California on Thursday became the first state to guarantee free health care for all low-income immigrants living in the country illegally, a move that will provide coverage for an additional 764,000 people at an eventual cost of about $2.7 billion a year.

Gov. Gavin Newsom signed a $307.9 billion operating budget that pledges to make all low-income adults eligible for the state’s Medicaid program by 2024 regardless of their immigration status. It’s a long-sought victory for health care and immigration activists, who have been asking for the change for more than a decade.

Nationwide, federal and state governments join together to give free health care to low-income adults and children through Medicaid. But the federal government won’t pay for people who are living in the country illegally. Some states, including California, have used their own tax dollars to cover a portion of health care expenses for some low-income immigrants.

Now, California wants to be the first to do that for everyone.

About 92% of of Californians currently have some form of health insurance, putting the state in the middle of the pack nationally. But that will change once this budget is fully implemented, as adults living in the country illegally make up one of the largest groups of people without insurance in the state.

“This will represent the biggest expansion of coverage in the nation since the start of the Affordable Care Act in 2014,” said Anthony Wright, executive director of Health Access California, a statewide consumer health care advocacy group. “In California we recognize (that) everybody benefits when everyone is covered.”

People living in the country illegally made up about 7% of the population nationwide in 2020, or about 22.1 million people, according to the Kaiser Family Foundation, a health care nonprofit. They are not eligible for most public benefit programs, even though many have jobs and pay taxes.

Immigrants have slowly been getting access to some health care programs. Eighteen states now provide prenatal care to people regardless of their immigration status, while the District of Columbia and five states — California, Illinois, New York, Oregon and Washington — cover all children from low-income families regardless of their immigration status. California and Illinois have expanded Medicaid to cover older adult immigrants.

In California, Republicans and conservative groups have opposed expanding health care to immigrants living in the country illegally. Jon Coupal, president of the Howard Jarvis Taxpayers Association, said offering free health care will make California “a magnet for those who are not legally authorized to enter the country.”

“I think many of us are very sympathetic to the immigrant community, but we really wish we had better control of who enters this nation and this state,” Coupal said.

California’s expansion of Medicaid won’t be easy. A confluence of events, including the state’s slow rollout of the expansion and the end of some federal pandemic policies, mean about 40,000 low-income immigrants will likely lose their health coverage for up to a year in 2023 before being eligible to get it back — illustrating the difficulty of navigating the government-run health insurance system that is supposed to make it easier for people to get coverage.

Beatriz Hernandez came to the United States in 2007 as a 11-year-old. She got health care through Medicaid when she was a child. She lost that coverage once she turned 19 because of her immigration status, but it was restored in 2020 when the state began covering low-income immigrants 26 and younger.

Hernandez turned 26 in February. She hasn’t lost her coverage yet because of emergency federal rules during the pandemic. But those rules could expire later this year, making her one of the estimated 40,000 people who will temporarily lose their coverage before California’s new program starts on Jan. 1, 2024, according to an analysis by the nonpartisan Legislative Analyst’s Office.

Hernandez lives in Merced in California’s Central Valley and works as an organizer with the California Immigrant Policy Center. She said her mother would benefit the most from the expansion, having never had health insurance since moving to the U.S.

But for Hernandez, she’s worried a gap in her coverage would cause her to lose access to the medication she takes to treat depression. In the meantime, she’s scheduling as many appointments as she can this year — including for the dentist, optometrist and dermatologist — before she loses coverage.

“It’s great that California is taking that step to set that example for other states,” said Hernandez, who said she does not have a work permit or other permission to live in the United States. “I do believe that we can do better by making sure that people like myself and hundreds of others, thousands of others, do not fall out of their health care simply because they turn 26.”

Previous expansions of California’s Medicaid system have taken six months to a year to implement. But the Newsom administration says it needs a year and a half to complete this expansion because it is so much larger than the previous ones.

Health care advocates say the gap in coverage is significant for low-income immigrants living in the country illegally because they don’t have other options. Citizens who lose their Medicaid coverage can purchase coverage from Covered California, the state-run health insurance exchange, and likely qualify for a significant discount.

“But for this population, that’s it. (Medicaid) is the only public program available to them,” said Sarah Dar, director of health and public benefits policy for the California Immigrant Policy Center.

Democrats in the state Legislature say they are working with the Newsom administration on speeding up the process.

“We’re doing all that we can. We’re talking to the administration, talking to the leadership in the (California) Department of Health, to make sure that we do it as fast as possible and that nobody loses it in the meanwhile,” said Democratic Sen. Maria Elena Durazo. “It doesn’t make sense to lose them and then pull them back in.”