Health Policy and Management's assignment
May 2012
Ensuring California’s Future by Insuring California’s Undocumented
W hy Excluding Undocumented Californians from the A!ordable Care Ac t Hur ts All of Us
By Enrico Marcelli, Manuel Pastor, and Steve Wallace
May 2014
Introduction 1
How does the ACA exclude some
Californians?
2
Undocumented Californians:
Geography, economics, and medical
insurance coverage
3
How expanded access to insurance
ZLOO�LPSURYH�KHDOWK��ÀQDQFHV��DQG� our communities
4
Making it real: Effectively reaching
undocumented Californians
5
Political considerations 5
End Notes 7
* This policy memo is based on a longer report to be released by USC CSII in the summer of 2014. That report takes the form ŽĨ�Ă�ůŝƚĞƌĂƚƵƌĞ�ƐLJŶƚŚĞƐŝƐ�Ăƚ�ƚŚĞ�ŝŶƚĞƌƐĞĐƟŽŶ�ŽĨ�ƌĞƐĞĂƌĐŚ�ŽŶ�ƚŚĞ� ĚĞŵŽŐƌĂƉŚŝĐƐ�ĂŶĚ�ŐĞŽŐƌĂƉŚŝĐ�ĚŝƐƚƌŝďƵƟŽŶ�ŽĨ�ƵŶĚŽĐƵŵĞŶƚĞĚ� immigrants in California, access to medical insurance, health outcomes, the health policy landscape, and framing for policy reform. Visit the CSII website at: ŚƩƉ͗ͬͬĐƐŝŝ͘ƵƐĐ͘ĞĚƵͬĞŶƐƵƌŝŶŐͺ ĐĂͺĨƵƚƵƌĞ͘Śƚŵů
** Photo credits from cover: >ĞŌ͗��ĂůŝĨŽƌŶŝĂ�/ŵŵŝŐƌĂŶƚ�WŽůŝĐLJ��ĞŶƚĞƌ�;�/W�Ϳ͕��ŽƉLJƌŝŐŚƚ�Ξ� 2014. DŝĚĚůĞ͗�WŚŽƚŽ�ďLJ�ZĂũŵƵŶĚ��ĂďƌŽǁƐŬŝ�Ͳ��ŽƉLJƌŝŐŚƚ�Ξ�ϮϬϭϭ͕�ϮϬϭϰ ZŝŐŚƚ͗��ĂůŝĨŽƌŶŝĂ�/ŵŵŝŐƌĂŶƚ�WŽůŝĐLJ��ĞŶƚĞƌ�;�/W�Ϳ͕��ŽƉLJƌŝŐŚƚ�Ξ� 2014.
Contents
1
Introduction dŚĞ��īŽƌĚĂďůĞ��ĂƌĞ��Đƚ�;���Ϳ�ƌĞƉƌĞƐĞŶƚƐ�ƚŚĞ�ŵŽƐƚ�ĚƌĂŵĂƟĐ�ŝŶĐƌĞĂƐĞ�ŝŶ�ĂĐĐĞƐƐ�ƚŽ�ŵĞĚŝĐĂů�ŝŶƐƵƌĂŶĐĞ�ƐŝŶĐĞ�ƚŚĞ� ŐƌŽǁƚŚ�ŽĨ�ĞŵƉůŽLJĞƌͲƉƌŽǀŝĚĞĚ�ŝŶƐƵƌĂŶĐĞ�ŝŶ�ƚŚĞ�ƉŽƐƚͲtt//�ƉĞƌŝŽĚ�ĂŶĚ�ƚŚĞ�ĐƌĞĂƟŽŶ�ŽĨ�DĞĚŝĐĂƌĞ�ĂŶĚ�DĞĚŝĐĂŝĚ� ŝŶ�ƚŚĞ�ϭϵϲϬƐ͘��Ŷ�ĞƐƟŵĂƚĞĚ�Ϯϲ�ŽĨ�ƚŚĞ�ϱϬ�ŵŝůůŝŽŶ�ŶŽŶͲĞůĚĞƌůLJ�ƵŶŝŶƐƵƌĞĚ��ŵĞƌŝĐĂŶƐ�ĂƌĞ�ƉƌŽũĞĐƚĞĚ�ƚŽ�ŐĂŝŶ� ŶĞǁ�ĐŽǀĞƌĂŐĞ͘1�tŚŝůĞ�ƚŚĞ�ŐŽĂů�ŽĨ�ƚŚĞ�����ŝƐ�ƚŽ�ĞǀĞŶƚƵĂůůLJ�ƉƌŽǀŝĚĞ�ĐŽǀĞƌĂŐĞ�ƚŽ�Ăůů��ŵĞƌŝĐĂŶƐ͕�ŽŶĞ�ŐƌŽƵƉ�ŽĨ� residents who are an important part of our economy and society are explicitly excluded: the undocumented.
�džƉĂŶĚŝŶŐ�ĐŽǀĞƌĂŐĞ�ƚŽ�Ăůů�ŵĂŬĞƐ�ƐĞŶƐĞ�ĨŽƌ�Ăůů�ŽĨ��ĂůŝĨŽƌŶŝĂ͘�tŚŝůĞ�ŽŶůLJ�ŽŶĞ�ŽĨ�ŵĂŶLJ�ĚĞƚĞƌŵŝŶĂŶƚƐ�ŽĨ� ŚĞĂůƚŚ͕�ĞdžƉĂŶĚŝŶŐ�ĂĐĐĞƐƐ�ƚŽ�ŝŶƐƵƌĂŶĐĞ�ŝƐ�ůŝŬĞůLJ�ƚŽ�ŝŵƉƌŽǀĞ�ŚĞĂůƚŚ͘�EĞĂƌůLJ�ĐĞƌƚĂŝŶůLJ͕ �ŝƚ�ǁŝůů�ƌĞƐƵůƚ�ŝŶ�ĞĐŽŶŽŵŝĐ� ƐƚĂďŝůŝƚLJ�ďLJ�ƉƌĞǀĞŶƟŶŐ�ƉĞƌƐŽŶĂů�ĮŶĂŶĐŝĂů�ĐĂƚĂƐƚƌŽƉŚĞ�ʹ�ŝŵƉŽƌƚĂŶƚ�ĨŽƌ�ƵŶĚŽĐƵŵĞŶƚĞĚ��ĂůŝĨŽƌŶŝĂŶƐ͕�ƚŚĞŝƌ� ;ŽǀĞƌǁŚĞůŵŝŶŐůLJ�ĐŝƟnjĞŶͿ�ĐŚŝůĚƌĞŶ͕�ĂŶĚ�ƚŚĞŝƌ�ĐŽŵŵƵŶŝƟĞƐ͘�DŽƌĞŽǀĞƌ͕ �ŽƵƌ�ƐƚĂƚĞ�ŝŶƐƵƌĂŶĐĞ�ĞdžĐŚĂŶŐĞ͕��ŽǀĞƌĞĚ� �ĂůŝĨŽƌŶŝĂ͕�ǁŽƵůĚ�ďĞ�ƐƚƌĞŶŐƚŚĞŶĞĚ�ďĞĐĂƵƐĞ�ŝƚ�ǁŝůů�ŝŵƉƌŽǀĞ�ƌŝƐŬ�ƐŚĂƌŝŶŐ�ďLJ�ĂĚĚŝŶŐ�Ă�ŐƌŽƵƉ�ƚŚĂƚ�ƚĞŶĚƐ�ƚŽ�ďĞ� LJŽƵŶŐĞƌ�ĂŶĚ�ŚĞĂůƚŚŝĞƌ�ʹ�ĂŶĚ�ǁĞ�ĐŽƵůĚ�ĂůƐŽ�ƉƌĞǀĞŶƚ�ĨƵƚƵƌĞ�ĮŶĂŶĐŝĂů�ďƵƌĚĞŶ�ďLJ�ĂĚĚƌĞƐƐŝŶŐ�ŚĞĂůƚŚ�ƉƌŽďůĞŵƐ� ŶŽǁ�ŝŶƐƚĞĂĚ�ŽĨ�ŝŶ�ƚŚĞ�;ŵŽƌĞ�ĞdžƉĞŶƐŝǀĞͿ�ĞŵĞƌŐĞŶĐLJ�ƌŽŽŵ͘�
�ƵƌƌĞŶƚůLJ͕ �ůĞŐŝƐůĂƟŽŶ�ƉƌŽƉŽƐĞĚ�ďLJ�^ƚĂƚĞ�^ĞŶĂƚŽƌ�ZŝĐĂƌĚŽ�>ĂƌĂ�;�Ͳ>ŽŶŐ��ĞĂĐŚͿ�ǁŽƵůĚ�ƐĞĞŬ�ƚŽ�ĂĚĚƌĞƐƐ�ƚŚŝƐ�ŝƐƐƵĞ� ďLJ�ŵĂŬŝŶŐ�DĞĚŝͲ�Ăů͕�ƚŚĞ�ƉƵďůŝĐ�ŝŶƐƵƌĂŶĐĞ�ƐĞƚ�ƵƉ�ĨŽƌ�ůŽǁͲŝŶĐŽŵĞ�ƌĞƐŝĚĞŶƚƐ͕�ĂǀĂŝůĂďůĞ�ƚŽ�ƚŚĞ�ƵŶĚŽĐƵŵĞŶƚĞĚ� ĂŶĚ�ĚĞǀĞůŽƉŝŶŐ�Ă�ƉƌŝǀĂƚĞ�ŝŶƐƵƌĂŶĐĞ�ĞdžĐŚĂŶŐĞ�ŽƉƟŽŶ�ŶĞĂƌůLJ�ŝĚĞŶƟĐĂů�ƚŽ��ŽǀĞƌĞĚ��ĂůŝĨŽƌŶŝĂ͘��ĞďĂƚĞƐ�ĂďŽƵƚ�ƚŚŝƐ� ďŝůů�ĂŶĚ�ŝƚƐ�ŐŽĂůƐ�ĂƌĞ�ůŝŬĞůLJ�ƚŽ�ƌĂŝƐĞ�ƚŚĞ�ƵƐƵĂů�ƉĂƐƐŝŽŶƐ�ĂďŽƵƚ�ŝŵŵŝŐƌĂƟŽŶ͕�ƉĂƐƐŝŽŶƐ�ƚŚĂƚ�ĐĂŶ�ŽŌĞŶ�ŐĞƚ�ŝŶ�ƚŚĞ� way of good public policy design. The goal of this ďƌŝĞĨ�ŝƐ�ƚŽ�ƉƌŽǀŝĚĞ�Ă�ĨĂĐƚƵĂů�ďĂƐŝƐ�ĨŽƌ�Ă�ĐŽŶƐŝĚĞƌĂƟŽŶ� ŽĨ�ďŽƚŚ�ƚŚĞ�>ĂƌĂ�ďŝůů�ĂŶĚ�ŽƚŚĞƌ�ĂůƚĞƌŶĂƟǀĞƐ�ƚŚĂƚ� may surface in the near future.
tĞ�ƐƉĞĐŝĮĐĂůůLJ�ĨŽĐƵƐ�ŽŶ�ƚŚĞ�ĨŽůůŽǁŝŶŐ�ƋƵĞƐƟŽŶƐ͗�
ͻ�tŚĂƚ�ƐƚĂŶĚƐ�ŝŶ�ƚŚĞ�ǁĂLJ�ŽĨ�ŝŶĐůƵƐŝŽŶ�ŽĨ�Ăůů� Californians because of policy design?
ͻ�tŚŽ�ĂƌĞ�ƚŚĞ�ƵŶĚŽĐƵŵĞŶƚĞĚ��ĂůŝĨŽƌŶŝĂŶƐ�ůĞŌ� out of the reform?
ͻ�How does access to medical insurance impact undocumented Californians and the state?
ͻ�tŚĂƚ�ĚŽĞƐ�ƉĂƐƚ�ĞdžƉĞƌŝĞŶĐĞ�ƐƵŐŐĞƐƚ�ŝƐ�ƚŚĞ� ďĞƐƚ�ǁĂLJ�ƚŽ�ƌĞĂĐŚ�ƚŚŝƐ�ƉŽƉƵůĂƟŽŶ͍
ͻ�/Ɛ�ŝƚ�ƉŽůŝƟĐĂůůLJ�ĨĞĂƐŝďůĞ�ĨŽƌ��ĂůŝĨŽƌŶŝĂ�ƚŽ� ĞdžƉĂŶĚ�ĐŽǀĞƌĂŐĞ�ĨŽƌ�Ăůů͍
WŚŽƚŽ�ďLJ��ĂůŝĨŽƌŶŝĂ�/ŵŵŝŐƌĂŶƚ�WŽůŝĐLJ��ĞŶƚĞƌ�;�/W�Ϳ͘
2
How does the ACA exclude some
Californians? Undocumented immigrants are excluded from the ACA and its medical insurance expansion programs.2 ^ƉĞĐŝĮĐĂůůLJ͕ �ƚŚĞLJ�ĂƌĞ�ŝŶĞůŝŐŝďůĞ�ĨŽƌ�;ϭͿ�ƐƵďƐŝĚŝĞƐ�ƚŽ� ŵĂŬĞ�ƉƌŝǀĂƚĞ�ŚĞĂůƚŚ�ŝŶƐƵƌĂŶĐĞ�ŵŽƌĞ�ĂīŽƌĚĂďůĞ͕�;ϮͿ� DĞĚŝĐĂŝĚ�ĞdžƉĂŶƐŝŽŶ͕�ĂŶĚ�;ϯͿ�ƚŚĞ��ĂƐŝĐ�,ĞĂůƚŚ�WƌŽŐƌĂŵ� ;�,WͿ�ŽƉƟŽŶ�ǁŚŝĐŚ�ŝƐ�ĚĞƐŝŐŶĞĚ�ƚŽ�ďƌŝĚŐĞ�DĞĚŝĐĂŝĚ� ĂŶĚ�ƐƵďƐŝĚŝnjĞĚ�ƉƌŝǀĂƚĞ�ŝŶƐƵƌĂŶĐĞ�;ǁŚŝĐŚ�ŽŶůLJ�Ă� ŚĂŶĚĨƵů�ŽĨ�ƐƚĂƚĞƐ�ĂƌĞ�ŽƉƟŶŐ�ƚŽ�ƐĞƚ�ƵƉͿ͘ϯ hŶĚŽĐƵŵĞŶƚĞĚ�ŝŵŵŝŐƌĂŶƚ�LJŽƵƚŚ�ǁŚŽ�ŚĂǀĞ�ƌĞĐĞŝǀĞĚ� �����;͞�ĞĨĞƌƌĞĚ��ĐƟŽŶ�ŽŶ��ŚŝůĚŚŽŽĚ��ƌƌŝǀĂůƐ͟�ǁŚŝĐŚ� ŐƌĂŶƚƐ�ƚĞŵƉŽƌĂƌLJ�ƉĞƌŵŝƐƐŝŽŶ�ƚŽ�ƐƚĂLJ�ŝŶ�ƚŚĞ�h͘^͘Ϳ�ĂƌĞ� also excluded from all of these programs.4 In �ĂůŝĨŽƌŶŝĂ͕�ƐŽŵĞ�ƵŶĚŽĐƵŵĞŶƚĞĚ��ĂůŝĨŽƌŶŝĂŶƐ�ǁŝůů�ŚĂǀĞ� ũŽďͲďĂƐĞĚ�ĐŽǀĞƌĂŐĞ͕�ƉƌŝǀĂƚĞůLJͲƉƵƌĐŚĂƐĞĚ�ŝŶƐƵƌĂŶĐĞ͕�Žƌ� ŽƚŚĞƌ�ĐŽǀĞƌĂŐĞ͕�ďƵƚ�ϭ͘ϰ�ƚŽ�ϭ͘ϱ�ŵŝůůŝŽŶ�ǁŝůů�ƌĞŵĂŝŶ� uninsured.ϱ
The ACA will increase direct funding to Community Health Centers, including designated Migrant Health Centers on which immigrants rely, and other Federally YƵĂůŝĮĞĚ�,ĞĂůƚŚ��ĞŶƚĞƌƐ�;&Y,�ƐͿ�ďLJ�Ψϭϭ�ďŝůůŝŽŶ�ŽǀĞƌ� ƚŚĞ�ĮǀĞ�LJĞĂƌƐ͕6 although the threat of losing funding is constant.7�,ŽǁĞǀĞƌ͕ �ŝƚ�ĂůƐŽ�ƌĞĚƵĐĞƐ�ĨĞĚĞƌĂů�ĨƵŶĚŝŶŐ� ĨŽƌ�ŚŽƐƉŝƚĂůƐ�ƚŚĂƚ�ŚĞůƉ�ĐŽǀĞƌ�ĐĂƌĞ�ĨŽƌ�ƚŚĞ�ƵŶŝŶƐƵƌĞĚ͕8 ǁŚŝĐŚ�ŵĂLJ�ƉƌŽǀĞ�ƚŽ�ďĞ�ĚĞƚƌŝŵĞŶƚĂů�ĨŽƌ�ƵŶŝŶƐƵƌĞĚ� ŝŵŵŝŐƌĂŶƚƐ͘��ǀĞŶ�ŝĨ�ĂŶ�ŝŵŵŝŐƌĂƟŽŶ�ƌĞĨŽƌŵ�ďŝůů�ǁŝƚŚ�Ă� ƉĂƚŚǁĂLJ�ƚŽ�ĐŝƟnjĞŶƐŚŝƉ�ǁĞƌĞ�ƚŽ�ƉĂƐƐ͕�ĐƵƌƌĞŶƚ� proposals deny access to public funding to insure the ŶĞǁůLJ�ůĞŐĂůŝnjĞĚ�ĨŽƌ�Ăƚ�ůĞĂƐƚ�ϭϭ�LJĞĂƌƐ͘9
�ĂůŝĨŽƌŶŝĂ�ŝƐ�Ă�ĨŽƌĞƌƵŶŶĞƌ�ŝŶ�ƉƌŽǀŝĚŝŶŐ�ŵĞĚŝĐĂů� insurance access to all of its residents. The state has ĂĚŽƉƚĞĚ�ďƌŽĂĚ�����ƉƌŽŐƌĂŵ�ŽƉƟŽŶƐ�;ďŽƚŚ�Ă�ŚŝŐŚĞƌ� ƉŽǀĞƌƚLJ�ƚŚƌĞƐŚŽůĚ�ŽĨ�ϭϯϯ�ƉĞƌĐĞŶƚ�ĂŶĚ��,/WͿ͕10 is
ƌƵŶŶŝŶŐ�ŝƚƐ�ŽǁŶ�ŝŶƐƵƌĂŶĐĞ�ĞdžĐŚĂŶŐĞ͕�ĂŶĚ�ƉƌŽǀŝĚĞƐ� ƐŽŵĞ�ĨƵůůLJ�ƐƚĂƚĞͲĨƵŶĚĞĚ�ŵĞĚŝĐĂů�ĐĂƌĞ�ƉƌŽŐƌĂŵƐ� regardless of status.11 California also pays 100 percent ŽĨ�DĞĚŝͲ�Ăů�ĨƵŶĚŝŶŐ�ĨŽƌ�ůĞŐĂů�ƉĞƌŵĂŶĞŶƚ�ƌĞƐŝĚĞŶƚƐ� ;>WZƐͿ�ĚƵƌŝŶŐ�ƚŚĞŝƌ�ĮƌƐƚ�ĮǀĞ�LJĞĂƌƐ�ŽĨ�ƌĞƐŝĚĞŶĐLJ͘12 The number of uninsured undocumented may be reduced ƐŝŶĐĞ�ƚŚĞ�ƐƚĂƚĞ�ŝƐ�ĞdžƚĞŶĚŝŶŐ�ĨƵůůͲƐĐŽƉĞ�DĞĚŝͲ�Ăů�ĨŽƌ� ŝŶĐŽŵĞͲĞůŝŐŝďůĞ�����Ɛ�ƵƐŝŶŐ�ƐƚĂƚĞ�ĨƵŶĚƐ͘ϭϯ
EŽƚ�ũƵƐƚ�Ă�ƋƵĞƐƟŽŶ�ŽĨ�ƐƚĂƚĞ�ƉŽůŝĐLJ͕ �ĐŽƵŶƟĞƐ�ĂƌĞ� ŝŵƉŽƌƚĂŶƚ�ŵĞĚŝĐĂů�ƐĞƌǀŝĐĞ�ƉƌŽǀŝĚĞƌƐ�ĂŶĚ� ĚĞĐŝƐŝŽŶͲŵĂŬĞƌƐ͕�ĂƐ�ǁĞůů͘�&Žƌ�ĞdžĂŵƉůĞ͕��ůĂŵĞĚĂ͕� &ƌĞƐŶŽ͕�<ĞƌŶ͕�>ŽƐ��ŶŐĞůĞƐ͕�ZŝǀĞƌƐŝĚĞ͕�^ĂŶ�&ƌĂŶĐŝƐĐŽ͕� ^ĂŶ�DĂƚĞŽ͕�^ĂŶƚĂ��ůĂƌĂ͕�ĂŶĚ�^ĂŶƚĂ��ƌƵnj��ŽƵŶƟĞƐ� ƉƌŽǀŝĚĞ�ƐĞƌǀŝĐĞƐ�ƚŽ�ƉĂƟĞŶƚƐ�ƌĞŐĂƌĚůĞƐƐ�ŽĨ�ŝŵŵŝŐƌĂƟŽŶ� ƐƚĂƚƵƐ�ĂŶĚ��ŽŶƚƌĂ��ŽƐƚĂ�ĐŽǀĞƌƐ�ƵŶĚŽĐƵŵĞŶƚĞĚ� ĐŚŝůĚƌĞŶ�;ŽŶůLJͿ͘14 Healthy Kids in San Francisco uses ĐŝƚLJ�ĨƵŶĚŝŶŐ�ƚŽ�ƉƌŽǀŝĚĞ�ĐŽǀĞƌĂŐĞ�ƚŽ�Ăůů�ƵŶŝŶƐƵƌĞĚ� ĐŚŝůĚƌĞŶ�ƵŶĚĞƌ�ϭϵ�ǁŚŽ�ĚŽ�ŶŽƚ�ƋƵĂůŝĨLJ�ĨŽƌ�ŽƚŚĞƌ� federal or state programs, regardless of legal status.ϭϱ
hŶĨŽƌƚƵŶĂƚĞůLJ͕ �ƚŚĞƐĞ�ůŽĐĂů�ĞīŽƌƚƐ�ĂƌĞ�Ăƚ�ƌŝƐŬ͘ The State ŝƐ�ĐƵƫŶŐ�ŝƚƐ�ĨƵŶĚŝŶŐ�ĨŽƌ�ůŽǁͲŝŶĐŽŵĞ�ĂŶĚ�ƵŶŝŶƐƵƌĞĚ� ŵĞĚŝĐĂů�ƐĞƌǀŝĐĞƐ�ƚŚĂƚ�ŐŽĞƐ�ƚŽ�ĐŽƵŶƟĞƐ�ďĞĐĂƵƐĞ�ŽĨ� ĂŶƟĐŝƉĂƚĞĚ�ŝŶĐƌĞĂƐĞĚ�ĐŽǀĞƌĂŐĞ�ĨƌŽŵ�ƚŚĞ����͘16 In ƌĞƐƉŽŶƐĞ͕�ĐŽƵŶƟĞƐ�ůŝŬĞ�&ƌĞƐŶŽ�ĂƌĞ�ĂƩĞŵƉƟŶŐ�ƚŽ�ĐƵƚ� ŵĞĚŝĐĂů�ĐĂƌĞ�ƐĞƌǀŝĐĞƐ�ƚŽ�ƵŶĚŽĐƵŵĞŶƚĞĚ�ŝŵŵŝŐƌĂŶƚƐ͘17 KŶĞ�ƐŽůƵƟŽŶ�ƚŽ�ƚĂƩĞƌŝŶŐ�ƐĂĨĞƚLJ�ŶĞƚƐ͗�ĚŝƌĞĐƚ�ĨĞĚĞƌĂů� ,ĞĂůƚŚ�ĂŶĚ�,ƵŵĂŶ�^ĞƌǀŝĐĞƐ�ĨƵŶĚƐ�ƚŽ�ƐƚĂƚĞƐ�ǁŝƚŚ�ůĂƌŐĞ� informal labor markets where undocumented and ŽƚŚĞƌ�ůŽǁͲŝŶĐŽŵĞ�ŝŵŵŝŐƌĂŶƚƐ�ůŝǀĞ͘18
'ŝǀĞŶ�ƚŚŝƐ�ŐĂƉ�ŝŶ�ĚŝƌĞĐƚ�ƐƵƉƉŽƌƚ�ĂŶĚ�ƚŚĞ�ƚŚƌĞĂƚƐ�ƚŽ� indirect support of medical insurance for the
undocumented, State Senator Lara has proposed ĂŶ�ĞdžƉĂŶƐŝŽŶ�ŽĨ�DĞĚŝͲ�Ăů�ĂǀĂŝůĂďŝůŝƚLJ�ƚŽ�ƚŚĞ� ƵŶĚŽĐƵŵĞŶƚĞĚ�ĂƐ�ǁĞůů�ĂƐ�Ă�ƉƌŝǀĂƚĞ�ŝŶƐƵƌĂŶĐĞ� ĞdžĐŚĂŶŐĞ�ŽƉƟŽŶ�ƚŚĂƚ�ǁŽƵůĚ�ĞƐƐĞŶƟĂůůLJ�ŵŝƌƌŽƌ� �ŽǀĞƌĞĚ��ĂůŝĨŽƌŶŝĂ͘19�tŚŝůĞ�ƚŚĞ�ĐŽƐƚƐ�ƚŽ�ƚŚĞ�^ƚĂƚĞ� ŶĞĞĚ�ƚŽ�ďĞ�ĐŽŶƐŝĚĞƌĞĚ�ĂŶĚ�ĂƌĞ�ďĞŝŶŐ�ĞƐƟŵĂƚĞĚ͕20 it ŝƐ�ĂůƐŽ�ŝŵƉŽƌƚĂŶƚ�ƚŽ�ƌĞĂůŝnjĞ�ƚŚĂƚ�ƵŶĚŽĐƵŵĞŶƚĞĚ� �ĂůŝĨŽƌŶŝĂŶƐ�ƉĂLJ�ΨϮ͘ϳ�ďŝůůŝŽŶ�ĂŶŶƵĂůůLJ�ŝŶ�ƐĂůĞƐ͕� income and property taxes.21 To get a sense of the ƉŽƉƵůĂƟŽŶ�ƚŚĂƚ�ŝƐ�ďĞŝŶŐ�ůĞŌ�ŽƵƚ�ʹ�ĂŶĚ�ǁŚŽ�ƚŚĞ�>ĂƌĂ� ďŝůů�ŵŝŐŚƚ�ŚĞůƉ�ʹ�ǁĞ�ƚƵƌŶ�ďĞůŽǁ�ƚŽ�ĞƐƟŵĂƚĞƐ�ŽĨ�ƚŚĞ� ƐŝnjĞ�ŽĨ�ƚŚĞ�ƵŶĚŽĐƵŵĞŶƚĞĚ�ƉŽƉƵůĂƟŽŶ�ŝŶ�ƚŚĞ�'ŽůĚĞŶ� State.
WŚŽƚŽ�ďLJ��ĂůƐĞƌĂ��ŽŵŵƵŶŝĐĂƟŽŶƐ
3
Undocumented Californians:
Geography, economics, and medical
insurance coverage California has about 2.6 million undocumented ŝŵŵŝŐƌĂŶƚƐ͕�ĂďŽƵƚ�ŽŶĞͲƋƵĂƌƚĞƌ�ŽĨ�ƚŚĞ�ŶĂƟŽŶ Ɛ͛� undocumented residents.22�dŚĞLJ�ĐŽŶƐƟƚƵƚĞ�ŶĞĂƌůLJ�ϳ� ƉĞƌĐĞŶƚ�ŽĨ�ƚŚĞ�ƐƚĂƚĞ Ɛ͛�ƚŽƚĂů�ƉŽƉƵůĂƟŽŶ͕�ϴ�ƉĞƌĐĞŶƚ�ŽĨ�Ăůů� ĂĚƵůƚƐ͕�ĂŶĚ�ϵ�ƉĞƌĐĞŶƚ�ŽĨ�ƚŚĞ�ƐƚĂƚĞ Ɛ͛�ǁŽƌŬĨŽƌĐĞ͘�dŚĞLJ� ǁŽƌŬ�ŝŶ�ŝŶĚƵƐƚƌŝĞƐ�ƐƵĐŚ�ĂƐ�ĂŐƌŝĐƵůƚƵƌĞ�;ϯϳ�ƉĞƌĐĞŶƚ�ŽĨ� ƚŚĞ�ŝŶĚƵƐƚƌLJͿ͕�ĐŽŶƐƚƌƵĐƟŽŶ�;ϭϲ�ƉĞƌĐĞŶƚͿ͕�ƉĞƌƐŽŶĂů� ƐĞƌǀŝĐĞƐ�;ϭϲ�ƉĞƌĐĞŶƚͿ͕�ĂŶĚ�ƌĞƚĂŝů�;ϭϰ�ƉĞƌĐĞŶƚͿ�ʹ�ĂŶĚ� ŵŽƐƚůLJ�ŝŶ�ũŽďƐ�ƚŚĂƚ�ƚĞŶĚ�ƚŽ�ƉĂLJ�ůŽǁ�ǁĂŐĞƐ͘�/ŶĚĞĞĚ͕� ƚŚĞ�ŵĞĚŝĂŶ�ŝŶĐŽŵĞ�ĨŽƌ�ĨƵůůͲƟŵĞ�ƵŶĚŽĐƵŵĞŶƚĞĚ� ǁŽƌŬĞƌƐ�ŝƐ�ΨϮϬ͕ϬϬϬ͕�ǁŚŝĐŚ�ŝƐ�ΨϯϬ͕ϬϬϬ�ůŽǁĞƌ�ƚŚĂŶ�ƚŚĂƚ� ŽĨ�h͘^ Ͳ͘ďŽƌŶ�ǁŽƌŬĞƌƐ͕�ĂŶĚ�ƚǁŽ�ŽƵƚ�ŽĨ�ƚŚƌĞĞ�ĐŚŝůĚƌĞŶ� ;ϲϳ�ƉĞƌĐĞŶƚͿ�ǁŝƚŚ�ĂŶ�ƵŶĚŽĐƵŵĞŶƚĞĚ�ƉĂƌĞŶƚ�ůŝǀĞ� ďĞůŽǁ�ϭϱϬ�ƉĞƌĐĞŶƚ�ŽĨ�ƚŚĞ�ĨĞĚĞƌĂů�ƉŽǀĞƌƚLJ�ůĞǀĞů͘�
�ĞƐƉŝƚĞ�ŽǀĞƌĂůů�ƉŽǀĞƌƚLJ͕ �ƚŚĞ�ĂŐŐƌĞŐĂƚĞ�ĂŶŶƵĂů�ŝŶĐŽŵĞ� of undocumented Californians in the workforce totals Ψϯϭ͘ϱ�ďŝůůŝŽŶ͘�ZĞƐĞĂƌĐŚ�ƐƵŐŐĞƐƚƐ�ƚŚĂƚ�ůĞŐĂůŝnjĂƟŽŶ�ĂŶĚ� ŶĂƚƵƌĂůŝnjĂƟŽŶ�ŽĨ�ƚŚŝƐ�ƉŽƉƵůĂƟŽŶ�ĐŽƵůĚ�ŝŶĐƌĞĂƐĞ�ƚŚĞŝƌ� ŝŶĐŽŵĞ�ďLJ�Ψϰ͘ϲ�ƚŽ�Ψϳ͘ϵ�ďŝůůŝŽŶ͘Ϯϯ Already, work and ŝŶĐŽŵĞ�ƉŽƐƐŝďŝůŝƟĞƐ�ŚĂǀĞ�ŝŶĐƌĞĂƐĞĚ�ĨŽƌ�ƚŚĞ�ϯϬϬ͕ϬϬϬ�Žƌ� ŵŽƌĞ��ĂůŝĨŽƌŶŝĂŶƐ�ĞůŝŐŝďůĞ�ĨŽƌ�����͘24��ŽŵƉƌĞŚĞŶƐŝǀĞ� ŝŵŵŝŐƌĂƟŽŶ�ƌĞĨŽƌŵ�ǁŽƵůĚ�ĐŚĂŶŐĞ�ƚŚĞ�ĞĐŽŶŽŵŝĐ� ƐƚĂƚƵƐ�ŽĨ�ƚŚŝƐ�ƉŽƉƵůĂƟŽŶ�ĚƌĂŵĂƟĐĂůůLJ�ʹ�ĂůƚŚŽƵŐŚ�ĂƐ� ŶŽƚĞĚ�ĂďŽǀĞ͕�ƚŚĞ�ĐƵƌƌĞŶƚ�ƉƌŽƉŽƐĞĚ�ůĞŐŝƐůĂƟŽŶ�ǁŽƵůĚ� ƐƟůů�ĞdžĐůƵĚĞ�ƚŚŝƐ�ƉŽƉƵůĂƟŽŶ�ĨƌŽŵ�ƚŚĞ�ďĞŶĞĮƚƐ�ŽĨ�ƚŚĞ� ����ĨŽƌ�ŽǀĞƌ�Ă�ĚĞĐĂĚĞ͘
�ĞƌƚĂŝŶ�ƌĞŐŝŽŶƐ�ŚĂǀĞ�ŵŽƌĞ�ŚŝƐƚŽƌLJ�ǁŝƚŚ� undocumented Californians. The predominantly rural �ĞŶƚƌĂů�sĂůůĞLJ�ĂŶĚ�ŝŵŵŝŐƌĂŶƚ�ĞŶĐůĂǀĞƐ�ŝŶ�^ŽƵƚŚĞƌŶ� �ĂůŝĨŽƌŶŝĂ�;ŝ͘Ğ͘�ƚŚĞ�^ĂŶ�&ĞƌŶĂŶĚŽ�sĂůůĞLJ͕ �ŝŶ�ŵŝĚͲĐŝƚLJ�>ŽƐ� �ŶŐĞůĞƐ͕�ĂŶĚ�ŝŶŶĞƌͲƌŝŶŐ�ƐƵďƵƌďƐ�ŝŶ�ĂŶĚ�ĂƌŽƵŶĚ�^ĂŶƚĂ� �ŶĂ�ĂŶĚ�ƉĂƌƚƐ�ŽĨ�KƌĂŶŐĞ��ŽƵŶƚLJͿ�ŚĂǀĞ�ƚŚĞ�ŚŝŐŚĞƐƚ� ƐŚĂƌĞƐ�ŽĨ�ƚŚĞ�ĂĚƵůƚ�ƉŽƉƵůĂƟŽŶ�ǁŚŽ�ĂƌĞ� ƵŶĚŽĐƵŵĞŶƚĞĚ͘�EŽŶĞƚŚĞůĞƐƐ͕�ƵŶĚŽĐƵŵĞŶƚĞĚ� ŝŵŵŝŐƌĂŶƚƐ�ŚĂǀĞ�ƐĞƩůĞĚ�ƚŚƌŽƵŐŚŽƵƚ�ƚŚĞ�ƐƚĂƚĞ�ʹ�ĨŽƌ� ĞdžĂŵƉůĞ͕�ŶĞĂƌůLJ�ϮϬϬ͕ϬϬϬ�ůŝǀĞ�ŝŶ�ƚŚĞ�^ŝůŝĐŽŶ�sĂůůĞLJ� ƌĞŐŝŽŶ͘�EĞĂƌůLJ�ŚĂůĨ�;ϰϵ�ƉĞƌĐĞŶƚͿ�ŽĨ�ƵŶĚŽĐƵŵĞŶƚĞĚ� �ĂůŝĨŽƌŶŝĂŶƐ�ŚĂǀĞ�ůŝǀĞĚ�ŝŶ�ƚŚĞ�ƐƚĂƚĞ�ĨŽƌ�ŵŽƌĞ�ƚŚĂŶ�ϭϬ� LJĞĂƌƐ�ʹ�ŵĂŬŝŶŐ�ƚŚĞŵ�ůŽŶŐͲƐƚĂŶĚŝŶŐ�ŵĞŵďĞƌƐ�ŽĨ�ƚŚĞ� ƐƚĂƚĞ Ɛ͛�ƐŽĐŝĞƚLJ�ĂŶĚ�ĞĐŽŶŽŵLJ͘
hŶƐƵƌƉƌŝƐŝŶŐůLJ͕ �ŵĞĚŝĐĂů�ŝŶƐƵƌĂŶĐĞ�ĐŽǀĞƌĂŐĞ�ƌĂƚĞƐ�ĂƌĞ� ůŽǁ�ĂŵŽŶŐ�ƵŶĚŽĐƵŵĞŶƚĞĚ��ĂůŝĨŽƌŶŝĂŶƐ͘�ZŽƵŐŚůLJ�ŚĂůĨ� ƚŽ�ƚŚƌĞĞͲƋƵĂƌƚĞƌƐ�ŽĨ�ƵŶĚŽĐƵŵĞŶƚĞĚ��ĂůŝĨŽƌŶŝĂŶƐ�ĚŽ� ŶŽƚ�ŚĂǀĞ�ŵĞĚŝĐĂů�ŝŶƐƵƌĂŶĐĞ͘Ϯϱ�dŚŽƵŐŚ�ƚŚĞ�ĐŝƟnjĞŶ� children of undocumented parents are not excluded ĨƌŽŵ�ƚŚĞ���� Ɛ͛�ƉƌŽŐƌĂŵƐ͕�ƚŚĞŝƌ�ƌĂƚĞƐ�ŽĨ�ĐŽǀĞƌĂŐĞ�ĂŶĚ� ĂĐĐĞƐƐ�ƚŽ�ŵĞĚŝĐĂů�ƐĞƌǀŝĐĞƐ�ĨĂůů�ďĞŚŝŶĚ�ƚŚĞŝƌ�ƉĞĞƌƐ͘� Undocumented parents are less likely to access programs where they fear their legal status will be exposed.26�dŚŝƐ�ŝƐ�Ă�ƐŝŐŶŝĮĐĂŶƚ�ƉƌŽďůĞŵ�ĨŽƌ�ƚŚĞ�ŶĞdžƚ� ŐĞŶĞƌĂƟŽŶ�ŽĨ��ĂůŝĨŽƌŶŝĂŶƐ͗�dŚĞƌĞ�ĂƌĞ�ĂďŽƵƚ�ϭ͘ϱ� million children of undocumented parents, more than ϴϬ�ƉĞƌĐĞŶƚ�ŽĨ�ǁŚŽŵ�ĂƌĞ�h͘^͘�ĐŝƟnjĞŶƐ�ĂŶĚ�ƚŚƵƐ� ĞŶƟƚůĞĚ�ƚŽ�ĂĐĐĞƐƐ͘27
^Ž�ŝĨ�ǁĞ�ďƵŝůĚ�ŝƚ͕�ǁŝůů�ƚŚĞLJ�ĐŽŵĞ͍�dŚĞƌĞ�ŝƐ�ĞǀŝĚĞŶĐĞ� that undocumented immigrants might be eager to ƐŝŐŶ�ƵƉ�ŝĨ�ŵĞĚŝĐĂů�ŝŶƐƵƌĂŶĐĞ�ǁĂƐ�ŽīĞƌĞĚ͘�&Žƌ�ĞdžĂŵƉůĞ͕� ĂůƚŚŽƵŐŚ�ƚŚĞ�ƉƌŽƉŽƌƟŽŶ�ŽĨ�ƵŶĚŽĐƵŵĞŶƚĞĚ� ŝŵŵŝŐƌĂŶƚƐ�ǁŚŽ�ǁĞƌĞ�ĞůŝŐŝďůĞ�ĨŽƌ�ĞŵƉůŽLJĞƌͲƐƉŽŶƐŽƌĞĚ� medical insurance was slightly lower than the state ĂǀĞƌĂŐĞ͕�ƵŶĚŽĐƵŵĞŶƚĞĚ�>ĂƟŶŽƐ�ǁĞƌĞ�ƐŝŐŶŝĮĐĂŶƚůLJ� ŵŽƌĞ�ůŝŬĞůLJ�ƚŽ�ĞŵďƌĂĐĞ�;͞ƚĂŬĞͲƵƉ͟Ϳ�ƚŚŝƐ�ŽīĞƌ�ǁŚĞŶ� ĂǀĂŝůĂďůĞ͘28 So we know that extending insurance to ƚŚŝƐ�ƐĞƚ�ŽĨ��ĂůŝĨŽƌŶŝĂ�ƌĞƐŝĚĞŶƚƐ�ĂŶĚ�ĨĂŵŝůŝĞƐ�ǁŽƵůĚ�ĮŶĚ� Ă�ƌĞĂĚLJ�ĂŶĚ�ƐŝnjĂďůĞ�ŵĂƌŬĞƚ͘�tŚĂƚ�ƚŚĞŶ�ǁŽƵůĚ�ďĞ�ƚŚĞ� ďĞŶĞĮƚƐ�ƚŽ�ƚŚĞŵ�ĂŶĚ�ƚŽ�ŽƚŚĞƌ��ĂůŝĨŽƌŶŝĂŶƐ͍�
WŚŽƚŽ�ďLJ��LJ�EĞŝů�WĂƌĞŬŚͬ^�/h�,ĞĂůƚŚĐĂƌĞ
4
How expanded access to insurance
ZLOO�LPSURYH�KHDOWK��ÀQDQFHV��DQG�RXU� communities tŚŝůĞ�ŵĞĚŝĐĂů�ŝŶƐƵƌĂŶĐĞ�ŝƐ�ŽŶůLJ�ŽŶĞ�ŽĨ�ŵĂŶLJ� determinants of health,29 access to medical insurance ĂŶĚ�ĐĂƌĞ�ĐĂŶ�ŝŶĚĞĞĚ�ŝŵƉƌŽǀĞ�ŝŶĚŝǀŝĚƵĂů�ĂŶĚ� ƉŽƉƵůĂƟŽŶ�ŚĞĂůƚŚ͘ϯϬ�DĞĚŝĐĂŝĚ�ĂŶĚ��,/W�ŚĂƐ�ďĞĞŶ� ůŝŶŬĞĚ�ƚŽ�ďƌŽĂĚ�ƋƵĂůŝƚLJ�ŽĨ�ůŝĨĞ�ŝŵƉƌŽǀĞŵĞŶƚƐ�ĨŽƌ� ŝŵŵŝŐƌĂŶƚ�ĨĂŵŝůŝĞƐ�ďLJ�ƉƌŽǀŝĚŝŶŐ�ĂĐĐĞƐƐ�ƚŽ� ƉƌĞǀĞŶƚĂƟǀĞ�ĂŶĚ�ƉƌŝŵĂƌLJ�ĐĂƌĞ͕�ŚĞĂůƚŚ�ĞĚƵĐĂƟŽŶ͕�ĂŶĚ� ĐŽŶŶĞĐƟŶŐ�ĞůŝŐŝďůĞ�ŝŵŵŝŐƌĂŶƚƐ�ƚŽ�ƐŽĐŝĂů�ƐĞƌǀŝĐĞƐ͘ϯϭ Although access to medical insurance does not guarantee good health,ϯϮ most researchers agree that ĞdžƉĂŶĚĞĚ�ŝŶƐƵƌĂŶĐĞ�ĐŽǀĞƌĂŐĞ�ŝŶĐƌĞĂƐĞƐ�ƚŚĞ�ƵƐĞ�ĂŶĚ� ƋƵĂůŝƚLJ�ŽĨ�ŵĞĚŝĐĂů�ƐĞƌǀŝĐĞƐ͕�ĂƐ�ǁĞůů�ĂƐ�ƚŚĞ�ŚĞĂůƚŚ�ŽĨ� ƚŚŽƐĞ�ǁŝƚŚ�ŵĞĚŝĐĂů�ĐŽŶĚŝƟŽŶƐ͘ϯϯ
�ŽǀĞƌĂŐĞ�ŚĂƐ�ďĞĞŶ�ƐŚŽǁŶ�ƚŽ�ƌĞĚƵĐĞ�ƉƐLJĐŚŽůŽŐŝĐĂů� ĚŝƐƚƌĞƐƐ͕�ƚŽ�ŝŶĐƌĞĂƐĞ�ƵƐĞ�ŽĨ�ŵĞĚŝĐĂů�ƐĞƌǀŝĐĞƐ͕�ƚŽ� ĞƐƚĂďůŝƐŚ�ƵƐƵĂů�ƐŽƵƌĐĞƐ�ŽĨ�ĐĂƌĞ͕�ƚŽ�ŝŵƉƌŽǀĞ�ĐŽŶƟŶƵŝƚLJ� ŽĨ�ĐĂƌĞ͕�ĂŶĚ�Ăůů�ŽĨ�ƚŚĞƐĞ�ĞīĞĐƚƐ�ŽĨ�ĞdžƉĂŶĚĞĚ�ĐŽǀĞƌĂŐĞ� ĂƌĞ�ĂƌŐƵĂďůLJ�ĂŶĚ�ƉŽƐŝƟǀĞůLJ�ĂƐƐŽĐŝĂƚĞĚ�ǁŝƚŚ�ůŽŶŐͲƚĞƌŵ� ŝŶĚŝǀŝĚƵĂů�ŚĞĂůƚŚ͘�ϯϰ For example, mortality is higher
for the uninsured than the insured when they are ŚŽƐƉŝƚĂůŝnjĞĚ͘ϯϱ�/Ŷ�,ĂǁĂŝŝ�ĂŶĚ�DĂƐƐĂĐŚƵƐĞƩƐ͕�ǁŚĞƌĞ� ƚŚĞƌĞ�ŝƐ�ŶĞĂƌ�ƵŶŝǀĞƌƐĂů�ŝŶƐƵƌĂŶĐĞ�ĐŽǀĞƌĂŐĞ͕�ƌĞƐĞĂƌĐŚ�ŝƐ� showing lower mortality rates.ϯϲ
/Ŷ�ĂĚĚŝƟŽŶ͕�ƌĞƐĞĂƌĐŚ�ƐŚŽǁƐ�ƚŚĂƚ�ŵĞĚŝĐĂů�ŝŶƐƵƌĂŶĐĞ� ƉƌĞǀĞŶƚƐ�ŵĂũŽƌ�ĮŶĂŶĐŝĂů�ĐƌŝƐŝƐ�ĨŽƌ�ŝŶĚŝǀŝĚƵĂůƐ�ĂŶĚ� families.ϯϳ ��ŶĂƟŽŶĂů�ƐƚƵĚLJ�ĨŽƵŶĚ�ƚŚĂƚ�ϲϮ�ƉĞƌĐĞŶƚ�ŽĨ� Ăůů�ďĂŶŬƌƵƉƚĐŝĞƐ�ŝŶ�ϮϬϬϳ�ŝŶǀŽůǀĞĚ�ŵĞĚŝĐĂů�ĚĞďƚ͘ϯϴ The ƌĞƐĞĂƌĐŚ�ĐŽŶĮƌŵƐ�ǁŚĂƚ�ƵŶĚŽĐƵŵĞŶƚĞĚ�ŝŵŵŝŐƌĂŶƚƐ� ĞdžƉĞƌŝĞŶĐĞ͗�ŝŶ�Ă�ϮϬϭϯ�ƉŽůů�ŽĨ��ĂůŝĨŽƌŶŝĂŶƐ͕�ϴϮ�ƉĞƌĐĞŶƚ� ŽĨ�ƵŶĚŽĐƵŵĞŶƚĞĚ�ƌĞƐƉŽŶĚĞŶƚƐ�ƌĞƉŽƌƚĞĚ�ǁĂŶƟŶŐ� health insurance and 79 percent indicated that the ƉƌŝŵĂƌLJ�ƌĞĂƐŽŶ�ǁĂƐ�ƚŽ�ƉƌĞǀĞŶƚ�ĮŶĂŶĐŝĂů�ĐƌŝƐĞƐ�ŝŶ�ƚŚĞ� case of a medical emergency.ϯϵ Indeed, the uninsured ƉĂLJ�ĨŽƌ�ŵŽƌĞ�ƚŚĂŶ�ŽŶĞͲƚŚŝƌĚ�ŽĨ�ƚŚĞŝƌ�ĐĂƌĞ�ĨƌŽŵ� ŽƵƚͲŽĨͲƉŽĐŬĞƚ�ĂŶĚ�ĂƌĞ�ŽŌĞŶ�ĐŚĂƌŐĞĚ�ŚŝŐŚĞƌ�ĂŵŽƵŶƚƐ� than the insured.40�>ĞĂǀŝŶŐ�ƚŚĞ�ƵŶĚŽĐƵŵĞŶƚĞĚ� ǁŝƚŚŽƵƚ�ŝŶƐƵƌĂŶĐĞ�ĐŽǀĞƌĂŐĞ�ůĞĂǀĞƐ�Ă�ůĂƌŐĞ�ƐŚĂƌĞ�ŽĨ� ƚŚĞ�ƐƚĂƚĞ Ɛ͛�ƌĞƐŝĚĞŶƚƐ�ʹ�ĂŐĂŝŶ͕�ϳ�ƉĞƌĐĞŶƚ�ŽĨ�ƚŚĞ�ƐƚĂƚĞ�ŝƐ� ƵŶĚŽĐƵŵĞŶƚĞĚ�ʹ�ǀƵůŶĞƌĂďůĞ�ƚŽ�ĞĐŽŶŽŵŝĐ�ŚĂƌĚƐŚŝƉ͘41 �ĚĚƌĞƐƐŝŶŐ�ƚŚĞ�ƐĐŽƉĞ�ŽĨ�ďĞŶĞĮƚƐ͕�ĐŽƐƚͲƐŚĂƌŝŶŐ͕�ĂŶĚ� ŝŶĐůƵƐŝŽŶ�ŽĨ�ůŽǁͲŝŶĐŽŵĞ�ƉŽƉƵůĂƟŽŶƐ�ĂƌĞ�ĐƌŝƟĐĂů�ƚŽ� ĚĞĐƌĞĂƐŝŶŐ�ƌĂƚĞƐ�ŽĨ�ĮŶĂŶĐŝĂů�ĐĂƚĂƐƚƌŽƉŚĞ͘42
Finally, expanded access will be good for the state ĂŶĚ�ŝŶƐƵƌĂŶĐĞ�ƉŽŽůƐ͘�dŚĞ�EĂƟŽŶĂů��ĐĂĚĞŵLJ�ŽĨ� ^ĐŝĞŶĐĞƐ͛�/ŶƐƟƚƵƚĞ�ŽĨ�DĞĚŝĐŝŶĞ�ŚĂƐ�ĂƌŐƵĞĚ�ƚŚĂƚ�ŝƚ�ŝƐ� ŶŽƚ�ĐŽƐƚͲĞīĞĐƟǀĞ�ƚŽ�ĚĞŶLJ�ŝŶĚŝǀŝĚƵĂůƐ�ŝŶƐƵƌĂŶĐĞ�ʹ� ǁŚĞƚŚĞƌ�ĐŽŶƐŝĚĞƌŝŶŐ�ůĂďŽƌ�ƉƌŽĚƵĐƟǀŝƚLJ͕ �ŐŽǀĞƌŶŵĞŶƚ� ƐŽĐŝĂů�ƐƉĞŶĚŝŶŐ͕�Žƌ�ƚŚĞ�ŚĞĂůƚŚ�ĂŶĚ�ĮŶĂŶĐĞƐ�ŽĨ�ƚŚĞ� ƵŶŝŶƐƵƌĞĚ�ƚŚĞŵƐĞůǀĞƐ͘ϰϯ Insuring all Californians will ƌĞĚƵĐĞ�ĨƵƚƵƌĞ�ĐŽƐƚůLJ�ƉƵďůŝĐ�ĞŵĞƌŐĞŶĐLJ�ƌŽŽŵ�ǀŝƐŝƚƐ44 ʹ�ƚŚĞ�ĐŽƐƚƐ�ŽĨ�ǁŚŝĐŚ�ĂƌĞ�ƉĂƐƐĞĚ�ŽŶ�ƚŽ�ƚŚŽƐĞ�ƉĂLJŝŶŐ� into insurance pools.ϰϱ The success of medical insurance programs depends on risk sharing, where a ƌĞůĂƟǀĞůLJ�ůĂƌŐĞ�ŶƵŵďĞƌ�ŽĨ�ůŽǁͲƌŝƐŬ�ƉĞŽƉůĞ�ƉĂLJ�ƚŽ�ŚĞůƉ� ƐƉƌĞĂĚ�ƚŚĞ�ĐŽƐƚƐ�ŽĨ�Ă�ƐŵĂůůĞƌ�ŶƵŵďĞƌ�ŽĨ�ĞdžƉĞŶƐŝǀĞ� cases.46 Undocumented Californians are younger and ŚĞĂůƚŚŝĞƌ�ƚŚĂŶ�ƚŚĞ�ĂǀĞƌĂŐĞ�ƉŽƉƵůĂƟŽŶ47 and when they do use medical care, their costs are lower than U.S. residents.48
WŚŽƚŽ�ďLJ�^ƚĞǀĞ�ZŚŽĚĞƐ
5
Making it real: Effectively reaching
undocumented Californians ^Ž�ǁŚĂƚ�ĚŽ�ǁĞ�ŬŶŽǁ�ĂďŽƵƚ�ƌĞĂĐŚŝŶŐ�ƚŚŝƐ�ƉŽƉƵůĂƟŽŶ� from past experiences? In the early 2000s, the �ŚŝůĚƌĞŶ Ɛ͛�,ĞĂůƚŚ�/ŶŝƟĂƟǀĞƐ�;�,/ƐͿ�ƐƚĂƌƚĞĚ�ŝŶ� California, one program of a few intended to ŵĞĚŝĐĂůůLJ�ŝŶƐƵƌĞ�ůŽǁͲŝŶĐŽŵĞ�ŝŶĚŝǀŝĚƵĂůƐ�ǁŚŽ�ǁŽƵůĚ� ŶŽƚ�ŽƚŚĞƌǁŝƐĞ�ƋƵĂůŝĨLJ�ĨŽƌ�ĐŽǀĞƌĂŐĞ͘�&ŝŶĂŶĐĞĚ�ƚŚƌŽƵŐŚ� ĨŽƵŶĚĂƟŽŶ�ŐƌĂŶƚƐ͕�ƉƌŝǀĂƚĞ�ĚŽŶĂƟŽŶƐ͕�ĂŶĚ�ƐŽŵĞ� ĐŽƵŶƚLJ�ĨƵŶĚŝŶŐ͕��,/Ɛ�ƉƌŽǀŝĚĞĚ�ĐŽŵƉƌĞŚĞŶƐŝǀĞ� ĐŽǀĞƌĂŐĞ�ǁŝƚŚ�ǀĞƌLJ�ůŽǁ�ƉƌĞŵŝƵŵƐ�ĨŽƌ�ŵŽƌĞ�ƚŚĂŶ� ϴϱ͕ϬϬϬ�ĐŚŝůĚƌĞŶ�ŝŶ�Ϯϲ�ĐŽƵŶƟĞƐ�Ăƚ�ƚŚĞ�ƉƌŽŐƌĂŵ Ɛ͛� peak.49��Ŷ�ĞǀĂůƵĂƟŽŶ�ŽĨ�ƚŚĞ�ƉƌŽŐƌĂŵ�ĨŽƵŶĚ�ƚŚĂƚ� ĐŽŵƉĂƌĞĚ�ƚŽ�ƚŚŽƐĞ�ŽŶ�ƚŚĞ�ǁĂŝƚ�ůŝƐƚ�ĨŽƌ�ĐŽǀĞƌĂŐĞ�;Ă� ŐŽŽĚ�ĐŽŶƚƌŽů�ŐƌŽƵƉ�ƚŽ�ŝƐŽůĂƚĞ�ƚŚĞ�ŝŵƉĂĐƚƐͿ͕�ĞŶƌŽůůĞĞƐ� ǁĞƌĞ�ŵŽƌĞ�ůŝŬĞůLJ�ƚŽ�ŚĂǀĞ�Ă�ƵƐƵĂů�ƐŽƵƌĐĞ�ŽĨ�ĐĂƌĞ͘ϱϬ The ƉƌŽŐƌĂŵ Ɛ͛�ŵĂũŽƌ�ďĂƌƌŝĞƌ�ǁĂƐ�ůĂĐŬ�ŽĨ�ƐƚĂƚĞ�ĨƵŶĚŝŶŐ�ƚŽ� ĐůŽƐĞ�ƚŚĞ�ŐĂƉ�ďĞƚǁĞĞŶ�ĂǀĂŝůĂďŝůŝƚLJ�ĂŶĚ�ĚĞŵĂŶĚ͘ϱϭ
To make any medical insurance program work, ƚŚŽƵŐŚ͕�ŝƚ�ŵƵƐƚ�ďĞ�ƚĂŬĞŶͲƵƉ�ďLJ�ƌĞƐŝĚĞŶƚƐ�;ƐĞĞ�ƚŚĞ�ůŽǁ� ĞƐƟŵĂƚĞĚ�ƌĂƚĞƐ�ŽĨ�ŵĞĚŝĐĂů�ŝŶƐƵƌĂŶĐĞ�ŵĞŶƟŽŶĞĚ� ĞĂƌůŝĞƌͿ͘�/ŵŵŝŐƌĂŶƚƐ�ĐĂŶ�ďĞ�ĚŝƐƐƵĂĚĞĚ�ĨƌŽŵ�ƐĞĞŬŝŶŐ� ŝŶƐƵƌĂŶĐĞ�ŝĨ�ƐLJƐƚĞŵƐ�ĂƌĞ�ƚŽŽ�ďƵƌĞĂƵĐƌĂƟĐ͕�ŶŽƚ�
ĐƵůƚƵƌĂůůLJ�ƐĞŶƐŝƟǀĞ�Žƌ�ůŝŶŐƵŝƐƟĐĂůůLJ�ĂĐĐĞƐƐŝďůĞ͕�ĂŶĚ�ŶŽƚ� ƚƵŶĞĚ�ŝŶƚŽ�ƚŚĞ�ƌĞĂůŝƟĞƐ�ŽĨ�Ă�ƉŽƉƵůĂƟŽŶ�ǁŝƚŚ�ƚŽŽ�ŵĂŶLJ� ũŽďƐ͕�ƚŽŽ�ůŝƩůĞ�ƟŵĞ͕�ĂŶĚ�ŚŝŐŚ�ƵƐĞ�ŽĨ�ƉƵďůŝĐ�ƚƌĂŶƐŝƚ͘ϱϮ Another important factor is fear: immigrants worry ƚŚĂƚ�ƚŚĞLJ�;Žƌ�ƚŚĞŝƌ�ƌĞůĂƟǀĞƐ�Žƌ�ĨƌŝĞŶĚƐͿ�ǁŝůů�ŐĞƚ�ĐĂƵŐŚƚ� ƵƉ�ŝŶ�Ă�ƐLJƐƚĞŵ�ƐĞĞŵŝŶŐůLJ�ĨŽĐƵƐĞĚ�ŽŶ�ĚĞƉŽƌƚĂƟŽŶƐ͘ϱϯ /Ŷ�Ă�ƐƚƵĚLJ�ŽĨ�����ͲĞůŝŐŝďůĞ�ŝŵŵŝŐƌĂŶƚƐ͕�ĂĐƚƵĂů�ĂŶĚ� ƉĞƌĐĞŝǀĞĚ�ĐŽƐƚ�ǁĂƐ�ĂůƐŽ�ƐĞĞŶ�ĂƐ�Ă�ĚĞƚĞƌƌĞŶƚ͘ϱϰ
�ƉĂƌƚ�ĨƌŽŵ�ŵĂƩĞƌƐ�ŽĨ�ŝŶƐƵƌĂŶĐĞ�ƚĂŬĞͲƵƉ͕�ĂĐĐĞƐƐŝŶŐ� ĐĂƌĞ�ŚĂƐ�ƉŽůŝĐLJ�ĚĞƐŝŐŶ�ŝŵƉůŝĐĂƟŽŶƐ͘���ƐƚƵĚLJ�ĚŽŶĞ�ĨŽƌ� ƚŚĞ��ĞƉĂƌƚŵĞŶƚ�ŽĨ�,ĞĂůƚŚ�ĂŶĚ�,ƵŵĂŶ�^ĞƌǀŝĐĞƐ� recommends that agencies establish partnerships ǁŝƚŚ�ĐŽŵŵƵŶŝƚLJͲďĂƐĞĚ�ŽƌŐĂŶŝnjĂƟŽŶƐ�;��KƐͿ�ƚŽ�ŚĞůƉ� eligible immigrant families feel more comfortable in ĂĐĐĞƐƐŝŶŐ�ƐĞƌǀŝĐĞƐ͘ϱϱ Undocumented immigrants rely ŚĞĂǀŝůLJ�ŽŶ�ĐŽŵŵƵŶŝƚLJͲďĂƐĞĚ�ŚĞĂůƚŚ�ĐůŝŶŝĐƐϱϲ and ƐƚƌŽŶŐůLJ�ĨĂǀŽƌ�ƚŚĞƐĞ�ŽǀĞƌ�ŽƚŚĞƌ�ƉŽƐƐŝďůĞ�ƉůĂĐĞƐ�ŽĨ� care,ϱϳ except in emergencies.ϱϴ Training for health ĐĂƌĞ�ĂŶĚ�ĞŶƌŽůůŵĞŶƚ�ƐƚĂī�ŽŶ�ǁŚŽ�ŝƐ�ĞůŝŐŝďůĞ�ĂŶĚ� outreach to those groups will help close the gap.ϱϵ
Political considerations �ĂůŝĨŽƌŶŝĂŶƐ�ĂƌĞ�ŐĞŶĞƌĂůůLJ�ƋƵŝƚĞ�ƐƵƉƉŽƌƟǀĞ�ŽĨ�ĐŚĂŶŐĞƐ� ŝŶ�ŝŵŵŝŐƌĂƟŽŶ�ůĂǁ�ƚŚĂƚ�ŵŝŐŚƚ�ŝŵƉƌŽǀĞ�ƚŚĞ�ĐŽŶĚŝƟŽŶƐ� of undocumented immigrants. For example, 86 ƉĞƌĐĞŶƚ�ŽĨ��ĂůŝĨŽƌŶŝĂ�ĂĚƵůƚƐ�ĨĂǀŽƌ�Ă�ƉĂƚŚ�ƚŽ�ĐŝƟnjĞŶƐŚŝƉ� ĨŽƌ�͞ŝůůĞŐĂů�ŝŵŵŝŐƌĂŶƚƐ͟�ǁŚŽ�ŵĞĞƚ�ĐĞƌƚĂŝŶ� ĐŚĂƌĂĐƚĞƌŝƐƟĐƐ͕�ƐƵĐŚ�ĂƐ�ƉĂLJŝŶŐ�ĮŶĞƐ�ĂŶĚ�ďĂĐŬ�ƚĂdžĞƐ� ĂŶĚ�ůĞĂƌŶŝŶŐ��ŶŐůŝƐŚ͘�dŚĞ�ƐƵƉƉŽƌƚ�ŝƐ�ďŝͲƉĂƌƟƐĂŶ͗�ǁŚŝůĞ� ŝƚ�ŝƐ�ƚƌƵĞ�ƚŚĂƚ�ϵϬ�ƉĞƌĐĞŶƚ�ŽĨ�ƐĞůĨͲŝĚĞŶƟĮĞĚ��ĞŵŽĐƌĂƚƐ� ĨĂǀŽƌ�Ă�ƉĂƚŚ�ƚŽ�ĐŝƟnjĞŶƐŚŝƉ͕�ƐŽ�ĚŽ�ϳϮ�ƉĞƌĐĞŶƚ�ŽĨ� ƐĞůĨͲŝĚĞŶƟĮĞĚ�ZĞƉƵďůŝĐĂŶƐ͘60
DŽƌĞŽǀĞƌ͕ �ϱϴ�ƉĞƌĐĞŶƚ�ŽĨ��ĂůŝĨŽƌŶŝĂ�ƌĞƐŝĚĞŶƚƐ�ĂŶĚ�ϱϱ� ƉĞƌĐĞŶƚ�ŽĨ�ƌĞŐŝƐƚĞƌĞĚ�ǀŽƚĞƌƐ�ƐƵƉƉŽƌƚ�ƚŚĞ�ƐƚĂƚĞ� ŐŽǀĞƌŶŵĞŶƚ�ŵĂŬŝŶŐ�ŝƚƐ�ŽǁŶ�ƉŽůŝĐŝĞƐͶƐĞƉĂƌĂƚĞ�ĨƌŽŵ� ƚŚĞ�ĨĞĚĞƌĂů�ŐŽǀĞƌŶŵĞŶƚͶƚŽ�ĂĚĚƌĞƐƐ�ƚŚĞ�ŶĞĞĚƐ�ŽĨ� undocumented immigrants.61�^ƵĐŚ�ƐƚĂƚĞͲůĞǀĞů�ĞīŽƌƚƐ� ŚĂǀĞ�ďĞĐŽŵĞ�ŝŶĐƌĞĂƐŝŶŐůLJ�ƉŽƉƵůĂƌ�ŐŝǀĞŶ�ƚŚĞ�
ƐƚĂůĞŵĂƚĞ�ŝŶ�tĂƐŚŝŶŐƚŽŶ�ŽŶ�ĐŽŵƉƌĞŚĞŶƐŝǀĞ�ƌĞĨŽƌŵ� ĂŶĚ�ƚŚĞ�>ĂƌĂ�ďŝůů͕�ƚŚĞ�͞,ĞĂůƚŚ�ĨŽƌ��ůů��Đƚ͕͟ �ŝƐ�ŽŶĞ�ƐƵĐŚ� ĞīŽƌƚ͘
tŚŝůĞ�ǁĞ�ŚĂǀĞ�ƐĞĞŶ�ŶŽ�ƐƉĞĐŝĮĐ�ƉŽůůŝŶŐ�ŽŶ�ƚŚĞ�ŚĞĂůƚŚ� ƐŝĚĞ͕�ƚŚŝƐ�ŵĂLJ�ƐĞĞŵ�ƚŽ�ďĞ�Ă�ŚĂƌĚĞƌ�ůŝŌ�ƚŚĂŶ�ƐŝŵƉůLJ� ƐƵƉƉŽƌƟŶŐ�Ă�ƉĂƚŚ�ƚŽ�ĐŝƟnjĞŶƐŚŝƉ͘�KŶ�ƚŚĞ�ŽƚŚĞƌ�ŚĂŶĚ͕� ŶĂƟŽŶǁŝĚĞ͕�ϲϯ�ƉĞƌĐĞŶƚ�ŽĨ��ŵĞƌŝĐĂŶƐ�ďĞůŝĞǀĞ� ƵŶĚŽĐƵŵĞŶƚĞĚ�ŝŵŵŝŐƌĂŶƚƐ�ǁŚŽ�ǁŽƵůĚ�ĂĐŚŝĞǀĞ� ƉƌŽǀŝƐŝŽŶĂů�ƐƚĂƚƵƐ�ƵŶĚĞƌ�ĐŽŵƉƌĞŚĞŶƐŝǀĞ�ƌĞĨŽƌŵ� ƐŚŽƵůĚ�ŚĂǀĞ�ĂĐĐĞƐƐ�ƚŽ�DĞĚŝĐĂŝĚ�ĂŶĚ�ϱϵ�ƉĞƌĐĞŶƚ� ďĞůŝĞǀĞ�ƚŚĞLJ�ƐŚŽƵůĚ�ŚĂǀĞ�ĂĐĐĞƐƐ�ƚŽ�ŝŶƐƵƌĂŶĐĞ� subsidies under the ACA.62�^ƚƌŝŬŝŶŐůLJ͕ �ƚŚĞ�ŝŵŵŝŐƌĂƟŽŶ� ƌĞĨŽƌŵ�ďŝůů�ƉĂƐƐĞĚ�ďLJ�ƚŚĞ�^ĞŶĂƚĞ�ŝŶ�:ƵŶĞ�ϮϬϭϯ�ŝŐŶŽƌĞĚ� ƉƵďůŝĐ�ŽƉŝŶŝŽŶ�ŽŶ�ƚŚĞ�ŵĂƩĞƌ�ĂŶĚ�ǁƌŽƚĞ�ƚŚŽƐĞ� ƉŽƉƵůĂƟŽŶƐ�ŽƵƚ͘
6
�Ɛ�ǁĞ�ŚĂǀĞ�ĂƌŐƵĞĚ�ĂďŽǀĞ͕�ǁƌŝƟŶŐ�ŽƵƚ�ƵŶĚŽĐƵŵĞŶƚĞĚ� �ĂůŝĨŽƌŶŝĂŶƐ�ŝƐ�ƉƌŽďůĞŵĂƟĐ�ĨƌŽŵ�ƚŚĞ�ƉŽŝŶƚ�ŽĨ�ǀŝĞǁ�ŽĨ� ŽǀĞƌĂůů�ƉƵďůŝĐ�ŚĞĂůƚŚ�ĂŶĚ�ǁĞůůͲďĞŝŶŐ͘�/ƚ�ŚƵƌƚƐ�ƵƐ�ŶŽǁ͕� it hurts us in the future, and it makes us less prepared ĨŽƌ�ǁŚĂƚ�ǁĞ�ƚŚŝŶŬ�ŝƐ�ŝŶĞǀŝƚĂďůĞ͗�Ă�ĨƵƚƵƌĞ�ŝŵŵŝŐƌĂƟŽŶ� ƌĞĨŽƌŵ�ƚŚĂƚ�ǁŝůů�ĮŶĂůůLJ�ƌĞŇĞĐƚ�ƚŚĞ�ĐŽŵŵŽŶ�ƐĞŶƐĞ�ĂŶĚ� open hearts of the American people.
Such a reform is broadly popular and extending health care to all could, with proper leadership and framing, pass the test of public opinion as well. DŽƌĞŽǀĞƌ͕ �ǁŚŝůĞ�ŽƉŝŶŝŽŶ�ŵĂƩĞƌƐ�ŝŶ�ƉŽůŝƟĐƐ͕�ǁĞ�ĂůƐŽ� ƵƌŐĞ�ĚĞĐŝƐŝŽŶͲŵĂŬĞƌƐ�ƚŽ�ĐŽŶƐŝĚĞƌ�ƚŚĞ�ŚƵŵĂŶ�ĐŽƐƚ�ŽĨ� ŝŶĂĐƟŽŶ͘�DĂŶLJ�ƵŶĚŽĐƵŵĞŶƚĞĚ�ƌĞƐŝĚĞŶƚƐ�ĐĂŶŶŽƚ� ĂĐĐĞƐƐ�Žƌ�ĂīŽƌĚ�ŵĞĚŝĐĂů�ĐĂƌĞ�ƐŽ�ƉƌĞƐƐŝŶŐ�ŵĞĚŝĐĂů� needs are going unaddressed.ϲϯ They remain under ƚŚĞ�ƚŚƌĞĂƚ�ŽĨ�ƐŝĐŬŶĞƐƐ�ĂŶĚ�ĮŶĂŶĐŝĂů�ĐŽůůĂƉƐĞ͘�,ĞĂůƚŚ� ŝŶƐƵƌĂŶĐĞ�ĂŶĚ�ĂĐĐĞƐƐ�ƚŽ�ĐĂƌĞ�ŚĂǀĞ�ďĞĐŽŵĞ�ƐŝŐŶŝĮĐĂŶƚ� ĨĂĐƚŽƌƐ�ŝŶ�ǁĞůůͲďĞŝŶŐ�ŝŶ�ŽƵƌ�ŶĂƟŽŶ͘��ŶĚ�ǁŚŝůĞ�ƚŚĂƚ� ƐŚŽƵůĚ�ďĞ�ƌĞĂƐŽŶ�ĞŶŽƵŐŚ͕��ĂůŝĨŽƌŶŝĂ Ɛ͛�ƵŶĚŽĐƵŵĞŶƚĞĚ�
ĂƌĞ�ǁŽǀĞŶ�ƚŚƌŽƵŐŚŽƵƚ�ŽƵƌ�ĐŽŵŵƵŶŝƟĞƐ�ĂŶĚ�ĚƌŝǀĞ� ŝŵƉŽƌƚĂŶƚ�ƉŽƌƟŽŶƐ�ŽĨ�ŽƵƌ�ĞĐŽŶŽŵLJ͘
California has historically been a place of opportunity and a place where new ideas are tested; a place ǁŚĞƌĞ�ŝŶŶŽǀĂƟŽŶ�ĂŶĚ�ŝŶĐůƵƐŝŽŶ�ĐŽŵĞ�ƚŽŐĞƚŚĞƌ�ƚŽ� ƐŚŽǁ�ƚŚĞ�ŶĂƟŽŶ�Ă�ďƌŝŐŚƚĞƌ�ĨƵƚƵƌĞ͘�/ƚ�ǁŝůů�ƚĂŬĞ� ĐŽƵƌĂŐĞŽƵƐ�ĂĐƟŽŶ�ŽŶ�ƚŚĞ�ƉĂƌƚ�ŽĨ�ŵĂŶLJ�ƚŽ�ƚƌƵůLJ�ŽīĞƌ� the stability of health insurance access for all, but it ǁŝůů�ŵŽǀĞ�ƵƐ�ĨŽƌǁĂƌĚ͕�ƚŽŐĞƚŚĞƌ͘ �DŽƌĞŽǀĞƌ͕ �ĂƐ�ǁŝƚŚ�ŽƵƌ� ĚĞŵŽŐƌĂƉŚŝĐƐ͕��ĂůŝĨŽƌŶŝĂ�ŝƐ�ŽŌĞŶ�͞�ŵĞƌŝĐĂ�ĨĂƐƚ� ĨŽƌǁĂƌĚ͟�ʹ�ǁŚĂƚ�ŚĂƉƉĞŶƐ�ŚĞƌĞ�ĚŽĞƐ�ŶŽƚ�ƐƚĂLJ�ŚĞƌĞ�ĂŶĚ� ƐŽ�ƚŚĞ�ůĞƐƐŽŶƐ�ǁĞ�ǁŝůů�ůĞĂƌŶ�ĨƌŽŵ�ƚŚĞƐĞ�ĞīŽƌƚƐ�ǁŝůů� also be important for the country as a whole. Another ;ĂŶĚ�ŚĞĂůƚŚŝĞƌͿ�ǁŽƌůĚ�ŝƐ�ƉŽƐƐŝďůĞ�ďƵƚ�ŽŶůLJ�ŝĨ�ǁĞ� ƌĞĐŽŐŶŝnjĞ�ƚŚĂƚ�ŝŶĐůƵĚŝŶŐ�ĞǀĞƌLJŽŶĞ�ǁŝůů�ƵůƟŵĂƚĞůLJ� ďĞŶĞĮƚ�ĞǀĞƌLJŽŶĞ͘
WŚŽƚŽ�ďLJ��ĂůŝĨŽƌŶŝĂ�/ŵŵŝŐƌĂŶƚ�WŽůŝĐLJ��ĞŶƚĞƌ�;�/W�Ϳ͘
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ϵϱϬ�t͘�:ĞīĞƌƐŽŶ��ůǀĚ͕͘�:�&�ϭϬϮ >ŽƐ��ŶŐĞůĞƐ͕����ϵϬϬϴϵͲϭϮϵϭ
tĞď͗�ŚƩƉ͗ͬͬĐƐŝŝ͘ƵƐĐ͘ĞĚƵ
Email: [email protected]
WŚŽŶĞ͗�Ϯϭϯ͘ϴϮϭ͘ϭϯϮϱ
&Ădž͗�Ϯϭϯ͘ϳϰϬ͘ϱϲϴϬ
This report was funded by The California Endowment.