Advocates of a single-payer healthcare system in California have struggled to come up with a realistic and feasible way to pay for it, so this year they're pushing for more incremental steps toward universal health insurance coverage. The most far-reaching of these would be to expand Medi-Cal, the joint federal and state insurance program for poor and disabled Californians, to cover low-income residents who are living in the country illegally.
Now is not the time to take that step, however. Lawmakers should resist the temptation posed by this year's huge budget surplus to commit billions of tax dollars annually to fixing a problem created by the federal government's failed immigration policies.
Granted, bringing everyone — including people living in the country illegally — under the insurance umbrella is one of the steps along the path to a more affordable healthcare system. It's also more humane than the current system, in which impoverished people without health coverage typically obtain care only for acute conditions. Universal coverage would enable insurers — whether private or governmental — to promote more cost-effective treatments by changing the way healthcare is delivered and funded.
Attaining universal coverage, however, requires covering every person living here, legally or otherwise, and that's not cheap. In California there were an estimated 3 million uninsured last year, according to modeling by UC Berkeley and UCLA; of those, almost 1.8 million are immigrants ineligible for Medi-Cal or subsidized private insurance because they are here illegally. And of that number, the UC researchers estimated, 1.2 million to 1.3 million have such low incomes or disabilities that they would qualify for Medi-Cal.
It's worth noting that a limited version of Medi-Cal already is available to immigrants here illegally, covering such services as emergency and maternity care, and the Legislature extended full Medi-Cal coverage to minors in 2016 regardless of their immigration status. Extending it to adults as well would cost an additional $3 billion a year, the Legislative Analyst's Office estimated last week. Because the entire cost would be borne by the state — federal Medicaid dollars can be spent only on services for legal residents — the move would raise the state's Medi-Cal bill by 13%.
The state Senate and Assembly health committees weren't deterred by the potential costs — in fact, they advanced proposals to expand Medi-Cal to all income-eligible residents regardless of immigration status (SB 974 and AB 2965) before there was any estimate of the price tag. The measures are awaiting more preliminary votes before moving to the Senate and Assembly floors.
Meanwhile, the GOP-controlled Congress and the Trump administration have been pushing in the other direction on Medicaid, trying repeatedly to cut funding and cap future outlays. If they prevail, the state will have to bear more of the cost of covering those already enrolled in Medi-Cal — or start denying coverage to some of those now eligible. The effects of those proposals could be devastating; by one estimate, the state would lose $35 billion in federal aid between 2020 and 2027.
The state already spends too little on Medi-Cal, keeping reimbursements to doctors so low that Medi-Cal patients in some parts of the state have trouble obtaining the care they need. Adding more than 1 million additional potential patients won't make it any easier for enrollees to find doctors willing to treat them at the state's low rates.
Advocates of the Medi-Cal expansion argue that it's not fair to provide insurance coverage to some poor Californians and not to others based solely on their immigration status. But before the Legislature acts on this issue, there are sure to be many Californians posing a different question: How can you expect legal residents who don't qualify for Medi-Cal to pay ever higher premiums for coverage with ever higher out-of-pocket costs while providing it at no cost to those here illegally? And how fair would it be to state taxpayers to open Medi-Cal to all comers, potentially drawing people in need of care from neighboring states that aren't so generous?
The ultimate problem here is not only the rising cost of care, but also failed federal immigration policy that leaves millions of longtime residents with no legal right to work and unable to afford insurance.
Expanding Medi-Cal would help ease the symptoms of these problems, but it wouldn't solve either one.