Starting Monday, over 700,000 undocumented immigrants in California will have access to free healthcare as part of the state’s largest coverage expansion in ten years.

This initiative will ultimately require the state to spend approximately $3.1 billion annually, bringing California closer to the Democratic objective of offering universal healthcare to its roughly 39 million inhabitants.

In 2022, Democratic Governor Gavin Newsom and legislators reached an agreement to grant healthcare coverage to all low-income adults, regardless of their immigration status, through California’s Medicaid program, also known as Medi-Cal.

California is the state with the highest population that guarantees this coverage, although Oregon also implemented it in July.

When Newsom suggested the changes two years ago, he described them as a significant move towards improving the healthcare system for all citizens of California.

Newsom made the commitment when the state had the largest budget surplus in its history. But as the program kicks off next week, California faces a record $68 billion budget deficit, raising questions and concerns about the economic ramifications of the expansion.

Republican Senator Roger Niello, the vice-chair of the Senate Budget and Fiscal Review Committee, stated that it is illogical for us to contribute to our deficit, regardless of one’s stance on the matter.

Advocates for immigration and health care have worked tirelessly for over ten years to achieve these reforms. They believe that the increased coverage will bridge the gap in health care access and ultimately save the state money. Undocumented residents often postpone or avoid seeking medical treatment due to their ineligibility for most coverage, resulting in higher costs when they eventually seek care in emergency rooms.

According to Dr. Efrain Talamantes, the chief operating officer at AltaMed in Los Angeles, the largest federally qualified health center in California, this is a mutually beneficial situation as it enables us to offer thorough healthcare and we are confident that this will contribute to the overall well-being of our communities.

This update will be the biggest increase in healthcare coverage in California since the Affordable Care Act, implemented by former President Barack Obama in 2014. This act gave states the option to include adults with incomes below 138% of the federal poverty level in their Medicaid programs. As a result, California’s uninsured rate decreased from around 17% to 7%.

However, a significant portion of the population was excluded: individuals residing in the United States without legal authorization. They are ineligible for the majority of public assistance programs, despite being employed and contributing taxes.

Several states have allocated their tax funds to assist with some of the costs of healthcare for certain low-income immigrants. In 2015, California was the first to provide healthcare benefits to low-income children who did not have legal status, and eventually expanded the coverage to include young adults and individuals over the age of 50.

The state’s Medicaid program is now available for adults aged 26 to 49, completing the eligibility for all groups.

State officials estimate that more than 700,000 people will obtain comprehensive health coverage through the expansion, although the exact number is unknown. This will enable them to receive preventative care and other necessary treatment. It is worth noting that this is a larger number than the entire Medicaid population in some states.

Anthony Wright, the executive director of Health Access California, a consumer advocacy organization, stated that they have placed an asterisk next to individuals’ immigration status. He also emphasized the significance of this from a numerical standpoint.

The Republican party and other conservative organizations are concerned that the recent expansion will add more strain to an already overwhelmed healthcare system. They have criticized the high cost of the expansion.

According to a nonpartisan analysis by the Legislative Analyst’s Office, the expansion of the Medi-Cal program is expected to cost $1.2 billion in the first six months and $3.1 billion annually after that. This increase in spending will make it the second-largest expense in California’s budget, with the program currently costing about $37 billion per year.

In December, officials from the state Department of Finance informed The Associated Press that they had sent a letter advising state agencies to reduce expenses due to the deficit. However, they did not provide specific instructions regarding the Medicaid expansion.

The state of California will encounter additional obstacles in its expansion of Medicaid. Currently, the state is undergoing a reassessment of the eligibility of Medicaid recipients, the first time in over three years, due to the expiration of certain federal pandemic measures. As a result, many immigrants who previously had their coverage safeguarded during the COVID-19 pandemic are now deemed ineligible due to their changed financial status.

John Baackes, the Chief Executive Officer of L.A. Care Health Plan, which is the biggest Medicaid plan in the state with approximately 2.6 million members, stated that around 20,000 members have had their Medicaid coverage terminated during the review period in the past year and are now seeking alternative insurance options. Baackes’ organization is currently managing the task of assisting individuals in navigating through both procedures.

According to Baackes, individuals are constantly inundated with information. It is difficult to imagine how someone would not feel incredibly confused while trying to navigate through it all.

He exclaimed, “The phones are constantly ringing!”

According to Sarah Dar, the policy director for the California Immigrant Policy Center, fear and lack of trust are obstacles to growth.

Numerous immigrants refrain from utilizing public programs or benefits due to concerns that it may impede their ability to obtain legal status under the “public charge” regulation. This federal law mandates that individuals looking to attain permanent residency or legal status must demonstrate that they will not be a burden to the United States, or a “public charge.” Although Medicaid is no longer considered a factor under President Joe Biden’s administration, the apprehension persists, according to the source.

Dar stated that additional resources and effort are necessary in order to reach this particular population due to their past experiences of being entirely excluded and not interacting with the healthcare system or government programs for a significant period of time.

According to Dar, California still has progress to make in achieving “universal coverage,” or a 0% uninsured rate.

One issue is that immigrants residing in the United States without legal authorization are currently unable to buy insurance from Covered California, which is a government program that provides significant discounts for individuals who meet specific income criteria. However, there is a proposed bill in the state Legislature, backed by the California Immigrant Policy Center, that aims to modify this restriction.

Dar stated that it will be another significant endeavor, and although revenues have decreased, it is our responsibility to advocate for these communities that require the most assistance during economic downturns.

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Adam Beam, a reporter for the Associated Press, contributed to this report.