In 2013, earlier than the Reasonably priced Care Act helped hundreds of thousands 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 physician.
For a number of years, that quantity has been zero within the predominantly white, largely rural county stretching from Sacramento’s japanese suburbs to the shores of Lake Tahoe.
The pattern might be short-lived.
County well being officers there and throughout the nation are bracing for an estimated 10 million newly uninsured sufferers over the following decade within the wake of Republicans’ One Huge Stunning Invoice Act. The act, which President Donald Trump signed into regulation this previous summer time, can also be anticipated to cut back Medicaid spending by greater than $900 billion over that interval.
“That is the second the place a number of laborious selections need to be made about who will get care and who doesn’t,” stated Nadereh Pourat, director of the Well being Economics and Analysis Analysis Program at UCLA. “The variety of people who find themselves going to lose protection is massive, and a number of the techniques that had been in place to supply care to these people have both 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 via what are generally known as indigent care applications. Beneath Obamacare, each states had been capable of broaden 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 companies.
Placer County, which estimates that 16,000 residents may lose well being care protection by 2028, stop working its personal clinics practically a decade in the past.
“A lot of the infrastructure that we needed to meet these wants is gone,” stated Rob Oldham, Placer County’s director of well being and human companies. “It is a a lot greater downside than it was a decade in the past and far more expensive.”
In December, county officers requested to hitch a statewide affiliation 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 take care of seniors and behavioral well being advantages after a lot of its poorest residents certified for Medicaid. Now, federal cuts may drive the county to rethink, stated Jamie Michael, Doña Ana’s well being and human companies director.
“Sooner or later we’re going to have to have a look at both allocating more cash or decreasing the advantages,” Michael stated.
Straining State Budgets
Some states, comparable to 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 usually delay care or obtain it at hospital emergency rooms or group clinics. These clinics are sometimes supported by a mixture of federal, state, and native funds, in line with the Nationwide Affiliation of Group Well being Facilities.
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’ve extra progress, extra individuals coming in, it’s tougher and tougher to fund issues which are required by the state legislature, and this isn’t one we are able to lower,” stated Windy Johnson, program supervisor with the Texas Indigent Well being Care Affiliation. “It’s a fiscal situation.”
California lawmakers face an almost $18 billion price range deficit within the 2026-27 fiscal yr, in line with the newest estimates by the state’s nonpartisan Legislative Analyst’s Workplace. Gov. Gavin Newsom, who has acknowledged he’s mulling a White Home run, has rebuffed a number of efforts to considerably increase taxes on the ultra-wealthy. Regardless of blasting the invoice handed by Republicans in Congress as a “full ethical 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 pressured this system to borrow $4.4 billion from the state’s normal fund.
H.D. Palmer, a spokesperson for the state’s Division of Finance, stated that the Newsom administration continues to be refining its fiscal projections and that it will be “untimely” to debate potential price range options.
Newsom will unveil his preliminary price range proposal in January. State officers have stated California may lose $30 billion a yr in federal funding for Medi-Cal beneath the brand new regulation, as a lot as 15% of the state program’s whole price range.
“Native governments don’t actually have a lot capability to lift income,” stated Scott Graves, a director on the unbiased California Finances & Coverage Heart with a concentrate on state budgets. “State leaders, in the event that they select to prioritize it, must determine the place they’re going to search out the funding that might be wanted to assist those that are going to lose well being care on account of these federal funding and coverage cuts.”
Reviving county-based applications within the close to time period would require “appreciable fiscal restructuring” via the state price range, the Legislative Analyst’s Workplace stated in an October report.
No Simple Fixes
It’s not clear how many individuals are at present enrolled in California’s county indigent applications, as a result of the state doesn’t monitor enrollment and utilization. However 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 tip of 2014, in line with a survey on the time by Well being Entry California.
“We’re going to wish state funding,” stated Michelle Gibbons, government director of the County Well being Executives Affiliation of California. “After the Reasonably priced Care Act and as of us obtained protection, we didn’t think about a second like this the place probably that progress can be unwound and folk can be falling again into indigent care.”
In November, voters in prosperous Santa Clara County accepted a gross sales tax enhance, partly to backfill the lack of federal funds. However even within the house of Silicon Valley, the place the median family revenue is about 1.7 occasions the statewide common, that’s anticipated to cowl solely a 3rd of the $1 billion a yr the county stands to lose.
Well being advocates worry that, absent main state investments, Californians may see a return to the earlier patchwork of county-run applications, with native governments selecting whom and what they cowl and for the way lengthy.
In lots of instances, indigent applications didn’t embrace specialty care, behavioral well being, or common entry to major care. Counties may exclude individuals based mostly on immigration standing or revenue. Earlier than the ACA, many uninsured individuals who wanted care didn’t get it, which may result in them winding up in ERs with untreated well being situations and even dying, stated Kiran Savage-Sangwan, government director of the California Pan-Ethnic Well being Community.
Rachel Linn Gish, interim deputy director of Well being Entry California, a shopper advocacy group, stated that “it created a really unequal, maldistributed program all through the state.”
“Many people,” she stated. “together with counties, are reeling making an attempt to determine: What are these downstream impacts?”