Should Medicaid expansion include undocumented immigrants? Californians say yes.

One of the biggest fissures in the ongoing Red State/Blue State Medicaid debate is not in the South but in California. That makes sense, since it's also home to thousands of earthquake faults that will remain undetected until one erupts explosively.

That fissure was borne out by The Field Poll, which is California's most important internal polling organization. A survey released late last month not only showed far wider support for the Affordable Care Act (ACA) than in national polls (62 percent of residents support it), but an astonishing 58 percent believe that Medi-Cal, the state's Medicaid program, should be expanded to include undocumented immigrants. Support was seven percentage points higher than a year ago. Just 39 percent were opposed to such an expansion.

That Field Poll data mostly went unreported outside of California, and perhaps with good reason. You would hardly believe that there is any room in the U.S. to provide anything to undocumented residents other than a swift kick back to where they came from.

The notion of "self-deportation" floated during the 2012 presidential campaign has intensified. Gov. Scott Walker of Wisconsin had advocated for building a wall to separate ourselves from Canada--no doubt worried about the threat of surreptitious curling matches. Donald Trump--who has essentially made himself the id of aggrieved white voters--wants to build a Southern border wall reaching into space. Oh, and make Mexico pay for it.

At the same time, the Obama administration has formally "removed" from the U.S. about 3 million undocumented residents during its tenure, far more than the George W. Bush administration. A removal is far harsher than a "return," which is essentially dumping the person back into his or her own country. It means an official record was made of each individual's deportation and he or she could be punished harshly if the person is caught sneaking over the border again.

Then there's the Medicaid program itself. Alabama presents a stark contrast to California. The legislature is pondering how much to cut from its budget–it could be as much as $156 million, or a 3 percent reduction, in 2016. Then there's Florida, which is auditing its safety-net hospitals trying to see if there are some Medicaid dollars that it could claw back. Of course, neither of these states would dream of expanding Medicaid eligibility under the ACA and receiving billions of dollars in additional revenue.

I'm not going to even get into the Draconian rules that states such as Mississippi or Kansas have for enrollment that systematically exclude the working poor.

Of course, hospitals want every dollar they can extract from the Medicaid program at either the state or federal level. And despite all this grumbling from conservatives that it's a waste of taxpayer funds, every measly dollar a hospital can squeeze from Medicaid is one less dollar that's cost-shifted over to commercially insured patients or those uninsured who are charged full freight.

All the poo-pooing about California's wacky, granola-infused mellowness is just that. You cannot grow the nation's largest state economy (and eighth-largest in the world) merely by holding some yoga or acting classes. You do that by thinking ahead. The electorate here apparently seem to think it's a good idea to expand Medicaid to include even more residents. It goes to follow that a lot of other Americans elsewhere will agree--eventually.

But it's not going to happen without some epic political battles first. They could get ugly, or violent--not unlike a sharp and unexpected earthquake. Of course, I have said it here repeatedly that the state hospital lobbies could exploit the current loopholes in campaign financing to better try and shift the Red State-Medicaid debate in their favor. The sooner that happens, the better. - Ron (@FierceHealth)

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