Rolling back health benefits for undocumented migrants would betray success.
One recent morning, I interviewed a farmworker over breakfast at a McDonald’s in the south Salinas Valley. Then I drove out of town to talk to a dozen of his colleagues in a cauliflower field.
Over a couple hours, we chatted about their diverse circumstances. Some were married, some had children in California schools and colleges, and some were single, living far from family. The workers had migrated here from various states and countries, and they had made their homes in different communities across California.
But they had one thing in common. Everyone reported feeling much healthier than they had in years.
I’ve heard the same thing recently from other undocumented workers around California. For this improved health, they can thank one of the smartest public policies enacted recently in California: the expansion of Medi-Cal, the Golden State’s version of Medicaid, the federal health program for the poor. It now covers all Californians, regardless of immigration status.
But that policy is now under threat—precisely because of its success.
Nearly 15 million Californians are covered under Medi-Cal today, 5.7 million of them children.
California extended Medi-Cal for undocumented immigrants over the last decade, starting with low-income children in 2016, adding young adults up to age 25 in 2020, and adults 50 or over in 2022, and then completing the circle of coverage with adults ages 26-49 in January 2024.
Enrollment by the undocumented in Medi-Cal, and the utilization of the health care system, has exceeded projections. State officials seemed to think that the decline in the number of undocumented Californians—which has shrunk from 2.7 million to 1.8 million over the past two decades—would limit costs. But undocumented Californians are not young, new arrivals of the old stereotype; most have been here for at least 20 years, and had considerable pent-up demand for health care after lives of hard work.
The state had budgeted more than $2 billion annually for this expansion, but costs this past year added up to $2.7 billion more than planned. In the early months of this year, state officials borrowed additional billions for cash flow for Medi-Cal and to cover these additional costs—turning the expansion into a white-hot political issue.
The higher costs are only partially about immigrant enrollment. Prescription drug prices and health care bills are rising faster than inflation. Medi-Cal also has seen costs surge after an expansion of enrollments during the pandemic, and by the state’s decision to stop counting assets (such as homes or savings accounts) when considering seniors’ eligibility. Also, the passage of Proposition 35 last November reduced the tax on managed care organizations—money that helps support Medi-Cal.
But Republicans in California and Trumpists in Washington, possessed with anti-immigrant hatred, have blamed the growing costs primarily on the undocumented, and demanded a rollback of the expansion. Congressional Republicans are citing the California expansion to justify hundreds of billions in cuts to Medicaid over the next 10 years.
Fearing the impact, some liberal commentators and Democratic politicians have buckled. In California, even progressive politicians have suggested that the state can no longer afford the full expansion.
Among these are Gov. Gavin Newsom, a champion of the expansion, who just revised his budget to freeze program enrollment for immigrant adults, and charge $100-per-month premiums to those already enrolled.
This is bad politics—caving to destructive anti-immigrant prejudice only encourages more prejudice. It’s even worse health policy, as I saw firsthand in the cauliflower field.
The farmworkers, who ranged in age from 32 to 61, told me that getting coverage had changed their lives by allowing them to get care to reduce the pains of years of twisting, pulling, and bending over in the fields.
Newly covered, four had gotten surgeries, and lined up rehab for knees, ankles, or feet. Two had had back treatments, needed after years of picking lettuce and other leafy greens. One had a wrist procedure, and two—both of whom also worked at a nearby vineyard—had had shoulder operations. These procedures had corrected injuries that had dogged them for a decade or more. More than half said they had new doctors, or new prescriptions for high blood pressure.
In a saner country, these kinds of results would be seen as a roaring success.
In a kinder country, the additional costs would be seen as payback, for all the deferred costs of pain.
In a calmer country, today’s rising costs might be seen as a blip.
All but one of the farmworkers’ surgeries had happened in the past two years. But none of the farmworkers expected to have more procedures. The problem with going to the doctor, or getting surgery, is that it costs you work hours and thus pay. No one was eager to do it again. When I mentioned the controversy over rising costs, the workers suggested those numbers should go down once the newly covered deal with their serious, long-untreated problems.
Such temporary surges in health care utilization aren’t new. And they shouldn’t surprise California leaders, much less cause them to roll back successful programs. There was a similar surge in poor Americans using health care in the first few years after the Affordable Care Act, aka Obamacare, went into effect in 2014. The surge in utilization was greatest in states that chose to expand their Medicaid programs. Studies show that the surge produced higher costs, but made people healthier.
In the cauliflower field, workers expressed appreciation for their better health, and for better working conditions. Over the last generation, California has made farmworker pay hourly, raised the minimum wage, and guaranteed sick leave benefits. Such policies took years of planning and political struggle.
Cutting back the expansion won’t save all that much money in a $300-billion-plus state budget—maybe $5 billion over the next four years, according to the governor’s budget proposal. On an annual basis, such savings would amount to less than 1 percent of the $160 billion-plus in total Medi-Cal spending in the current fiscal year. Meanwhile, excluding people from health care coverage means that they get less preventive care, and can get stuck with higher medical bills, debt, or conditions that hurt workers, and thus their families and communities.
Thanks to Medi-Cal expansion, the undocumented people who grow this state’s food, build homes and shopping centers, and do any number of other jobs while raising the next generation of Californians, are finally feeling better.
These Californians, who are our neighbors, haven’t quit on us. Let’s not quit on them now.
