Tuesday, 11 August 2026, 15:21
Two years ago, California nearly achieved universal healthcare. Now, budget shortfalls and new federal restrictions are reversing that progress. Millions of residents are at risk of losing Medi-Cal coverage, and the consequences could last for years.
California hit a record insured rate of 95% in 2024. By 2030, the uninsured rate could nearly double to almost 15%, according to projections from the UC Berkeley Labor Center and UCLA Center for Health Policy Research.
"I knew it was going to be bad, but seeing that doubling was shocking to me," said Miranda Dietz, director of the labor center's healthcare program.
An estimated 2.2 million people could lose insurance over the next four years from combined state and federal cuts, the researchers found. The losses will hit low-income families and immigrant communities hardest.
President Donald Trump’s tax law cut nearly $1 trillion from Medicaid over the next decade, and California officials estimate Medi-Cal could lose roughly $30 billion annually. Experts say work requirements and shorter eligibility periods often kick eligible people off public assistance due to bureaucratic errors. Bukola Olusanya, a street medicine provider with St. John’s Community Health, said, "We're talking about people that do not have access to a cell phone. They don't have access to internet. They don't have access to a printer or paper or anything for them to complete the eligibility process." She said most unhoused people will be unable to comply with the work requirement even if they have a qualifying exemption such as a disability, leading to massive coverage losses.
Anthony Wright, executive director of Families USA, called the combined cuts "the biggest rollback in coverage in history."
A new documentary from CalMatters and Evident Media goes inside St. John’s Community Health in Los Angeles, showing how Californians are being forced to choose between medicine and food. Reporter Kristen Hwang follows providers anxious about the safety net’s future even as they wrestle daily with the tangled legacy of past decisions.
State guidance says most Medi-Cal enrollees will not see changes. But the rules are shifting for specific groups.
The coverage system was not always this strong. In 2008, Kandi Hill had just given birth to her third child. When she started throwing up and experiencing irregular menstrual cycles with heavy bleeding, she struggled to find a doctor who would run any tests other than an STD panel. In a matter of months, she died from stage four cervical cancer. She was 31.
Cervical cancer has a 91% five-year survival rate if caught and treated early, according to the National Cancer Institute. But back then, the Medi-Cal system was bare bones, and doctors didn’t seem to take poor Black patients seriously, said her husband, Ramonte Means. Means was left to raise two small children and an infant alone. He has been the sole provider for his family ever since, often working part-time and frequently without insurance, stitching together multiple jobs, including janitorial work, customer service, and job coaching, to make ends meet.
Usually, Means said, his employers won’t give him full-time hours so that they don’t have to provide benefits. With multiple part-time jobs, he tries to keep his income low enough to qualify for Medi-Cal and ensure his kids stay covered too. He’d rather get insurance through an employer, but he can’t afford a plan out-of-pocket. Today’s Medi-Cal isn’t perfect, Means says, but it’s much better than when his wife died; patients have more benefits and can see specialists. "I truly believe if all this happened now, she’d have been fine," Means said. "The system failed my kids more than anything, failed the whole family."
"None of us want anything for free. I work two jobs. My kids go to school," Means said. "We're just asking for some dignity."
The impact will not be spread evenly. Researchers say Southern California will bear the brunt because of its larger share of low-income and immigrant residents. The uninsured rate is projected to more than double among Black and Asian Californians. Statewide, Medi-Cal remains a lifeline for about 15 million people, and even small administrative changes can cause coverage gaps for families who rely on it.
Hospitals will be on the front lines. By law, hospitals cannot refuse anyone who comes into the emergency room, so when more patients become uninsured, somebody has to absorb the cost. The California Hospital Association expects uncompensated care to jump from $2 billion to $4 billion each year, and more than half of the state’s hospitals are already operating at a loss. Hospitals have laid off more than 3,000 workers in preparation for the cuts. Carmela Coyle, the association’s president and CEO, said, "The way that everybody feels it is an inability to get access to the care they need when they need it."
Low-income patients who rely on public insurance will be hit hardest, but people with commercial insurance will feel the effects too. When hospitals tighten their belts, they reduce services for everyone regardless of insurance status: cutting wages or laying off staff, reducing or eliminating expensive services like labor and delivery, or shuttering emergency departments. Quality could decline, and premiums may rise. Financially fragile hospitals are likely to close altogether. “If you don’t have as many paying patients, your income as an organization goes down,” said Nadereh Pourat, associate director at the UCLA Center for Health Policy Research. “These are nonprofit institutions, so all of that income goes toward delivery of care.”
The closure of Martin Luther King Jr. Harbor Hospital in 2007 shows what can happen when hospitals collapse under pressure. Neighboring hospitals saw emergency department wait times exceed 11 hours, more trauma cases and more uninsured patients. The people who felt the strain weren't just King-Harbor's former patients; they were also the privately insured patients of those neighboring institutions. Researchers later concluded the closure worsened patient care throughout the region and increased mortality. Experts warn such ripple effects could become more common as hospitals grapple with a coming spike in uninsured patients.
The Affordable Care Act had previously created a lifeline for hospitals by expanding Medi-Cal to millions of previously uninsured low-income Californians. It also created an insurance marketplace for middle-income residents. In the decade before that expansion, 26 California hospitals closed and an additional 22 shuttered their emergency departments.
California expanded Medi-Cal quickly after the Affordable Care Act passed in 2010. More than 5 million childless adults and low-income earners gained coverage. Another 1.7 million middle-income residents bought private plans through Covered California. Gov. Gavin Newsom later expanded Medi-Cal to all low-income undocumented adults, completing the system in 2024.
Before the ACA, Medi-Cal was reserved for women and children, seniors, and people with disabilities. Low-income adults were excluded unless they had dependent children. The law raised the income limit to 138% of the federal poverty level, about $22,000 for an individual today. "So 138% poverty is not a lot of money in terms of increasing income, but when you talk about how many people actually become eligible it has a significant impact," said Nadereh Pourat, associate director at the UCLA Center for Health Policy Research. Rachel Linn Gish, spokesperson for Health Access California, called the expansion "a huge policy change," adding, "Millions and millions and millions of Californians covered in 10 years. No other state can say that." Still, one major group remained uninsured: undocumented immigrants, who account for about 2.3 million residents according to the Public Policy Institute of California.
Gavin Newsom campaigned on a promise to bring single-payer healthcare to the state, but he pivoted to expanding access within the existing system. His administration transformed Medi-Cal with new benefits and a focus on high-quality primary care, and launched the state’s second-largest coverage expansion. Phasing in eligibility for low-income undocumented adults, the state-funded expansion covered 1.4 million adults and 217,000 children at its peak.
“We’re making sure that universal access to healthcare coverage becomes a reality here in California,” Newsom said in 2022 when the state allowed undocumented seniors to enroll in Medi-Cal.
Ramonte Means was among the more than 5 million Californians who gained coverage through the ACA expansion. Before the change, he had occasionally earned too much money to qualify for Medi-Cal, leaving him without insurance at those times.
Congress also declined to renew about $3 billion in subsidies for middle-income families who buy insurance through Covered California. Prices rose sharply in January, and roughly 140,000 people have dropped out of the marketplace since the beginning of the year. Nearly 2 million privately insured Californians have already experienced the repercussions of these cuts, many opting for lower-value plans. UC Berkeley and UCLA project that number will grow by another 176,000, and officials have announced premiums will rise next year by nearly 10%.
That growth made California a national outlier. Now the state is reversing course under budget pressure and new federal restrictions.
California built one of the most inclusive health systems in the nation over 15 years. The next four years will test whether that progress can survive. For millions of residents, the difference between coverage and a gap in care could be a single missed letter.
