Over the last year, California politicians have been blazing a trail many doubted the rest of the country would follow: offering free healthcare to hundreds of thousands of people in the country illegally.
But on Tuesday, presidential front-runner Hillary Rodham Clinton took a stance on the contentious issue during a televised Democratic debate, boosting it onto a prominent national stage.
Clinton said she favored efforts by states such as California to extend health benefits to these immigrants.
"First of all, I want to make sure every child gets healthcare ... and I want to support states that are expanding healthcare and including undocumented children and others," Clinton said. "I want to open up the opportunity for immigrants to be able to buy into the exchanges under the Affordable Care Act."
The estimated 11 million people who are in the country illegally are barred from signing up for insurance under the Affordable Care Act and make up a growing proportion of those who remain uninsured.
How much the issue will resonate in a presidential contest where immigration policy has loomed large remains to be seen. Some political experts said Clinton's comments appeared to be part of a larger, ongoing effort to shore up support in her party's liberal base, where her chief rival, Vermont Sen. Bernie Sanders, has been gaining ground.
"This is very much a primary issue. It's not a general election issue," said Jack Pitney, a professor of political science at Claremont McKenna College.
"I seriously doubt she'll be running ads on this issue in October of next year" if she wins the Democratic nomination, he said of Clinton.
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Pitney also said Clinton might be trying to gain support outside of her African American and white base. "If she can build a firewall among Hispanic voters, then it would be very hard to deny her the nomination," he said.
Randy Capps, director of research for U.S. programs at the nonpartisan Migration Policy Institute, noted how different things were in conversations among Republicans, with candidates proposing such things as abolishing birthright citizenship and building a wall between the U.S. and Mexico.
"Certainly it sets the stage for this issue being part of the debate in the general election, where there will be a huge contrast between whoever the Democratic nominee is and whoever the Republican nominee is," he said.
Responding to a question during the Las Vegas debate on Tuesday, Clinton generally endorsed California's approach.
In June, Gov. Jerry Brown signed a budget that for the first time funds healthcare for children in the country illegally, making California the largest state to do so. In addition, the number of counties in the state that have committed to providing low-cost, government-run medical care to such residents jumped from 11 to 48 this year.
Some California legislators have vowed to continue expanding coverage until everyone has insurance. State Sen. Ricardo Lara (D-Bell Gardens) has introduced a bill that would allow unauthorized immigrants to purchase a medical plan through the state's Obamacare exchange and let poorer immigrants sign up for the state's low-income health program, known as Medi-Cal.
Lara called Clinton's comments a "paradigm shift," noting how quickly California's approach entered the national political conversation.
"When I began the push for health for all, I was often told that my vision was too ambitious and needed to take a more incremental approach," he said. "With national Democratic candidates taking note of what we're doing in California, I'm confident that public support will continue to grow across the country."
Lara and other advocates say it's smart to provide coverage to unauthorized immigrants, because they often end up in emergency rooms, racking up bigger bills than if they'd received routine medical care earlier.
Critics say actions like those being taken in California on healthcare are exacerbating the problem of people coming to the U.S. illegally.
Federation for American Immigration Reform spokesman Ira Mehlman cited a 2009 Congressional Budget Office report that found expansion of preventive care generally leads to higher, not lower, spending.
In California, some proposals to extend healthcare to people who lack legal status have been priced at more than $1 billion. "It seems that sometimes they stay up late there in Sacramento dreaming up new benefits and services and protections they can provide to people who are in the country illegally even as they're cutting all kinds of things to everybody else," Mehlman said.
Under the Affordable Care Act, legal residents, depending on their income, can either buy insurance through new Obamacare exchanges using government-provided subsidies, or they can sign up for coverage through Medicaid, the federal health program for the poor.
Sanders has expressed broad support for extending heath coverage to people here illegally, calling it a fundamental right. Approximately 36 million U.S. residents are uninsured, 6 million of whom are here illegally, according to data from Gallup and the Migration Policy Institute.
Former Maryland Gov. Martin O'Malley, also running for the Democratic nomination, has proposed allowing approximately 5 million immigrants who are eligible for temporary immunity from deportation to either take advantage of government subsidies and purchase medical coverage through the insurance exchanges or sign up for Medicaid programs.
Clinton agreed Tuesday that undocumented immigrants should be allowed to buy coverage through the exchanges. But she stopped short of saying that they should be given taxpayer subsidies.
"It would be very difficult to administer," Clinton said. "It needs to be part of a comprehensive immigration reform, when we finally do get to it."
Experts said that without providing subsidies, opening up the exchanges is mostly a symbolic move, partly because many people living here illegally wouldn't be able to afford insurance premiums on their own.
"It's basically saying, 'Yes, you can go into the store and you can buy things too. We won't keep you out of the store,'" said George Washington University health policy professor Leighton Ku.
Clinton's position is likely to be unpopular in many parts of the country, where political leaders are against Obamacare.
And that means she may have to adjust her stance during the general election — a common tactic in presidential politics, said Claremont McKenna professor Pitney.
"I think every Republican opposition researcher has noticed this statement," he said.
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