As health insurance and immigration take center stage in national politics, California is working on multiple fronts to expand health insurance coverage for undocumented immigrants. With the passage of the annual budget on June 13, California lawmakers expanded health insurance coverage for undocumented immigrants between the ages of 19 and 26 under the State’s Medicaid program, Medi-Cal. There are also two bills working through the Senate and Assembly seeking to expand Medi-Cal eligibility for adult undocumented immigrants of all ages.
Background
According to the Floor Analysis for Senate Bill 29 (“SB 29”), undocumented immigrants represent 40 percent of California’s uninsured population. Approximately 1.5 million undocumented immigrants are projected to lack health insurance in California in 2020, based on the findings of a February 2019 study by the Center for Labor Research and Education at the University of California Berkeley (“Berkeley Study”). Under Welfare and Institutions Code Section 17000, counties are ultimately responsible for the care of the medically indigent. However, the Berkeley Study found county programs and funding priorities vary widely, and access to care for uninsured undocumented immigrants fluctuates from county to county. The Berkeley Study also found that care for the uninsured falls largely to social safety net providers like public hospitals, emergency departments, community clinics and Federally Qualified Health Centers (“FQHCs”), which generally offer care without regard for ability to pay and on a sliding scale basis based on patient income. The result of this, according to the Berkeley Study is that several regions in the State have demands for care from safety net providers that exceed supply.
In 2015, Medi-Cal eligibility was expanded to include undocumented immigrant children. This expansion led to the enrollment of 250,000 children, according to legislative analysis of Assembly Bill 4 (“AB 4”). Presently, adult undocumented immigrants may only be eligible for limited-scope Medi-Cal, which covers long-term care, pregnancy services, emergency services, certain cancer treatments, and family planning services. The analysis of AB 4 projects that the Medi-Cal expansion under the newly-adopted annual budget, which expanded eligibility to include undocumented immigrants between 19 and 26 years old, will provide full-scope coverage to 138,000 individuals at a cost of $194 million in the first year. The Berkeley Study concluded that a further eligibility expansion covering adults of all ages could provide coverage to an additional 680,000 to 1.05 million individuals.
Bills Proposing Expansion
AB 4 and SB 29 both seek to expand Medi-Cal eligibility to undocumented immigrants over age 19. Both bills would enroll current, limited-scope Medi-Cal patients who would now be eligible for full-scope Medi-Cal under the proposed expansion without requiring a new application. Additionally, both bills prioritize continuity of care by requiring eligibility and enrollment plans to ensure to the maximum extent possible that individuals be able to maintain their primary care provider without disruption so long as that provider is a contracted in-network provider within the applicable Medi-Cal managed health care plan.
The two bills differ in their approach to expansion of eligibility. AB 4, currently in the Assembly Committee on Health, would immediately open up eligibility for full-scope Medi-Cal to otherwise-eligible individuals regardless of immigration status. In contrast, SB 29, re-referred to the Senate Committee on Appropriations July 10, would expand eligibility regardless of immigration status only to those over 65. However, SB 29 was amended July 2 to include individuals aged 19-65.
Impact of Federal Immigration Law
The estimated expansion in health insurance coverage for adult undocumented immigrants through Medi-Cal ranges from 680,000 to 1.05 million individuals. This wide range takes into account potential reluctance of eligible individuals to enroll in light of recent proposed changes to federal immigration law. On October 11, 2018, the Department of Homeland Security (“DHS”) proposed regulations to expand the definition of “public charge” to include receipt of public benefits like full-scope Medi-Cal. By expanding the definition of “public charge”, the government would be able to consider an applicant’s receipt of Medi-Cal benefits when determining admissibility for lawful permanent residence. Although the proposed “public charge” rule change is complex and would not apply to every applicant, the Berkeley Study determined there are credible concerns such that the “public charge” rule could have a chilling effect on enrollment of 15 to 35 percent.
Takeaways for Safety Net Providers
The proposed expansion in Medi-Cal eligibility to adult undocumented immigrants would provide safety net providers an expanded opportunity to provide services to Medi-Cal patients, particularly in counties lacking robust programs to provide care to the uninsured. However, the increased access to care provided by the expansion may also increase demand on care providers already struggling to meet community needs in high-demand areas as newly eligible individuals enroll and make use of their Medi-Cal benefits. Such increasing demands run the risk of making it more difficult for low-income uninsured individuals not covered under the expansion to receive care as the newly eligible may be a more financially viable client base for safety net providers.
The potential chilling effect of proposed federal actions further complicates predictions of the expansion’s impact, creating a wide range in participation estimates. However, the impact of Medi-Cal eligibility expansion can be expected to be most strongly felt by safety net providers, as major providers of care both to Medi-Cal beneficiaries and low-income uninsured individuals.
Questions?
If you have any questions concerning this Legal Alert, please contact the following from our office, or the attorney with whom you normally consult.
Jennifer Scott
jscott@kmtg.com | 916.321.4349