By Eric Gelber
Two bills now pending before the Legislature would extend medical coverage under the state Medi-Cal program to otherwise eligible low-income adults regardless of their immigration status: SB 56 (Durazo) would extend eligibility to income-eligible adults age 65 and older, whereas AB 4 (Arambula) would extend eligibility to all income-eligible adults.
What problem/issue would the bills address?
The federal Medicaid program provides medical coverage to low-income individuals paid for by state and federal funds. Medicaid is implemented in California through the Medi-Cal program.
Federal law prohibits undocumented individuals from being eligible for any state or local public benefits (including Medicaid), except for assistance for health care items and services that are necessary for the treatment of an emergency medical condition, public health assistance for immunizations, and for testing and treatment of symptoms of communicable disease.
Under current state law, eligibility for “full-scope” Medi-Cal services depends on several factors, including income, age, disability, and immigration status. In general, undocumented immigrants are eligible only for “restricted scope” services, such as emergency care and pregnancy-related services.
Since 2015, full-scope, state-only funded Medi-Cal was extended to undocumented children under the age of 19 (SB 4 (Lara 2015)). In 2019, full-scope state-only funded Medi-Cal eligibility was extended to undocumented adults ages 19-25 (SB 104 (Committee on Budget and Fiscal Review 2019)). Undocumented adults age 25 and above remain ineligible for full-scope Medi-Cal services.
According to Senator Durazo, author of SB 56, “no Californian should be forced to face worse health outcomes simply because of where they were born. In response to the ongoing COVID-19 pandemic’s disproportionate impacting on communities of color, including our immigrant communities, now more than ever California must demonstrate its commitment to healthcare 
coverage as a basic human right by providing equitable access to care for all.”
Senator Durazo also notes that “undocumented Californians pay an estimated $3 billion every year in state and local taxes and make up one-tenth of the state’s workforce. They pick the fruits and vegetables for our families and sew the clothes we wear. They drive the trucks that put the food on the shelves of our grocery stores. Despite contributing significantly to California’s economic vitality, they are unjustly excluded from the economic prosperity they have helped to generate. Treatment for common conditions, such as asthma and diabetes, is out of reach for many undocumented residents and treatable illnesses often result in permanent disability or death, devastating results that have been exacerbated by the COVID-19 pandemic.”
What would the bills do?
Despite the rationale Senator Durazo has offered for SB 56, the bill, effective July 1, 2022, would apply only to adults ages 65 and above. Undocumented working age adults, beginning at age 25 and ending at age 65 would continue to be ineligible for full-scope Medi-Cal services. That gap would be filled, however, with the enactment of Assemblymember Arambula’s AB 4, which is not limited to undocumented seniors. Effective July 1, 2022, AB 4 would extend full-scope Medi-Cal benefits to all otherwise eligible adults regardless of immigration status. In each instance, to the extent that federal financial participation continues to be unavailable, services would be provided using state-only funds.
Comments
There have been prior legislative efforts to extend full-scope Medi-Cal benefits to undocumented seniors or to all immigrants ages 25 and above. Each of those efforts died in the Legislature. One of those failed attempts was last session’s SB 29, also authored by Senator Durazo, which was substantially similar to this year’s SB 56. Reportedly, Senator Durazo agreed to keep SB 29 in the Assembly with the commitment from Governor Newsom to work with the Legislature to address the issue of expansion of Medi-Cal to low-income undocumented seniors.
There are approximately 2.3 million undocumented immigrants living in California. These immigrants, most of whom are not currently eligible under Medi-Cal, may purchase health insurance directly from insurers or may receive health care benefits through an employer. However, federal law prohibits undocumented individuals from purchasing health insurance through Covered California and prohibits individuals from receiving any federal subsidies. Because undocumented immigrants are more likely to work in industries and occupations that do not offer health insurance, they are far less likely than citizens or green card holders to receive health coverage through employer-sponsored insurance.
In some counties, limited health care services may be available through the county indigent health program. Those services vary by each county program. In counties where undocumented individuals are ineligible for county indigent health programs, low-income undocumented individuals may seek care through other safety net providers, such as community clinics or hospital emergency departments.
Supporters of SB 56, including co-sponsors Health Access California and the California Immigrant Policy Center, note that the COVID-19 pandemic has demonstrated the disparities and deadly impacts that undocumented adults face when they are excluded from access to preventive care. They state that undocumented immigrants are overrepresented in “essential” jobs during the pandemic and face a disproportionate risk of exposure for themselves and their family. They also note that California has set up programs to cover COVID-related care for the uninsured, but this does not effectively meet the broader health needs of the immigrant community, who may have gone years without a checkup. Supporters argue that health care for undocumented seniors should be an urgent priority to provide them appropriate preventive care before the onset of conditions that disproportionately impact the elderly.
The cost of implementing SB 56 is likely to be the major hurdle the bill will face. Last session’s SB 29, which, like SB 56, extended Medi-Cal eligibility only to undocumented seniors, was estimated in 2019 to have a fiscal impact on state funds of $94.5 million annually. The estimated cost of extending coverage to undocumented adults age 26-64 (which AB 4 would do) was $507 million annually in state general funds. Notably, however, these cost estimates do not take into account offsetting savings that would result from reduced reliance on far more expensive emergency care due to the availability of early intervention and preventive healthcare.
SB 56 has broad support from healthcare providers and advocates. No organizations are on record in opposition. The bill was heard in the Senate Health Committee on March 10th. No one testified in opposition; however, one committee member questioned whether enactment of SB 56 would result in an increase in illegal immigration by seniors coming to take advantage of available health care. As noted in response, however, obtaining public health benefits is not a primary motivation for immigration to the U.S. Typically, people come to escape persecution or dangerous conditions in their home countries, to seek employment, for education, to reunite with family members, or to achieve a better quality of life.
SB 56 will next be heard in the Senate Appropriations Committee. AB 4 is currently in the Assembly Health Committee, but a hearing date has not been set.
Eric Gelber, now retired, is a 1980 graduate of UC Davis School of Law (King Hall). He has nearly four decades of experience monitoring, analyzing, and crafting legislation through positions as a disability rights attorney, Chief Consultant with the Assembly Human Services Committee, and Legislative Director of the California Department of Developmental Services.
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Thanks for the article, Eric. I suppose it will come as no surprise that I strongly favor these bills and will be writing to our appropriate electeds in support.
This is a matter of individual health care, but also will prove cost-effective overall as individuals are able to obtain primary and secondary preventive care as well as the more expensive and less cost-effective ER care only.