Ever since Obamacare took effect two years ago, many California legislators have been fighting to get health insurance for those it left out — the quarter of all immigrants in the country illegally who live within the state's borders.
Next month, California will make a sizable dent in that effort when immigrants younger than 19 who are here without papers begin receiving free health coverage through Medi-Cal, the state's low-income health program. State officials estimate that 170,000 residents will be eligible.
But insuring children is an easy battle to win, experts say, because of kids' emotional appeal and their low medical expenses. California isn't blazing the way here. Massachusetts, Illinois, New York, Washington and Washington, D.C., already have extended coverage to children in the country illegally.
The remaining frontier — covering adults — will be a much tougher sell — and a more significant test of California's larger push to provide additional services to those here illegally.
"The next steps are harder, the air gets thinner, the angles get tougher to ascend," said Anthony Wright, executive director of Sacramento-based advocacy group Health Access.
The children's coverage came at a high cost, in a last-minute budget deal. To make it happen, Gov. Jerry Brown pledged $20 million in state funds to provide coverage from May through the end of the fiscal year, and $143 million in the upcoming fiscal year, said Medi-Cal spokesman Tony Cava.
The state had to foot the entire bill. Even though Medi-Cal traditionally is funded with a mix of state and federal money, the Affordable Care Act prohibits the use of federal money to pay for covering immigrants in the country illegally.
Some young people here illegally are already eligible to receive healthcare through county programs, such as My Health LA in Los Angeles County.
Approximately 115,000 youths also get coverage for emergencies through Medi-Cal, according to state officials. They will be rolled into the newly expanded program on May 16, but will be covered retroactively from May 1, Cava said.
As many as 27,500 children who have not yet been signed up for Medi-Cal are expected to enroll in the first year, Cava said. For minors to qualify, a family must earn less than 266% of the federal poverty level — or less than $53,626 for a family of three or $75,650 for a family of five.
Maria Graciela, who lives in South El Monte, plans to get her 14-year-old daughter Ingrid's eyes examined as soon as her Medi-Cal coverage kicks in.
"I just feel so fortunate," said Graciela, who cleans houses and hasn't been able to afford to take her daughter to the ophthalmologist or the dentist in years.
Sonya Schwartz, a research fellow at Georgetown University Health Policy Institute's Center for Children and Families, said offering health insurance to kids is a smart investment, because research shows that children with access to Medicaid have fewer emergency room visits and lower blood pressure as adults. They also are more likely to graduate from college than those who do not have health coverage.
"It's kind of penny-wise and pound-foolish not to cover these kids," Schwartz said.
Even with the expanded coverage, UC Berkeley researchers estimate that as many as 1.5 million of the 2.67 million immigrants who are in the state illegally will remain uninsured by 2019. They would make up roughly half of California's anticipated uninsured population.
"The big piece of unfinished business around health coverage is undocumented adults," said Daniel Zingale, senior vice president of The California Endowment, which leads a statewide campaign called Health4All.
The government already prohibits anyone who turns up in an emergency room from being refused treatment, regardless of immigration status. Zingale said it makes more sense to invest taxpayer money in cheaper, preventive care to stave off serious problems that generate big emergency room bills down the road.
Last year, a bill that would have covered all those here illegally made it through the state Senate but was whittled down to only children during budget deliberations. The original proposal could have cost as much as $1 billion annually.
Opponents of expanding Medi-Cal say it is misguided to spend money on those here illegally when services for Californians lawfully in the country are being cut. They also cite studies that conclude that increasing access to medical care increases use and expenses, instead of lowering costs.
Now, advocates for those here illegally are trying another, less expensive approach.
Sen. Ricardo Lara (D-Bell Gardens) recently introduced a bill in Sacramento that would ask the federal government for permission to allow unauthorized immigrants to buy insurance from the state's health exchange, Covered California. California would be the first state in the nation to do this, but the move would be mostly symbolic, because immigrants still wouldn't get subsidies to help them afford coverage.
The new proposal, combined with the rollout of coverage for those under 19, "will bring us closer to providing coverage to all Californians, regardless of where they were born," Lara said in a statement to The Times.
State officials also are following a Supreme Court case that concerns President Obama's executive actions on immigration. An unusual policy in California allows those granted temporary relief from deportation to sign up for Medi-Cal, and researchers estimate that up to half a million Californians could apply for Medi-Cal if the executive actions being challenged in court are upheld.
Even as advocates fight for more coverage, some who are eligible — whether they are here legally or not — aren't signing up, they say. That's partly because of confusion surrounding the patchwork of coverage.
When the Dolores Huerta Foundation led an effort to knock on thousands of doors in the Central Valley to spread the word about the upcoming Medi-Cal expansion, many people told the advocates they were worried they would endanger themselves or family members in the country illegally by giving information to the government, said Yesenia Contreras, the foundation's civic engagement coordinator.
President Obama has said that immigration officials will not have access to personal information submitted during health insurance sign-ups. But assuaging those fears, and getting eligible immigrants to enroll, remains difficult, Zingale said.
"What most undocumented Californians know about Obamacare is that it excluded them," he said.
For the moment, such exclusion still is being felt even in families about to get at least some health coverage.
Carolina Moran, who lives in Canoga Park, is looking forward to taking her 14-year-old daughter Lizeth to the dentist when the Medi-Cal extension starts. She thinks Lizeth has five unfilled cavities.
As for herself, the mother of five will remain without medical care. Her chronic kidney condition, she says, takes her to the emergency room every few months when she is too sick to go on.
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