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California 1332 Waiver Would Move State Closer to Health Insurance for All


Covered California could be the first exchange in the country to sell health insurance to undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients. The state marketplace is trying to use a Section 1332 “state innovation” waiver to obtain federal approval for a plan to offer coverage to all Californians, regardless of immigration status. While the proposal does not allow undocumented people and DACA recipients to receive financial assistance to help them with the costs of insurance, it is an important step toward universal coverage.

The waiver proposal requires the legislature’s signoff. In late April, the bill authorizing the state to apply for the waiver, SB 10, passed out of the Assembly Health Committee and is now making its way through the California State Assembly. As Covered California’s Executive Director Peter Lee, has said, “The ball is now in the legislature’s court.”

We asked three groups leading this effort– California Immigrant Policy Center, National Immigration Law Center (NILC) and Health Access California—how advocates in the state managed to get this far and what this waiver could mean for other states in the country.

Families USAHow did California’s waiver proposal come about? 

Betzabel Estudio, California Immigrant Policy Center: Since the implementation of the Affordable Care Act, millions of Californians have received health coverage through Covered California, the state’s marketplace, or Medi-Cal, the state’s Medicaid program. However, many California immigrants remain excluded from health coverage due to their immigration status.

In 2014, the Health for All Coalition convened to address this health injustice and begin advocating through legislative and budget efforts to expand access to care for all Californians, regardless of immigration status. The Health for All Coalition includes over 80 organizations including immigrant rights, health advocates, labor and faith based groups, and is led by the California Immigrant Policy Center and Health Access California.

This year, advocacy for Health for All continues through SB 10 (Lara). SB 10 is a bill that directs the state to apply for a waiver under Section 1332 of the Affordable Care Actallowing undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients to purchase health coverage through Covered California; though subsidies would not be included.

Allowing undocumented people and DACA recipients to access Covered California ensures everyone in a family can view and choose a healthcare plan available to them.

Families USAWhy does California’s waiver to cover all immigrants matter to other states?

Gabrielle Lessard, National Immigration Law Center (NILC): California’s proposal to use a 1332 waiver to allow undocumented Californians and DACA recipients to purchase plans through its state-based exchange represents an acknowledgement of three fundamental principles:

1. Undocumented immigrants make significant contributions to our economies. In California, they pay more than $3 billion a year in state and local taxes.  Nationwide, the 11 million undocumented immigrants currently living in the United States collectively paid more than $11 billion in state and local taxes.

2. Communities and the health care system are better off when everyone is able to get access to comprehensive care provided in the most appropriate setting.

3. Many undocumented immigrants have U.S citizen or lawfully present family members, who are often children.  Allowing all family members to select and purchase coverage through a single point of entry promotes all family members’ enrollment and access to health care.

The advance of the waiver proposal is a proof of concept. If CMS and the IRS approve the waiver, it potentially could be replicated in the other states (and Washington, D.C) that have state-based exchanges.

While California chose to provide access without subsidies, other state or local governments could use their own funds to help make plans more affordable for their residents.

Families USAHow is your statewide health consumer advocacy coalition partnering on the 1332 waiver campaign?

Bethany Snyder, Health Access: As co-lead for the Health for All Coalition, Health Access has helped lead many of the efforts to ensure that all Californians have access to quality, affordable health care.

Health Access led the development of the 1332 waiver proposal, working with NILC, the Center on Budget and Policy Priorities, and academics at the University of California-Berkeley. Our staff, along with members of the Health for All Coalition, has also met with state lawmakers, agency officials, Covered California staff and leaders, the governor’s office, as well as federal officials, including the Obama administration.

After months of meeting with policymakers, policy experts, community organizations and other stakeholders, we produced a report outlining the various options for a 1332 waiver, including the measure to allow undocumented immigrants to purchase unsubsidized health plans through Covered California.

Health Access also testified as an expert witness at a Covered California Board meeting where options for the 1332 waiver were discussed. Further, we have coordinated media outreach, providing policy analysis and background to the press on this topic in concert with Health for All’s leading organizations. 

Since Covered California gave the green light to move forward on this measure as part of the 1332 waiver, Health Access continues to provide leadership to ensure the measure passes legislative and administrative hurdles. Along with the Health for All Coalition, we lobbied to ensure the measure passed the state Senate and the Assembly Health Committee and continue to strategize to ensure it becomes law and receives federal approval.

We have helped organize grassroots efforts to engage the vast Health for All Coalition, including social media campaigns, webinars, and town hall meetings. We have also organized district meetings with legislators across the state, coordinating with participating organizations to ensure diverse voices are represented.

All of these efforts have involved the Health for All Coalition, from strategizing to planning to implementation. Having a range of organizations representing children, immigrants, patients, academics, providers along with policy experts and legislators has led to the success of the Health for All Coalition.

Families USA: What are some steps that have gotten you this far?

Betzabel Estudillo, CIPC: The Health for All Coalition has been key in moving state and local policy that provide access to care to undocumented Californians, including mobilizing legislative support, organizing events and actions, and shifting the narrative on immigrant inclusion in health care.

In addition, those directly affected have been at the forefront of the issue by testifying in committees, mobilizing community members, and discussing strategy and next steps.

Community-driven efforts have also raised the visibility of the issue, as immigrant families have courageously shared their stories of being undocumented and uninsured and urged the Governor and key legislators to support SB 4 (Lara) and SB 10 (Lara).

One of those efforts, was the UndocuCAREvan, a statewide tour that traveled 300 miles across 5 cities with undocumented and uninsured activists who shared and gathered testimonies at community forums, discussed legislative and budget updates, and highlighted the urgency of making Health for All a reality.

Through creative cultural events, like a Health For All “Posada”, a holiday procession symbolizing the search for health access, as well as a through a robust calendar of media events, including press conferences and briefings, launching opinion editorials (authored by researchers as well as directly impacted individuals), the Health for All Coalition has built a strong drumbeat on the issue of health coverage for the undocumented and uninsured.

Thanks to the courageous efforts of immigrant community members and Coalition partners, California has been able to move closer to a vision of health care coverage for all. The partnership between immigrant rights organizations and health care advocates has moved California in the right direction and helped elevate the message that health care is a human right.