By Gene Lewit
On Tuesday in California, legislative leaders and the Governor agreed on a 2015-16 budget bill that would allow all otherwise-eligible children to enroll in the state’s Medicaid program, regardless of their immigration status. The agreement includes $40 million in funding for children’s coverage that would begin in May 2016. An estimated 170,000 children would qualify under this coverage expansion.
This is not the first time that the California legislature has acted to extend coverage to all children regardless of immigration status. In 2005, a similar bill was passed by the legislature, but unlike today, vetoed by the Governor because it did not provide funding for the coverage expansion. The ensuing collapse in the state’s finances took the issue off the table for almost a decade. Yet many valuable lessons were learned from the earlier period.
The earlier effort in California represented the culmination of a grassroots effort to cover all children in the state. It began in Santa Clara County, where advocates and local officials built on funds from a successful lawsuit against the major tobacco companies to create the Santa Clara Children’s Health Initiative (SCCHI). The goal of the SCCHI was to provide health care coverage to all children in the county regardless of their immigration status by creating a new locally-funded, low-cost health insurance product, Healthy Kids, for low-income children not eligible for Medicaid or CHIP and creating an integrated “no wrong door” outreach and enrollment interface for all three programs. With support from private foundations and local government entities, the CHI model spread to 30 of California’s 58 counties by 2008 and although many of the county CHIs have retrenched or closed in recent years as funding levels have fallen, some remain active and retain their Healthy Kids programs.
Of particular relevance in the current environment is that a rigorous evaluation of the SCCHI found that access to medical and dental care improved dramatically for children enrolled in Healthy Kids. For instance, the proportion of children with a usual source of primary care rose from 49 percent to 89 percent, while the proportion of children with a usual source of dental care jumped from 30 percent to 81 percent. Parents also reported that their children’s health status improved as did school attendance – an important outcome as undocumented children are entitled to a public education. Evaluations of CHIs in Los Angeles and San Mateo Counties also showed positive results. The evaluation also provided the first rigorous evidence of the “welcome mat effect” and the value of a “no wrong door” outreach and enrollment interface since almost as many additional eligible but previously unenrolled children were added to the Medicaid and CHIP programs as were enrolled in Healthy Kids.
The “no wrong door” approach to outreach and enrollment has been adopted by the ACA, but unauthorized immigrant children are explicitly excluded and the substantial unmet health needs of that largely invisible population of kids not addressed.
Four states and the District of Columbia do, however, provide coverage for low income unauthorized immigrant children in state-funded programs that pre-date the ACA. In addition, a small number of states including California provide coverage for individuals aged 15 to 31, brought into this country as children and eligible for the Obama administration’s 2012 Deferred Action for Childhood Arrivals (DACA) initiative. However, more than 110,000 unauthorized immigrant children in California and an almost 300,000 children in other states who are eight to 14 years old are not eligible to benefit from DACA until they turn 15. And even younger children are excluded from DACA all together. Because of the strong evidence of the value of investing in young children, requiring children to wait until they reach age 15 to benefit from DACA, and the state-funded Medicaid coverage that DACA status would bring in California, appears shortsighted as does excluding the youngest children.
This week’s budget agreement in California helps fill in an important gap in coverage for low-income children and provides an opportunity for a welcome mat effect for many currently Medicaid-eligible children who remain unenrolled. The action in California also helps shine a light on an important gap in the system of coverage for low-income children, the almost 1,000,000 unauthorized immigrant children who are excluded under federal law from Medicaid, CHIP, and the ACA health care market place and helps set the stage for action on the issue in other states in the future.
Gene Lewit is Consulting Professor of Health Research and Policy at Stanford University and affiliated with Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research. He helped create the Georgetown University Center for Children and Families in 2005.
