Like many blue states, California enthusiastically embraced Obamacare, signing up millions for health insurance. Now, it's venturing into a potentially costly and controversial new frontier of health policy: offering medical coverage to hundreds of thousands of people living in the country illegally.
In a matter of months, the number of California counties committed to providing low-cost, government-run medical care to such residents jumped from 11 to 48. And in June, Gov. Jerry Brown signed a state budget that for the first time funds healthcare for such children.
Key state legislators have vowed not to stop until all immigrants living in California illegally have coverage, a proposal that could cost the state more than $1 billion annually.
The effort has set California apart from most other states and the federal government, which barred those here illegally from signing up for insurance under the landmark Affordable Care Act, which overhauled the nation's healthcare system.
With 2.6 million such immigrants, the Golden State is politically sympathetic to their needs, said Randy Capps, director of research for U.S. programs at the Migration Policy Institute, a nonpartisan think tank. "It's logical that California would be out front about this," he said.
But even here the issue remains contentious. Some counties have opted not to offer such care. And a recent USC Dornsife/Los Angeles Times poll found that though close to half of state voters believed immigrants here illegally should be eligible to receive free or low-cost health insurance through Medi-Cal or a similar program, a statistically equivalent 47% said they opposed such policies.
National Immigration Law Center attorney Gabrielle Lessard said the nature of debate among political leaders over expanding such benefits has changed in California over the last 15 years. The legal and philosophical arguments against providing healthcare services to those here illegally generally have receded, and "the only conversation about this has been about cost," she said.
Indeed, the price of providing medical coverage to immigrants remains a hurdle for legislators and advocates — even more so in other parts of the country.
"I wouldn't mistake momentum inside California for momentum outside of California," Capps said.
Still, some experts say that with an improving economy, easing pressures on government budgets and greater acceptance of those in the country illegally in some regions, offering medical coverage to such immigrants could be the next big healthcare policy battleground.
They note that the U.S. Supreme Court upheld Obamacare this summer, allowing supporters of universal healthcare coverage to press new initiatives. And the lead being taken by California might help, they said.
"I'm sure we'll inspire other states," said UCLA health policy professor Steven Wallace. "I think it's inevitable."
There are signs the debate could spill into the 2016 presidential contest, especially from the political bookends, where immigration policy has been a dominant theme.
Spokespersons for Republican presidential front-runner Donald Trump, who has made deporting immigrants here illegally a centerpiece of his campaign, and the leading Democratic candidate, Hillary Clinton, declined requests from The Times to address the issue.
But Vermont Sen. Bernie Sanders, who is running to the left of Clinton and gaining in the Democratic field, "believes that healthcare is a human right, not a privilege," said Warren Gunnels, Sanders' policy director. "Your ability to access healthcare services should not be dependent on your income or your immigration status."
On the Republican right, former Pennsylvania Sen. Rick Santorum said California's approach is at cross purposes with what's best for the nation.
"Look, we can't be in a situation where we are encouraging behavior that we know is dangerous to people and dangerous to our country, which is either coming into this country illegally" or less dangerously overstaying a visa and "simply not going home and signing up for benefits," Santorum said in a recent post-debate interview.
South Carolina Sen. Lindsey Graham, a GOP moderate in the race, also disagreed with the California approach. "I think it's going down a bad road there," he said. The solution, he said, is to provide a pathway to legal status for people living here illegally and who aren't criminals.
Republican candidates Carly Fiorina, Florida Gov. Jeb Bush, Texas Sen. Ted Cruz and Florida Sen. Marco Rubio did not respond to requests for comment.
Besides California, just four states — Massachusetts, Illinois, New York and Washington — and Washington, D.C., have agreed to provide health coverage to children in the country illegally. Legislators in those jurisdictions will probably soon consider broadening those programs to include adults, health advocates predict.
"We haven't seen that particular level of progress, so I think it definitely helps build momentum," said Claudia Calhoon, director of health advocacy at the New York Immigration Coalition.
Lara's bill was scaled back to cover only children here illegally after the price tag for including adults was estimated at more than $1 billion. The approved program will serve up to 170,000 Californians younger than 19 and cost $40 million in this year's budget, growing to an estimated $132 million annually after that.
Lara said he plans to continue fighting to expand health coverage to all state residents. He's currently pushing a bill that would allow immigrants to purchase policies through Covered California, the state-run insurance marketplace. He said he intends to reintroduce legislation next year that would allow the state's poorest residents living here illegally to enroll in Medi-Cal.
UCLA's Wallace said more states may well begin extending coverage to children in the U.S. illegally because it's a small, healthy population, and is seen as a good investment because many eventually become citizens.
"Kids are kind of a low-hanging fruit of the undocumented," he said. "It's politically attractive, and not terribly expensive."
Advocates argue it's financially smart to provide health services to all 11 million immigrants in the country illegally because less expensive primary care can avoid serious and costly illnesses that require patients to be treated in emergency rooms.
However, Federation for American Immigration Reform spokesman Ira Mehlman pointed to a 2009 Congressional Budget Office report that found expansion of preventative care generally leads to higher, not lower, spending.
Mehlman said states are being forced to choose between picking up large ER costs from uninsured immigrants, or providing them medical coverage, because legislators have passed other laws encouraging immigrants to come here illegally. One example, he said, was California's decision to offer driver's licenses to such residents. "Either way, these are not good choices," he said.
That's a view still shared in much of the country. More than 15 states, including Florida and Texas, chose not to expand Medicaid, the federal health program for the poor, under Obamacare, meaning large numbers of legal residents in those states remain uninsured. Advocates in those places say their first priority is securing health insurance for those low-income U.S. citizens.
And in some states that did expand Medicaid to cover the poor, resistance to extending benefits to immigrants remains strong. Laura Martin, communications director for the Progressive Leadership Alliance of Nevada, noted that state's attorney general has joined a lawsuit challenging President Obama's program to grant temporary immunity from deportation to thousands of immigrants.
"I couldn't imagine having the conversation now to talk about providing healthcare for undocumented children," she said. "We are not the same as California."
One test could come in Oregon. The state expanded Medicaid under Obamacare to cover poor residents, but a bill to include immigrant children died this year in the Legislature.
Lawmakers voiced concerns about both the cost and making the state too welcoming to immigrants, said Alberto Moreno, executive director of the Oregon Latino Health Coalition. He said he plans to push the bill next year. "We hope to follow California's suit," he said.
Mirna Castro, with Servicios De La Raza in Denver, said California is seen as a laboratory. Colorado health advocates and legislators will watch to see how the nation's largest state finances and manages expanded medical care for immigrant residents in the years ahead.
"It'll definitely inform Colorado ... to maybe take a step in that direction," she said.
Times staff writer Seema Mehta contributed to this report.
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