BILL ANALYSIS                                                                                                                                                                                                    Ó

                                                                       SB 4

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          4 (Lara)

          As Amended  September 1, 2015

          Majority vote

          SENATE VOTE:  28-11

          |Committee       |Votes|Ayes                  |Noes                |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |Health          |12-6 |Bonta, Bonilla,       |Maienschein,        |
          |                |     |Burke, Chiu, Gomez,   |Chávez, Lackey,     |
          |                |     |Gonzalez,             |Patterson,          |
          |                |     |                      |Steinorth, Waldron  |
          |                |     |                      |                    |
          |                |     |Roger Hernández,      |                    |
          |                |     |Nazarian, Rodriguez,  |                    |
          |                |     |Santiago, Thurmond,   |                    |
          |                |     |Wood                  |                    |
          |                |     |                      |                    |
          |Appropriations  |12-5 |Gomez, Bloom, Bonta,  |Bigelow, Chang,     |
          |                |     |Calderon, Nazarian,   |Gallagher, Jones,   |
          |                |     |Eggman, Eduardo       |Wagner              |
          |                |     |Garcia, Holden,       |                    |
          |                |     |Quirk, Rendon, Weber, |                    |
          |                |     |Wood                  |                    |


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          |                |     |                      |                    |
          |                |     |                      |                    |

          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.

          FISCAL EFFECT:  According to the Assembly Appropriations  
          Committee, minor, absorbable costs to CHHSA and costs in the  
          range of $100,000 to Covered California (California Health Trust  
          Fund) to pursue a narrow federal waiver; minor, absorbable  
          ongoing administrative costs to Covered California (California  
          Health Trust Fund) to designate California qualified health  
          plans (QHPs); significant Information Technology costs to  
          Covered California, potentially in the millions (California  
          Health Trust Fund), potentially significant, unknown ongoing  
          costs from the same fund; and, negligible increased costs  
          associated with a 30-day timeline for transition of children to  
          full-scope Medi-Cal.  The 2015-16 Budget assumed transition by  
          June 1, 2016.

          COMMENTS:  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  


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          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 (Budget  
          and Fiscal Review Committee), 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  
          Patient Protection and Affordable Care Act (ACA), but only when  
          we include everyone can we have a truly healthy California.

          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.  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 Advanced  
          Premium Tax Credits and cost-sharing subsidies are only  
          available for individuals purchasing coverage in Covered  


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          California, undocumented individuals are also not eligible for  
          these subsidies intended to make health insurance and the cost  
          of care more affordable.  

          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. 

          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 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.  

          A January 2015 report from the University of California Berkeley  


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          Center for Labor Research and Education and the University of  
          California Los Angeles 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 the ACA.  The  
          report indicates that between 2.7 and 3.4 million Californians  
          will remain uninsured by 2019.  Overall, between 1.4 million and  
          1.5 million undocumented immigrants in California are projected  
          to remain uninsured in 2019, comprising up to half of all  
          Californians remaining uninsured. 

          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  


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          California leads the way in implementing the ACA, providing  
          comprehensive health coverage for undocumented children is just  
          the humane thing to do.

          We the People Rising states in opposition to a previous version  
          of this bill, that United States 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.

          Analysis Prepared by:                                             
                          Lara Flynn / HEALTH / (916) 319-2097  FN: