UPDATE: What about the OTHER 4.5 million undocumented immigrants?

Last week I noted that of the 33 million people still uninsured in the United States, around 6.5 million of them can't be covered via Affordable Care Act provisions because they're undocumented immigrants, who aren't legally allowed to #GetCovered via either the ACA exchanges (private coverage) or Medicaid expansion (public coverage). Another 3.7 million legal residents/citizens, of course, are caught in the Medicaid Gap. I also brought up the undocumented immigrant factor in a piece yesterday trying to break out the other portions of that 33 million total.

Anyway, in the comments, "dawgitall" asked a reasonable question: If there's around 11 million undocumented immigrants in the U.S. total (everyone seems to agree on that estimate), and 6.5 million of them aren't insured at all, what's the deal with the remaining 4.5 million?

I pointed out that off-exchange individual policies, directly via the insurance companies, likely make up the bulk of these, since there's no advantage to Blue Cross, UnitedHealthcare, Humana etc. to be too nosey about the legal residency status of their customers as long as they keep paying the premiums. However, that was just an assumption; I really didn't have any hard numbers about it or anything.

Fortunately, back in April of last year, Lisa Zamosky of the L.A. Times wrote a pretty comprehensive article which details all of the different ways undocumented immigrants can get covered. She doesn't try to estimate the actual numbers, but the options are more extensive than I would have figured:

• Student health plans. Many colleges and universities require students to either buy their school's health insurance policy or show proof of other coverage. Immigration status is generally not questioned when students apply, and the plans are affordable.

• Employer-based health insurance. Upon graduation, if Lozano lands a job that offers health insurance, she'll be able to take advantage of it. People without legal status in the U.S. are sometimes hired by companies that offer employee health benefits, and they are generally able to sign up without having to show proof of their immigration status.

• Private health insurance. Although this is an expensive option for many people, undocumented immigrants are also allowed to purchase private health coverage as long as they do so directly from an insurance carrier or through a broker.

• Medi-Cal coverage. The state provides a full range of low-cost healthcare options for poor Californians, and some of those Medi-Cal benefits are available regardless of a person's immigration status.

• Community health centers. Funded in part by federal grant money, roughly 1,200 health centers operate around the country.

• State-based health programs. Unlike most states, California makes a number of health programs available to low-income residents regardless of immigration status.

• Healthy Way L.A. Unmatched. This program provides primary care for uninsured patients, including immigrants without legal status.

The article goes into more detail about each of these options, but the main point is that yes, a larger-than-expected percentage of undocumented immigrants are covered by some form of health insurance.

In addition, that percentage may be about to get significantly larger. California has anywhere from 1.3 - 1.5 million of the 6.5 million uninsured, undocumented immigrants nationally (the estimate varies depending on the source). As it happens, the California state legislature recently passed--and Gov. Jerry Brown signed--into law a state budget which includes funding to allow up to 170K undocumented children to be enrolled in Medi-Cal (the state's name for Medicaid):

The coverage under Medi-Cal, the state’s version of Medicaid, is expected to result in more preventive care and better long-term health for an estimated 170,000 children who have long relied on safety-net clinics and emergency rooms. But while many policymakers, advocates and researchers celebrated the budget deal announced by Gov. Jerry Brown last month, they also said the new coverage is limited because it doesn’t guarantee access to doctors and doesn’t include adults.

But wait, there's more! As I noted back in April of this year, there's a bill being debated over in the CA state legislature, Senate Bill 4 (SB4), which, if passed and signed into law, would allow all undocumented immigrants (who otherwise qualify financially) to enroll in Medi-Cal as well. I'm not sure what portion of the 1.1 - 1.3 million undocumented adults that would entail, but I'd imagine it would apply to most of them.

As for the last group--uninsured, undocumented immigrants with incomes higher than 133% of the federal poverty level, SB4 includes another provision as well, although this one would also require a federal waiver from the HHS Dept. and wouldn't go into effect until 2017: It would allow that population to go ahead and enroll in private coverage via Covered California, and would even grant them tax credits...although the credits would be provided by the state of California, not the federal government, since the ACA doesn't allow for federal funds to be provided to undocumented immigrants under any circumstances.

Assuming SB4 does go through, gets signed into law and receives the federal waiver, it could theoretically mean that up to 1.5 million undocumented Californians would be removed from the "uninsured" tally.

I can't imagine it would be that high; many would still be scared to death of being deported, of course, and CoveredCA has been struggling to get those currently allowed to enroll signed up as it is. Still, I could see, say, 500K being added to Medi-Cal and perhaps 150K signing up via the ACA exchange over the next year or two. If that happened, it would knock the national uninsured rate down by another 0.2% all by itself.

UPDATE: Oops...ok, it looks like the whole "California SB-4" scenario is gonna end up being much smaller scale than I thought in the end; thanks to Esther F. for the heads up:

The drive to expand health care coverage to all undocumented immigrants in California has moved out of the fast lane and will advance more gradually than originally envisioned by Senator Ricardo Lara, the Legislature’s primary proponent of “health for all.”

Senate Bill 4 — the main legislative vehicle for expanding coverage to undocumented immigrants excluded from care — was amended yesterday [EF: that's last week] to remove a provision that would have opened the door to Medi-Cal coverage for undocumented adults. (This provision was moved to SB 10, which is now on hold until 2016.) Under this proposed change, adults who are excluded from Medi-Cal due to their immigration status could begin signing up for the program — which provides health care coverage to Californians with low incomes — so long as enough money is set aside to pay for services. Although this provision would not create an “entitlement” to Medi-Cal services for undocumented adults, there was apparently concern that Governor Brown was nonetheless opposed to it, so it was moved out of SB 4 and put on the slow track through the legislative process.

OK, so that puts the kibosh (at least for the moment) on undocumented adults qualifying for Medi-Cal. Still, that leaves the 170K undocumented children, plus several hundred thousand adults being allowed to enroll in private policies via CoveredCA:

SB 4 still aims to forge — at no cost to the state — a coverage pathway for undocumented immigrants outside of Medi-Cal. Under SB 4, state officials would ask the feds to let undocumented immigrants purchase coverage through Covered California, the health insurance marketplace — or “exchange” — that California set up as part of federal health care reform. (Under federal law, exchanges are currently off limits to undocumented immigrants.) California would pursue this request under a waiver provision — Section 1332 — of the Affordable Care Act. If federal officials say “yes,” then undocumented residents could buy health insurance through Covered California, although they’d be prohibited from accessing any of the federal financial assistance that reduces the cost of coverage. If the feds say “no,” then it’s back to the drawing board. SB 4, as newly amended, will be heard by the Assembly Health Committee on July 14.

Hmmm...OK, the remaining question (aside from the reduced bill actually passing/being signed into law and receiving the federal waiver) is whether any undocumented immigrants would be able to receive tax credits from the state, or if they'd have to pay full price no matter what.

If the state would cover the equivalent dollar amount to the federal tax credits, then it'd still be game on. If not, then I'm not even sure what the point is anymore; there'd be no advantage for an undocumented immigrant to enroll via CoveredCA instead of directly via the insurance company.