SACRAMENTO, California—As 2024 came to a close, Mar Velez and her team of outreach workers were fanned out across California, signing undocumented immigrants up for Medi-Cal, the state’s health insurance program. They made a compelling, straight-forward offer: It’s free, no questions asked.
A year later, that pitch was much more complicated – and the stakes far higher.
They were, for one, racing against the clock to enroll people before January 1, when a cost-saving freeze on new enrollments imposed by the state took hold. But, at the same time, there was a new risk that cames with enrolling as the Trump administration seeks to use personal information collected by states to find and deport immigrants who are in the country illegally.
“We live in a new reality,” said Velez, the director of policy at the Latino Coalition For A Healthy California, a group that advocates for health policy in Sacramento and funds community health workers on the ground. “The things we could rely on before aren’t there anymore.”
California first offered Medi-Cal to some undocumented children in 2016 and expanded the program gradually until 2024, when immigrants of all ages who met income requirements were able to enroll regardless of immigration status.
That final expansion blew up the state’s budget, costing almost $3 billion more than anticipated. Gov. Gavin Newsom and Democratic lawmakers scaled back the ambitious program this year with the enrollment freeze and $30 monthly premiums for undocumented immigrants already in the program that start in 2027, which together are expected to reduce costs by about $78 million in the first year and up to $3.3 billion by 2029.
The fallout from those moves will be significant as the freeze and premiums are projected to cause the number of people enrolled in Medi-Cal to fall by 1.5 million by 2030.
The Trump Administration has injected uncertainty and risk into the equation with its crackdown on illegal immigration. To help identify and deport undocumented immigrants, the administration wants ICE agents to have access to information California and other Democratic-led states collect on people enrolled in their health insurance programs. After it was revealed in June that some data had been shared, the states sued and a judge temporarily barred the government from continuing with the practice,
Trump officials made clear in November that they intend to resume the data sharing as soon as possible and earlier this month a federal judge indicated he may allow them to do so.
The fight over the legality of the data sharing won’t be resolved until after the start of the new year, leaving undocumented immigrants in California with a stark choice to forgo free health care or roll the dice that signing up for Medi-Cal won’t bring ICE agents to their door.
Some people have moved so they’re no longer at the address they used to register for Medi-Cal, Velez said.
Instead of cheerleading for enrollment, the Spanish-speaking workers Velez has dispatched around the state, who are called promotoras de salud, say they’re being more neutral. They provide information about registration deadlines, what personal information is needed to enroll, and how that data could be shared.
“These are your rights, and these are the risks,” Lisbet Ruiz, a promotora in San Diego said she tells her clients. “But at the end of the day, we don’t tell them to make a decision.”
The stakes are high, and promotoras are keeping their opinions to themselves on whether or not it’s too risky to enroll. The best they can do is empower people with information, Ruiz said.
There’s also fear among Ruiz’s clients over the “public charge rule," a proposal from the Trump Administration to consider the amount of public services a person has used when evaluating their application for residency or citizenship. Though the rule isn’t yet in effect, the fear of it one day coming to pass is keeping people from enrolling in Medi-Cal, Ruiz said.
Ruiz recalled a woman who was in the U.S. on a visa issued to people fleeing domestic violence who was afraid to get services for herself or her autistic son. Despite Ruiz’s assurances that taking food benefits or Medi-Cal for her and her autistic son was unlikely to hurt her chances of being able to remain in the country, the woman refused.
“She still made the decision not to get into it because of the risk,” Ruiz said.
Despite the turmoil, some counties and nonprofits are aggressively pushing enrollment before the freeze sets in. In Santa Clara, the county earmarked $2.5 million for an outreach and enrollment campaign, especially for the undocumented population.
“We don’t want [undocumented] people…to forever lose their access to health care,” said Nikki Fortunado Bas, a county supervisor.
Community health workers in San Jose are working with the county on outreach. Darcie Green, executive director of Latinas Contra Cancer, a health advocacy group in the county, said there’s an “immediate need” to get people re-enrolled or enrolled for the first time before they lose eligibility.
Green said she’s trying to quell fears while still being realistic with people and encouraging them to get care.
“These are conversations we’re going to continue having, but the directive we have right now from our county and our clinic system is that we’re still encouraging people to enroll,” she said.
And many are balancing the threat of immigration enforcement against their need for prenatal care, prescription medications or other medical services this year. Karem Martinez is the enrollment lead at East Valley Community Health Center, a clinic that serves Pomona, Covina, West Covina and El Monte.
At her clinic, people are less afraid of immigration enforcement now than earlier this year when ICE had a major presence in Los Angeles. She said people are taking the looming enrollment freeze seriously. Some of her clients have come in with pay stubs every month trying to see if their income is low enough to qualify.
Patricia Lopez, the manager of the health insurance program at the Venice Family Clinic is seeing similar decisions play out in real time.
A woman recently came to Lopez after allowing her Medi-Cal coverage to lapse.
Worried about immigration enforcement, the woman had decided to go without health insurance but then sought Lopez’s help when she realized she couldn’t afford her medication.
Lopez said she reminded the woman that in the new year she would be shut out from re-enrolling forever if she let her coverage lapse again.
Lopez said that in previous years she typically had 30 or 40 people coming in for help with insurance during each three-hour walk in window, and that these days the number is in the teens. Clinics don’t collect information on a client’s immigration status, so there’s no way of knowing how much of the decline is among citizens or the undocumented population.
Minisinformation and misunderstanding is common, making it even harder to get people enrolled, advocates said. People think the freeze and premiums have already started, or that come January everyone will get kicked off the program.
For now, Velez said she’s trying to get the message out that there’s still time to sign up, but she’s being realistic about the risks associated with Medi-Cal.
“It’s hard to deliver that kind of information to communities,” Velez said. “But if we’re not doing that, we aren’t doing our jobs.”
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