But not in California, where there are an estimated 2.6 million illegal immigrants. Here, public health officials, elected representatives and advocacy groups are going in the opposite direction, trying to cobble together ways to provide preventive care for such immigrants, who are expected to make up the largest share of the remaining uninsured once the state’s expanded Medicaid program takes full effect. By many measures, California, with roughly seven million people currently uninsured, more than any other state, is taking the lead in aggressively rolling out changes before January, when most Americans will be required by law to have medical coverage or pay a penalty, the so-called universal mandate. While other states are resisting efforts to expand Medicaid, California has already begun public campaigns to encourage more residents to enroll in subsidized health plans. But in counties with large immigrant populations like Los Angeles, officials say that not including immigrants in coverage, regardless of their legal status, will only cost local government more in the long run. So they are lobbying state and federal officials to find ways to pay for preventive health care, rather than rely on emergency rooms to care for them. The push shows how dramatically the debate around immigration has shifted in California, which approved a state ballot initiative 20 years ago that prohibited illegal immigrants from receiving any kind of public benefit, including health care. Now, public opinion polls show that the vast majority of the state’s residents approve granting illegal immigrants a path to citizenship, though they are opposed to offering them the same benefits for public services as legal residents. Granting any kind of access to health care for immigrants is becoming a focal point in the current Congressional debate, as many Republicans have said they would refuse to support change if it included providing care for immigrants who have been living in the country illegally. Representative Raul R. Labrador of Idaho, for instance, walked out of bipartisan negotiations in the House, arguing that illegal immigrants should be denied emergency room care and that unpaid medical bills should become a deportable offense. In the current system, illegal immigrants in California rely on a patchwork of community clinics, whose services and availability vary across the state. Few offer comprehensive coverage, and those that do often struggle to find government money to pay for the services they offer. Some advocates worry that as more people get insurance or enroll in Medicaid, the clinics will be inundated with new patients and forced to squeeze out anyone — including illegal immigrants — who cannot pay for care. Nowhere is this issue more pressing than in California, which has more illegal immigrants than any other state. “California has really acknowledged that all immigrants who are here are part of our present and our future, so we need them to be healthy and included in any effort we make to expand health care,” said Daniel Zingale, a senior vice president with California Endowment, a health care foundation leading the charge to persuade the state to pay for comprehensive care for all immigrants. County leaders, immigrant advocates and labor unions have formed an unlikely alliance to press for change. “It doesn’t take much to figure out these people will be driving our economy in the decades to come, so it’s in our interest to keep them healthy,” he said. While the state budget does not explicitly earmark any money to pay for health care for illegal immigrants, it also does not forbid counties from using state money to do so, something Mr. Zingale and others count as a victory.
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