In California, almost 11 million immigrants and migrants reside and contribute to the economy. That is 27% of California's population, based on the latest data released by the Public Policy Institute of California in 2021. According to the Center for Migration Studies, about 22% of immigrants and migrants in California are undocumented. The 1996 welfare law created two categories of immigrants for benefits eligibility purposes: “qualified” and “not qualified”.

California is currently considering how to improve its healthcare system called Medi-Cal Health Care. Before any changes are implemented, it is important to consider whether sexual and reproductive healthcare (SRH) requirements are being met, and how this system will be able to provide for undocumented people. 

IMMIGRANTS AND LACK OF ACCESS TO HEALTH INSURANCE 

Accessing a wide scope of sexual and reproductive health services is essential to the good health of every person, family, and community. When women use contraceptives, they have greater control over their reproductive goals, which can allow them to pursue full-time careers, seek further education, and be in a better financial situation. Access to SRH services is necessary to ensure women have this ability to control their productive futures. Additionally, services like sex education, STI testing, and cancer screenings are essential to help prevent pelvic inflammatory diseases, pregnancy complications, cervical cancer, and related deaths. Having insurance makes these services affordable and accessible.

However, due to their immigration status, undocumented immigrants and migrants have barriers to accessing SRH. Various laws prevent most foreigners from acquiring economic health coverage in the United States. Lawfully present immigrants and migrants (those who qualify as non-citizens through Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, or victims of trafficking) are allowed to buy private insurance through the Affordable Care Act (“ACA”). However, undocumented immigrants and migrants are completely banned from purchasing private health insurance. The Deferred Action for Childhood Arrivals (“DACA”) initiative allowed those granted DACA status to live in California lawfully, but they were still blocked from almost every form of public health insurance, ACA plans, and other affordability programs. 

MAKING MEDI-CAL A UNIVERSAL HEALTHCARE SYSTEM 

In 2016, the state of California implemented an extension of Medi-Cal treatment to undocumented children up to 18 years of age. Compared to the United States Federal Medicaid program, aimed to help cut healthcare costs for low-income and vulnerable populations, Medi-Cal offers some coverage for emergency medical services to undocumented individuals of all ages. While this is a great step for California, there is an ongoing conversation about whether universal healthcare is actually an option financially. The importance of carrying over current users and non-users into a new program is crucial to the overall success of a universal healthcare model. 

From the time the ACA was passed in 2010, California has seen lower rates of uninsured individuals. The $1.9 trillion dollar relief and recovery package was predicted to assist over 1.6 million Californians in qualifying for subsidies for the first time. In June 2021, Gavin Newsom, the current governor, proposed an extension of Medi-Cal coverage to undocumented individuals and seniors age 50 and over. If approved, this proposal would take effect in January 2024 and make California the first state to have a universal model of healthcare. 

ISSUES WITH ACCESS TO THIS NEW SYSTEM FOR UNDOCUMENTED PEOPLE

Following joint research done by the UC Berkeley Labor Center and the UCLA Center for Health Policy Research, undocumented Californians remain the largest group of uninsured individuals based on a 2022 study. This research found that "nearly 3.2 million Californians will remain uninsured in 2022, or about 9.5% of the population aged 0-64, according to our projections. The highest uninsured rates will be among undocumented Californians (65%).” 

The most recent proposal by Governor Newson is set to be approved by June 2022. California would use $2.7 billion per year to provide universal healthcare for all citizens based on income (individuals with income at or below 138% Federal Poverty Level (FPL) are generally eligible for Medi-Cal). While undocumented immigrants and migrants contribute to the United States and California’s economy, a majority of those who are undocumented would qualify as falling under the FPL. For most adult enrollees, the limit to qualify for Medi-Cal is 138% of the federal poverty level. Eligibility takes into consideration income and household size, while certain groups like pregnant women qualify for Medi-Cal with slightly higher incomes.

However, advancing undocumented women’s sexual and reproductive health would require action from policymakers. There are various options to help remove the care blocks for undocumented immigrants and migrants, however, issues arise when documentation is needed for proof of legal residence to access programs like Medi-Cal. Overall, confusion of eligibility and language barriers often impede access to benefits for immigrants and migrants. A review of the current Federal Poverty Levels would be vital in order to reach a multitude of people who are unable to qualify because they have jobs where they earn above Medi-Cal’s annual income thresholds for most adults.

While the federal government provides undocumented women with the option of accessing prenatal protection under the State Children’s Health Insurance Program, the fear of being detained or deported comes at the time of application for programs that allow undocumented people access to services. This fear comes from the risk that when an undocumented woman applies for services, this could expose other family members to deportation. A universal healthcare option might eliminate fear of deportation, because it would be a statewide implementation of support.

STEPS TOWARDS A TRULY UNIVERSAL SYSTEM 

Overall, it is important to consider whether or not SRH requirements are being met currently, and what the landscape would look like under the proposed model. While SRH has been lightly laid out in the proposal, the need for deeper consideration of accessibility is high. A model for SRH integration should cover three key components: education, adequate treatment, and a holistic approach. Education would involve language access and comprehensive and holistic sexual education, including contraceptive education and counselling. Detection, prevention, and treatment of reproductive cancers and HIV/STIs, as well as detection and prevention of sexual and gender-based violence are all key considerations. Lastly, comprehensive and holistic care is important for a universal health system, ensuring safe abortion services, antenatal, childbirth, and postnatal care. A comprehensive and holistic approach is required to effectively meet people’s sexual and reproductive health needs. 

By ensuring equity in access, quality of care, accessibility, and accountability across all sexual and reproductive health providers, without discrimination based on documentation status, California will be able to continue towards the first universal healthcare system in the United States. The hope is that a universal system will bring equal access to healthcare for all uninsured, undocumented immigrants and migrants, and allow for safe and affordable sexual and reproductive healthcare for everyone.

Josephine is a current Masters student in Migration Studies at the University of San Francisco. With a proactive approach to policy and immigration research, Josephine has a passion for public health, reproductive justice and access to care.

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