Perla Lopez hands a stack of papers to Baudeilio, a 44-year-old undocumented immigrant and day laborer. She has just helped him apply for Medi-Cal at the benefits center at St. John’s Community Health’s in South Los Angeles.

“If you see anything you don’t understand from the county, come back here,” Lopez tells Baudeilio in Spanish.

The application takes less than 20 minutes. The paperwork, though brief, marks a major milestone in California’s decades-long expansion of health care for undocumented immigrants.

Beginning Jan. 1, for the first time, undocumented immigrants of all ages will qualify for Medi-Cal, the state’s health insurance program for extremely low-income people. It makes California the only state to fund comprehensive health care for undocumented immigrants.

Baudeilio, who has been denied coverage before and asked that his last name not be published to protect him from immigration authorities, will join more than 700,000 undocumented immigrants between the ages of 26 and 49 who will become eligible for Medi-Cal as part of the state’s final expansion of the program — the realization of a long-awaited dream for Californians without legal status.

“This is the culmination of literally decades of work, and it’s huge,” said Sarah Darr, policy director for the California Immigrant Policy Center. “It’s huge because of all the work and effort and advocacy that went into making this possible, and it’s also huge because of the impact that it’s going to have.”

Gov. Gavin Newsom and the state’s Democratic-led Legislature have committed more than $4 billion to the Medi-Cal expansion annually. Newsom’s 2022 budget made the latest expansion possible, and though the state is now headed into a $68 billion deficit, advocates say the positive impact Medi-Cal will have on individual health is priceless.

The change resonates deeply with Lopez, who is herself undocumented.

Last year, when the state expanded Medi-Cal to older immigrants over 50, Lopez’s mother was finally able to get medication and blood testing equipment for her diabetes. This year, surrounded by tinsel and other Christmas decorations in the brightly lit office, Lopez is happy she gets to deliver good news to undocumented patients.

“It really touches me,” said Lopez, who is eligible to work through the Deferred Action for Childhood Arrivals program. “It’s a stressor we take away from them…For people with health issues, Medi-Cal really makes a difference.”

The clinic where Lopez works estimates about 13,000 of its patients will become eligible for Medi-Cal in the new year. They’re part of the largest group in California’s ambitious plan to close the insurance gap. Los Angeles County alone accounts for roughly half of the enrollees who are expected to qualify for Medi-Cal.

“It’s an exciting moment for our patients as well as for us,” said Annie Uraga, benefits counselor coordinator at St. John’s Community Health. “They’re ready. Many of them are in need or waiting for specialist visits.”

California’s health insurance expansion

The final expansion comes nine years after then-Gov. Jerry Brown signed the law making undocumented children eligible for state insurance in 2015, and is due to the efforts of advocates trekking to the Capitol to plead their case.

“When we talk to people who are impacted by this, the difference it makes in their lives is something that truly numbers and words cannot even describe,” Darr with the California Immigrant Policy Center said. “In many cases people have lived for decades without any kind of health care whatsoever.”

Full-scope Medi-Cal, which offers access to primary and preventive care, specialists, pharmaceuticals, and other wraparound services, will change lives, Darr said. California does not share immigration information with federal authorities, and enrolling in Medi-Cal will not threaten chances to pursue legal residency, something known as the public charge rule.

The California Immigrant Policy Center along with consumer advocacy group Health Access California have been the leading force in the campaign to eliminate citizenship requirements for Medi-Cal. The work was not easy even in left-leaning California. Many moderate Democrats voted against the legislation or refrained from weighing in on the debate in the early days, Darr said, but slowly, public opinion and political will shifted.

About 66% of California adults supported health coverage for undocumented immigrants in March 2021, up from 54% in 2015, according to a survey by the Public Policy Institute of California.

Former Republican President Donald Trump lambasted California’s expansion for young adults in 2020, and claimed California and other states would “bankrupt our nation by providing free taxpayer-funded healthcare to millions of illegal aliens.” Elected California Republicans, though less harsh in their condemnation of the state’s immigration policies in recent years, have accused Newsom of overloading the state’s budget and Medi-Cal system.

“Medi-Cal is already strained by serving 14.6 million Californians—more than a third of the state’s population. Adding 764,000 more individuals to the system will certainly exacerbate current provider access problems,” the Senate Republican Caucus said in a January 2022 budget analysis.

Newsom, for his part, has played a critical role in propelling the movement forward, said Rachel Linn Gish, communications director for Health Access California. Newsom, who took office in 2019, campaigned on the promise of establishing universal health care in California, and advocates have spent the duration of his governorship pushing him to keep that promise.

“You cannot talk about coverage for all if you’re not talking about coverage for everyone regardless of their immigration status,” Linn Gish said. “Gov. Newsom made it a major platform of his from day one, and I think it’s hard to untie those two things.”

Still, Newsom has faced pressure to do more for undocumented immigrants and to do it faster. Advocates and some legislators lobbied Newsom to roll out this last expansion sooner, in part because of the disproportionate toll COVID-19 took on essential workers, many of whom are undocumented.

This expansion is projected to cost more than $835 million in the next six months and $2.6 billion every year thereafter. Previous expansions, which opened the door to more than 1.1 million undocumented enrollees, cost the state approximately $1.6 billion annually, according to past Legislative Analysis Office reports. The total $4 billion price tag, though significant, represents a fraction of Medi-Cal’s expansive $37 billion budget.

Still, many undocumented Californians will remain ineligible for health insurance. Roughly half a million immigrants make too much money to qualify for Medi-Cal but still can’t afford private insurance. Advocates want to expand Covered California to include that population, but the state’s ballooning deficit makes that unlikely in the near future.

Health disparities among undocumented immigrants

Undocumented immigrants often avoid medical care, making it difficult to compare their health to other Californians. Some studies indicate they experience higher rates of chronic conditions like heart disease, asthma and high blood pressure. Immigrants without legal status in California are also more likely to suffer from mental distress and self-report poor health.

Dr. Efrain Talamantes, chief operating officer at AltaMed in Los Angeles, the largest federally qualified health center in California, said he frequently sees young, undocumented individuals who feel healthy but “already are having the end damage of chronic conditions that have not been detected.”

The change will allow Talamantes and others who serve those communities to give patients affordable, high-level care. Although California offers many undocumented immigrants emergency Medi-Cal and some counties fund their own programs, services can be disjointed with monthslong wait times.

“When these patients now receive Medi-Cal and are part of a managed care health care plan with us, then we’re responsible for their entire care from primary and specialty to hospital care,” Talamantes said.

Miriam Pozuelos is one such person. The Los Angeles-area mother said the expansion lifts a huge financial burden from her family. She and her husband pay out-of-pocket for any medical services, and often go without. Both have already applied to full-scope Medi-Cal for January.

“When me and my family heard about this expansion, we were just really hoping that it would actually come true and that we can start getting the care that we need and not be worried about ‘I have to pay this enormous bill,’” Pozuelos said in Spanish.

Back at the St. John’s Community Health benefits center, Lopez helps another undocumented immigrant renew his emergency Medi-Cal, which will automatically roll over to full-scope next month. Wilder, 41, who requested his last name be withheld to protect him from immigration authorities, said he needs two root canals totaling $8,000. He has searched for months for a cheaper option without success, Wilder said. He also needs medication for high blood pressure but can’t always afford it.

The Medi-Cal expansion means he’ll finally be able to take care of his health, he said.

“It’s nice seeing them leaving happy and smiling,” Lopez said. “Even if it takes us three hours, they leave with a sense of relief that they can see the doctor.”

Kristen Hwang is a reporter with CalMatters.