California relaunches their effort to provide ACA exchange eligibility to undocumented immigrants

As I noted last week, Washington State is the first in the nation to finally correct one of the dumbest provisions of the Affordable Care Act as it was originally passed:

(3) Access limited to lawful residents.--If an individual is not, or is not reasonably expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States, the individual shall not be treated as a qualified individual and may not be covered under a qualified health plan in the individual market that is offered through an Exchange.

Again, this doesn't just mean that they can't get federal financial help; it means they can't enroll via ACA exchanges at all:

Undocumented immigrants aren’t eligible to buy Marketplace health coverage, or for premium tax credits and other savings on Marketplace plans. But they may apply for coverage on behalf of documented individuals.

Again, there are several reasons why having the ability to enroll in on-exchange ACA policies is a big deal for undocumented immigrants even if they aren't eligible for federal financial assistance if they can do so:

  • To avoid marketing/eligibility confusion: Every fall during the annual Open Enrollment Period, both the federal and state-based ACA exchanges launch big marketing/awareness campaigns urging Americans to visit HealthCare.Gov (or their state exchange) and #GetCovered. If you're an undocumented immigrant, you may do just that, only to discover that you're not eligible to enroll at any price, which no doubt confuses, upsets and discourages people. This may even lead them not to bother trying to enroll in an off-exchange ACA plan since they may falsely assume it means they aren't eligible to enroll in those either.
  • To avoid confusion re. mixed-status households: Louise Norris goes into the healthcare coverage options for undocumented immigrants in detail and as you can see, some situations could get pretty confusing:

It’s important to understand that if you’re lawfully present, you can enroll in a plan through the exchange even if some members of your family are not lawfully present. Family members who aren’t applying for coverage are not asked for details about their immigration status. And clarifies that immigration details you provide to the exchange during your enrollment and verification process are not shared with any immigration authorities.

  • To be eligible for state-based financial help: While the ACA prohibits federal ACA financial subsidies from being provided to undocumented immigrants, some states may choose to do so. This is already the case when it comes to Medicaid: California pays for Medi-Cal coverage for hundreds of thousands of undocumented immigrants themselves without any federal funding.

Well, Washington State has already done exactly this, opening up ACA exchange enrollment eligibility to over 100,000 undocumented Washingtonians...and now California (which has an estimated 1.75 million undocumented immigrants residing in the state) is looking to follow suit.

California had actually begun the process to do exactly this years before Washington State, however; they actually passed legislation to authorize an application for a Section 1332 Waiver to open up Covered California to undocumented residents back in the final year of the Obama Administration in 2016. However, they then withdrew their waiver application less than a year later, with good reason:

At the behest of the state Legislature, Covered California, the state’s insurance exchange, withdrew its request to sell unsubsidized health plans to people who are here illegally. The withdrawal was first reported by the Sacramento Bee.

...The effort to give undocumented immigrants access to the state exchange was spearheaded by state Sen. Ricardo Lara (D-Bell Gardens) and other Democrats. They passed legislation last year and Gov. Jerry Brown signed the measure in June. It authorized Covered California to submit an application to federal officials to waive the ban on such sales.

But the chances of federal approval dimmed considerably with the election of Donald Trump, who has pledged to deport immigrants in the country without official papers, and to repeal the Affordable Care Act.

...Lara said in a written statement that he was withdrawing the plan because he feared the Trump administration might use information gleaned from it for the purpose of deporting undocumented immigrants.

The plan to sell to undocumented immigrants is “the first California casualty of the Trump presidency,” Lara wrote. “I take Trump at his words that anyone is subject to deportation at any time, and California will not be part of a wasteful and inhumane campaign against immigrants who are working hard and playing by the rules.”

...Covered California estimated last August that only 17,000 Californians would have gained health coverage as a result opening the exchange to the undocumented population.

Why only 17,000 out of 1.75 million (less than 1% of the total number of undocumented immigrants in the state)? Two main reasons: First, not all of those 1.75M are uninsured; around 35% of them have some form of healthcare coverage in the state. This is a far higher uninsured rate than among documented Americans, but it still lops 1/3 of the undocumented population off the pool. The larger issue is the lack of federal financial subsidies; without financial help, undocumented immigrants enrolling in ACA exchange plans would have to do so at full price, vastly reducing the practical pool of enrollees.

In any event, California Assembly Bill 4, which would be revive the attempt to open CoveredCA up to this population, was introduced back in December and currently has 11 cosponsors as of this writing:

AB 4, as amended, Arambula. Covered California: expansion.Existing federal law, the Patient Protection and Affordable Care Act (PPACA), requires each state to establish an American Health Benefit Exchange to facilitate the purchase of qualified health benefit plans by qualified individuals and qualified small employers. Existing state law creates the California Health Benefit Exchange, also known as Covered California, to facilitate the enrollment of qualified individuals and qualified small employers in qualified health plans as required under PPACA.

Existing law requires the Exchange to apply to the United States Department of Health and Human Services for a waiver to allow individuals who are not eligible to obtain health coverage through the Exchange because of their immigration status to obtain coverage from the Exchange, by waiving the requirement that the Exchange offer only qualified health plans solely for the purpose of offering coverage to persons otherwise not able to obtain coverage by reason of immigration status.

Existing law limits the waiver of that requirement to requiring the Exchange to offer only “California qualified health plans,” as specified, to those individuals. Existing law requires an issuer that offers a qualified health plan in the individual market through the Exchange to concurrently offer a California qualified health plan that meets prescribed criteria.

This bill would revise those provisions by deleting the requirement that limits coverage for the described individuals to the California qualified health plans. Contingent upon federal approval of the waiver, specified requirements for applicants eligible for the coverage described in the bill would become operative on January 1, 2025, for coverage effective for qualified health plans beginning January 1, 2026. This bill would declare the intent of the Legislature to enact legislation to expand Covered California access to all Californians regardless of immigration status.

Of course if California makes good on their intention to provide healthcare coverage to all undocumented immigrants, it's quite possible that they'll also follow in Washington State's footsteps by providing state subsidies to this population for enrolling in ACA exchange plans as well, which could increase the potential enrollment numbers significantly.