Pandemic's Economic Toll Leaves Plan to Insure California's Undocumented Seniors in Doubt

Dr. Kimberly Ceci trains a nurse practitioner in telehealth at LifeLong Brookside San Pablo Health Center on April 27, 2020. Ceci says expanding Medi-Cal to undocumented seniors would improve their health outcomes.  (Beth LaBerge/KQED)

Irma, an undocumented immigrant, has worked as a cook at the same fast food restaurant for more than two decades. But the resident of Rialto, in San Bernardino County, said her employer doesn’t provide health insurance and she hasn’t been able to afford a private plan.

Now, at 64, Irma hopes California will start including older immigrants like her in Medi-Cal, the state’s version of the federal Medicaid health coverage program for low-income residents.

“Ever since I came to this country in 1995, it was difficult for me to get health insurance,” said Irma, who didn’t want her last name used because of her immigration status. “And now more than ever, I need full-scope Medi-Cal because as I age I am more likely to get sick.”

As California continues to grapple with the coronavirus pandemic, public health experts and immigrant advocates are pushing for Gov. Gavin Newsom to expand Medi-Cal benefits to tens of thousands of undocumented seniors. The elderly are among those most at risk for complications from COVID-19.

In January, Newsom proposed spending $80.5 million next year to begin covering 27,000 undocumented adults 65 and older. The expansion would cost $350 million per year once it’s fully implemented. But that plan is now in doubt as the state enters an economic downturn, with tax revenues expected to fall by billions of dollars and potential budget cuts on the horizon.

“Job loss and abrupt halting of economic activity make it clear that we have entered a recession,” the Legislative Analyst’s Office communicated in a letter to the state Senate Budget Committee earlier this month.

California has enrolled undocumented children in Medi-Cal since 2016, and this year became the first state to offer health coverage to undocumented young adults through age 25. More than 60,000 have enrolled so far, about two-thirds of those eligible, according to the California Department of Health Care Services.

But an estimated 1.5 million undocumented Californians remain uninsured. They comprise about 40% of the total number of state residents who lack health insurance, according to a report by the UC Berkeley Labor Center.

For the state to fully recover from the pandemic, more undocumented residents must gain access to health care, starting with vulnerable seniors, said state Sen. Maria Elena Durazo. D-Los Angeles, who authored a 2018 bill that would expand Medi-Cal to undocumented residents 65 and older.

“I know there's uncertainty around the economy and the finances, but it should continue to be a priority,” Durazo said. “Undocumented workers continue to work. Year after year after year they have paid taxes, but they haven’t gotten in return the same benefits as other Californians.”

Currently, low-income, undocumented immigrants 26 and older are only eligible for Medi-Cal if they face a health care emergency, or to obtain prenatal care if they are pregnant. Undocumented immigrants are excluded from the Affordable Care Act, and cannot purchase coverage through Covered California, the state’s ACA health exchange.

If they are not insured by an employer or able to purchase a private plan, they must generally rely on county health programs, which can vary widely throughout the state.

Eleana Ellner, a nurse at LifeLong Brookside San Pablo Health Center, prepares to take temperatures and check in visitors on April 27, 2020. (Beth LaBerge/KQED)

Undocumented residents who live in Contra Costa County can enroll in a county program that provides primary care free of charge at community clinics and health centers. Services available through the Contra Costa CARES program include immunizations and a 24-hour nurse advice line.

“We were really fortunate that the county, the hospitals ... everyone banded together to fund this program specifically for undocumented residents,” said Dr. Kimberly Ceci, associate medical director at the LifeLong Brookside San Pablo Health Center.

The program helps people manage chronic diseases and stay out of emergency rooms, she said. But it doesn’t cover the cost of prescriptions (though a similar program in neighboring Alameda County does), or care by specialists, she said.

“There’s limitations that we can’t get referrals, we can't go further than primary care,” Ceci said. “And that is unfortunately necessary for many people’s care, especially over 65.”

While most counties in California reimburse health providers for some non-emergency care for undocumented patients, 11 counties do not, including San Diego and San Bernardino, according to the nonprofit organization Health Access.

Even without county funding, community health centers in San Bernardino offer uninsured patients a sliding fee scale, and will care for anyone regardless of ability to pay or immigration status, said Deanna Stover, president and CEO of Community Health Association Inland Southern Region.

But the fact that San Bernardino County doesn’t cover these services means people are less likely to seek care, she said.

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“When a county offers the plan, you get increased knowledge, and it definitely increases access to care,” said Stover, a registered nurse. “We want high-risk, vulnerable populations to get care so that it's a healthier community overall.”

On April 8, the state began covering the costs of COVID-19 testing and medical treatment for people who need the assistance, regardless of immigration status.

While that’s a critical step during the public health crisis, more needs to be done to help vulnerable communities withstand the coronavirus and other health challenges, said Héctor Plascencia, an advocate with the Health4All campaign, who has been pushing the state to cover all undocumented residents.

“We still want folks to be covered beyond this testing because often it's not enough,” said Plascencia, who is undocumented and identifies as transgender. “If it's a severe case, it is often someone that has other health ailments aside from COVID as well, that we want to make sure that they are comprehensively covered.”

Plascencia expressed hope that Newsom would abide by his earlier plan to insure low-income undocumented seniors, and was encouraged by the governor’s recent announcement that the state will provide unprecedented $500 emergency grants to Californians hard hit by the pandemic but ineligible for state and federal benefits because of their immigration status.

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But as stay-at-home orders and the pandemic have paralyzed entire industries across the state and millions of people lose their jobs, California is expecting dramatic cuts to tax revenue this year and beyond. State agencies and departments “should have no expectation of full funding for either new or existing proposals and adjustments,” according to a March letter from the Department of Finance.

The state’s budget revenue shortfall could be as much as $35 billion in the coming fiscal year, and $85 billion in later years because of the pandemic, legislative analyst Gabriel Petek told a state Senate budget subcommittee last week.

Newsom is still deciding how his budget plan will change, and whether covering health care for more people will be part of it, said H.D. Palmer, a spokesman with the state Department of Finance. The revised budget proposal is due to the Legislature by May 14.

“The governor has not yet made final decisions regarding that proposal, as we are still in the process of updating our revenue forecast and our expenditure projections,” Palmer said.