California is poised to become the first state in the nation to offer full health coverage to undocumented adults even as the Trump administration intensifies its crackdown by separating families at the border.

The proposal — which would build on Gov. Jerry Brown’s 2015 decision to extend health coverage to all children, regardless of immigration status — is one of the most daring examples yet of blue-state Democrats thumbing their nose at President Donald Trump as they pursue diametrically opposed policies, whether on immigration, climate change, legalized marijuana or health care.


“California has never waited for the federal government, or for a political climate, to be able to take leadership on a whole host of issues,” state Sen. Ricardo Lara, author of the state Senate bill to extend Medicaid coverage to all adults, told POLITICO.

But at a time when Trump is already attempting to re-energize state Republican voters — he met with California conservatives at the White House last week to strategize against the state’s sanctuary policies — the initiative might be risky. For starters, it will be costly: The annual price tag to expand Medicaid benefits to poor adult immigrants without legal status is projected at $3 billion annually. Some also worry that extending health coverage could make California a magnet for undocumented immigrants from other states.

“It would give Republicans relevance in California they would never have before,” said David McCuan, a political analyst and political science professor at Sonoma State University. He suggested the proposal would energize Republican voters, who make up a quarter of the electorate, as well as conservative-leaning unaffiliated voters.

Any meaningful opposition could slow the plan’s progress through the state Legislature despite its strong backing from Democrats, providers and advocates for the poor.

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Brown, who is leaving office later this year and has not yet committed to the plan, is required by law to sign or veto bills passed this session by Sept. 30, just five weeks before the midterm elections. And the injection of immigration politics into the universal health care debate will likely provide talking points for both parties.

“It seems to me astounding that California could consider an expansion like this at this particular moment,” said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. He described the plan as “fiscally very dangerous” given California’s fragile long-term financial outlook and the potential negative effects of the Republican tax overhaul on the state’s budget.

But Lara, the son of undocumented Mexican immigrants who grew up without health coverage, contended the state is already paying for health care for the undocumented in the most expensive way possible, through hospital emergency rooms. He pushed unsuccessfully for a single payer health plan for California last year, and argues California needs to be a laboratory for social change by taking the lead on progressive causes.

“We are trying to address the fact that, whether you like it or not,” he said, “our undocumented community needs the care, and we are paying for it anyway.”

Democrats say they want to build on the coverage gains made under Obamacare by targeting the state’s nearly 3 million remaining uninsured — about 60 percent of whom are undocumented immigrants and 1.2 million of whom would qualify for the state’s Medicaid program, known as Medi-Cal, based on their incomes. Companion bills in the state Assembly and Senate have easily passed their respective health committees with party-line votes.

Still, the latest revisions to Brown’s proposed budget last week did not include significant increases in health spending — a move that frustrated some backers of the expansion, who note the state’s budget surplus has swelled to nearly $9 billion — about $3 billion more than expected.

“It’s doable for a fraction of the budget surplus we have,” said Anthony Wright, executive director of Health Access California, a consumer advocacy coalition. “We recognize if we were to do so, we would be the first state to expand Medicaid to an [undocumented] adult population.”

Wright acknowledged the price tag may look alarming but said it should be viewed within the context of Medi-Cal's $100 billion budget. He also emphasized that covering only poor young people and the elderly — which the budget forecasts estimated at $140 million and $330 million, respectively — could be more achievable in the short term. A Senate health budget sub-committee on Thursday recommended covering undocumented adults over age 65 as part of the Senate funding package to be considered during negotiations.

California already provides emergency and pregnancy-related Medi-Cal benefits for undocumented immigrants to the tune of about $1.7 billion annually. The $3 billion for full Medi-Cal benefits assumes that all eligible adults would enroll in the program over 12 months, which is unlikely.

Micah Weinberg, president of the Bay Area Council Economic Institute, said the cost debate must take into account the measure’s broader benefits, including increased worker productivity and improved community health.

“Since most undocumented immigrants are productive members of society, it would, of course, be much better to give them all a path to citizenship and immediately naturalize them to make it easier for them to buy regular health insurance,” Weinberg said. “But just because we have bad immigration policy does not mean we shouldn’t have good health policy. And truly universal coverage is good health policy.”

Other health economists struck a more cautious note.

Jay Bhattacharya, a Stanford physician and health economist, said the plan should have a dedicated funding source, which could mean higher taxes. “Looking at the current surplus and saying we’re likely to have that forever so we should spend more doesn’t seem like a wise idea to me,” Bhattacharya said.

Bhattacharya also expressed concerns that the extension could exacerbate the state’s illegal immigration problems. “If you make a program like this available, undocumented workers in other states might be attracted to California because of this,” he said.

But Lara insisted the bill is not only a long-term cost-saver, it’s the right thing to do.

“All you have to do is say ‘immigration’ in Washington, D.C., and everyone runs to their respective corners,” he said. “That doesn’t happen in California.”

