For more than two decades, the community health worker has supported hundreds of families throughout southeast Los Angeles by helping them sign up for food assistance, sharing information about affordable health coverage, and managing medications for their chronic illnesses. She’s guided by the expression “an ounce of prevention is worth a pound of cure.”

But she makes only around $20 an hour from a community health organization and must hold down a second job to make ends meet. “They pay us very little and expect too much,” she said in Spanish. “We build trust. We offer support. We’re the shoulder people rely on, but we don’t get fair wages.”

California looked to professionalize thousands of community health workers such as Hernández to improve the health of immigrant populations, particularly Hispanic residents, who often experience of chronic diseases, are more , and face more cultural and linguistic barriers when trying to access services. Studies show their work hospitalizations as well as emergency room and urgent care visits.

The state hewed closely to a series of put out in 2019 to standardize training and certification, integrate these workers into the health care workforce, and provide fair wages, including reimbursements through Medi-Cal, the state’s Medicaid health insurance program, to compensate for work that traditionally has been done on a volunteer basis or for low pay. But six years in, California has backed out of many of those initiatives.

The state has eliminated a certification program and rolled back nearly all funding to train and expand this workforce even though it set a goal of by this year. Although Medi-Cal began covering their services, participating health plans set uneven billing requirements, making it difficult for workers to get reimbursed. And the state didn’t follow through on a planned pay raise.

With federal funding cuts just passed and President Donald Trump targeting immigrants for deportation — even with the Department of Homeland Security — advocates fear California is abandoning its health equity initiative for immigrants, people of color, and people with low incomes when they say that effort is needed most.

“We’re in a very dire situation right now,” said Cary Sanders, senior policy director for the California Pan-Ethnic Health Network, a statewide health equity advocacy group.

A spokesperson for Gov. Gavin Newsom, Elana Ross, said “the state has taken difficult but necessary steps to ensure fiscal stability” and that the administration continues to have a dialogue with community health workers. Ross added that the Democratic governor, a , remains committed to defending immigrants being targeted by the Trump administration.

‘Our Office Is on the Street’

There are more than 60,000 community health workers nationwide, including roughly 9,200 in California, and this workforce is projected to grow 13% over the next decade, three times as fast as for all occupations, according to from the U.S Bureau of Labor Statistics. But experts say these numbers are an undercount given the various titles community health workers hold and that many work outside of health care and governmental institutions.

Community health worker is an umbrella term that includes peer supporters and community health representatives. These workers, often known as promotores, who work in clinics, hospitals, public health departments, and local nonprofits, places where they are trusted and have a grasp of their community’s most pressing health needs.

Besides helping people manage chronic illnesses such as heart disease and diabetes, they promote reproductive health, children’s health, and oral hygiene, and they help prevent injuries and review medications. They can make people feel safe when reporting domestic violence and other abuses. They also connect people to housing and food assistance. “The community health worker is not sitting at a desk,” Hernández said. “Our office is on the street.”

Back in 2019, the California Future Health Workforce Commission recommended integrating community health workers into the health care system, and in 2022, the state authorized over three years for the California Department of Health Care Access and Information, which oversees health care workforce development, to recruit, train, and certify them.

The agency sought to standardize training and certification, but some community groups feared that would create barriers to entry by not giving enough credit for lived experiences and cultural competency. But just as the agency offered more flexibility and allowed community-based training, the state slashed $250 million in funding last year due to budget constraints. This year, the certification program was officially eliminated.

Spokesperson Andrew DiLuccia said the agency is now considering a program to accredit community organizations rather than individual workers and plans to spend its remaining $12 million on technical assistance, workforce development, and salaries for those working with immigrant communities.

According to the National Academy for State Health Policy, offer a voluntary or mandatory community health worker certification program.

Some community health advocates say California’s missing an opportunity to carve a career path for this workforce. Currently, some courses offered by nonprofits, counties, and colleges , a degree, English fluency, or prior experience. Most are concentrated in the San Francisco or Los Angeles area, leaving in much of the state.

Lourdes Bernis, a dentist from Ecuador, is a model for how community health workers could be integrated into the health care system. She began as a volunteer promotora more than a decade ago and in 2019 received free training from Los Angeles County, allowing her to move into a full-time job with benefits for the county’s Department of Mental Health to help Spanish-speaking women manage depression and anxiety as they recover from drug use.

Bernis now plans to become a peer-to-peer support specialist inside hospitals and clinics. Meanwhile, many of her colleagues with decades of experience remain stuck in low-paying roles and can’t afford training to advance. “There are promotoras who have 20 to 25 years of experience, but they are still volunteering,” Bernis said in Spanish.

Medi-Cal’s Role

To pay community health workers, Medi-Cal began covering their services in July 2022, but California for them after voters approved Proposition 35, which hiked the pay of physicians, hospitals, community clinics, and other providers instead. Since then, the state has yet to establish a uniform system for how health plans should contract with organizations that employ community health workers.

“We have to jump through hoops,” said Maria Lemus, executive director at Visión y Compromiso, a Los Angeles-based nonprofit representing community health workers. “It just causes havoc, because each plan could have different requirements.”

Lemus said it took the organization nearly six months to establish payment with one health plan.

And though Medi-Cal reimbursements are tied to individual tasks, ranging from $9.46 to $27.54 for 30 minutes of work, advocates say they aren’t fully compensated for the time they spend building trust and following up with patients. Advocates say these workers should earn at least $30 a visit, with benefits, but many earn about , often without benefits.

Advocates say they’re surprised by how infrequently these services are used in a program with 15 million Californians. More than 16,000 Medi-Cal enrollees used these services in the first year, rising to 68,000 last year, according to state data. “I don’t think it’s reached the potential that the governor talked about, and that we all imagined that it could possibly achieve,” Sanders said.

Griselda Melgoza, a spokesperson for the California Department of Health Care Services, said the agency, which administers Medi-Cal, has seen “a steady, upward trend” and believes the data underestimates utilization because the benefit is sometimes bundled with other services.

to assess whether Medi-Cal managed care plans are doing enough outreach and education to enrollees about community health services died this year.

More Crucial Than Ever

With health funding cuts from the Trump administration and passage of the GOP’s tax and spending legislation, advocates fear there will be even less funding and support for community health worker positions, shrinking a workforce tackling health disparities. Already, Fresno County’s Department of Public Health said it has cut its community health workers by more than half, from 49 positions to 20.

Yet, outreach is more crucial than ever. As the Trump administration continues immigration raids, which appear to have targeted in the state, advocates and policy researchers say community health workers could act as intermediaries for immigrant patients afraid to seek medical care in hospitals and clinics.

Without a state certification program, no raises, and dwindling training funds, the path to professionalizing community health workers is unclear, leaving workers feeling left behind.

“The community trusts me,” said Hernández, the veteran community health worker, “but at the government level, there’s still a long way to go before this work is valued and fairly compensated.”

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LISTEN: Federal law entitles patients to interpreters if they don’t have a strong grasp of English. Ñî¹óåú´«Ã½Ò•îl Health News correspondent Vanessa G. Sánchez appeared on WAMU’s “Health Hub” on July 9 to explain why some Trump administration policies are leaving patients fearful to ask for language services. 

Patients need to communicate clearly with their health care provider. But that’s getting more difficult for those in the U.S. who don’t speak English. 

Budget cuts by the Trump administration have left some providers scrambling to keep qualified medical interpreters. And an executive order designating English the official language of the United States has created confusion among providers about what services should be offered. 

Patients who don’t speak English are left afraid, and perhaps at risk for medical mistakes. What happens when those who need help are too frightened to ask? 

In WAMU’s July 9 “Health Hub” segment, Ñî¹óåú´«Ã½Ò•îl Health News correspondent Vanessa G. Sánchez explained why health advocates worry these changes could lead to worse patient outcomes. 

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At the same time, people with limited English proficiency have scaled back their requests for language services, which health care advocates attribute in part to President Donald Trump’s immigration crackdown and his declaring English as the national language.

Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. “People are going to have a hard time accessing benefits they’re entitled to and need to live independently,” said Carol Wong, a senior rights attorney for Justice in Aging, a national advocacy group.

Nearly 69 million people in the U.S. speak a language other than English, and 26 million of them speak English less than “very well,” according to the most available, from 2023. A from that year found that immigrants with limited English proficiency reported more barriers accessing health care and worse health than English-proficient immigrants.

Health advocates fear that, without adequate support, millions of people in the U.S. with limited English proficiency will be more likely to experience medical errors, misdiagnosis, neglect, and other adverse outcomes. During the start of the pandemic in 2020, that a woman with coronavirus symptoms died in Brooklyn after missing out on timely treatment because emergency room staffers could not communicate with her in Hungarian. And, at the height of the crisis, that on a state website erroneously stated that the covid-19 vaccine was not necessary.

In 2000, President Bill Clinton signed an aimed at improving access to federal services for people with limited English proficiency. Research shows language assistance results in higher , as well as , misdiagnoses, and adverse health outcomes. Language services also by reducing hospital stays and readmissions.

Trump’s order repealed Clinton’s directive and left it up to each federal agency to decide whether to maintain or adopt a new language policy. Some have already scaled back: The and the reportedly reduced language services, and the Justice Department says it is . A is broken.

It’s unclear what the Department of Health and Human Services intends to do. HHS did not respond to questions from Ñî¹óåú´«Ã½Ò•îl Health News.

implemented under President Joe Biden, during public health emergencies and disasters, has been archived, meaning it may not reflect current policies. However, HHS’s still informs patients of their right to language assistance services when they pick up a prescription, apply for a health insurance plan, or visit a doctor.

And the office that prohibit health providers from using untrained staff, family members, or children to provide interpretation during medical visits. It also required that translation of sensitive information using artificial intelligence be reviewed by a qualified human translator for accuracy.

Those safeguards could be undone by the Trump administration, said Mara Youdelman, a managing director at the National Health Law Program, a national legal and health policy advocacy organization. “There’s a process that needs to be followed,” she said, about making changes with public input. “I would strongly urge them to consider the dire consequences when people don’t have effective communication.”

Even if the federal government ultimately doesn’t offer language services for the public, Youdelman said, hospitals and health providers are required to provide language assistance at no charge to patients.

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race or national origin, protections that extend to language. And the 2010 Affordable Care Act, which expanded health coverage for millions of Americans and adopted numerous consumer protections, requires health providers receiving federal funds to make language services, including translation and interpretation, available. 

“English can be the official language and people still have a right to get language services when they go to access health care,” Youdelman said. “Nothing in the executive order changed the actual law.”

Insurers still need to include multi-language taglines in their correspondence to enrollees explaining how they can access language services. And health facilities must post visible notices informing patients about language assistance services and guarantee certified and qualified interpreters.

State and local governments could broaden their own language access requirements. A few states have taken such actions in recent years, and California state lawmakers are that would establish a language access director, mandate human review of AI translations, and improve surveys assessing language needs.

“With increasing uncertainty at the federal level, state and local access laws and policies are even more consequential,” said Jake Hofstetter, policy analyst at the Migration Policy Institute.

The Los Angeles Department of Public Health and San Francisco’s Office of Civic Engagement and Immigrants Affairs said their language services have not been affected by Trump’s executive order or federal funding cuts.

Demand, however, has dropped. Aurora Pedro of Comunidades Indígenas en Liderazgo, one of the few medical interpreters in Los Angeles who speaks Akatek and Qʼanjobʼal, Mayan languages from Guatemala, said she has received fewer calls for her services since Trump took office.  

And other pockets of California have reduced language services because of the federal funding cuts. 

Hernán Treviño, a spokesperson for the Fresno County Department of Public Health, said the county cut the number of community health workers by more than half, from 49 to 20 positions. That reduced the availability of on-the-ground navigators who speak Spanish, Hmong, or Indigenous languages from Latin America and help immigrants enroll in health plans and schedule routine screenings.

Treviño said staffers are still available to support residents in Spanish, Hmong, Lao, and Punjabi at county offices. A free phone line is also available to help residents access services in their preferred language.

Mary Anne Foo, executive director of the Orange County Asian and Pacific Islander Community Alliance, said the federal Substance Abuse and Mental Health Services Administration froze $394,000 left in a two-year contract to improve mental health services. As a result, the alliance is planning to let go 27 of its 62 bilingual therapists, psychiatrists, and case managers. The organization serves more than 80,000 patients who speak over 20 languages.

“We can only keep them through June 30,” Foo said. “We’re still trying to figure it out — if we can cover people.”

Orozco Rodriguez reported from Elko, Nevada.

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It’s a striking reversal for the Democrat, who had promised universal health care and called health coverage for immigrants the . But a, potential federal spending cuts, and larger-than-expected Medi-Cal enrollment have forced him to dial back.

Newsom said he had no other choice but to call for major cost-cutting measures affecting how some immigrants are covered by Medi-Cal, the state’s Medicaid program, which covers about 15 million Californians.

“The challenge that we face this year and the challenge we will face for many years is on growth of our Medicaid system, Medi-Cal,” Newsom told reporters at his budget presentation. “Instead of rolling back the program, cutting people off for basic care, we have to adjust the comprehensive nature of the care.”

California is that offer health coverage to low-income adults regardless of immigration status, and that has put the program in the political crosshairs of national Republicans. The would cut Medicaid funding by 10 percentage points for states that provide coverage for immigrants without legal status — an approach Newsom on Wednesday described as legally questionable. Meanwhile, the Trump administration cited California’s health coverage of noncitizens as an example of states “” when it issued a proposed rule Monday to overhaul Medicaid provider taxes.

Some 1.6 million immigrants — most without legal status — are enrolled in Medi-Cal. Federal law prohibits Medicaid dollars from being used to cover unauthorized residents, meaning California must foot the bill for the vast majority of their health care. And those costs have ballooned.

Newsom cautioned that California, like other states, could soon be in a more dire budget situation if Republicans advance their proposal to cut Medicaid. That plan includes work requirements and would cap taxes levied on providers that help states draw additional federal money. However, the governor’s budget proposal was silent on potential federal cuts.

The $321.9 billion budget proposes a for immigrants 19 and older without legal status, starting Jan. 1. Beginning in 2027, immigrants 19 and older in the country illegally, as well as those with legal residency for less than five years, would be required to pay $100 monthly premiums to maintain coverage.

The Newsom administration estimated those two moves would save the state $5.4 billion by the 2028-29 fiscal year. The governor also called for eliminating dental and long-term care benefits for those without legal status and for legal residents who arrived in the U.S. less than five years ago, according to California Department of Finance spokesperson H.D. Palmer.

The changes would not apply to the roughly 217,000 children and young adults without legal status covered by Medi-Cal. Those 18 and under were the first to receive Medi-Cal coverage, in 2016. Children are generally healthier and require less care, and a Ñî¹óåú´«Ã½Ò•îl Health News analysis showed that, in many cases, children lacking legal status were cheaper to cover than citizens.

Maria, a street vendor from Los Angeles, said the monthly premium alone would force her and others to forgo care.

“They say they are one of the largest economies, but they don’t want to help us,” said Maria, who didn’t want to give her full name, out of fear of retaliation from immigration authorities. “We are contributing to the state. It’s not fair that we, the poor, have to pay what we don’t have.”

“Where am I going to get the $100?” Maria asked.

Federal law prohibits charging the poorest Medicaid enrollees a premium, and Newsom’s $100 monthly payment would be considered unaffordable for current beneficiaries, said Laurel Lucia, director of the health care program at the University of California-Berkeley Labor Center.

Newsom is proposing a $194.5 billion Medi-Cal budget for 2025-26. Lawmakers have until June 15 to pass the budget. Democratic leaders signaled their intent to protect health care for the state’s poorest residents.

The governor and Assembly Speaker Robert Rivas blamed fiscal headwinds brought on by President Donald Trump’s tariffs, which they said had led to a massive $16 billion dip in state tax revenue forecasts since April. But Medi-Cal spending surged well before the tariffs took effect. State costs to cover Californians with “unsatisfactory immigration status” — those without status and legal residents who have been here less than five years — is roughly $10.8 billion per year, up from the $6.4 billion officials projected in November. The federal government pays $1.2 billion of that to cover mandated emergency and pregnancy care.

“It’s laughable that he’s trying to blame Trump for anything,” Republican Assembly member Joe Patterson, who sits on the Assembly Budget Committee, said of Newsom. “He overpromised to them, and he’s pulling the carpet out from underneath them.”

Other states that have extended coverage to immigrants are also struggling with escalating costs. Minnesota, for example, originally projected that 5,700 residents without legal status would sign up for the state Medicaid program, known as MinnesotaCare, at a cost of $200 million. Both figures have increased roughly threefold.

Illinois is ending services for adult immigrants, except seniors, on , citing higher-than-anticipated enrollment. The mostly state-funded health plan will stop covering around 30,000 noncitizens ages 42 to 64, including those living in the country without authorization.

Newsom said Wednesday that without a suite of his proposed changes to Medi-Cal, program costs could grow by an additional $10 billion through June 2026 and would “contribute significantly to the structural imbalance in future years.”

But consumer advocates and lawmakers said the move is a betrayal of the governor’s commitment to bring California closer to universal health care and warned it would push immigrants into costly emergency room care. Sen. María Elena Durazo, a Democrat who championed the Medi-Cal expansion, said California shouldn’t single out immigrants to solve its budget deficit.

“I don’t agree that we should be isolating and abandoning and separating a particular group of Californians, as if they are responsible for the problem,” Durazo said. “I don’t care what you call them, they work, they contribute.”

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Reddy can’t match the salaries offered by larger health systems — a difficulty compounded by a widespread shortage of primary care doctors.

The shortage is tied largely to the lower pay and relative lack of prestige associated with primary care, making recruitment difficult. “It certainly is challenging to expose medical students early in their careers to the joys of this kind of integrated health care,” Reddy said. “The relationships we build and the care we provide truly allow people to live longer with a better quality of life.”

Hoping to increase revenue so Acacia can afford to pay more, Reddy has signed the practice up for alternative payment methods with health plans that offer bonuses for meeting certain primary care goals tied to child vaccinations, blood pressure control, and screenings for breast cancer, colorectal cancer, and mental health. Such pay-for-performance arrangements are among the many efforts by industry players and state officials to confront the problems plaguing primary care.

frequently opt not to go into primary care, and that’s not good for patients. People with regular primary care providers are more likely to that avoids serious illnesses and feel more empowered to advocate for themselves. They’re also less likely to encounter language barriers, resort to costly emergency room visits, or forgo care.

Six years after the influential California Future Health Workforce Commission made a to plug a projected shortage of 4,100 primary care providers in 2030, a number of public and private initiatives have proliferated around the state to address the problem. They include new residency slots, debt forgiveness, waived medical school tuition, new ways of paying doctors, expanded nurse practitioner roles, and a statewide target to increase primary care spending. Hundreds of millions of taxpayer dollars have been allocated for some of these efforts.

But numerous academic experts and medical professionals believe those moves, while well intended, have been scattershot and insufficient. “The pieces are there,” said Monica Soni, chief medical officer of Covered California, the state’s Affordable Care Act health insurance marketplace. “I am worried we started a little too late, and I think it’s a little too siloed.”

A by the California Health Care Foundation found that substantial progress had been made on some of those goals, including recruitment of students from low-income households and communities of color. A separate analysis from the foundation showed that, from 2020 to 2023, California jumped about 10 spots in a ranking of states by primary care residents and fellows per capita.

However, the latest state data shows nearly 15 million Californians live in areas without enough primary care providers to meet patient needs.

State budget constraints and , especially to Medicaid, could exacerbate shortages in areas already desperate for clinicians and dampen hopes of building a robust primary care system that state officials and virtually everyone in the industry agree would be a strong defense against serious — and costly — illnesses. Federal cuts could also hit medical training and hospital systems.

“Many of us are very scared about threats from both the Trump administration and Republicans in Congress,” said , a family community medicine professor at the University of California-San Francisco.

Acute Primary Care Shortages

California’s lack of primary care providers, including doctors, nurse practitioners, and physician assistants, is most acute in rural parts of the state, particularly in the north and the Central Valley. Entire rural counties, including Del Norte, Madera, Tulare, and Yuba, are designated shortage areas, according to state data. Some densely populated urban areas, including parts of Los Angeles, also confront shortages.

Many Californians face months-long waits for appointments or have to travel long distances or go to emergency rooms for nonurgent medical needs, which means hours spent in crowded waiting rooms for unnecessarily expensive care.

In Chico, 90 miles north of Sacramento, the emergency room at the only hospital in town has seen a sharp increase in patients over the past decade, due in part to a lack of primary care providers in the area.

“People who don’t have a primary care provider — which is a lot, because there are not enough — end up in the ER when they need routine care,” said David Alonso, a local internal medicine doctor. “The ER then says, ‘OK, you should follow up with your primary care provider,’ and they’re like, ‘We don’t have one.’”

, director of the Robert Graham Center for Policy Studies, a health policy think tank, said failure to invest robustly in primary care has robbed the public of its benefits.

The field has historically been underfunded, accounting for of national health care spending in 2022, according to the Milbank Memorial Fund, a national nonprofit focused on population health and health equity.

The consequences are clear.

The U.S. spends significantly more per capita on health care than other industrialized nations, and yet Americans aren’t any healthier. Chronic conditions such as heart disease, diabetes, arthritis, and Alzheimer’s, as well as mental illness, account for 90% of the $4.5 trillion spent on health care .

Medical students, often faced with staggering educational debt, are increasingly over primary care. The average salary of a family medicine physician is slightly over $300,000, compared with more than $565,000 for a cardiologist and over $763,000 for a neurosurgeon, according to .

“If you are going to pay over $300,000 to go to medical school, you want to be a neurosurgeon; you don’t want to be a family practice doctor,” said William Barcellona, executive vice president of government affairs at , a Los Angeles-based professional association representing 360 medical groups and independent practice associations nationwide.

Barcellona said the Golden State’s high housing costs also make recruiting difficult.

But it’s not only pay that tempers enthusiasm for primary care. It’s also burnout from so many unpaid hours spent recording details of medical visits in electronic health records; haggling with insurance companies for treatment authorization; answering phone calls and emails from patients; or searching far and wide — often in a health care desert — for specialists with the right expertise.

Debby Lee, the daughter of Hmong immigrants from Laos, experienced this kind of frustration firsthand.

Cultural and linguistic barriers faced by her family motivated her to pursue internal medicine. Lee worked part of her residency at a community clinic serving Hmong in the Sacramento area. She loved the patients, as well as her co-workers. But she was burdened by outdated technology that limited the number of patients she could see. “I just saw myself kind of burning out being in that setting,” Lee said.

When the clinic invited her to stay, she declined, taking a job with a bigger health system.

Solutions to the Shortage

Besides residencies, other efforts support primary care.

The Health Plan of San Mateo offers grants to help medical practices retain and add to primary care staff. In exchange, the practices — some single physicians serving patients in California’s Medicaid program, Medi-Cal — must show they have increased their patient load and retained newly hired providers for five years.

The idea is to provide capital so doctors can hire the staff they need to run their practices efficiently, increase salaries, offer bonuses, and even take sabbaticals. Such efforts are consistent with one of the main thrusts of the 2019 workforce report: to increase investment in primary care.

California recently joined several other states, including Connecticut, Oklahoma, and Rhode Island, in setting a target to increase primary care spending. So far, those policies have yielded .

Late last year, California’s Office of Health Care Affordability set a target to make primary care of total health care spending by 2034, more than double the current proportion. It imposes no requirements, relying on the goodwill of health plans to work with medical providers.

Greater spending on primary care would mean better pay and more people working in the field, said Richard Kronick, a public health professor at UC-San Diego and a member of the OHCA board. “That’s a big change. Will it happen? I don’t think anyone can predict the future with any certainty.”

Stephen Shortell, a professor emeritus of health policy and management at UC-Berkeley, said “some of that increase might occur, but at some point, it might need to be made mandatory.”

In its report, the workforce commission also cited the importance of alternative forms of primary care payment that offer extra cash for quality care. The affordability office has to encourage such payment methods. The aim is to transform the system from one in which every medical service has a price tag to one that treats people holistically, and in which adherence to medical standards brings more money to doctors and their office staff.

Such arrangements are common among HMOs, though less so in primary care practices. Where they do exist, different health plans and other payers generally design them differently, which means primary care practices manage multiple payment models, adding to their administrative burden.

Reddy’s family practice is participating in a one-year demonstration project intended to reduce that burden by having multiple insurers work together in one payment plan.

The project brings together three large insurers — Health Net, Aetna, and Blue Shield of California — and 10 independent practices across the state with the goal of improving care while boosting revenue for the medical groups. It is administered by two industry groups, the and the .

On top of customary payments, either for services rendered or monthly per-member allotments, the medical practices receive bonuses for meeting targets or improving their performance on .

Participating practices also receive monthly per-patient payments for “population health management,” which means managing the collective health of their patients. And they can search a single platform to find all their patients covered by one of the three plans.

In addition to extra payments and fewer administrative hassles, the health plans pay for a “practice coach,” whose job is to help primary care groups meet their targets and provide more seamless care.

The idea is to add more insurers and medical groups over time, said Todd May, Health Net’s medical director for commercial health plans, who is among those driving the project. “In addition to better outcomes, we’d like to see a stronger, more robust, and more satisfied primary care workforce,” he said.

Reddy hopes she can increase Acacia’s revenue by 20%, using the extra money from this and other pay-for-performance arrangements. That, she said, would enable her to raise pay for her staff and hire clinicians.

For many years, her practice has limited the number of patients it has accepted. But after searching for the better part of five years, Reddy has hired a doctor on a half-time basis and another is coming on board in June.

“This is the most hopeful I have felt in decades,” Reddy said.

Phillip Reese contributed to this report.

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Josephine, 16, has been diagnosed with , severe autism, severe obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder, among other conditions, which will require constant assistance and supervision for the rest of her life.

Ortiz, 25, is Josephine’s caregiver. A Venezuelan immigrant, Ortiz helps Josephine eat, bathe, and perform other daily tasks that the teen cannot do alone at her home in West Orange, New Jersey. Over the past 2½ years, Ortiz said, she has developed an instinct for spotting potential triggers before they escalate. She closes doors and peels barcode stickers off apples to ease Josephine’s anxiety.

But Ortiz’s ability to work in the U.S. has been thrown into doubt by the Trump administration, which to the temporary protected status program for some Venezuelans on April 7. On March 31, a federal judge , giving the administration a week to appeal. If the termination goes through, Ortiz would have to leave the country or risk detention and deportation.

“Our family would be gutted beyond belief,” said Krysta Senek, Josephine’s mother, who has been trying to win a reprieve for Ortiz.

Americans depend on many such foreign-born workers to help care for family members who are older, injured, or disabled and cannot care for themselves. Nearly 6 million people receive personal care in a private home or a group home, and about 2 million people use these services in a nursing home or other long-term care institution, according to a .

Increasingly, the workers who provide that care are immigrants such as Ortiz. The foreign-born share of nursing home workers rose three percentage points from 2007 to 2021, to about 18%, according to an by the Baker Institute for Public Policy at Rice University in Houston.

And foreign-born workers make up a high share of other direct care providers. More than 40% of home health aides, 28% of personal care workers, and 21% of nursing assistants were foreign-born in 2022, compared with 18% of workers overall that year, according to .

That workforce is in jeopardy amid an immigration crackdown President Donald Trump launched on his first day back in office. He signed executive orders that without a court hearing, , and more recently for nationals of Cuba, Haiti, Nicaragua, and Venezuela.

In to deport Venezuelans and attempting to for others, the Trump administration has sparked fear that even those who have followed the nation’s immigration rules could be targeted.

“There’s just a general anxiety about what this could all mean, even if somebody is here legally,” said , president of LeadingAge, a nonprofit representing more than 5,000 nursing homes, assisted living facilities, and other services for aging patients. “There’s concern about unfair targeting, unfair activity that could just create trauma, even if they don’t ultimately end up being deported, and that’s disruptive to a health care environment.”

Shutting down pathways for immigrants to work in the United States, Smith Sloan said, also means many other foreign workers may go instead to countries where they are welcomed and needed.

“We are in competition for the same pool of workers,” she said.

Growing Demand as Labor Pool Likely To Shrink

Demand for caregivers is predicted to surge in the U.S. as the youngest baby boomers reach retirement age, with the need for home health and personal care aides over a decade, according to the Bureau of Labor Statistics. Those 820,000 additional positions represent the most of any occupation. The need for also is projected to grow, by about 65,000 positions.

Caregiving is often low-paying and physically demanding work that doesn’t attract enough native-born Americans. The median pay ranges from about to a year, according to the Bureau of Labor Statistics.

Nursing homes, assisted living facilities, and home health agencies have long struggled with high turnover rates and staffing shortages, Smith Sloan said, and they now fear that Trump’s immigration policies will choke off a key source of workers, leaving many older and disabled Americans without someone to help them eat, dress, and perform daily activities.

With the Trump administration , which runs programs supporting older adults and people with disabilities, and Congress considering deep cuts to Medicaid, the largest payer for long-term care in the nation, the president’s anti-immigration policies are creating “a perfect storm” for a sector that has not recovered from the covid-19 pandemic, said , an executive vice president of the Service Employees International Union, which represents nursing facility workers and home health aides.

The relationships caregivers build with their clients can take years to develop, Frane said, and replacements are already hard to find.

In September, LeadingAge to help the industry meet staffing needs by raising caps on work-related immigration visas, expanding refugee status to more people, and allowing immigrants to test for professional licenses in their native language, among other recommendations.

But, Smith Sloan said, “There’s not a lot of appetite for our message right now.”

The White House did not respond to questions about how the administration would address the need for workers in long-term care. Spokesperson Kush Desai said the president was given “a resounding mandate from the American people to enforce our immigration laws and put Americans first” while building on the “progress made during the first Trump presidency to bolster our healthcare workforce and increase healthcare affordability.”

Refugees Fill Nursing Home Jobs in Wisconsin

Until Trump suspended the refugee resettlement program, some nursing homes in Wisconsin had partnered with local churches and job placement programs to hire foreign-born workers, said Robin Wolzenburg, a senior vice president for LeadingAge Wisconsin.

Many work in food service and housekeeping, roles that free up nurses and nursing assistants to work directly with patients. Wolzenburg said many immigrants are interested in direct care roles but take on ancillary roles because they cannot speak English fluently or lack U.S. certification.

Through a partnership with the Wisconsin health department and local schools, Wolzenburg said, nursing homes have begun to offer training in English, Spanish, and Hmong for immigrant workers to become direct care professionals. Wolzenburg said the group planned to roll out training in Swahili soon for Congolese women in the state.

Over the past 2½ years, she said, the partnership helped Wisconsin nursing homes fill more than two dozen jobs. Because refugee admissions are suspended, Wolzenburg said, resettlement agencies aren’t taking on new candidates and have paused job placements to nursing homes.

Many older and disabled immigrants who are permanent residents rely on foreign-born caregivers who speak their native language and know their customs. Frane with the SEIU noted that many members of San Francisco’s large Chinese American community want their aging parents to be cared for at home, preferably by someone who can speak the language.

“In California alone, we have members who speak 12 different languages,” Frane said. “That skill translates into a kind of care and connection with consumers that will be very difficult to replicate if the supply of immigrant caregivers is diminished.”

The Ecosystem a Caregiver Supports

Caregiving is the kind of work that makes other work possible, Frane said. Without outside caregivers, the lives of the patient and their loved ones become more difficult logistically and economically.

“Think of it like pulling out a Jenga stick from a Jenga pile, and the thing starts to topple,” she said.

Thanks to the one-on-one care from Ortiz, Josephine has learned to communicate when she’s hungry or needs help. She now picks up her clothes and is learning to do her own hair. With her anxiety more under control, the violent meltdowns that once marked her weeks have become far less frequent, Ortiz said.

“We live in Josephine’s world,” Ortiz said in Spanish. “I try to help her find her voice and communicate her feelings.”

Ortiz moved to New Jersey from Venezuela in 2022 as part of an au pair program that connects foreign-born workers with people who are older or children with disabilities who need a caregiver at home. Fearing political unrest and crime in her home country, she got temporary protected status when her visa expired last year to keep her authorization to work in the United States and stay with Josephine.

Losing Ortiz would upend Josephine’s progress, Senek said. The teen would lose not only a caregiver, but also a sister and her best friend. The emotional impact would be devastating.

“You have no way to explain to her, ‘Oh, Alanys is being kicked out of the country, and she can’t come back,’” she said.

It’s not just Josephine: Senek and her husband depend on Ortiz so they can work full-time jobs and take care of themselves and their marriage. “She’s not just an au pair,” Senek said.

The family has called its congressional representatives for help. Even a relative who voted for Trump sent a letter to the president asking him to reconsider his decision.

In the March 31 court decision, U.S. District Judge Edward Chen wrote that canceling the protection could “inflict irreparable harm on hundreds of thousands of persons whose lives, families, and livelihoods will be severely disrupted.”

‘Doing the Work That Their Own People Don’t Want To Do’

News of immigration dragnets that sweep up and are causing a lot of stress, even for those who have followed the rules, said Nelly Prieto, 62, who cares for an 88-year-old man with Alzheimer’s disease and a man in his 30s with Down syndrome in Yakima County, Washington.

Born in Mexico, she immigrated to the United States at age 12 and became a U.S. citizen under authorized by President Ronald Reagan that made any immigrant who entered the country before 1982 eligible for amnesty. So, she’s not worried for herself. But, she said, some of her co-workers working under are very afraid.

“It kills me to see them when they talk to me about things like that, the fear in their faces,” she said. “They even have letters, notarized letters, ready in case something like that happens, saying where their kids can go.”

Foreign-born home health workers feel they are contributing a valuable service to American society by caring for its most vulnerable, Prieto said. But their efforts are overshadowed by rhetoric and policies that make immigrants feel as if they don’t belong.

“If they cannot appreciate our work, if they cannot appreciate us taking care of their own parents, their own grandparents, their own children, then what else do they want?” she said. “We’re only doing the work that their own people don’t want to do.”

In New Jersey, Ortiz said life has not been the same since she received the news that her TPS authorization was slated to end soon. When she walks outside, she fears that immigration agents will detain her just because she’s from Venezuela.

She’s become extra cautious, always carrying proof that she’s authorized to work and live in the U.S.

Ortiz worries that she’ll end up in a detention center. But even if the U.S. now feels less welcoming, she said, going back to Venezuela is not a safe option.

“I might not mean anything to someone who supports deportations,” Ortiz said. “I know I’m important to three people who need me.”

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When patients picked up prescriptions for testosterone replacement therapy, law enforcement retrieved their names and addresses .

And when a father was arrested by immigration authorities, agents his personal information from a medical clinic where he received diabetes treatment.

Progressive California lawmakers have proposed a number of bills aimed at bolstering privacy protections for women, transgender people, and immigrants in response to such intrusions by anti-abortion groups, conservative states, and federal law enforcement agencies as President Donald Trump declares the nation “” and flexes his executive power to roll back rights.

Democrats have supermajorities in the state legislature, but even if they pass the proposals, they may first need to lobby one of their own: Gov. Gavin Newsom, who has noticeably tempered his once harsh criticism of Trump.

Last month, the Democratic governor issued against a bill that would expand the state’s sanctuary law to limit cooperation between state prisons and federal immigration agents. And Newsom recently called transgender athletes’ participation in women’s sports on his new podcast with guest Charlie Kirk, a founder of the conservative group Turning Point USA. Newsom went on to tell Kirk that he had a “” the way the right talks about transgender people.

Billions of dollars are also on the line for California. Newsom visited the White House last month seeking for wildfire victims in Los Angeles, and the state relies on Washington for over 60% of its Medicaid budget, which is vulnerable to significant cuts under the GOP’s budget blueprint.

“California’s leaders have not been as aggressive, out of recognition that there are many things that the state needs federal cooperation on,” said , a political science professor at the University of California-San Diego.

A Newsom spokesperson declined to comment on pending legislation. He has a track record of supporting abortion, transgender, and immigrant rights.

Since taking office, Trump has granted the Elon Musk-controlled Department of Government Efficiency — created through a Trump executive order — access to , including medical information, raising concerns that sensitive information could be exposed without proper safeguards. 

The White House did not respond to requests for comment.

While most Americans are familiar with the Health Insurance Portability and Accountability Act, known as HIPAA, it offers only narrow protection for patients in health care settings. There’s no comprehensive federal law protecting data privacy.

Health care information has increasingly become a tool of surveillance and enforcement, and in states that have banned certain medical treatments or toughened immigration laws, vulnerable populations are at greater risk, said Suzanne Bernstein, a health privacy rights expert with the Electronic Privacy Information Center.

Progressive Democrats are concerned that personal information and people’s medical decisions could be used to monitor or criminalize patients, facilitate arrests in or near health care facilities, or jeopardize access to health care services.

They and health privacy advocates say now is the time to shore up protections for the nearly 2 million immigrants living in California without authorization, the more than transgender adults in the state, and — living in the state or out of state — in need of abortion care in California each year. Some of these laws could take effect immediately if signed.

“This is about making sure that people are able to access critical health care in California and to take the politics out of our hospitals and health clinics,” said state Sen. Jesse Arreguín, who hopes the governor would sign his .

The bills are expected to be debated in Sacramento in the coming months.

Since the Supreme Court overturned the constitutional right to abortion, anti-abortion groups have purchased location information from consumer data companies to target people seeking abortion care with anti-abortion ads. And authorities in states with abortion bans have to enforce laws beyond their borders.

A bill introduced by state Assembly member Rebecca Bauer-Kahan, , would make geofencing, the collection of phone location by data brokers, illegal around health care facilities that provide in-person services. It would reproductive health information collected during research from being disclosed in response to out-of-state requests.

Conservative organizations said the proposal would single them out by restricting their ability to inform women about alternatives to abortion, including services offered by crisis pregnancy centers.

“I think that could very well be a First Amendment violation,” said Jonathan Keller, president of the California Family Council, a statewide anti-abortion nonprofit. “It doesn’t seem like the bill would be prohibiting or putting any restrictions on a group like Planned Parenthood if they wanted to market or target to a local high school or college.”

So far this year, lawmakers in 49 states have introduced more than 700 anti-transgender bills, seeking to ban gender-affirming care, prohibit gender identity education in schools, or restrict transgender students from participating in sports, according to the , a national research organization tracking bills affecting transgender people. Transgender adults represent of the U.S. population.

And some states with bans or restrictions on gender-affirming care have been targeting health care data. In 2023, requested that Florida universities release data on the number of individuals who have been diagnosed with gender dysphoria or received treatment at campus clinics. That same year, Missouri’s Republican attorney general, Andrew Bailey, submitted to one hospital seeking information about gender-affirming care procedures.

Trump has issued a series of executive orders to ban access to gender-affirming care for minors. Federal judges some portions of his orders.

To guard against other states that criminalize or ban gender-affirming care, California state Sen. Scott Wiener wants to expand current protections for minors to include adults.

His bill, , would require law enforcement to obtain a warrant to access state databases on gender-affirming care and make it a misdemeanor to release the data to unauthorized parties. It would also prohibit health care providers, employers, and insurers from releasing information about a person who seeks or obtains gender-affirming physical and mental health care to an agency or individual from another state.

“We want to make sure that we are as comprehensively as possible shielding trans people from hate emanating from the federal government, other states, and private parties,” Wiener said.

Keller countered that authorities in states with bans on abortion or gender-affirming care should have access to medical information as they investigate providers who could harm patients or coerce them into procedures against their will. He cited a over a teenager who detransitioned after undergoing gender-affirming care. A found it was uncommon for people undergoing gender-affirming care to decide to permanently detransition.

“The only way that you’re able to uncover that level of widespread malpractice and malfeasance is if these health care records are able to be accessed,” Keller said.

The California Family Council plans to oppose both bills.

Earlier this year, Trump rescinded a long-standing policy of not making immigration arrests near hospitals, schools, or churches. The decision has providers fearful that Immigration and Customs Enforcement agents will disrupt their work at health facilities and prompt immigrants to skip medical care — for themselves or, of particular concern, their children.

Anticipating the move, California’s Democratic attorney general, Rob Bonta, issued guidance in December advising health care providers how best to respond if ICE comes to their doorstep. But while private entities are encouraged to follow these policies, only state-run facilities are required to adopt them.

“Some health care providers have implemented them, but not everyone has,” Arreguín said.

Arreguín’s would require all health care facilities, including hospitals and community-based clinics, to follow state guidance to limit cooperation with immigration authorities. It would also prohibit providers from granting access to private areas or places where a patient is actively receiving treatment or care, unless there’s a warrant.

Another immigration bill, , would limit the sharing of local law enforcement information if agents plan to make an arrest within a one-mile radius of a hospital or medical office, a child care or day care facility, a religious institution, or a place of worship. California law enforcement has some discretion to share information with immigration agents when an individual has been convicted of a serious crime or felony.

Kousser said immigration is more complicated for California politicians than health privacy. Although a February poll by the Public Policy Institute of California found that Californians think immigrants are a benefit to the state, Kousser said that lawmakers, especially those who won by narrow margins in contested districts, still have to make tough political choices.

Senate Republican leader Brian Jones, who represents a predominantly Democratic district in San Diego, to change California’s sanctuary policies to require law enforcement to share information with ICE when a person has been convicted of a serious crime.

“When these violent felons are released from local custody, they go right back into the communities that they came from to re-victimize those same immigrant communities,” Jones said.

But Jones acknowledged the need for nuance when it comes to health privacy.

“Look, the bottom line for me on this immigration reform in America is it needs to be humanitarian and it needs to make sense,” Jones said. “And so, if there are areas that we need to protect folks, it might make sense.”

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His administration not to arrest people without legal status at or near sensitive locations, including hospitals. That has left different states offering starkly different guidelines to hospitals, community clinics, and other health facilities for interacting with immigrant patients.

• California health care providers to avoid including patients’ immigration status in bills and medical records and telling them that, while they should not physically obstruct immigration agents, they are under no obligation to assist with an arrest. The guidance from Democratic Attorney General Rob Bonta also encourages facilities to post information about patients’ right to remain silent and provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.”
• Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization. Still, patients can refuse to answer questions about their immigration status without losing access to care.

Some health care providers fear immigration authorities will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. They point to examples from Trump’s first term, when agents arrested a child , a young man , and a woman .

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

On Tuesday, Trump directed the U.S. Department of Justice to who don’t cooperate with immigration enforcement.

But no matter the guidelines that states issue, hospitals around the U.S. stress one thing: Patients won’t be turned away for care because of their immigration status.

“None of this changes the care patients receive,” said Carrie Williams, a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

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Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization.

Donald Trump returned to the White House declaring a at the U.S.-Mexico border, , and , or the policy of giving U.S. citizenship to anyone born in the U.S. As he begins carrying out the “” in the nation’s history, states have offered starkly different guidelines to hospitals, community clinics, and other health facilities for immigrant patients.

Trump has also not to arrest people without legal status at or near sensitive locations, including schools, churches, and hospitals. to formalize such protections died in Congress in 2023.

But no matter the guidelines that states issue, hospitals around the U.S. say patients won’t be turned away for care because of their immigration status. “None of this changes the care patients receive,” said , a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

During Trump’s first term, immigration agents arrested people receiving emergency care in hospitals and a child during an . Immigration officers in Texas arrested a in a hospital in Fort Worth. In Portland, Oregon, officers leaving a hospital, and in San Bernardino, California, a woman to give birth after her husband was arrested at a gas station.

An estimated 11 million immigrants live in the United States without authorization, with the in California, Texas, Florida, New York, New Jersey, and Illinois, according to Pew Research Center.

Half of immigrant adults likely without authorization are uninsured, compared with fewer than 1 in 10 citizens, according to the , the largest nongovernmental survey of immigrants in the U.S. to date. While some states are highlighting health care expenses incurred by immigrants, a noted that immigrants contribute more to the system through health insurance premiums and taxes than they use. Immigrants also have lower health care costs than citizens.

Some health care providers fear Immigration and Customs Enforcement agents will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. On Trump’s first day, the Republican president issued an executive order aimed at ending birthright citizenship for children born to a parent without legal authorization or on a visa, which could leave them ineligible for federal health and social programs. The order was immediately challenged and a .

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need, who may not be able to get treatment for an ear infection or surgery,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

A conducted by the Im/migrant Well-Being Research Center at the University of South Florida found that 66% of noncitizens reported increased hesitation in seeking care after Florida Gov. Ron DeSantis signed in 2023 requiring hospitals that accept Medicaid to ask about a patient’s legal status. That’s compared with just 27% for citizens.

“That really was alarming to me to see how this law made people hesitant to go to the doctor, even in an emergency,” said , a co-author of the survey and report.

In signing the law, DeSantis as “the most ambitious anti-illegal immigration” legislation in the nation. This month, the Republican governor called for a special session of the state legislature to help support Trump’s immigration agenda.

Jackson Health System, a public safety net provider in Miami, said in a statement that quarterly reports to the state don’t contain individual patient information. “We do adhere to all required cooperation with law enforcement agencies, including ICE, as part of any criminal investigations, understanding that privacy laws mandate we only release private patient information through a court-ordered warrant.”

In August, Texas Gov. Greg Abbott, a Republican, issued an similar to Florida’s law to record health care costs incurred by immigrants without legal authorization. All hospitals that receive funding from Medicaid or the Children’s Health Insurance Program are expected to begin reporting the data to Texas Health and Human Services in March.

Even cities controlled by Democrats are walking a fine line. New York City Mayor Eric Adams met in December with Trump’s incoming “border czar,” Tom Homan, and pledged to who have been convicted of a major felony and lack legal status to remain in the country.

At the same time, Adams proposed an awareness campaign to let immigrants and asylum-seekers know they are safe to use the city’s hospital systems.

Some states are going further by advising health facilities to do all they can to protect immigrant patients.

In December, California Attorney General Rob Bonta released a 42-page document recommending providers avoid including patients’ immigration status in bills and medical records. The guidance also emphasized that while providers should not physically obstruct immigration agents, they are under no obligation to assist with an arrest.

According to the document, health care facilities should post information about patients’ right to remain silent and are encouraged to provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.” If feasible, it says, the facility should designate an immigrant-affairs liaison to help train staff and provide nonlegal advice to families.

“We cannot let the Trump deportation machine create a culture of fear and mistrust that prevents immigrants from accessing vital public services,” said Bonta, a Democrat.

On Tuesday, the Trump administration directed the Department of Justice to who don’t cooperate with immigration enforcement. During Trump’s first term, California limited cooperation with federal authorities, citing public safety and community trust concerns. The department, then under Jeff Sessions, but the state won in federal court, arguing that states have the authority to decide whether local resources are used to enforce federal law. The Trump administration appealed, but the Supreme Court turned down the petition.

Under California law, state-run health care facilities are required to adopt policies to limit their participation in immigration enforcement, and private entities are encouraged to follow similar protocols. David Simon, a spokesperson for the California Hospital Association, which represents more than 400 hospitals, said members have incorporated such policies, ensuring patient privacy.

“Hospitals don’t call ICE about patients,” Simon said.

California is bracing for a new round of clashes with Trump. Gov. Gavin Newsom and fellow Democratic state leaders have agreed to set aside for litigation and grants to nonprofit immigrant groups.

Lawmakers in New Jersey are to limit health care facilities from asking about a patient’s immigration status. The bill would also require the state attorney general to establish policies for hospitals and health care facilities for ensuring patient access.

In New York City, hospital administrators are directing staff to seek guidance from an “immigration liaison” if immigration authorities show up, and to take photos and videos of any enforcement actions if they can’t reach them first. They are also discouraging staff from actively helping a person hide from ICE. In Massachusetts, some clinics and hospitals are training staff on how to read ICE warrants and plan to require ICE agents to identify themselves and present a warrant if they want to enter a private area.

“You can’t be scrambling in the moment,” said Altaf Saadi, a neurologist who co-directs a clinic for asylum-seekers at the Massachusetts General Hospital. “We have to prepare for these worst-case scenarios, and we hope that they don’t happen, but we do need to be prepared.”

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At the same time, immigrants living illegally in Southern California told Ñî¹óåú´«Ã½Ò•îl Health News they thought the economy would improve and their incomes might increase under Trump, and for some that outweighed concerns about health care.

Community health workers say fear of deportation is already affecting participation in Medi-Cal, the state’s Medicaid program for low-income residents, which was expanded in phases to all immigrants regardless of residency status over the past several years. That could undercut the state’s progress in reducing the uninsured rate, which reached a record low of 6.4% last year.

Immigrants lacking legal residency have long worried that participation in government programs could make them targets, and Trump’s election has compounded those concerns, community advocates say.

The incoming Trump administration is also expected to target Medicaid with funding cuts and enrollment restrictions, which activists worry could threaten the Medi-Cal expansion and kneecap efforts to extend health insurance subsidies under Covered California to all immigrants.

“The fear alone has so many consequences to the health of our communities,” said , director of policy with the Latino Coalition for a Healthy California. “This is, as they say, not their first rodeo. They understand how the system works. I think this machine is going to be, unfortunately, a lot more harmful to our communities.”

Alongside such worries, though, is a strain of optimism that Trump might be a boon to the economy, according to interviews with immigrants in Los Angeles whom health care workers were soliciting to sign up for Medi-Cal.

Selvin, 39, who, like others interviewed for this article, asked to be identified by only his first name because he’s living here without legal permission, said that even though he believes Trump dislikes people like him, he thinks the new administration could help boost his hours at the food processing facility where he works packing noodles. “I do see how he could improve the economy. From that perspective, I think it’s good that he won.”

He became eligible for Medi-Cal this year but decided not to enroll, worrying it could jeopardize his chances of changing his immigration status.

“I’ve thought about it,” Selvin said, but “I feel like it could end up hurting me. I won’t deny that, obviously, I’d like to benefit — get my teeth fixed, a physical checkup.” But fear holds him back, he said, and he hasn’t seen a doctor in nine years.

It’s not Trump’s mass deportation plan in particular that’s scaring him off, though. “If I’m not committing any crimes or getting a DUI, I think I won’t get deported,” Selvin said.

Petrona, 55, came from El Salvador seeking asylum and enrolled in Medi-Cal last year.

She said that if her health insurance benefits were cut, she wouldn’t be able to afford her visits to the dentist.

A street food vendor, she hears often about Trump’s deportation plan, but she said it will be the criminals the new president pushes out. “I’ve heard people say he’s going to get rid of everyone who’s stealing.”

Although she’s afraid she could be deported, she’s also hopeful about Trump. “He says he’s going to give a lot of work to Hispanics because Latinos are the ones who work the hardest,” she said. “That’s good, more work for us, the ones who came here to work.”

Newly elected Republican Assembly member Jeff Gonzalez, who flipped a seat long held by Democrats in the Latino-heavy desert region in the southeastern part of the state, said his constituents were anxious to see a new economic direction.

“They’re just really kind of fed up with the status quo in California,” Gonzalez said. “People on the ground are saying, ‘I’m hopeful,’ because now we have a different perspective. We have a businessperson who is looking at the very things that we are looking at, which is the price of eggs, the price of gas, the safety.”

Gonzalez said he’s not going to comment about potential Medicaid cuts, because Trump has not made any official announcement. Unlike most in his party, Gonzalez said he supports the extension of health care services to all residents regardless of immigration status.

Health care providers said they are facing a twin challenge of hesitancy among those they are supposed to serve and the threat of major cuts to Medicaid, the federal program that provides over 60% of the funding for Medi-Cal.

Health providers and policy researchers say a loss in federal contributions could lead the state to roll back or downsize some programs, including the expansion to cover those without legal authorization.

California and Oregon are the only states that offer comprehensive health insurance to all income-eligible immigrants regardless of status. About 1.5 million people without authorization have enrolled in California, at a cost of over $6 billion a year to state taxpayers.

“Everyone wants to put these types of services on the chopping block, which is really unfair,” said state Sen. Lena Gonzalez, a Democrat and chair of the California Latino Legislative Caucus. “We will do everything we can to ensure that we prioritize this.”

Sen. Gonzalez said it will be challenging to expand programs such as Covered California, the state’s health insurance marketplace, for which immigrants lacking permanent legal status are not eligible. A big concern for immigrants and their advocates is that Trump could reinstate changes to the which can deny green cards or visas based on the use of government benefits.

“President Trump’s mass deportation plan will end the financial drain posed by illegal immigrants on our healthcare system, and ensure that our country can care for American citizens who rely on Medicaid, Medicare, and Social Security,” Trump spokesperson Karoline Leavitt said in a statement to Ñî¹óåú´«Ã½Ò•îl Health News.

During his first term, in 2019, Trump broadened the policy to include the use of Medicaid, as well as housing and nutrition subsidies. The Biden administration rescinded the change in 2021.

KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News, found than people born in the United States. And about 1 in 4 likely undocumented immigrant adults said they have avoided applying for assistance with health care, food, and housing because of immigration-related fears, according to a .

Another uncertainty is the fate of the Affordable Care Act, which was opened in November to immigrants who were brought to the U.S. as children and are protected by the Deferred Action for Childhood Arrivals program. If DACA eligibility for the act’s plans, or even the act itself, were to be reversed under Trump, that would leave roughly 40,000 California DACA recipients, and about , without access to subsidized health insurance.

On Dec. 9, a federal court in North Dakota issued an order blocking DACA recipients from accessing Affordable Care Act health plans in that had challenged the Biden administration’s rule.

Clinics and community health workers are encouraging people to continue enrolling in health benefits. But amid the push to spread the message, the chilling effects are already apparent up and down the state.

“¿Ya tiene Medi-Cal?” community health worker Yanet Martinez said, asking residents whether they had Medi-Cal as she walked down Pico Boulevard recently in a Los Angeles neighborhood with many Salvadorans.

“¡Nosotros podemos ayudarle a solicitar Medi-Cal! ¡Todo gratuito!” she shouted, offering help to sign up, free of charge.

“Gracias, pero no,” said one young woman, responding with a no thanks. She shrugged her shoulders and averted her eyes under a cap that covered her from the late-morning sun.

Since Election Day, Martinez said, people have been more reluctant to hear her pitch for subsidized health insurance or cancer prevention screenings.

“They think I’m going to share their information to deport them,” she said. “They don’t want anything to do with it.”

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For more than two decades, the community health worker has supported hundreds of families throughout southeast Los Angeles by helping them sign up for food assistance, sharing information about affordable health coverage, and managing medications for their chronic illnesses. She’s guided by the expression “an ounce of prevention is worth a pound of cure.”

But she makes only around $20 an hour from a community health organization and must hold down a second job to make ends meet. “They pay us very little and expect too much,” she said in Spanish. “We build trust. We offer support. We’re the shoulder people rely on, but we don’t get fair wages.”

California looked to professionalize thousands of community health workers such as Hernández to improve the health of immigrant populations, particularly Hispanic residents, who often experience of chronic diseases, are more , and face more cultural and linguistic barriers when trying to access services. Studies show their work hospitalizations as well as emergency room and urgent care visits.

The state hewed closely to a series of put out in 2019 to standardize training and certification, integrate these workers into the health care workforce, and provide fair wages, including reimbursements through Medi-Cal, the state’s Medicaid health insurance program, to compensate for work that traditionally has been done on a volunteer basis or for low pay. But six years in, California has backed out of many of those initiatives.

The state has eliminated a certification program and rolled back nearly all funding to train and expand this workforce even though it set a goal of by this year. Although Medi-Cal began covering their services, participating health plans set uneven billing requirements, making it difficult for workers to get reimbursed. And the state didn’t follow through on a planned pay raise.

With federal funding cuts just passed and President Donald Trump targeting immigrants for deportation — even with the Department of Homeland Security — advocates fear California is abandoning its health equity initiative for immigrants, people of color, and people with low incomes when they say that effort is needed most.

“We’re in a very dire situation right now,” said Cary Sanders, senior policy director for the California Pan-Ethnic Health Network, a statewide health equity advocacy group.

A spokesperson for Gov. Gavin Newsom, Elana Ross, said “the state has taken difficult but necessary steps to ensure fiscal stability” and that the administration continues to have a dialogue with community health workers. Ross added that the Democratic governor, a , remains committed to defending immigrants being targeted by the Trump administration.

‘Our Office Is on the Street’

There are more than 60,000 community health workers nationwide, including roughly 9,200 in California, and this workforce is projected to grow 13% over the next decade, three times as fast as for all occupations, according to from the U.S Bureau of Labor Statistics. But experts say these numbers are an undercount given the various titles community health workers hold and that many work outside of health care and governmental institutions.

Community health worker is an umbrella term that includes peer supporters and community health representatives. These workers, often known as promotores, who work in clinics, hospitals, public health departments, and local nonprofits, places where they are trusted and have a grasp of their community’s most pressing health needs.

Besides helping people manage chronic illnesses such as heart disease and diabetes, they promote reproductive health, children’s health, and oral hygiene, and they help prevent injuries and review medications. They can make people feel safe when reporting domestic violence and other abuses. They also connect people to housing and food assistance. “The community health worker is not sitting at a desk,” Hernández said. “Our office is on the street.”

Back in 2019, the California Future Health Workforce Commission recommended integrating community health workers into the health care system, and in 2022, the state authorized over three years for the California Department of Health Care Access and Information, which oversees health care workforce development, to recruit, train, and certify them.

The agency sought to standardize training and certification, but some community groups feared that would create barriers to entry by not giving enough credit for lived experiences and cultural competency. But just as the agency offered more flexibility and allowed community-based training, the state slashed $250 million in funding last year due to budget constraints. This year, the certification program was officially eliminated.

Spokesperson Andrew DiLuccia said the agency is now considering a program to accredit community organizations rather than individual workers and plans to spend its remaining $12 million on technical assistance, workforce development, and salaries for those working with immigrant communities.

According to the National Academy for State Health Policy, offer a voluntary or mandatory community health worker certification program.

Some community health advocates say California’s missing an opportunity to carve a career path for this workforce. Currently, some courses offered by nonprofits, counties, and colleges , a degree, English fluency, or prior experience. Most are concentrated in the San Francisco or Los Angeles area, leaving in much of the state.

Lourdes Bernis, a dentist from Ecuador, is a model for how community health workers could be integrated into the health care system. She began as a volunteer promotora more than a decade ago and in 2019 received free training from Los Angeles County, allowing her to move into a full-time job with benefits for the county’s Department of Mental Health to help Spanish-speaking women manage depression and anxiety as they recover from drug use.

Bernis now plans to become a peer-to-peer support specialist inside hospitals and clinics. Meanwhile, many of her colleagues with decades of experience remain stuck in low-paying roles and can’t afford training to advance. “There are promotoras who have 20 to 25 years of experience, but they are still volunteering,” Bernis said in Spanish.

Medi-Cal’s Role

To pay community health workers, Medi-Cal began covering their services in July 2022, but California for them after voters approved Proposition 35, which hiked the pay of physicians, hospitals, community clinics, and other providers instead. Since then, the state has yet to establish a uniform system for how health plans should contract with organizations that employ community health workers.

“We have to jump through hoops,” said Maria Lemus, executive director at Visión y Compromiso, a Los Angeles-based nonprofit representing community health workers. “It just causes havoc, because each plan could have different requirements.”

Lemus said it took the organization nearly six months to establish payment with one health plan.

And though Medi-Cal reimbursements are tied to individual tasks, ranging from $9.46 to $27.54 for 30 minutes of work, advocates say they aren’t fully compensated for the time they spend building trust and following up with patients. Advocates say these workers should earn at least $30 a visit, with benefits, but many earn about , often without benefits.

Advocates say they’re surprised by how infrequently these services are used in a program with 15 million Californians. More than 16,000 Medi-Cal enrollees used these services in the first year, rising to 68,000 last year, according to state data. “I don’t think it’s reached the potential that the governor talked about, and that we all imagined that it could possibly achieve,” Sanders said.

Griselda Melgoza, a spokesperson for the California Department of Health Care Services, said the agency, which administers Medi-Cal, has seen “a steady, upward trend” and believes the data underestimates utilization because the benefit is sometimes bundled with other services.

to assess whether Medi-Cal managed care plans are doing enough outreach and education to enrollees about community health services died this year.

More Crucial Than Ever

With health funding cuts from the Trump administration and passage of the GOP’s tax and spending legislation, advocates fear there will be even less funding and support for community health worker positions, shrinking a workforce tackling health disparities. Already, Fresno County’s Department of Public Health said it has cut its community health workers by more than half, from 49 positions to 20.

Yet, outreach is more crucial than ever. As the Trump administration continues immigration raids, which appear to have targeted in the state, advocates and policy researchers say community health workers could act as intermediaries for immigrant patients afraid to seek medical care in hospitals and clinics.

Without a state certification program, no raises, and dwindling training funds, the path to professionalizing community health workers is unclear, leaving workers feeling left behind.

“The community trusts me,” said Hernández, the veteran community health worker, “but at the government level, there’s still a long way to go before this work is valued and fairly compensated.”

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LISTEN: Federal law entitles patients to interpreters if they don’t have a strong grasp of English. Ñî¹óåú´«Ã½Ò•îl Health News correspondent Vanessa G. Sánchez appeared on WAMU’s “Health Hub” on July 9 to explain why some Trump administration policies are leaving patients fearful to ask for language services. 

Patients need to communicate clearly with their health care provider. But that’s getting more difficult for those in the U.S. who don’t speak English. 

Budget cuts by the Trump administration have left some providers scrambling to keep qualified medical interpreters. And an executive order designating English the official language of the United States has created confusion among providers about what services should be offered. 

Patients who don’t speak English are left afraid, and perhaps at risk for medical mistakes. What happens when those who need help are too frightened to ask? 

In WAMU’s July 9 “Health Hub” segment, Ñî¹óåú´«Ã½Ò•îl Health News correspondent Vanessa G. Sánchez explained why health advocates worry these changes could lead to worse patient outcomes. 

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At the same time, people with limited English proficiency have scaled back their requests for language services, which health care advocates attribute in part to President Donald Trump’s immigration crackdown and his declaring English as the national language.

Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. “People are going to have a hard time accessing benefits they’re entitled to and need to live independently,” said Carol Wong, a senior rights attorney for Justice in Aging, a national advocacy group.

Nearly 69 million people in the U.S. speak a language other than English, and 26 million of them speak English less than “very well,” according to the most available, from 2023. A from that year found that immigrants with limited English proficiency reported more barriers accessing health care and worse health than English-proficient immigrants.

Health advocates fear that, without adequate support, millions of people in the U.S. with limited English proficiency will be more likely to experience medical errors, misdiagnosis, neglect, and other adverse outcomes. During the start of the pandemic in 2020, that a woman with coronavirus symptoms died in Brooklyn after missing out on timely treatment because emergency room staffers could not communicate with her in Hungarian. And, at the height of the crisis, that on a state website erroneously stated that the covid-19 vaccine was not necessary.

In 2000, President Bill Clinton signed an aimed at improving access to federal services for people with limited English proficiency. Research shows language assistance results in higher , as well as , misdiagnoses, and adverse health outcomes. Language services also by reducing hospital stays and readmissions.

Trump’s order repealed Clinton’s directive and left it up to each federal agency to decide whether to maintain or adopt a new language policy. Some have already scaled back: The and the reportedly reduced language services, and the Justice Department says it is . A is broken.

It’s unclear what the Department of Health and Human Services intends to do. HHS did not respond to questions from Ñî¹óåú´«Ã½Ò•îl Health News.

implemented under President Joe Biden, during public health emergencies and disasters, has been archived, meaning it may not reflect current policies. However, HHS’s still informs patients of their right to language assistance services when they pick up a prescription, apply for a health insurance plan, or visit a doctor.

And the office that prohibit health providers from using untrained staff, family members, or children to provide interpretation during medical visits. It also required that translation of sensitive information using artificial intelligence be reviewed by a qualified human translator for accuracy.

Those safeguards could be undone by the Trump administration, said Mara Youdelman, a managing director at the National Health Law Program, a national legal and health policy advocacy organization. “There’s a process that needs to be followed,” she said, about making changes with public input. “I would strongly urge them to consider the dire consequences when people don’t have effective communication.”

Even if the federal government ultimately doesn’t offer language services for the public, Youdelman said, hospitals and health providers are required to provide language assistance at no charge to patients.

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race or national origin, protections that extend to language. And the 2010 Affordable Care Act, which expanded health coverage for millions of Americans and adopted numerous consumer protections, requires health providers receiving federal funds to make language services, including translation and interpretation, available. 

“English can be the official language and people still have a right to get language services when they go to access health care,” Youdelman said. “Nothing in the executive order changed the actual law.”

Insurers still need to include multi-language taglines in their correspondence to enrollees explaining how they can access language services. And health facilities must post visible notices informing patients about language assistance services and guarantee certified and qualified interpreters.

State and local governments could broaden their own language access requirements. A few states have taken such actions in recent years, and California state lawmakers are that would establish a language access director, mandate human review of AI translations, and improve surveys assessing language needs.

“With increasing uncertainty at the federal level, state and local access laws and policies are even more consequential,” said Jake Hofstetter, policy analyst at the Migration Policy Institute.

The Los Angeles Department of Public Health and San Francisco’s Office of Civic Engagement and Immigrants Affairs said their language services have not been affected by Trump’s executive order or federal funding cuts.

Demand, however, has dropped. Aurora Pedro of Comunidades Indígenas en Liderazgo, one of the few medical interpreters in Los Angeles who speaks Akatek and Qʼanjobʼal, Mayan languages from Guatemala, said she has received fewer calls for her services since Trump took office.  

And other pockets of California have reduced language services because of the federal funding cuts. 

Hernán Treviño, a spokesperson for the Fresno County Department of Public Health, said the county cut the number of community health workers by more than half, from 49 to 20 positions. That reduced the availability of on-the-ground navigators who speak Spanish, Hmong, or Indigenous languages from Latin America and help immigrants enroll in health plans and schedule routine screenings.

Treviño said staffers are still available to support residents in Spanish, Hmong, Lao, and Punjabi at county offices. A free phone line is also available to help residents access services in their preferred language.

Mary Anne Foo, executive director of the Orange County Asian and Pacific Islander Community Alliance, said the federal Substance Abuse and Mental Health Services Administration froze $394,000 left in a two-year contract to improve mental health services. As a result, the alliance is planning to let go 27 of its 62 bilingual therapists, psychiatrists, and case managers. The organization serves more than 80,000 patients who speak over 20 languages.

“We can only keep them through June 30,” Foo said. “We’re still trying to figure it out — if we can cover people.”

Orozco Rodriguez reported from Elko, Nevada.

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It’s a striking reversal for the Democrat, who had promised universal health care and called health coverage for immigrants the . But a, potential federal spending cuts, and larger-than-expected Medi-Cal enrollment have forced him to dial back.

Newsom said he had no other choice but to call for major cost-cutting measures affecting how some immigrants are covered by Medi-Cal, the state’s Medicaid program, which covers about 15 million Californians.

“The challenge that we face this year and the challenge we will face for many years is on growth of our Medicaid system, Medi-Cal,” Newsom told reporters at his budget presentation. “Instead of rolling back the program, cutting people off for basic care, we have to adjust the comprehensive nature of the care.”

California is that offer health coverage to low-income adults regardless of immigration status, and that has put the program in the political crosshairs of national Republicans. The would cut Medicaid funding by 10 percentage points for states that provide coverage for immigrants without legal status — an approach Newsom on Wednesday described as legally questionable. Meanwhile, the Trump administration cited California’s health coverage of noncitizens as an example of states “” when it issued a proposed rule Monday to overhaul Medicaid provider taxes.

Some 1.6 million immigrants — most without legal status — are enrolled in Medi-Cal. Federal law prohibits Medicaid dollars from being used to cover unauthorized residents, meaning California must foot the bill for the vast majority of their health care. And those costs have ballooned.

Newsom cautioned that California, like other states, could soon be in a more dire budget situation if Republicans advance their proposal to cut Medicaid. That plan includes work requirements and would cap taxes levied on providers that help states draw additional federal money. However, the governor’s budget proposal was silent on potential federal cuts.

The $321.9 billion budget proposes a for immigrants 19 and older without legal status, starting Jan. 1. Beginning in 2027, immigrants 19 and older in the country illegally, as well as those with legal residency for less than five years, would be required to pay $100 monthly premiums to maintain coverage.

The Newsom administration estimated those two moves would save the state $5.4 billion by the 2028-29 fiscal year. The governor also called for eliminating dental and long-term care benefits for those without legal status and for legal residents who arrived in the U.S. less than five years ago, according to California Department of Finance spokesperson H.D. Palmer.

The changes would not apply to the roughly 217,000 children and young adults without legal status covered by Medi-Cal. Those 18 and under were the first to receive Medi-Cal coverage, in 2016. Children are generally healthier and require less care, and a Ñî¹óåú´«Ã½Ò•îl Health News analysis showed that, in many cases, children lacking legal status were cheaper to cover than citizens.

Maria, a street vendor from Los Angeles, said the monthly premium alone would force her and others to forgo care.

“They say they are one of the largest economies, but they don’t want to help us,” said Maria, who didn’t want to give her full name, out of fear of retaliation from immigration authorities. “We are contributing to the state. It’s not fair that we, the poor, have to pay what we don’t have.”

“Where am I going to get the $100?” Maria asked.

Federal law prohibits charging the poorest Medicaid enrollees a premium, and Newsom’s $100 monthly payment would be considered unaffordable for current beneficiaries, said Laurel Lucia, director of the health care program at the University of California-Berkeley Labor Center.

Newsom is proposing a $194.5 billion Medi-Cal budget for 2025-26. Lawmakers have until June 15 to pass the budget. Democratic leaders signaled their intent to protect health care for the state’s poorest residents.

The governor and Assembly Speaker Robert Rivas blamed fiscal headwinds brought on by President Donald Trump’s tariffs, which they said had led to a massive $16 billion dip in state tax revenue forecasts since April. But Medi-Cal spending surged well before the tariffs took effect. State costs to cover Californians with “unsatisfactory immigration status” — those without status and legal residents who have been here less than five years — is roughly $10.8 billion per year, up from the $6.4 billion officials projected in November. The federal government pays $1.2 billion of that to cover mandated emergency and pregnancy care.

“It’s laughable that he’s trying to blame Trump for anything,” Republican Assembly member Joe Patterson, who sits on the Assembly Budget Committee, said of Newsom. “He overpromised to them, and he’s pulling the carpet out from underneath them.”

Other states that have extended coverage to immigrants are also struggling with escalating costs. Minnesota, for example, originally projected that 5,700 residents without legal status would sign up for the state Medicaid program, known as MinnesotaCare, at a cost of $200 million. Both figures have increased roughly threefold.

Illinois is ending services for adult immigrants, except seniors, on , citing higher-than-anticipated enrollment. The mostly state-funded health plan will stop covering around 30,000 noncitizens ages 42 to 64, including those living in the country without authorization.

Newsom said Wednesday that without a suite of his proposed changes to Medi-Cal, program costs could grow by an additional $10 billion through June 2026 and would “contribute significantly to the structural imbalance in future years.”

But consumer advocates and lawmakers said the move is a betrayal of the governor’s commitment to bring California closer to universal health care and warned it would push immigrants into costly emergency room care. Sen. María Elena Durazo, a Democrat who championed the Medi-Cal expansion, said California shouldn’t single out immigrants to solve its budget deficit.

“I don’t agree that we should be isolating and abandoning and separating a particular group of Californians, as if they are responsible for the problem,” Durazo said. “I don’t care what you call them, they work, they contribute.”

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Reddy can’t match the salaries offered by larger health systems — a difficulty compounded by a widespread shortage of primary care doctors.

The shortage is tied largely to the lower pay and relative lack of prestige associated with primary care, making recruitment difficult. “It certainly is challenging to expose medical students early in their careers to the joys of this kind of integrated health care,” Reddy said. “The relationships we build and the care we provide truly allow people to live longer with a better quality of life.”

Hoping to increase revenue so Acacia can afford to pay more, Reddy has signed the practice up for alternative payment methods with health plans that offer bonuses for meeting certain primary care goals tied to child vaccinations, blood pressure control, and screenings for breast cancer, colorectal cancer, and mental health. Such pay-for-performance arrangements are among the many efforts by industry players and state officials to confront the problems plaguing primary care.

frequently opt not to go into primary care, and that’s not good for patients. People with regular primary care providers are more likely to that avoids serious illnesses and feel more empowered to advocate for themselves. They’re also less likely to encounter language barriers, resort to costly emergency room visits, or forgo care.

Six years after the influential California Future Health Workforce Commission made a to plug a projected shortage of 4,100 primary care providers in 2030, a number of public and private initiatives have proliferated around the state to address the problem. They include new residency slots, debt forgiveness, waived medical school tuition, new ways of paying doctors, expanded nurse practitioner roles, and a statewide target to increase primary care spending. Hundreds of millions of taxpayer dollars have been allocated for some of these efforts.

But numerous academic experts and medical professionals believe those moves, while well intended, have been scattershot and insufficient. “The pieces are there,” said Monica Soni, chief medical officer of Covered California, the state’s Affordable Care Act health insurance marketplace. “I am worried we started a little too late, and I think it’s a little too siloed.”

A by the California Health Care Foundation found that substantial progress had been made on some of those goals, including recruitment of students from low-income households and communities of color. A separate analysis from the foundation showed that, from 2020 to 2023, California jumped about 10 spots in a ranking of states by primary care residents and fellows per capita.

However, the latest state data shows nearly 15 million Californians live in areas without enough primary care providers to meet patient needs.

State budget constraints and , especially to Medicaid, could exacerbate shortages in areas already desperate for clinicians and dampen hopes of building a robust primary care system that state officials and virtually everyone in the industry agree would be a strong defense against serious — and costly — illnesses. Federal cuts could also hit medical training and hospital systems.

“Many of us are very scared about threats from both the Trump administration and Republicans in Congress,” said , a family community medicine professor at the University of California-San Francisco.

Acute Primary Care Shortages

California’s lack of primary care providers, including doctors, nurse practitioners, and physician assistants, is most acute in rural parts of the state, particularly in the north and the Central Valley. Entire rural counties, including Del Norte, Madera, Tulare, and Yuba, are designated shortage areas, according to state data. Some densely populated urban areas, including parts of Los Angeles, also confront shortages.

Many Californians face months-long waits for appointments or have to travel long distances or go to emergency rooms for nonurgent medical needs, which means hours spent in crowded waiting rooms for unnecessarily expensive care.

In Chico, 90 miles north of Sacramento, the emergency room at the only hospital in town has seen a sharp increase in patients over the past decade, due in part to a lack of primary care providers in the area.

“People who don’t have a primary care provider — which is a lot, because there are not enough — end up in the ER when they need routine care,” said David Alonso, a local internal medicine doctor. “The ER then says, ‘OK, you should follow up with your primary care provider,’ and they’re like, ‘We don’t have one.’”

, director of the Robert Graham Center for Policy Studies, a health policy think tank, said failure to invest robustly in primary care has robbed the public of its benefits.

The field has historically been underfunded, accounting for of national health care spending in 2022, according to the Milbank Memorial Fund, a national nonprofit focused on population health and health equity.

The consequences are clear.

The U.S. spends significantly more per capita on health care than other industrialized nations, and yet Americans aren’t any healthier. Chronic conditions such as heart disease, diabetes, arthritis, and Alzheimer’s, as well as mental illness, account for 90% of the $4.5 trillion spent on health care .

Medical students, often faced with staggering educational debt, are increasingly over primary care. The average salary of a family medicine physician is slightly over $300,000, compared with more than $565,000 for a cardiologist and over $763,000 for a neurosurgeon, according to .

“If you are going to pay over $300,000 to go to medical school, you want to be a neurosurgeon; you don’t want to be a family practice doctor,” said William Barcellona, executive vice president of government affairs at , a Los Angeles-based professional association representing 360 medical groups and independent practice associations nationwide.

Barcellona said the Golden State’s high housing costs also make recruiting difficult.

But it’s not only pay that tempers enthusiasm for primary care. It’s also burnout from so many unpaid hours spent recording details of medical visits in electronic health records; haggling with insurance companies for treatment authorization; answering phone calls and emails from patients; or searching far and wide — often in a health care desert — for specialists with the right expertise.

Debby Lee, the daughter of Hmong immigrants from Laos, experienced this kind of frustration firsthand.

Cultural and linguistic barriers faced by her family motivated her to pursue internal medicine. Lee worked part of her residency at a community clinic serving Hmong in the Sacramento area. She loved the patients, as well as her co-workers. But she was burdened by outdated technology that limited the number of patients she could see. “I just saw myself kind of burning out being in that setting,” Lee said.

When the clinic invited her to stay, she declined, taking a job with a bigger health system.

Solutions to the Shortage

Besides residencies, other efforts support primary care.

The Health Plan of San Mateo offers grants to help medical practices retain and add to primary care staff. In exchange, the practices — some single physicians serving patients in California’s Medicaid program, Medi-Cal — must show they have increased their patient load and retained newly hired providers for five years.

The idea is to provide capital so doctors can hire the staff they need to run their practices efficiently, increase salaries, offer bonuses, and even take sabbaticals. Such efforts are consistent with one of the main thrusts of the 2019 workforce report: to increase investment in primary care.

California recently joined several other states, including Connecticut, Oklahoma, and Rhode Island, in setting a target to increase primary care spending. So far, those policies have yielded .

Late last year, California’s Office of Health Care Affordability set a target to make primary care of total health care spending by 2034, more than double the current proportion. It imposes no requirements, relying on the goodwill of health plans to work with medical providers.

Greater spending on primary care would mean better pay and more people working in the field, said Richard Kronick, a public health professor at UC-San Diego and a member of the OHCA board. “That’s a big change. Will it happen? I don’t think anyone can predict the future with any certainty.”

Stephen Shortell, a professor emeritus of health policy and management at UC-Berkeley, said “some of that increase might occur, but at some point, it might need to be made mandatory.”

In its report, the workforce commission also cited the importance of alternative forms of primary care payment that offer extra cash for quality care. The affordability office has to encourage such payment methods. The aim is to transform the system from one in which every medical service has a price tag to one that treats people holistically, and in which adherence to medical standards brings more money to doctors and their office staff.

Such arrangements are common among HMOs, though less so in primary care practices. Where they do exist, different health plans and other payers generally design them differently, which means primary care practices manage multiple payment models, adding to their administrative burden.

Reddy’s family practice is participating in a one-year demonstration project intended to reduce that burden by having multiple insurers work together in one payment plan.

The project brings together three large insurers — Health Net, Aetna, and Blue Shield of California — and 10 independent practices across the state with the goal of improving care while boosting revenue for the medical groups. It is administered by two industry groups, the and the .

On top of customary payments, either for services rendered or monthly per-member allotments, the medical practices receive bonuses for meeting targets or improving their performance on .

Participating practices also receive monthly per-patient payments for “population health management,” which means managing the collective health of their patients. And they can search a single platform to find all their patients covered by one of the three plans.

In addition to extra payments and fewer administrative hassles, the health plans pay for a “practice coach,” whose job is to help primary care groups meet their targets and provide more seamless care.

The idea is to add more insurers and medical groups over time, said Todd May, Health Net’s medical director for commercial health plans, who is among those driving the project. “In addition to better outcomes, we’d like to see a stronger, more robust, and more satisfied primary care workforce,” he said.

Reddy hopes she can increase Acacia’s revenue by 20%, using the extra money from this and other pay-for-performance arrangements. That, she said, would enable her to raise pay for her staff and hire clinicians.

For many years, her practice has limited the number of patients it has accepted. But after searching for the better part of five years, Reddy has hired a doctor on a half-time basis and another is coming on board in June.

“This is the most hopeful I have felt in decades,” Reddy said.

Phillip Reese contributed to this report.

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Josephine, 16, has been diagnosed with , severe autism, severe obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder, among other conditions, which will require constant assistance and supervision for the rest of her life.

Ortiz, 25, is Josephine’s caregiver. A Venezuelan immigrant, Ortiz helps Josephine eat, bathe, and perform other daily tasks that the teen cannot do alone at her home in West Orange, New Jersey. Over the past 2½ years, Ortiz said, she has developed an instinct for spotting potential triggers before they escalate. She closes doors and peels barcode stickers off apples to ease Josephine’s anxiety.

But Ortiz’s ability to work in the U.S. has been thrown into doubt by the Trump administration, which to the temporary protected status program for some Venezuelans on April 7. On March 31, a federal judge , giving the administration a week to appeal. If the termination goes through, Ortiz would have to leave the country or risk detention and deportation.

“Our family would be gutted beyond belief,” said Krysta Senek, Josephine’s mother, who has been trying to win a reprieve for Ortiz.

Americans depend on many such foreign-born workers to help care for family members who are older, injured, or disabled and cannot care for themselves. Nearly 6 million people receive personal care in a private home or a group home, and about 2 million people use these services in a nursing home or other long-term care institution, according to a .

Increasingly, the workers who provide that care are immigrants such as Ortiz. The foreign-born share of nursing home workers rose three percentage points from 2007 to 2021, to about 18%, according to an by the Baker Institute for Public Policy at Rice University in Houston.

And foreign-born workers make up a high share of other direct care providers. More than 40% of home health aides, 28% of personal care workers, and 21% of nursing assistants were foreign-born in 2022, compared with 18% of workers overall that year, according to .

That workforce is in jeopardy amid an immigration crackdown President Donald Trump launched on his first day back in office. He signed executive orders that without a court hearing, , and more recently for nationals of Cuba, Haiti, Nicaragua, and Venezuela.

In to deport Venezuelans and attempting to for others, the Trump administration has sparked fear that even those who have followed the nation’s immigration rules could be targeted.

“There’s just a general anxiety about what this could all mean, even if somebody is here legally,” said , president of LeadingAge, a nonprofit representing more than 5,000 nursing homes, assisted living facilities, and other services for aging patients. “There’s concern about unfair targeting, unfair activity that could just create trauma, even if they don’t ultimately end up being deported, and that’s disruptive to a health care environment.”

Shutting down pathways for immigrants to work in the United States, Smith Sloan said, also means many other foreign workers may go instead to countries where they are welcomed and needed.

“We are in competition for the same pool of workers,” she said.

Growing Demand as Labor Pool Likely To Shrink

Demand for caregivers is predicted to surge in the U.S. as the youngest baby boomers reach retirement age, with the need for home health and personal care aides over a decade, according to the Bureau of Labor Statistics. Those 820,000 additional positions represent the most of any occupation. The need for also is projected to grow, by about 65,000 positions.

Caregiving is often low-paying and physically demanding work that doesn’t attract enough native-born Americans. The median pay ranges from about to a year, according to the Bureau of Labor Statistics.

Nursing homes, assisted living facilities, and home health agencies have long struggled with high turnover rates and staffing shortages, Smith Sloan said, and they now fear that Trump’s immigration policies will choke off a key source of workers, leaving many older and disabled Americans without someone to help them eat, dress, and perform daily activities.

With the Trump administration , which runs programs supporting older adults and people with disabilities, and Congress considering deep cuts to Medicaid, the largest payer for long-term care in the nation, the president’s anti-immigration policies are creating “a perfect storm” for a sector that has not recovered from the covid-19 pandemic, said , an executive vice president of the Service Employees International Union, which represents nursing facility workers and home health aides.

The relationships caregivers build with their clients can take years to develop, Frane said, and replacements are already hard to find.

In September, LeadingAge to help the industry meet staffing needs by raising caps on work-related immigration visas, expanding refugee status to more people, and allowing immigrants to test for professional licenses in their native language, among other recommendations.

But, Smith Sloan said, “There’s not a lot of appetite for our message right now.”

The White House did not respond to questions about how the administration would address the need for workers in long-term care. Spokesperson Kush Desai said the president was given “a resounding mandate from the American people to enforce our immigration laws and put Americans first” while building on the “progress made during the first Trump presidency to bolster our healthcare workforce and increase healthcare affordability.”

Refugees Fill Nursing Home Jobs in Wisconsin

Until Trump suspended the refugee resettlement program, some nursing homes in Wisconsin had partnered with local churches and job placement programs to hire foreign-born workers, said Robin Wolzenburg, a senior vice president for LeadingAge Wisconsin.

Many work in food service and housekeeping, roles that free up nurses and nursing assistants to work directly with patients. Wolzenburg said many immigrants are interested in direct care roles but take on ancillary roles because they cannot speak English fluently or lack U.S. certification.

Through a partnership with the Wisconsin health department and local schools, Wolzenburg said, nursing homes have begun to offer training in English, Spanish, and Hmong for immigrant workers to become direct care professionals. Wolzenburg said the group planned to roll out training in Swahili soon for Congolese women in the state.

Over the past 2½ years, she said, the partnership helped Wisconsin nursing homes fill more than two dozen jobs. Because refugee admissions are suspended, Wolzenburg said, resettlement agencies aren’t taking on new candidates and have paused job placements to nursing homes.

Many older and disabled immigrants who are permanent residents rely on foreign-born caregivers who speak their native language and know their customs. Frane with the SEIU noted that many members of San Francisco’s large Chinese American community want their aging parents to be cared for at home, preferably by someone who can speak the language.

“In California alone, we have members who speak 12 different languages,” Frane said. “That skill translates into a kind of care and connection with consumers that will be very difficult to replicate if the supply of immigrant caregivers is diminished.”

The Ecosystem a Caregiver Supports

Caregiving is the kind of work that makes other work possible, Frane said. Without outside caregivers, the lives of the patient and their loved ones become more difficult logistically and economically.

“Think of it like pulling out a Jenga stick from a Jenga pile, and the thing starts to topple,” she said.

Thanks to the one-on-one care from Ortiz, Josephine has learned to communicate when she’s hungry or needs help. She now picks up her clothes and is learning to do her own hair. With her anxiety more under control, the violent meltdowns that once marked her weeks have become far less frequent, Ortiz said.

“We live in Josephine’s world,” Ortiz said in Spanish. “I try to help her find her voice and communicate her feelings.”

Ortiz moved to New Jersey from Venezuela in 2022 as part of an au pair program that connects foreign-born workers with people who are older or children with disabilities who need a caregiver at home. Fearing political unrest and crime in her home country, she got temporary protected status when her visa expired last year to keep her authorization to work in the United States and stay with Josephine.

Losing Ortiz would upend Josephine’s progress, Senek said. The teen would lose not only a caregiver, but also a sister and her best friend. The emotional impact would be devastating.

“You have no way to explain to her, ‘Oh, Alanys is being kicked out of the country, and she can’t come back,’” she said.

It’s not just Josephine: Senek and her husband depend on Ortiz so they can work full-time jobs and take care of themselves and their marriage. “She’s not just an au pair,” Senek said.

The family has called its congressional representatives for help. Even a relative who voted for Trump sent a letter to the president asking him to reconsider his decision.

In the March 31 court decision, U.S. District Judge Edward Chen wrote that canceling the protection could “inflict irreparable harm on hundreds of thousands of persons whose lives, families, and livelihoods will be severely disrupted.”

‘Doing the Work That Their Own People Don’t Want To Do’

News of immigration dragnets that sweep up and are causing a lot of stress, even for those who have followed the rules, said Nelly Prieto, 62, who cares for an 88-year-old man with Alzheimer’s disease and a man in his 30s with Down syndrome in Yakima County, Washington.

Born in Mexico, she immigrated to the United States at age 12 and became a U.S. citizen under authorized by President Ronald Reagan that made any immigrant who entered the country before 1982 eligible for amnesty. So, she’s not worried for herself. But, she said, some of her co-workers working under are very afraid.

“It kills me to see them when they talk to me about things like that, the fear in their faces,” she said. “They even have letters, notarized letters, ready in case something like that happens, saying where their kids can go.”

Foreign-born home health workers feel they are contributing a valuable service to American society by caring for its most vulnerable, Prieto said. But their efforts are overshadowed by rhetoric and policies that make immigrants feel as if they don’t belong.

“If they cannot appreciate our work, if they cannot appreciate us taking care of their own parents, their own grandparents, their own children, then what else do they want?” she said. “We’re only doing the work that their own people don’t want to do.”

In New Jersey, Ortiz said life has not been the same since she received the news that her TPS authorization was slated to end soon. When she walks outside, she fears that immigration agents will detain her just because she’s from Venezuela.

She’s become extra cautious, always carrying proof that she’s authorized to work and live in the U.S.

Ortiz worries that she’ll end up in a detention center. But even if the U.S. now feels less welcoming, she said, going back to Venezuela is not a safe option.

“I might not mean anything to someone who supports deportations,” Ortiz said. “I know I’m important to three people who need me.”

This article was produced by Ñî¹óåú´«Ã½Ò•îl Health News, which publishes , an editorially independent service of the . 

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When patients picked up prescriptions for testosterone replacement therapy, law enforcement retrieved their names and addresses .

And when a father was arrested by immigration authorities, agents his personal information from a medical clinic where he received diabetes treatment.

Progressive California lawmakers have proposed a number of bills aimed at bolstering privacy protections for women, transgender people, and immigrants in response to such intrusions by anti-abortion groups, conservative states, and federal law enforcement agencies as President Donald Trump declares the nation “” and flexes his executive power to roll back rights.

Democrats have supermajorities in the state legislature, but even if they pass the proposals, they may first need to lobby one of their own: Gov. Gavin Newsom, who has noticeably tempered his once harsh criticism of Trump.

Last month, the Democratic governor issued against a bill that would expand the state’s sanctuary law to limit cooperation between state prisons and federal immigration agents. And Newsom recently called transgender athletes’ participation in women’s sports on his new podcast with guest Charlie Kirk, a founder of the conservative group Turning Point USA. Newsom went on to tell Kirk that he had a “” the way the right talks about transgender people.

Billions of dollars are also on the line for California. Newsom visited the White House last month seeking for wildfire victims in Los Angeles, and the state relies on Washington for over 60% of its Medicaid budget, which is vulnerable to significant cuts under the GOP’s budget blueprint.

“California’s leaders have not been as aggressive, out of recognition that there are many things that the state needs federal cooperation on,” said , a political science professor at the University of California-San Diego.

A Newsom spokesperson declined to comment on pending legislation. He has a track record of supporting abortion, transgender, and immigrant rights.

Since taking office, Trump has granted the Elon Musk-controlled Department of Government Efficiency — created through a Trump executive order — access to , including medical information, raising concerns that sensitive information could be exposed without proper safeguards. 

The White House did not respond to requests for comment.

While most Americans are familiar with the Health Insurance Portability and Accountability Act, known as HIPAA, it offers only narrow protection for patients in health care settings. There’s no comprehensive federal law protecting data privacy.

Health care information has increasingly become a tool of surveillance and enforcement, and in states that have banned certain medical treatments or toughened immigration laws, vulnerable populations are at greater risk, said Suzanne Bernstein, a health privacy rights expert with the Electronic Privacy Information Center.

Progressive Democrats are concerned that personal information and people’s medical decisions could be used to monitor or criminalize patients, facilitate arrests in or near health care facilities, or jeopardize access to health care services.

They and health privacy advocates say now is the time to shore up protections for the nearly 2 million immigrants living in California without authorization, the more than transgender adults in the state, and — living in the state or out of state — in need of abortion care in California each year. Some of these laws could take effect immediately if signed.

“This is about making sure that people are able to access critical health care in California and to take the politics out of our hospitals and health clinics,” said state Sen. Jesse Arreguín, who hopes the governor would sign his .

The bills are expected to be debated in Sacramento in the coming months.

Since the Supreme Court overturned the constitutional right to abortion, anti-abortion groups have purchased location information from consumer data companies to target people seeking abortion care with anti-abortion ads. And authorities in states with abortion bans have to enforce laws beyond their borders.

A bill introduced by state Assembly member Rebecca Bauer-Kahan, , would make geofencing, the collection of phone location by data brokers, illegal around health care facilities that provide in-person services. It would reproductive health information collected during research from being disclosed in response to out-of-state requests.

Conservative organizations said the proposal would single them out by restricting their ability to inform women about alternatives to abortion, including services offered by crisis pregnancy centers.

“I think that could very well be a First Amendment violation,” said Jonathan Keller, president of the California Family Council, a statewide anti-abortion nonprofit. “It doesn’t seem like the bill would be prohibiting or putting any restrictions on a group like Planned Parenthood if they wanted to market or target to a local high school or college.”

So far this year, lawmakers in 49 states have introduced more than 700 anti-transgender bills, seeking to ban gender-affirming care, prohibit gender identity education in schools, or restrict transgender students from participating in sports, according to the , a national research organization tracking bills affecting transgender people. Transgender adults represent of the U.S. population.

And some states with bans or restrictions on gender-affirming care have been targeting health care data. In 2023, requested that Florida universities release data on the number of individuals who have been diagnosed with gender dysphoria or received treatment at campus clinics. That same year, Missouri’s Republican attorney general, Andrew Bailey, submitted to one hospital seeking information about gender-affirming care procedures.

Trump has issued a series of executive orders to ban access to gender-affirming care for minors. Federal judges some portions of his orders.

To guard against other states that criminalize or ban gender-affirming care, California state Sen. Scott Wiener wants to expand current protections for minors to include adults.

His bill, , would require law enforcement to obtain a warrant to access state databases on gender-affirming care and make it a misdemeanor to release the data to unauthorized parties. It would also prohibit health care providers, employers, and insurers from releasing information about a person who seeks or obtains gender-affirming physical and mental health care to an agency or individual from another state.

“We want to make sure that we are as comprehensively as possible shielding trans people from hate emanating from the federal government, other states, and private parties,” Wiener said.

Keller countered that authorities in states with bans on abortion or gender-affirming care should have access to medical information as they investigate providers who could harm patients or coerce them into procedures against their will. He cited a over a teenager who detransitioned after undergoing gender-affirming care. A found it was uncommon for people undergoing gender-affirming care to decide to permanently detransition.

“The only way that you’re able to uncover that level of widespread malpractice and malfeasance is if these health care records are able to be accessed,” Keller said.

The California Family Council plans to oppose both bills.

Earlier this year, Trump rescinded a long-standing policy of not making immigration arrests near hospitals, schools, or churches. The decision has providers fearful that Immigration and Customs Enforcement agents will disrupt their work at health facilities and prompt immigrants to skip medical care — for themselves or, of particular concern, their children.

Anticipating the move, California’s Democratic attorney general, Rob Bonta, issued guidance in December advising health care providers how best to respond if ICE comes to their doorstep. But while private entities are encouraged to follow these policies, only state-run facilities are required to adopt them.

“Some health care providers have implemented them, but not everyone has,” Arreguín said.

Arreguín’s would require all health care facilities, including hospitals and community-based clinics, to follow state guidance to limit cooperation with immigration authorities. It would also prohibit providers from granting access to private areas or places where a patient is actively receiving treatment or care, unless there’s a warrant.

Another immigration bill, , would limit the sharing of local law enforcement information if agents plan to make an arrest within a one-mile radius of a hospital or medical office, a child care or day care facility, a religious institution, or a place of worship. California law enforcement has some discretion to share information with immigration agents when an individual has been convicted of a serious crime or felony.

Kousser said immigration is more complicated for California politicians than health privacy. Although a February poll by the Public Policy Institute of California found that Californians think immigrants are a benefit to the state, Kousser said that lawmakers, especially those who won by narrow margins in contested districts, still have to make tough political choices.

Senate Republican leader Brian Jones, who represents a predominantly Democratic district in San Diego, to change California’s sanctuary policies to require law enforcement to share information with ICE when a person has been convicted of a serious crime.

“When these violent felons are released from local custody, they go right back into the communities that they came from to re-victimize those same immigrant communities,” Jones said.

But Jones acknowledged the need for nuance when it comes to health privacy.

“Look, the bottom line for me on this immigration reform in America is it needs to be humanitarian and it needs to make sense,” Jones said. “And so, if there are areas that we need to protect folks, it might make sense.”

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His administration not to arrest people without legal status at or near sensitive locations, including hospitals. That has left different states offering starkly different guidelines to hospitals, community clinics, and other health facilities for interacting with immigrant patients.

• California health care providers to avoid including patients’ immigration status in bills and medical records and telling them that, while they should not physically obstruct immigration agents, they are under no obligation to assist with an arrest. The guidance from Democratic Attorney General Rob Bonta also encourages facilities to post information about patients’ right to remain silent and provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.”
• Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization. Still, patients can refuse to answer questions about their immigration status without losing access to care.

Some health care providers fear immigration authorities will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. They point to examples from Trump’s first term, when agents arrested a child , a young man , and a woman .

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

On Tuesday, Trump directed the U.S. Department of Justice to who don’t cooperate with immigration enforcement.

But no matter the guidelines that states issue, hospitals around the U.S. stress one thing: Patients won’t be turned away for care because of their immigration status.

“None of this changes the care patients receive,” said Carrie Williams, a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

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Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization.

Donald Trump returned to the White House declaring a at the U.S.-Mexico border, , and , or the policy of giving U.S. citizenship to anyone born in the U.S. As he begins carrying out the “” in the nation’s history, states have offered starkly different guidelines to hospitals, community clinics, and other health facilities for immigrant patients.

Trump has also not to arrest people without legal status at or near sensitive locations, including schools, churches, and hospitals. to formalize such protections died in Congress in 2023.

But no matter the guidelines that states issue, hospitals around the U.S. say patients won’t be turned away for care because of their immigration status. “None of this changes the care patients receive,” said , a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

During Trump’s first term, immigration agents arrested people receiving emergency care in hospitals and a child during an . Immigration officers in Texas arrested a in a hospital in Fort Worth. In Portland, Oregon, officers leaving a hospital, and in San Bernardino, California, a woman to give birth after her husband was arrested at a gas station.

An estimated 11 million immigrants live in the United States without authorization, with the in California, Texas, Florida, New York, New Jersey, and Illinois, according to Pew Research Center.

Half of immigrant adults likely without authorization are uninsured, compared with fewer than 1 in 10 citizens, according to the , the largest nongovernmental survey of immigrants in the U.S. to date. While some states are highlighting health care expenses incurred by immigrants, a noted that immigrants contribute more to the system through health insurance premiums and taxes than they use. Immigrants also have lower health care costs than citizens.

Some health care providers fear Immigration and Customs Enforcement agents will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. On Trump’s first day, the Republican president issued an executive order aimed at ending birthright citizenship for children born to a parent without legal authorization or on a visa, which could leave them ineligible for federal health and social programs. The order was immediately challenged and a .

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need, who may not be able to get treatment for an ear infection or surgery,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

A conducted by the Im/migrant Well-Being Research Center at the University of South Florida found that 66% of noncitizens reported increased hesitation in seeking care after Florida Gov. Ron DeSantis signed in 2023 requiring hospitals that accept Medicaid to ask about a patient’s legal status. That’s compared with just 27% for citizens.

“That really was alarming to me to see how this law made people hesitant to go to the doctor, even in an emergency,” said , a co-author of the survey and report.

In signing the law, DeSantis as “the most ambitious anti-illegal immigration” legislation in the nation. This month, the Republican governor called for a special session of the state legislature to help support Trump’s immigration agenda.

Jackson Health System, a public safety net provider in Miami, said in a statement that quarterly reports to the state don’t contain individual patient information. “We do adhere to all required cooperation with law enforcement agencies, including ICE, as part of any criminal investigations, understanding that privacy laws mandate we only release private patient information through a court-ordered warrant.”

In August, Texas Gov. Greg Abbott, a Republican, issued an similar to Florida’s law to record health care costs incurred by immigrants without legal authorization. All hospitals that receive funding from Medicaid or the Children’s Health Insurance Program are expected to begin reporting the data to Texas Health and Human Services in March.

Even cities controlled by Democrats are walking a fine line. New York City Mayor Eric Adams met in December with Trump’s incoming “border czar,” Tom Homan, and pledged to who have been convicted of a major felony and lack legal status to remain in the country.

At the same time, Adams proposed an awareness campaign to let immigrants and asylum-seekers know they are safe to use the city’s hospital systems.

Some states are going further by advising health facilities to do all they can to protect immigrant patients.

In December, California Attorney General Rob Bonta released a 42-page document recommending providers avoid including patients’ immigration status in bills and medical records. The guidance also emphasized that while providers should not physically obstruct immigration agents, they are under no obligation to assist with an arrest.

According to the document, health care facilities should post information about patients’ right to remain silent and are encouraged to provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.” If feasible, it says, the facility should designate an immigrant-affairs liaison to help train staff and provide nonlegal advice to families.

“We cannot let the Trump deportation machine create a culture of fear and mistrust that prevents immigrants from accessing vital public services,” said Bonta, a Democrat.

On Tuesday, the Trump administration directed the Department of Justice to who don’t cooperate with immigration enforcement. During Trump’s first term, California limited cooperation with federal authorities, citing public safety and community trust concerns. The department, then under Jeff Sessions, but the state won in federal court, arguing that states have the authority to decide whether local resources are used to enforce federal law. The Trump administration appealed, but the Supreme Court turned down the petition.

Under California law, state-run health care facilities are required to adopt policies to limit their participation in immigration enforcement, and private entities are encouraged to follow similar protocols. David Simon, a spokesperson for the California Hospital Association, which represents more than 400 hospitals, said members have incorporated such policies, ensuring patient privacy.

“Hospitals don’t call ICE about patients,” Simon said.

California is bracing for a new round of clashes with Trump. Gov. Gavin Newsom and fellow Democratic state leaders have agreed to set aside for litigation and grants to nonprofit immigrant groups.

Lawmakers in New Jersey are to limit health care facilities from asking about a patient’s immigration status. The bill would also require the state attorney general to establish policies for hospitals and health care facilities for ensuring patient access.

In New York City, hospital administrators are directing staff to seek guidance from an “immigration liaison” if immigration authorities show up, and to take photos and videos of any enforcement actions if they can’t reach them first. They are also discouraging staff from actively helping a person hide from ICE. In Massachusetts, some clinics and hospitals are training staff on how to read ICE warrants and plan to require ICE agents to identify themselves and present a warrant if they want to enter a private area.

“You can’t be scrambling in the moment,” said Altaf Saadi, a neurologist who co-directs a clinic for asylum-seekers at the Massachusetts General Hospital. “We have to prepare for these worst-case scenarios, and we hope that they don’t happen, but we do need to be prepared.”

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At the same time, immigrants living illegally in Southern California told Ñî¹óåú´«Ã½Ò•îl Health News they thought the economy would improve and their incomes might increase under Trump, and for some that outweighed concerns about health care.

Community health workers say fear of deportation is already affecting participation in Medi-Cal, the state’s Medicaid program for low-income residents, which was expanded in phases to all immigrants regardless of residency status over the past several years. That could undercut the state’s progress in reducing the uninsured rate, which reached a record low of 6.4% last year.

Immigrants lacking legal residency have long worried that participation in government programs could make them targets, and Trump’s election has compounded those concerns, community advocates say.

The incoming Trump administration is also expected to target Medicaid with funding cuts and enrollment restrictions, which activists worry could threaten the Medi-Cal expansion and kneecap efforts to extend health insurance subsidies under Covered California to all immigrants.

“The fear alone has so many consequences to the health of our communities,” said , director of policy with the Latino Coalition for a Healthy California. “This is, as they say, not their first rodeo. They understand how the system works. I think this machine is going to be, unfortunately, a lot more harmful to our communities.”

Alongside such worries, though, is a strain of optimism that Trump might be a boon to the economy, according to interviews with immigrants in Los Angeles whom health care workers were soliciting to sign up for Medi-Cal.

Selvin, 39, who, like others interviewed for this article, asked to be identified by only his first name because he’s living here without legal permission, said that even though he believes Trump dislikes people like him, he thinks the new administration could help boost his hours at the food processing facility where he works packing noodles. “I do see how he could improve the economy. From that perspective, I think it’s good that he won.”

He became eligible for Medi-Cal this year but decided not to enroll, worrying it could jeopardize his chances of changing his immigration status.

“I’ve thought about it,” Selvin said, but “I feel like it could end up hurting me. I won’t deny that, obviously, I’d like to benefit — get my teeth fixed, a physical checkup.” But fear holds him back, he said, and he hasn’t seen a doctor in nine years.

It’s not Trump’s mass deportation plan in particular that’s scaring him off, though. “If I’m not committing any crimes or getting a DUI, I think I won’t get deported,” Selvin said.

Petrona, 55, came from El Salvador seeking asylum and enrolled in Medi-Cal last year.

She said that if her health insurance benefits were cut, she wouldn’t be able to afford her visits to the dentist.

A street food vendor, she hears often about Trump’s deportation plan, but she said it will be the criminals the new president pushes out. “I’ve heard people say he’s going to get rid of everyone who’s stealing.”

Although she’s afraid she could be deported, she’s also hopeful about Trump. “He says he’s going to give a lot of work to Hispanics because Latinos are the ones who work the hardest,” she said. “That’s good, more work for us, the ones who came here to work.”

Newly elected Republican Assembly member Jeff Gonzalez, who flipped a seat long held by Democrats in the Latino-heavy desert region in the southeastern part of the state, said his constituents were anxious to see a new economic direction.

“They’re just really kind of fed up with the status quo in California,” Gonzalez said. “People on the ground are saying, ‘I’m hopeful,’ because now we have a different perspective. We have a businessperson who is looking at the very things that we are looking at, which is the price of eggs, the price of gas, the safety.”

Gonzalez said he’s not going to comment about potential Medicaid cuts, because Trump has not made any official announcement. Unlike most in his party, Gonzalez said he supports the extension of health care services to all residents regardless of immigration status.

Health care providers said they are facing a twin challenge of hesitancy among those they are supposed to serve and the threat of major cuts to Medicaid, the federal program that provides over 60% of the funding for Medi-Cal.

Health providers and policy researchers say a loss in federal contributions could lead the state to roll back or downsize some programs, including the expansion to cover those without legal authorization.

California and Oregon are the only states that offer comprehensive health insurance to all income-eligible immigrants regardless of status. About 1.5 million people without authorization have enrolled in California, at a cost of over $6 billion a year to state taxpayers.

“Everyone wants to put these types of services on the chopping block, which is really unfair,” said state Sen. Lena Gonzalez, a Democrat and chair of the California Latino Legislative Caucus. “We will do everything we can to ensure that we prioritize this.”

Sen. Gonzalez said it will be challenging to expand programs such as Covered California, the state’s health insurance marketplace, for which immigrants lacking permanent legal status are not eligible. A big concern for immigrants and their advocates is that Trump could reinstate changes to the which can deny green cards or visas based on the use of government benefits.

“President Trump’s mass deportation plan will end the financial drain posed by illegal immigrants on our healthcare system, and ensure that our country can care for American citizens who rely on Medicaid, Medicare, and Social Security,” Trump spokesperson Karoline Leavitt said in a statement to Ñî¹óåú´«Ã½Ò•îl Health News.

During his first term, in 2019, Trump broadened the policy to include the use of Medicaid, as well as housing and nutrition subsidies. The Biden administration rescinded the change in 2021.

KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News, found than people born in the United States. And about 1 in 4 likely undocumented immigrant adults said they have avoided applying for assistance with health care, food, and housing because of immigration-related fears, according to a .

Another uncertainty is the fate of the Affordable Care Act, which was opened in November to immigrants who were brought to the U.S. as children and are protected by the Deferred Action for Childhood Arrivals program. If DACA eligibility for the act’s plans, or even the act itself, were to be reversed under Trump, that would leave roughly 40,000 California DACA recipients, and about , without access to subsidized health insurance.

On Dec. 9, a federal court in North Dakota issued an order blocking DACA recipients from accessing Affordable Care Act health plans in that had challenged the Biden administration’s rule.

Clinics and community health workers are encouraging people to continue enrolling in health benefits. But amid the push to spread the message, the chilling effects are already apparent up and down the state.

“¿Ya tiene Medi-Cal?” community health worker Yanet Martinez said, asking residents whether they had Medi-Cal as she walked down Pico Boulevard recently in a Los Angeles neighborhood with many Salvadorans.

“¡Nosotros podemos ayudarle a solicitar Medi-Cal! ¡Todo gratuito!” she shouted, offering help to sign up, free of charge.

“Gracias, pero no,” said one young woman, responding with a no thanks. She shrugged her shoulders and averted her eyes under a cap that covered her from the late-morning sun.

Since Election Day, Martinez said, people have been more reluctant to hear her pitch for subsidized health insurance or cancer prevention screenings.

“They think I’m going to share their information to deport them,” she said. “They don’t want anything to do with it.”

This article was produced by Ñî¹óåú´«Ã½Ò•îl Health News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/elections/california-trump-immigrants-medi-cal-economy-health-care/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">