month launched a statewide media campaign to get the issue into the public mainstream with television, radio and print ads.

The campaign, not tied to any specific legislation or ballot measure nationally or in California, was designed to “get the discussion started,” according to Endowment officials.

Now what? What’s the next step? We asked stakeholders how California policymakers should deal with health care for undocumented immigrants.

We got responses from:

From Awareness to Action

“Do you have a copy of your green card?” asked the enrollment worker. I paused, taken by surprise because I had reason to believe that Alameda County’s indigent health care program, HealthPAC, was open to immigrants like me. I answered proudly, “No. I am undocumented.”

Despite her briefly confused look, she approved my application. This experience offers a snapshot of the current state of health care for undocumented immigrants in California, exposing the pressing barriers but also the opportunities for moving forward.

There is a mindset endemic to the undocumented immigrant community that believes that we are undeserving of health care. For my family, living as undocumented immigrants in America has meant 14 years without any form of consistent health coverage. Because of this mindset, we assumed that we were not eligible for any health coverage options and had conditioned ourselves against challenging that notion. This is also the explanation for why only a select few within the immigrant community are aware that 11 counties actually have indigent care programs that are open to their undocumented residents. This status quo is simply unacceptable.

As of Jan. 1, 2014, immigration status will be the single most powerful determinant of health in the United States of America. This is precisely why we must redefine the relationship between health and immigration and we must do so now.

As Pre-Health Dreamers, undocumented aspiring health professionals who all share a vision for a healthier community, we have held forums and collaborated with The California Endowment’s Health4All campaign to begin reframing health to be seen and accepted as a right. However, as Californians — policymakers included — we all have the opportunity to do more. The sooner we can take ownership of health as a necessity for all immigrants, the sooner we will be able to advocate for it; to turn awareness into action.

As we witnessed this year with the passage of the TRUST Act, AB 1024 (allowing undocumented lawyers to practice), and AB 60 (driver’s licenses for undocumented residents), California has led the nation in standing by our immigrant friends, families, and neighbors. In the recent weeks, immigrant rights organizations around the state have started to come together to prioritize the health of our communities.

Policymakers should recognize this momentum as an opportunity to engage in intentional dialogue with the undocumented immigrant community in order to provide health coverage for all through legislation in 2014.

Support Safety Net Until Comprehensive Solution Is Found

In the fall of 2005, I was at a back-to-school night in Winters, reaching out to families whose children might need health care and met a young family: dad; mom; “Kevin,” age 7; and “Jessica,” age 3. Kevin was a cute kid with a bowl cut, glasses, and an inquisitive nature. After doing a basic intake, Kevin’s sister qualified for Medi-Cal, but Kevin was stuck: he was born in Mexico and made the trip to California with his parents when he was 3 and the family couldn’t secure a pathway to citizenship.

Because Kevin and his parents were undocumented, that meant they were ineligible for coverage. I worried what would happen if Kevin broke his glasses, got a toothache, or just needed a check-up or if either of his parents needed to see a doctor. The situation was plainly unjust and with so many more families like Kevin’s, where the failure to have health care for all is glaringly and painfully evident.

2013 was a major year for immigrant-rights legislation in California, with Gov. Jerry Brown (D) stepping up in many areas where Washington failed. But health care for immigrants who are undocumented was left on the backburner. So as we head into 2014, when so many Californians will gain access to health care, we must ask: What will it take to provide health equality for immigrants whose invaluable contributions helped build our Golden State?

California’s county-based patchwork system for the uninsured, mostly operated through public hospitals and clinics, just went through a huge adjustment in how the state funds those services. Those who got county services have traditionally been low-income people who couldn’t qualify for Medi-Cal, including undocumented immigrants, depending on county eligibility criteria. But while the Medi-Cal expansion will reduce enrollment in county safety-net programs, it is a fallacy to think that those programs will become superfluous. The state too provides programs to serve immigrants regardless of status, though mostly for emergencies or specific health conditions. Until we get a comprehensive solution, dismantling or diminishing existing systems will put the remaining uninsured at risk of not getting needed healthcare.

Eight years later, I’d like to tell Kevin’s mom she shouldn’t worry if he joins the soccer team, that she can stop worrying about her husband’s back pain, and that California is ready to invest in the health of ALL our residents, no matter where we’re from.

Maintain Safety Net for All Californians

While the historic expansion of coverage under the Affordable Care Act is providing new insurance options for millions of Californians and dramatically reducing the number of uninsured by half or more, potentially three million Californians will remain uninsured. Increased efforts at outreach, education and enrollment can bring that number down further, but there will be some who fall through the cracks.

For the many Californians who are left uninsured, there needs to be a safety net to provide basic care and coverage, to prevent the devastating health and financial consequences to individuals and the public health and economic repercussions to our communities. While not a majority, a good percentage of the remaining uninsured are immigrants not legally present, who are explicitly and unfortunately excluded from the subsidized coverage the ACA provides.

This issue thus falls to the state and counties, and it is not going away. Even if immigration reform passes, it’s likely that those on a more-than-a-decade-long “path to citizenship” will be barred from any federal financial help for health care, regardless of their income.

Health Access and community partners recently surveyed the counties that will continue to have the responsibility for providing care for the uninsured. Our new report, “California’s Uneven Safety-Net,” found that despite exciting progress in key counties, California will continue to have a highly variable patchwork of indigent care and safety-net programs and services. Some counties — like Alameda, Los Angeles, San Francisco, San Mateo and Santa Clara — are moving ahead in providing a medical home to the remaining uninsured, in some cases reorienting the Low-Income Health Programs that served as a “bridge” for the new Medi-Cal population. But there are only 10 (albeit populous) counties that explicitly provide primary and preventative care to undocumented Californians beyond emergency services. Three others (Contra Costa, Sacramento and Yolo) cut their care to undocumented immigrants in 2009 during the budget crisis.

Other counties even were discussing cutting safety-net services, as they faced reduced federal and state funds. If California does a good job enrolling people in coverage, counties may and should decide to use new savings and revenues to continue to provide a safety-net that survives and thrives for the remaining uninsured, including the undocumented. We urge advocates and organizations to engage with counties as they make initial decisions about their safety-net funding in January, and into the new year as counties assess the impact of health reform.

Ultimately, we need a statewide solution that recognizes the dignity of every Californian, regardless of which county they live, and the need to invest in our shared health and prosperity. California took an important step by including many legal immigrants who were excluded in the federal law — including recent legal immigrants and DREAM Act students — in our Medi-Cal expansion. We should take additional steps in 2014 and beyond. Our counties and ultimately our state can fulfill the full promise of health reform, and benefit from a health system that is more humane, more efficient and effective, and stronger, when everyone is included.


Finish the Job Obamacare Started

We’re getting our mojo back in California. Solutions to big challenges may elude our leaders in Washington, D.C., but our state leads the way in implementing Obamacare and enacting meaningful immigration reforms, according to everyone from New York Times columnist Paul Krugman to comedian Bill Maher.

But there’s one area where California may be moving backwards and not forward — ensuring access to basic, preventive health services for undocumented Californians.

I’ve been fortunate to meet many young undocumented dreamers and strivers as we’ve put together our Health4All campaign. I’ve met undocumented college students who dream of being scientists and engineers and teachers. I’ve met young undocumented architects and future doctors. I even got to meet Sergio Garcia, an undocumented Californian who went to law school, passed the California bar exam and fought so that undocumented Californians can become licensed lawyers, a reform that was recently signed into law by Gov. Jerry Brown (D). 

What’s remarkable about these young people is actually how unremarkable they are. There are many like them throughout California. According to the research, more than 90% of undocumented Americans work. They pay $2.7 billion in taxes to California. And they contribute $302 billion to our state’s economy.

These young people are the future of California. Our success as a state is inextricably bound to theirs. Immigrants arrive healthy and want to live responsible and healthy lives. Keeping them healthy is good for our economy. Simply crossing our fingers and hoping they’ll stay healthy, without making it easier for them to do so, is self-defeating.

And it just makes plain financial sense to allow people to access basic health care services and preventive care that provides checkups and screenings to catch problems before they become expensive crises. It might cost $30 to get a flu shot. But if that doesn’t happen and someone ends up in the hospital with influenza, we’ll pay thousands.

In the coming months, counties across California will be making important decisions about the safety-net health services they’ll provide to those who remain outside Obamacare.

Fortunately, solutions exist. Low Income Health Programs were set up a few years ago in 53 of 58 California Counties to provide a temporary way to provide care until Obamacare started. Counties can continue to use this infrastructure they’ve built to provide care to undocumented residents. Counties without Low Income Health Programs should maintain their medical indigent health care programs.

But the counties cannot do it alone. Moving forward, they’ll need new funding streams and incentives from the state. And leaders from throughout California should come together and explore a California solution to open up Obamacare and the exchanges to all Californians.  Only then will the promise of Obamacare become real. Until then, our work is not done.

Once again, California needs to lead. Not follow.

Invest in Safety Net Clinics, Health Centers

California is leading in implementing the Affordable Care Act. But we cannot overlook the fact that there are still many who will be left out of health care reform here in California and across the nation. We must include all individuals in the health care system. We cannot keep taking services from the one million undocumented people living in California and then deny them equal access to health care. For this to happen, policies need to be put in place to break down our nation’s current barriers to health care access.

We have long advocated that true reform will not happen until there are provisions extending health care coverage to individuals who are unfairly denied access solely due to immigration status. Until that happens, there are things we can do. Community clinics and health centers (CCHCs) are committed to providing services to all Californians, regardless of citizenship status. We must continue to invest in our CCHCs and strengthen our safety net, as these providers will continue to be the primary option for those who remain uninsured. 

We must also invest in programs that expand access to care now. California had a tremendously successful program that ensured access to primary care at CCHCs across the state that was defunded under the Schwarzenegger administration. The Expanded Access to Primary Care program was created to expand access for medically underserved areas and populations by providing additional funding for primary and preventive health care. With funding to this program restored to adequate levels, potentially millions of uninsured individuals with no other means of coverage would have access to needed services.

Without a broader initiative to address this issue at the federal level, we must make an investment here in California. We need to ensure the state’s safety net continues to thrive and is able to provide care for those who remain uninsured.

Finishing the Job

California has a long tradition of treating our immigrants with dignity and respect. When the 1996 federal welfare law restricted access to public benefit programs for lawfully present immigrants until they had resided in the U.S. for five years, California continued to provide Medi-Cal to recent lawful immigrants who had not yet met the “five year bar.” Medi-Cal is California’s Medicaid program.

The expansion of Medi-Cal program and the establishment of Covered California, the state’s health insurance exchange, make up the largest increase in health coverage our state has seen in 50 years. California extended Medi-Cal not just to childless adults, but also to childless adults who are recent legal immigrants and individuals who are permanently residing under color of law (PRUCOL). Deferred Action Childhood Arrivals are included in the PRUCOL eligibility category! This means thousands of immigrants will be eligible for coverage through Medi-Cal as detailed in our fact sheet, Summary of Medi-Cal Coverage for Immigrants.

As a result of these historic expansions due to the Affordable Care Act, California will be reducing our uninsured population by half — down from a high of more than seven million to three million to four million. We’re very close to the finish line of making sure all Californians are insured and can get affordable health care when they need it.

Across the state, counties that are transitioning their Low-Income Health Program enrollees to Medi-Cal are poised to step up and provide much needed care to the remaining uninsured by using the existing infrastructure they have already established. We need to make sure that the counties provide these much-needed safety-net services to the remaining uninsured.

The state must also continue to take a leadership role. Whether that is using our existing programs such as Medi-Cal or Covered California to extend coverage to the uninsured, or incentivizing the counties to do the right thing, it’s time to finish the job and provide coverage for our undocumented immigrants. It’s good health policy. It’s good for the state’s prosperity. And it’s good for the health of all Californians.