California is on the verge of becoming the first state to provide Medicaid to young adults who are unauthorized immigrants — a big deal in a state where unauthorized adults make up the largest group of uninsured people.

The state legislature and Gov. Gavin Newsom agreed on a plan on June 9 to expand Medi-Cal, the state’s version of Medicaid, to cover all eligible 19- to 25-year-olds regardless of immigration status. The expansion is part of a broader health care package that would require all Californians to have health insurance or pay a penalty, mimicking the individual insurance mandate in Obamacare that Congress struck down last year, and provide help to middle-income families to help them buy insurance plans.

The expansion will cover an estimated 138,000 people at a cost of $98 million, according to the budget summary. The deal, which will go into effect in January, will provide access to a health plan that offers a variety of coverage, including doctor visits, prescription drugs, and dental services.

In a statement released on Sunday, Newsom praised the deal, which was led by Budget Committee chairs Sen. Holly Mitchell and Assembly member Phil Ting, because it “invests in a California for All.”

The bill, which the Democratic-controlled legislature is expected to vote on later this week, is the latest example of how blue states are going against the Trump administration on shaping immigration and health care policy. California already provides health care for children regardless of immigration status, as do Illinois, Massachusetts, New York, Washington, and the District of Columbia. If California is able to expand Medi-Cal to cover some adult unauthorized immigrants, it would go further than other states with progressive health care ambitions: Already this year, Washington attempted, and failed, to expand health care to young adults.

Many unauthorized immigrants struggle to get insurance

In 2017, there were about 10.7 million unauthorized immigrants in the United States, according to the Pew Research Center.

Almost half of unauthorized, non-elderly immigrants — 47 percent — lack health insurance, according to the Kaiser Family Foundation. Many struggle to afford coverage or do not work in jobs that provide health care. And they are not eligible for Medicare or Medicaid, despite paying taxes that go to fund the program, because most welfare programs have been closed to unauthorized immigrants since the 1996 welfare reform law.

The problem is particularly acute in California, which has the largest population of unauthorized immigrants in the country. Out of its 2.2 million unauthorized immigrants, 1.5 million will lack insurance in 2020, according to a study from the University of California Berkeley Labor Center. Low-income immigrants have the highest uninsured rate: up to 90 percent, compared with 11 percent of low-income Californians who are citizens or hold green cards or visas.

California has expanded coverage for low-income children and those with Deferred Action for Childhood Arrivals (DACA) status using state funds. Many unauthorized immigrants are also enrolled in restricted-scope Medi-Cal, which is a federally mandated program that provides emergency and pregnancy-related service for low-income people regardless of immigration status. The benefits, however, are limited and don’t cover doctor visits, prescription drugs, or care for cancer and other chronic illnesses.

While covering young adults is a huge step forward for California, it still leaves out a lot of people. Lawmakers’ failure to achieve universal health care especially affects senior unauthorized immigrants, said Cynthia Buiza, executive director of the California Immigrant Policy Center, according to NPR.

“The exclusion of undocumented elders from the same health care their U.S. citizen neighbors are eligible for means beloved community members will suffer and die from treatable conditions,” she told NPR.

Unauthorized immigrants make up about 9 percent of the state’s workforce and annually contribute about $3 billion in state and local taxes, according to Steven Wallace, associate director of the UCLA Center for Health Policy.

Wallace argued in an interview that all immigrants should be covered by the programs they contribute to, and that doing so would be an economic boon: “Being able to both contribute to society, as well as being able to enjoy the benefits of being in the society, require that you be able to access health services in need to maintain and optimize the health that you have,” he said.

Newsom’s proposition could expand health care to 138,000 young adults

Expanding Medi-Cal has been proposed in the past, but then-Gov. Jerry Brown had ultimately rejected the idea last year. It seemed more likely to pass this year because California has a budget surplus, the push for universal health care is increasing, and Democrats have a supermajority in the state legislature.

Due to a recent robust increase in tax revenue, the state has a $21 billion surplus, which would be more than enough to cover health care expansion for unauthorized immigrants.

The major disagreement was over who would be covered, with Newsom eventually going for the most conservative option. The state Assembly wanted to completely expand Medi-Cal to all eligible adults regardless of immigration status — more than 1 million additional people — at a cost of $3 billion annually. The bill passed 51-17.

The state Senate, meanwhile, wanted to provide Medi-Cal to those ages 19 to 25 and 65 or older, and coverage for those ages 26 to 64 would gradually be added in subsequent years. The bill, which passed 24-11, would have provided coverage to about 150,000 young adults and about 28,000 seniors, according to the Ventura County Star.

Newsom argued that expanding Medi-Cal beyond younger adults posed a financial risk because state revenue would eventually and inevitably decline in economic slowdowns, according to the Wall Street Journal. By providing health care to just the 138,000 young unauthorized immigrants between the ages of 19 and 25, as estimated in his budget summary, he could keep the cost of the bill relatively low at $98 million. And following negotiations with the legislature leaders, he’s managed to convince others to stick with his plan.

Because the bills have been prompted by a surplus due to a booming economy, some fear that the plan won’t be financially sustainable. As part of its new insurance mandate, California will also tax those who don’t have health insurance and use those funds to support the expansion. Republicans have argued that it is not fair to give unauthorized immigrants health benefits while those who are here legally would be punished for not having health care, according to USA Today.

California’s expansion of Medicaid defies the policies of the Trump administration.

California’s actions are a sharp contrast with the Trump administration — and could end in a clash between the two.

The Trump administration has repeatedly tried to crack down on immigrants’ use of public benefits, even for immigrants who are in the US legally.

Most recently, the president signed a memo in late May that requires sponsors of immigrants to pay back the government for any public benefits that their sponsored immigrant uses.

The administration has also sought tougher standards for determining when an immigrant seeking a green card or visa would be a “public charge,” and has written a proposed regulation that could penalize immigrants for using welfare programs, including Medicaid, when applying for sponsorship. A study released in May found the proposed regulation is already deterring immigrants from seeking help via food stamps, subsidized housing, and children’s health care programs.

By seeking to expand eligibility for those programs, California, like other blue states, is flying in the face of the administration’s policies.

“I would say the current policy and political environment related to immigrants has really led to increasing fear broadly among immigrant communities; that is leading many to turn away from services for themselves and their children, who often are US-born citizen children,” said Samantha Artiga, associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured.

California’s expansion of Medicaid to unauthorized immigrants would be in direct opposition to these policies from the Trump administration. The move is especially a big deal for Gov. Newsom, a longtime Trump critic who made universal health care one of his key campaign promises, according to Politico.

“No state has more at stake on the issue of health care. California must lead,” Newsom said in May. “While the Trump Administration seeks to destroy the Affordable Care Act, California is leading the nation in expanding access to health care and tackling affordability.”

The deal on health insurance has been agreed to on all sides, but the clock is ticking — the entire legislature has to vote on the budget, and if they don’t pass it by June 15, they will forfeit their pay.