Christine Mai-Duc and Claudia Boyd-Barrett
In 2013, earlier than the Affordable Care Act helped tens of millions get medical insurance, California’s Placer County supplied restricted well being care to some 3,400 uninsured residents who couldn’t afford to see a health care provider.
For a number of years, that quantity has been zero within the predominantly white, largely rural county stretching from Sacramento’s jap suburbs to the shores of Lake Tahoe.
The development may very well be short-lived.
County well being officers there and throughout the nation are bracing for an estimated 10 million newly uninsured sufferers over the subsequent decade within the wake of Republicans’ One Big Beautiful Bill Act. The act, which President Donald Trump signed into legislation this previous summer time, can be anticipated to cut back Medicaid spending by more than $900 billion over that interval.
“This is the moment where a lot of hard decisions have to be made about who gets care and who doesn’t,” mentioned Nadereh Pourat, director of the Health Economics and Evaluation Research Program at UCLA. “The number of people who are going to lose coverage is large, and a lot of the systems that were in place to provide care to those individuals have either gone away or diminished.”
It’s an particularly thorny problem for states like California and New Mexico the place counties are legally required to assist their poorest residents by way of what are referred to as indigent care applications. Under Obamacare, each states had been able to expand Medicaid to incorporate extra low-income residents, assuaging counties of affected person hundreds and redirecting a lot of their funding for the patchwork of native applications that supplied bare-bones providers.
Placer County, which estimates that 16,000 residents might lose well being care protection by 2028, stop working its personal clinics practically a decade in the past.
“Most of the infrastructure that we had to meet those needs is gone,” mentioned Rob Oldham, Placer County’s director of well being and human providers. “This is a much bigger problem than it was a decade ago and much more costly.”
In December, county officers asked to join a statewide association that gives care to largely small, rural counties, citing an anticipated rise within the variety of uninsured residents.
New Mexico’s second-most-populous county, Doña Ana, added dental look after seniors and behavioral well being advantages after lots of its poorest residents certified for Medicaid. Now, federal cuts might drive the county to rethink, mentioned Jamie Michael, Doña Ana’s well being and human providers director.
“At some point we’re going to have to look at either allocating more money or reducing the benefits,” Michael mentioned.
Straining State Budgets
Some states, resembling Idaho and Colorado, deserted legal guidelines that required counties to be suppliers of final resort for his or her residents. In different states, uninsured sufferers typically delay care or obtain it at hospital emergency rooms or neighborhood clinics. Those clinics are sometimes supported by a mixture of federal, state, and native funds, in line with the National Association of Community Health Centers.
Even in states like Texas, which opted to not broaden its Medicaid program and continued to depend on counties to care for a lot of of its uninsured, rising well being care prices are straining native budgets.
“As we have more growth, more people coming in, it’s harder and harder to fund things that are required by the state legislature, and this isn’t one we can decrease,” mentioned Windy Johnson, program supervisor with the Texas Indigent Health Care Association. “It is a fiscal issue.”
California lawmakers face a virtually $18 billion budget deficit within the 2026-27 fiscal yr, in line with the most recent estimates by the state’s nonpartisan Legislative Analyst’s Office. Gov. Gavin Newsom, who has acknowledged he’s mulling a White House run, has rebuffed several efforts to considerably increase taxes on the ultra-wealthy. Despite blasting the invoice handed by Republicans in Congress as a “complete moral failure” that guts well being care applications, in 2025 the Democrat rolled again state Medi-Cal advantages for seniors and for immigrants with out authorized standing after rising prices compelled this system to borrow $4.4 billion from the state’s normal fund.
H.D. Palmer, a spokesperson for the state’s Department of Finance, mentioned that the Newsom administration continues to be refining its fiscal projections and that it might be “premature” to debate potential funds options.
Newsom will unveil his preliminary funds proposal in January. State officers have mentioned California could lose $30 billion a yr in federal funding for Medi-Cal underneath the brand new legislation, as a lot as 15% of the state program’s complete funds.
“Local governments don’t really have much capacity to raise revenue,” mentioned Scott Graves, a director on the unbiased California Budget & Policy Center with a deal with state budgets. “State leaders, if they choose to prioritize it, need to decide where they’re going to find the funding that would be needed to help those who are going to lose health care as a result of these federal funding and policy cuts.”
Reviving county-based applications within the close to time period would require “considerable fiscal restructuring” by way of the state funds, the Legislative Analyst’s Office mentioned in an October report.
No Easy Fixes
It’s not clear how many individuals are at the moment enrolled in California’s county indigent applications, as a result of the state doesn’t monitor enrollment and utilization. But enrollment in county well being security internet applications dropped dramatically within the first full yr of ACA implementation, going from about 858,000 individuals statewide in 2013 to roughly 176,000 by the top of 2014, according to a survey on the time by Health Access California.
“We’re going to need state investment,” mentioned Michelle Gibbons, government director of the County Health Executives Association of California. “After the Affordable Care Act and as folks got coverage, we didn’t imagine a moment like this where potentially that progress would be unwound and folks would be falling back into indigent care.”
In November, voters in prosperous Santa Clara County accredited a gross sales tax improve, partially to backfill the lack of federal funds. But even within the residence of Silicon Valley, the place the median family earnings is about 1.7 instances the statewide average, that’s anticipated to cover only a third of the $1 billion a yr the county stands to lose.
Health advocates concern that, absent main state investments, Californians might see a return to the earlier patchwork of county-run programs, with native governments selecting whom and what they cowl and for the way lengthy.
In many instances, indigent applications didn’t embrace specialty care, behavioral well being, or common entry to major care. Counties may exclude individuals based on immigration status or earnings. Before the ACA, many uninsured individuals who wanted care didn’t get it, which might result in them winding up in ERs with untreated well being circumstances and even dying, mentioned Kiran Savage-Sangwan, government director of the California Pan-Ethnic Health Network.
Rachel Linn Gish, interim deputy director of Health Access California, a client advocacy group, mentioned that “it created a very unequal, maldistributed program throughout the state.”
“Many of us,” she mentioned. “including counties, are reeling trying to figure out: What are those downstream impacts?”
