California’s ambitious push toward near-universal health coverage — a goal state leaders spent decades working toward — is now unraveling under the weight of budget shortfalls and new federal restrictions, leaving millions of residents at risk of losing their health insurance in the coming years.
Just two years ago, the state reached a milestone: nearly every Californian qualified for some form of health coverage regardless of immigration status or income, pushing the state’s insured rate to a record 95%. But a new analysis from the UC Berkeley Labor Center and the UCLA Center for Health Policy Research projects that the uninsured rate could nearly double, climbing to almost 15% by 2030.
“I knew it was going to be bad, but seeing that it will double was shocking to me,” said Miranda Dietz, who directs the health care program at the Berkeley center.
Researchers estimate roughly 2.2 million people could lose coverage over the next four years because of combined state and federal cuts. Undocumented immigrants and low-income Californians will bear the brunt of the losses, and the uninsured rate is expected to more than double among Black and Asian Californians. Southern California — home to a disproportionate share of immigrant and low-income residents — is expected to be hit hardest.
Many Californians remember all too well how difficult it was to get care before the state expanded and strengthened its insurance options.
In 2008, Kandi Hill had just given birth to her third child. When she began vomiting and experiencing irregular, heavy periods, she struggled to find a doctor willing to test her for anything beyond sexually transmitted infections. Within months, she was diagnosed with stage four cervical cancer and died. She was 31.
Cervical cancer has a 91% five-year survival rate when caught early, according to the National Cancer Institute. But Medi-Cal at the time offered only bare-bones coverage, and doctors didn’t seem to take poor Black patients seriously, said her husband, Ramonte Means.
Means was left to raise two young children and an infant alone. He has been the family’s sole provider ever since, often working part-time and frequently without insurance, juggling jobs as a janitor, in customer service, and in job placement to make ends meet. Employers, he said, often limit his hours specifically to avoid providing benefits. With several part-time jobs, he tries to keep his income low enough to qualify for Medi-Cal and ensure his children stay covered. He’d rather get insurance through an employer, but he can’t afford it on his own.
“None of us want anything for free. I work two jobs. My kids go to school,” Means said. “We’re just asking for a little dignity.”
Means said today’s Medi-Cal program isn’t perfect, but it’s far better than what existed when his wife died — patients now have more benefits and can see specialists.
“I honestly believe that if all this had happened now, she would be fine,” Means said. “The system failed my kids more than anyone else. It failed the whole family.”
MILLIONS GAINED COVERAGE
When the Affordable Care Act passed in 2010, California moved quickly to expand its Medicaid program. Previously, Medi-Cal was largely reserved for women and children, seniors, and people with disabilities — low-income adults without dependent children were excluded. The law let California open enrollment to childless adults and raised the income limit to 138% of the federal poverty level, or about $22,000 for an individual today.
More than 5 million Californians gained coverage under the expansion, including Means, who had previously earned too much to qualify at times.
“138% of poverty isn’t a lot of money in terms of an income increase, but in terms of how many people actually become eligible, it has a significant impact,” said Nadereh Pourat, associate director of the UCLA Center for Health Policy Research.
Another 1.7 million middle-income Californians bought coverage through the ACA’s commercial marketplace, known as Covered California.
“This is a landmark policy shift,” said Rachel Linn Gish, a spokesperson for the consumer advocacy group Health Access California. “Millions and millions of Californians will have coverage for the next 10 years. No other state can say that.”
Still, one major group remained locked out of coverage: undocumented immigrants, who make up roughly 2.3 million California residents, according to the Public Policy Institute of California.
NEWSOM: THE HEALTH CARE GOVERNOR
Gov. Gavin Newsom campaigned on a promise to bring single-payer health care to California. He later shifted strategy, focusing instead on expanding access within the existing system, adding new Medi-Cal benefits and emphasizing high-quality primary care.
His administration also carried out the state’s second-largest coverage expansion, gradually extending Medi-Cal eligibility to low-income undocumented adults until all adults and children qualified in 2024.
“We’re making sure that universal access to health care coverage becomes a reality here in California,” Newsom said in 2022, when the state allowed undocumented seniors to enroll in Medi-Cal.
At its peak, the state-funded expansion covered 1.4 million adults and 217,000 children, costing more than $10 billion annually.
Republican lawmakers have long criticized that price tag — and increasingly, so have moderate Democrats.
“We need to get costs under control,” state Sen. Catherine Blakespear, D-Encinitas, said when the Legislature approved last year’s budget.
Total Medi-Cal spending has more than doubled since Newsom took office in 2019, growing from roughly $96 billion to $217 billion this year. The nonpartisan Legislative Analyst’s Office attributes most of that growth to higher spending per enrollee — additional benefits, higher drug prices and some demographic shifts — rather than to enrollment growth itself. People are visiting doctors more often, and each visit costs more.
CUTS ON THE HORIZON
Orlando and Lourdes are immigrants from El Salvador. CalMatters is using only their middle names because they fear being identified by immigration authorities. Orlando has lived in Los Angeles for more than 20 years and works in construction under a work permit. Lourdes runs a store and is undocumented.
Recent federal immigration raids have already upended their lives. They’ve had to explain to their 6-year-old daughter that there are good police officers and bad ones. Now Lourdes, who needs radiation therapy to treat her cancer, fears losing her Medi-Cal coverage altogether.
To slow Medi-Cal’s growth, the state froze enrollment for undocumented adults starting in January — roughly 86,000 fewer undocumented immigrants are now covered.
Starting next summer, undocumented immigrants will lose dental benefits and be required to pay new monthly premiums. Combined with coverage cuts for some legal immigrants, these changes are expected to leave about 800,000 people uninsured, according to the UC Berkeley Labor Center.
“We pay taxes every year. We deserve to have health insurance,” Orlando said.
Services have been trimmed more broadly, too. Last year, the state eliminated coverage of weight-loss drugs like Ozempic for overweight patients, preserving it only for more serious diagnoses such as diabetes. This year, lawmakers scaled back comprehensive services, including case management and medically tailored meal delivery for low-income patients. They also reinstated an asset test that limits how much savings a beneficiary can have regardless of income — a policy advocates say punishes people for building any financial cushion.
The cuts have angered lawmakers on the left, some of whom want the state to raise revenue through corporate taxes or other means rather than shrink Medi-Cal.
State Sen. Lena Gonzalez, D-Long Beach and chair of the Latino Caucus, said she pressed Newsom and his staff twice to preserve benefits for undocumented residents.
“I told them this is a legacy they will carry forever, and I don’t want them to ever forget it,” Gonzalez said. “That this happened was truly shocking.”
Linn Gish acknowledged that Newsom championed health care access “from day one” but called the recent rollbacks disappointing. “We had hoped he would be an advocate to the very end,” she said.
Newsom’s office declined an interview request. In a statement, the Department of Health Care Services noted that the Legislature voted to approve the budget that included the cuts and said Newsom remains committed to supporting universal coverage responsibly.
“Governor Newsom has consistently highlighted California’s coverage gains as central to his broader commitment to universal health care coverage and a more inclusive safety net,” the statement read.
FEDERAL PRESSURES
Many Democrats, including Newsom, place much of the blame on President Donald Trump, whose sweeping tax and policy law altered Medi-Cal rules and cut federal funding to California. The law also allowed enhanced Affordable Care Act subsidies to expire, contributing to a drop of 140,000 people in Covered California enrollment. State officials estimate Medi-Cal could lose more than $30 billion annually once the federal changes take full effect in 2027.
The most significant change requires many adults to prove they are working or volunteering at least 80 hours a month. Research has shown that most low-income adults already meet such requirements but lose coverage anyway because of bureaucratic errors and paperwork mishaps.
“It just takes one letter to get lost for you to suddenly lose coverage… and things can spiral out of control,” said Dylan Roby, a health policy researcher and professor at UC Irvine.
Combined with shorter eligibility periods, the state estimates these federal changes alone will cause 1.3 million people to lose coverage over the next four years.
Those losses won’t be spread evenly. Los Angeles and other parts of Southern California are expected to see some of the steepest declines, according to the Labor Center, and Latino Californians are projected to lose coverage faster than other groups.
Linnea Koopmans, executive director of Local Health Plans of California, which represents Medi-Cal insurers, said the combined cuts will create a two-tiered system of haves and have-nots.
“There’s a lot at stake and a lot to lose,” Koopmans said.
But some Republican lawmakers argue that blaming Washington is disingenuous. California has run budget deficits for four consecutive years — well before most federal restrictions, many of which haven’t even taken effect yet.
State Sen. Roger Niello, R-Roseville and vice chair of the budget committee, estimated the current impact of federal health care restrictions at $3 billion out of a $351 billion state budget.
“It’s difficult to argue that the problems are caused by the federal government,” Niello said, calling the state’s spending issue structural. Revenue has grown, he said, but spending has grown even faster.
The current budget leaves the toughest health care decisions for the next governor to sort out.
“Governor Newsom says he solved the deficit for the next governor. He hasn’t,” Niello said.
Original source: CalMatters
