California's Undocumented Kids Could Be First to Lose Medical Care Under Trump

Written for CALmatters.org

On a recent rainy morning in Los Angeles, Maria Bernal’s stove clicks to life with a bright blue flame to toast bread on a griddle for her 9-year-old son Edwin to smear with peanut butter. As she scoops papaya chunks into the blender for a smoothie, she recalls her worry during all the years when she couldn’t afford health care and he suffered painful ear infections.

The waiting six months to get an appointment for Edwin at a county facility. The nights trying to calm him as he cried in constant pain. The months-long wait for each of three surgeries to insert tubes into his ears. The fear when the medical bills arrived.

At the time, she couldn’t afford health care, and he did not qualify for regular government-funded Medi-Cal coverage because she had brought Edwin to the United States illegally from Mexico when he was 1. He qualified for a local program and emergency Medi-Cal, but that didn’t provide all the care he needed.  Then last year, she heard on TV that California was creating a new program under Medi-Cal to fully cover poor undocumented children. Relieved, she rushed to sign Edwin up. As a result, she says, “I can take him in whenever he needs to go.”

Now, however, the ability of Edwin and some 164,000 poor undocumented California children to see a doctor for regular medical care hangs in the balance—with several experts predicting they could be among the first to lose health coverage if the Trump administration carries out its promise to end much of Obamacare, leaving California to try to make up the difference.

To be clear, the federal government does pay limited medical costs for kids in the country illegally under the restricted-scope Medi-Cal program, which is available to anyone regardless of immigration status for emergency and prenatal services only. Last May, however, California became one of a handful of states to provide state-funded full-scope Medi-Cal, California’s Medicaid program. About 71 percent of the program is funded by the state, according to the state Department of Health Care Services, with 29 percent paid for out of federal funds for emergency coverage. Also of note: Because the federal government funds emergency services, the state shares enrollee information with federal health officials.

In his most recent budget proposal, Gov. Jerry Brown allocated $279.5 million to cover approximately 185,000 kids in the coming year in what the state has dubbed its Health for All Kids program—double what the program was estimated to cost when it was approved.

With the election of Donald Trump, who took office last week, some health policy experts and advocates say the fledgling program is in danger. That’s assuming the new administration carries out plans to change how Medicaid is funded, health policy experts say California could stand to lose $17 billion the federal government currently provides for the Medi-Cal expansion that California adopted under the Affordable Care Act.

Such a cut would leave state leaders unable to fully make up the funding difference—and could force them to revisit a decades-old debate over whether the state has an obligation to care for sick children regardless of their immigration status, or should focus limited resources on citizens and legal residents.

It’s impossible to precisely predict the ripple effects. But, said Nancy Gomez, organizing director of the health advocacy organization Health Access California: “The first things that are going to go are these optional programs, They are not optional to us. But Health for All Kids are discretionary funds and they may be the first to go.”

Trying to make up the gap will be nearly impossible, experts say.

“These federal cuts to the broader Medi-Cal program would force California policymakers to make some difficult decisions—raise revenue by unprecedented amounts to maintain the current program, cut benefits, reduce eligibility, or make other cuts to the program,” said Laurel Lucia, manager of the Health Care Program at the UC Berkeley Center for Labor Research and Education. But, she acknowledged, “if the Legislature decides to take a "last in, first out" approach to making eligibility cuts in response to federal cuts, state-funded Medi-Cal for undocumented kids would especially be at risk because the expansion started less than one year ago.”

That’s as is should be, according to those who insist that anyone in the country illegally should not receive state resources—especially if funding is cut short.

“Sacramento should be focused on helping American citizens,” said Robin Hvidston, executive director of We The People Rising, a Claremont-based organization that fights against legislation that it says promotes illegal immigration. The group opposed the expansion, which she contends is merely an open invitation for illegal immigration. “It’s a program our state cannot afford.”

Nonetheless, the lawmaker who authored the expansion to cover undocumented children, Democratic Sen. Ricardo Lara of  Los Angeles, has vowed to protect them.

“I will fight to ensure that they remain a priority population in terms of receiving adequate healthcare and meeting their health needs,” Lara said. “It makes economic sense, it’s the moral thing to do.”

But in an unmistakable sign that the Democratic-controlled state is changing tactics in response to a less receptive White House, California recently retracted its request for a federal waiver that it had hoped would allow undocumented immigrants of all ages to buy unsubsidized health care via California’s Affordable Care Act exchange. Lara labeled it the “first California casualty of the Trump presidency.”

He said the state could always renew its quest for such a waiver, but won’t until it first ensures that the state can protect the data immigrants would be sharing with the federal government by using the health exchange.

“It’s very clear and apparent that we are dealing with a hostile administration toward our immigration community,” Lara said. “Given the fact that we are working currently on legislation to protect the privacy of the immigrant communities, we felt that it was appropriate to pull the waiver and focus on the fights ahead with the incoming administration.”

Newly installed President Donald Trump and the Republican-controlled Congress favor establishing caps on Medicaid and changing funding to a block grant formula that sets limits on total spending per state regardless of how many people are in the program. Currently it is funded as an entitlement for all enrollees who qualify.

Medicaid is the largest insurer in the country, with 73 million people enrolled, mostly low-income or disabled. In California, 13.5 million people are on Medi-Cal, or roughly one in three Californians. The program grew by 3.6 million people when it was expanded under the Affordable Care Act.

A study by the Center on Budget and Policy Priorities found that the proposals to reorganize Medicaid funding would decrease funding by one-third to one-half within a decade.

Such federal cuts would trigger a cascade of effects, said Senate President Pro Tem Kevin de Leon (D-Los Angeles).

“If the Trump administration decides to remove and take away access to quality healthcare that could possibly drive a budget deficit—and if you drive a budget deficit that means cuts would have to be made,” he said at a health care rally in Los Angeles after the November election. “If cuts have to be made that means other people could be hurt.”

But others aren’t ready to concede that outcome and say there are likely alternatives the state can employ to keep as many people covered as possible.

“The reality is if Congress has enough votes to change the Medicaid program into a block grant program, California will struggle to maintain its commitment to the 13.5 million people currently covered,” said Gerald Kominski, director of the UCLA Center for Health Policy Research. “I suspect the governor and Legislature will give higher priority to cutting covered services rather than cutting the number of beneficiaries.”

Sen. Lara said he hopes the state resists choosing one group over another—adding that he plans to suggest cutting coverage, as the state has done during lean times, or increasing eligibility thresholds in his fight to keep health care for the neediest across all groups, including among undocumented children.

For Edwin Bernal, he says going to the doctor more often is good for him because of his hearing challenges and ear tubes.

“My friends talk to me and I’m like ‘what, what,’ because I can’t hear them that good,” he said. “Same with my mom, she tells me something and I don’t really hear her and I don’t do the stuff she tells me because I can’t hear. So it’s better, I can hear her and I’m not getting in more trouble.”

If kids like Edwin Bernal lose Medi-Cal overage, their health care will depend largely on where they live.

In Los Angeles, where Edwin lives, the county offers a basic low-cost program to everyone regardless of immigration status and emergency Medi-Cal is expected to still be available. Private insurer Kaiser Permanente also offers a community benefit program for kids without legal status who live near their facilities.

“It’s going to be a challenge for us and the patients,” said Chona de Leon, senior vice president and chief operating officer at Eisner Pediatric & Family Center, in downtown Los Angeles, where Edwin has received care since he was a baby.

Clinics like Eisner would lose the increased funding that has come from previously uninsured patients getting access through the Affordable Care Act. de Leon says they would continue to serve uninsured patients as they always have but would have to work hard to find outside funding and donations.

But in 11 California counties, including Orange and San Diego, there are no programs for undocumented families to find care for their children outside of charitable clinics and hospital emergency rooms.

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