Marisol Pantoja Toribio found a lump in her breast in early January. Undocumented, uninsured, and without her family, the usually happy-go-lucky 43-year-old quickly realized how limited her options were.

“I said, ‘What am I going to do?’” she says in Spanish, quickly getting emotional. She immediately worried that she might have cancer. “I went back and forth — I have [cancer], I don’t have it, I have it, I don’t have it.” And if she was sick, she adds, she wouldn’t be able to work or pay her rent. Without health insurance, Pantoja Toribio couldn’t know for sure if she had a serious condition.

Beginning on January 1, 2024, Medi-Cal, California’s Medicaid program, expanded to include undocumented immigrants, timing that could have worked out perfectly for Pantoja Toribio, who has lived in Brentwood, Calif. for three years. But her application for Medi-Cal was quickly rejected — as a farmworker who gets paid $16 an hour, her annual income of roughly $24,000 was too high and she didn’t meet the income threshold to qualify for the program.

California is the first state in the country to expand Medicaid to all qualifying adults regardless of immigration status. The expansion has been celebrated by health advocates and political leaders across the state. But many undocumented immigrants, especially those who live in parts of California where the cost of living is much higher, earn slightly too much money to qualify for Medi-Cal. A subsidized health care plan through the alternative Covered California, an Affordable Care Act marketplace, is not an option for undocumented immigrants as the program is paid for by federal dollars.

Now, the same health advocates who fought for the Medi-Cal expansion say the next step in achieving health equity is expanding Covered California to undocumented adults by passing Assembly Bill 4, also known as #Health4All. 

“There are people in this state who work and are the backbone of so many sectors of our economy and contribute their labor and even taxes…but they are locked out of our social safety net,” says Sarah Dar, Policy Director at the California Immigrant Policy Center (CIPC), one of the two organizations sponsoring the #Health4All bill. 

In order to qualify for Medi-Cal, an individual needs to earn 138 percent of the Federal Poverty Level (FPL), which amounts to $​20,783 a year or less. That income threshold changes depending on household size. A family of three, for example, needs to earn less than $35,632 a year in order to qualify for Medi-Cal. Without Medi-Cal or Covered California, undocumented people who do not have health insurance through an employer have to turn to expensive private health insurance plans, or in many cases, choose to go without insurance and go years without seeing a health care provider.

Federal money cannot be used to subsidize a health care plan for undocumented people through Covered California. The marketplace offers various health plans based on income that can include federal and state subsidies and premiums that run as low as $10 a month. The #Health4All bill would create what advocates call a “mirrored” marketplace on the Covered California website so that undocumented people can be offered the same health insurance plans that would only be subsidized by the state. 

Despite a Democratic supermajority in the California state legislature, #Health4All might still struggle to pass as the state is attempting to slash its spending. On April 4, California Governor Gavin Newsom and state legislators announced a $17 billion package to reduce the state’s deficit, which includes some budget cuts.

Estimates for how much the “mirrored” marketplace for undocumented immigrants would cost vary, according to Assemblymember Joaquin Arambula, a Democrat from district 31 in Fresno and the #Health4All legislative sponsor. CIPC estimates that setting the marketplace up alone will cost at least $15 million. But Arambula adds that California has been a leader in improving access to health care for undocumented immigrants and that he believes the state will continue to support this movement.

“I do believe we’ve successfully been able to change the hearts and minds of many of the legislators and the Administration as California has a legacy of leading in this space,” he said. “I believe we will continue to stand up as we are working to make this a California for all.” 

The bill passed the State Assembly in July 2023, but is waiting for a vote by the Senate Appropriations Committee.

There are an estimated 520,000 undocumented people in California who would otherwise qualify for a Covered California plan if not for their legal status, according to the University of Berkeley Labor Center. Of those, about 80,000 reside in the Bay Area.

Pantoja Toribio, who immigrated alone to the U.S. after leaving an abusive relationship, says that she was lucky. She learned about alternative health care options when she made her weekly visit to a food pantry at Hijas Del Campo, a Contra Costa County farmworker advocacy organization, and they told her there she might qualify for a plan for low income people through Kaiser Permanente. Pantoja Toribio applied just in time before the open enrollment window closed at the end of January. Through the plan, she learned that the lump she found in her breast was not cancerous. 

“God heard me,” she says. “Thank god.”

This story was produced by El Timpano.