BILL ANALYSIS Ó
SB 4
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Date of Hearing: July 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
4 (Lara) - As Amended July 7, 2015
SENATE VOTE: 28-11
SUBJECT: Health care coverage: immigration status.
SUMMARY: Requires the Secretary of the California Health and
Human Services Agency (CHHSA) to apply for a federal waiver in
order to allow persons who are unable to obtain health insurance
coverage through California's Health Benefit Exchange (Covered
California) because of their immigration status, to do so.
Requires, when 2015 Budget bill language making undocumented
children under the age of 19 eligible for full scope Medi-Cal
benefits is implemented, that individuals enrolled in restricted
scope Medi-Cal at that time be transitioned to full scope
Medi-Cal within 30 days. Specifically, this bill:
1)Requires CHHSA to apply to the federal Department of Health
and Human Services for a waiver in order to allow persons
otherwise not able to obtain coverage by reason of immigration
status through Covered California to obtain coverage from
Covered California by waiving the requirement that Covered
California offer only qualified health plans (QHPs).
2)Requires the Exchange to offer California QHPs, which are
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required to be subject to the requirements of the existing
Covered California statute, including all of those
requirements applicable to QHPs.
3)Requires persons eligible to purchase California QHPs to pay
the cost of coverage without federal advanced premium tax
credit, federal cost-sharing reduction, or any other federal
assistance.
4)Makes enactment of these provisions contingent upon federal
approval of the waiver.
5)Defines a California QHP as a product offered to those not
otherwise eligible to purchase coverage from the Exchange by
reason of immigration status and that comply with the
requirements of current law for a QHP.
6)Requires, when 2015 Budget bill language is implemented to
make undocumented children under the age of 19 eligible for
full scope Medi-Cal benefits, that individuals enrolled in
restricted scope Medi-Cal at that time to be transitioned to
full scope Medi-Cal within 30 days.
7)Requires an individual made eligible for Medi-Cal under these
provisions to enroll in a Medi-Cal managed care plan if the
individual would otherwise have been required to enroll in the
plan.
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EXISTING STATE LAW:
1)Establishes Covered California in state government, and
specifies its duties and authority. Requires Covered
California to be governed by a board that includes the
Secretary of CHHSA and four members with specified expertise
who are appointed by the Governor and the Legislature.
2)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which low
income individuals are eligible for medical coverage.
3)Makes undocumented individuals, who are otherwise eligible for
Medi-Cal services, eligible only for care and services that
are necessary for the treatment of an emergency medical
condition and medical care directly related to the emergency,
as defined in federal law. Makes low-income undocumented
individuals Medi-Cal eligible for pregnancy-only coverage,
breast and cervical cancer-related treatment services, and
long-term care services.
4)Expands, through the 2015-16 Health Budget trailer bill,
full-scope Medi-Cal coverage to children, regardless of
immigration status, who currently would be eligible for
Medi-Cal if not for immigration status, beginning when DHCS
declares that systems are ready for implementation, but no
sooner than May 1, 2016. Requires children eligible in this
category to enroll in Medi-Cal managed care in those counties
in which a managed care plan is available. Requires DHCS to
seek federal financial participation (FFP), but requires
coverage to be provided regardless of FFP. Requires DHCS to
provide a semiannual status report to the Legislature until
regulations have been adopted.
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EXISTING FEDERAL LAW.
1)Requires, under the Patient Protection and Affordable Care Act
(ACA), as amended by the Health Care Education and
Reconciliation Act of 2010, each state, by January 1, 2014, to
establish an American Health Benefit Exchange that makes QHPs
available to qualified individuals and qualified employers.
Requires, if a state does not establish an Exchange, the
federal government to administer the Exchange. Establishes
requirements for the Exchange and for QHPs participating in
the Exchange, and defines who is eligible to purchase coverage
in the Exchange. Limits enrollment in the Exchanges to
citizen or nationals of the United States, or an alien
lawfully present in the United States.
2)Allows, under the ACA, and effective January 1, 2014, eligible
individual taxpayers, whose household income is between 100%
and 400% of the federal poverty level (FPL), an advanceable
and refundable premium tax credit (APTC) based on the
individual's income for coverage under a QHP offered in the
Exchange. Requires a reduction in cost-sharing for
individuals with incomes below 250% of the FPL, and a lower
maximum limit on out-of-pocket expenses for individuals whose
incomes are between 100% and 400% of the FPL. Legal
immigrants with household incomes less than 100% of the FPL
who are ineligible for Medicaid because of their immigration
status are also eligible for the APTC and the cost-sharing
reductions.
3)Prohibits Medicaid matching funds for medical assistance for
an undocumented individual, except for care and services
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necessary for the treatment of an emergency medical condition
(as defined) for an individual who otherwise meets the
eligibility requirements for medical assistance under the
state's Medicaid State Plan.
4)Authorizes, under Section 1332 of the ACA, waivers for state
innovation under which states can seek federal approval to
waive major provisions of the ACA, including the requirement
for Exchanges, QHPs, premium tax credits and cost-sharing
reductions, the individual mandate and the employer
responsibility requirement, provided federal requirements are
met for comprehensive benefits, affordability, and comparable
coverage are met and the state proposal does not increase the
federal deficit.
FISCAL EFFECT: The July 7, 2015 version of this bill has not
been analyzed by a fiscal committee; however, the Senate
Appropriations Committee notes that the rates at which
undocumented immigrants are likely to apply for unsubsidized
coverage are unknown at this time and are likely to be heavily
influenced by concerns over coming to the attention of
immigration authorities and language barriers.
Senate Appropriations Committee also assumes that, on the low
end, about 50% of eligible undocumented immigrants under age 19
would enroll in Medi-Cal under this bill - which is roughly the
number of undocumented immigrants under age 19, on average, who
access emergency- or pregnancy-related Medi-Cal services each
year. On the high end, Senate Appropriations assumes that about
60% of eligible individuals under age 19 enroll in Medi-Cal -
which is equal to the pre-ACA enrollment rate for Medi-Cal
eligible individuals in the state.
COMMENTS:
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1)PURPOSE OF THIS BILL. According to the author, without access
to affordable, quality health insurance, people are forced to
rely on emergency care, which means they delay treatment until
they are sicker and treatment is more expensive. The author
states that 60% of Californians who have individual coverage
have it through Covered California, and there is no reason why
undocumented immigrants should not be able to purchase it
through the Exchange as well.
The author also notes that the Legislature and the Governor,
through the enactment of the Budget Act of 2015 (SB 97
(Committee on Budget and Fiscal Review), Chapter 11, Statutes
of 2015) expanded Medi-Cal eligibility for children under the
age of 19, regardless of immigration status, to ensure that no
child in California who is income eligible will be denied
access to health care coverage. These provisions are slated
to go into effect some time on or after May 1, 2016. This
bill will make certain that children currently eligible for
limited scope Medi-Cal are quickly transitioned to full-scope
Medi-Cal. The author concludes, we've made enormous strides
to reduce California's uninsured population with the
implementation of the ACA, but only when we include everyone
can we have a truly healthy California.
2)BACKGROUND.
a) Covered California and the individual market. As an
active purchaser, Covered California chooses which plans
and products to offer and negotiates rates in order to
offer the best value for consumers. In contrast, most
other state exchanges and the federal health care exchange
accept all products that health insurance companies wish to
offer, at the rates they want to charge, provided that they
meet basic standards and have passed regulatory review.
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In the individual market outside Covered California, plans and
insurers are required to fairly and affirmatively offer, market,
and sell to all individuals and dependents in each service area
in which the plan or insurer provides services. Plans and
insurers are required to limit enrollment in individual products
to open enrollment periods and special enrollment periods.
Undocumented immigrants are prohibited from purchasing coverage
in Covered California under federal law. Because APTCs and
cost-sharing subsidies are only available for individuals
purchasing coverage in Covered California, undocumented
individuals are also not eligible for these subsidies intended
to make health insurance and the cost of care more affordable.
b) Section 1332 Waivers. This bill requires CHHSA to apply
for a Section 1332 waiver in order to allow persons who
cannot obtain coverage through Covered California because
of their immigration status to obtain such coverage.
Section 1332 of the ACA permits states to apply to the
federal government for a waiver of major provisions of the
ACA beginning in 2017. Known as "innovation waivers," the
provisions of the ACA that can be waived under Section 1332
include any or all parts of the provisions relating to QHPs
(including the essential health benefits package
requirement), the Exchanges, premium tax credits and
cost-sharing reductions, the minimum coverage requirement
(individual mandate), and the employer responsibility
requirements.
If a state is granted a Section 1332 waiver, the state can
fund its reforms through the aggregate amount of federal
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funding that otherwise would have been paid out within the
state for premium tax credits, cost-sharing reduction
payments, and small business tax credits. However, to
qualify for an innovation waiver, the state must establish
that its reform plan would provide coverage that:
i) Will provide coverage that is least as comprehensive
as ACA coverage;
ii) Will provide coverage and cost sharing protections
against excessive out-of-pocket spending that are at
least as affordable as the as ACA coverage;
iii) Will provide coverage to at least a comparable
number of its residents as the ACA would provide; and,
iv) Will not increase the federal deficit.
c) Current scope of Medi-Cal coverage for immigrants. In
order to be Medi-Cal eligible, an individual must be a
state resident and generally must be low-income. Recent
legal immigrants and undocumented immigrant adults who meet
income and residency requirements are Medi-Cal eligible,
but the scope of that coverage depends on the immigration
status of the immigrant. Under existing state and federal
law, undocumented immigrants are not eligible for full
scope services, and are instead eligible for "limited
scope" Medi-Cal benefits. Limited scope services are
long-term care, pregnancy-related benefits, and emergency
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services. Medi-Cal also provides coverage for undocumented
individuals needing breast and cervical cancer treatment,
family planning services through Family Planning, Access,
Care, and Treatment program, and through temporary
presumptive eligibility programs.
d) Presidential action on immigration. In November 2014,
President Obama announced that the federal Department of
Homeland Security (DHS) would not deport certain
undocumented parents of U.S. citizens and parents of lawful
permanent residents. President Obama also announced an
expansion of the Deferred Action for Childhood Arrivals
program for youth who came to the United States as
children. Under a directive from the Secretary of DHS,
these parents and youth may be granted a type of temporary
permission to stay in the U.S. called "deferred action."
Deferred action is a form of administrative relief from
deportation whereby DHS authorizes a noncitizen to remain
in the U.S. temporarily. These individuals may also apply
for an employment authorization document (a work permit)
during the deferred action period. A grant of deferred
action is temporary and does not grant citizenship or
permanent lawful status. However, a person granted deferred
action is considered by the federal government to be
lawfully present for as long as the grant of deferred
action status. These actions are expected to affect up to
4.4 million people, according to DHS.
e) The ACA and the remaining uninsured. A January 2015
report from the UC Berkeley Center for Labor Research and
Education and the UCLA Center for Health Policy Research
estimated the ACA is expected to reduce California's
uninsured rate by at least half by 2019, at which time the
ACA will be fully implemented, as they estimate 6.5 million
Californians would have remained uninsured by 2019 without
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the ACA. The report indicates that between 2.7 and 3.4
million Californians will remain uninsured by 2019.
Overall, between 1.4 and 1.5 million undocumented
immigrants in California are projected to remain uninsured
in 2019, comprising up to half of all Californians
remaining uninsured.
3)SUPPORT. Health Access California supports this bill stating,
some of the 350,000-400,000 Californians with incomes above
the Medi-Cal income threshold who are unauthorized and
uninsured can afford to pay for their own coverage. Health
Access notes, since the cost of coverage varies by age and
geographic region, the ability to afford coverage varies as
well, but for a family that makes less than 250% FPL, there is
coverage at a very modest price for the adults who are
citizens or lawful residents and the children, regardless of
immigration status. To give an example of affordable coverage
for a family, Health Access explains that, if the kids are on
Medi-Cal and the mother who is lawful is in Covered California
with a subsidy, the family that lives on $3,000-$4,000 a month
may be able to afford to pay the $200-$300 a month for health
insurance for the undocumented father who is the primary
earner. Health Access concludes those who are unauthorized
and uninsured should have the same opportunity as the rest of
us.
The National Immigration Law Center (NILC) states, individuals
and communities suffer when people are uninsured. NILC notes,
the uninsured are more likely to be diagnosed with cancer at
an advanced state, to die after a heart attack or accident,
and to suffer poor outcomes from a stroke. NILC concludes, we
are all better off when everyone has access to health
insurance. The Western Center on Law and Poverty supports
this bill, noting as California leads the way in implementing
the ACA, providing comprehensive health coverage for
undocumented children is just the humane thing to do.
4)OPPOSITION. We the People Rising states in opposition to a
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previous version of this bill, that US Veterans and their
children, children in foster care, homeless families, and the
unemployed should be the focus of legislation in Sacramento -
not individuals residing unlawfully in California.
5)RELATED LEGISLATION. SB 10 (Lara) was recently amended to
make individuals who meet all of the eligibility requirements
for full-scope Medi-Cal benefits, except for their immigration
status, eligible for full-scope Medi-Cal benefits. SB 10 is
currently pending a hearing in the Assembly Judiciary
Committee; however the bill will most likely be re-referred to
Assembly Health Committee.
6)PREVIOUS LEGISLATION.
a) SB 1005 (Lara) of 2014 would have established the
California Health Exchange Program for All Californians
(CHEPFAC) within state government and would have required
that CHEPFAC be governed by the executive board that
governs Covered California. SB 1005 would have required
Covered California, by January 1, 2016, to facilitate the
enrollment of individuals who would have been eligible to
purchase coverage through Covered California but for their
immigration status and extend eligibility for full-scope
Medi-Cal benefits to individuals who were otherwise
eligible for those benefits but for their immigration
status. SB 1005 was held on the Senate Appropriations
suspense file.
b) SB 900 (Alquist), Chapter 659, Statutes of 2010,
establishes Covered California as an independent public
entity within state government, and requires Covered
California to be governed by a board composed of the
Secretary of CHHSA, or his or her designee, and four other
members appointed by the Governor and the Legislature who
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meet specified criteria.
c) AB 1602 (John A. Pérez), Chapter 655, Statutes of 2010,
specifies the powers and duties of Covered California
relative to determining eligibility for enrollment in the
Covered California and arranging for coverage under QHPs.
d) AB X1 1 (John A.Pérez), Chapter 3, Statutes of 2013-14
First Extraordinary Session, implemented specified Medicaid
provisions of the ACA, including the expansion of federal
Medicaid coverage to low-income adults with incomes between
0% and 138% of the FPL. AB X1 1 also implemented a number
of the Medicaid ACA provisions to simplify the eligibility,
enrollment and renewal processes for Medi-Cal.
e) SB X1 1 (Ed Hernandez and Steinberg), Chapter 4,
Statutes of 2013-14 First Extraordinary Session,
established the existing Medi-Cal benefit package as the
benefit package for the expansion population eligible under
the ACA and expanded the Medi-Cal benefit package for the
existing population and newly eligible under the ACA to
include mental health services and substance use disorder
services required under the essential health benefit
legislation adopted in 2012 that were not currently covered
by Medi-Cal.
SB X1 1 also implemented a number of the Medicaid
ACA-related provisions to simplify the eligibility,
enrollment and renewal processes for Medi-Cal and also made
recent immigrant childless adults, who would be eligible
for Medicaid funding under the ACA except for the five-year
bar who are enrolled in Covered California with an APTC,
eligible for Medi-Cal benefits not covered by their Covered
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California plan. For these individuals, DHCS would be
required to pay the individual's premium and cost-sharing
(referred to as a "Medi-Cal wrap"). The Medi-Cal wrap has
not yet been implemented. Until it is, these recent legal
immigrant adults are Medi-Cal eligible.
7)SUGGESTED TECHNICAL AMENDMENT. As currently drafted this bill
requires, when 2015 Budget bill language making undocumented
children under the age of 19 eligible for full scope Medi-Cal
benefits is implemented, that individuals currently enrolled
in restricted scope Medi-Cal be transitioned to full scope
Medi-Cal within 30 days. The bill should be amended to
clarify the authors' intent that the individuals required to
be transitioned from restricted to full scope Medi-Cal are
under the age of 19.
REGISTERED SUPPORT / OPPOSITION:
Support
Advancement Project
AIDS Project Los Angeles
Alliance of Catholic Healthcare
California Coverage and Health Initiatives
California Immigrant Policy Center
California Pan-Ethnic Health Network
California Rural Legal Assistance Foundation
California State Council of the Service
Employees International Union
California Teachers Association
Children Now
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Children's Defense Fund California
Children's Partnership
Equality California
Health Access
Lutheran Office of Public Policy, California
March of Dimes California
National Immigrant Law Center
United Ways of California
Western Center on Law and Poverty
Support (previous version)
Alliance for Boys and Men of Color
American Civil Liberties Union of California
American Federation of State, County and
Municipal Employees
Anti-Defamation League
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Asian Americans Advancing Justice
Sacramento
Asian Law Alliance
ASPIRE Los Angeles
California Alliance of Retired Americans
California Asian Pacific Islander Budget
Partnership
California Association of Public Hospitals and
Health Systems
California Black Health Network
California Chapter of the American College of
Emergency Physicians
California Communities United Institute
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California Faculty Association
California Family Health Council
California Family Resource Association
California Healthy Nail Collaborative
California Labor Federation
California Latinas for Reproductive Justice
California Nurses Association
California Partnership
California Primary Care Association
California Program of All-Inclusive Care for
the Elderly
California School Employees Association
California School-Based Health Alliance
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Campaign for a Healthy California
Central California Alliance for Health
Center for Empowering Refugees and
Immigrants
Coalition for Humane Immigrant Rights of
Los Angeles
Community Action Fund of Planned
Parenthood of Orange and
San Bernardino Counties
Community Clinic Association of
Los Angeles County
Community Health Partnership
Consumers Union
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Friends Committee on Legislation of California
Health Care for All - Contra Costa County
HOPE (Hispanas Organized for Political
Equality)
Instituto Familiar de la Raza, Inc.
Korean Resource Center
Mexican American Legal Defense and
Educational Fund
National Association of Social Workers,
California Chapter
National Health Law Program
Pacific Asian Counseling Service
PICO California
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Planned Parenthood Action Fund of Santa
Barbara, Ventura and San Luis Obispo
Counties
Planned Parenthood Action Fund of the Pacific
Southwest
Planned Parenthood Advocacy Project
Los Angeles County
Planned Parenthood Affiliates of California
Planned Parenthood Pasadena and
San Gabriel Valley
Planned Parenthood Northern California
Action Fund
Planned Parenthood Mar Monte
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San Francisco Community Clinic Consortium
Santa Cruz Women's Health Center
St. Anthony Foundation
St. John's Well Child & Family Center
San Francisco Bay Area Physicians for Social
Responsibility
United Domestic Workers/AFSCME
Local 3930
Young Invincibles
Opposition (previous version)
We The People Rising
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Analysis Prepared by:Lara Flynn / HEALTH / (916)
319-2097