El dolor persistente por un accidente de auto ocurrido hace dos meses, sumado a una vida ya difícil, tiene a Angulo preocupada por su embarazo. Por eso sintió alivio cuando una camioneta móvil de medicina callejera de St. John’s Community Health llegó cerca de su asentamiento en febrero.

“Gracias a Dios que los tenemos”, dijo.

, que opera 28 clínicas, la mayoría en el condado de Los Ángeles, forma parte de la red nacional de clínicas comunitarias sin fines de lucro que atienden a los habitantes más pobres del país. Alrededor del 80% de sus 144.000 pacientes, incluida Angulo, tienen Medi-Cal, la versión de California del programa Medicaid para personas con bajos ingresos o discapacidades.

Pero los recortes federales al gasto de Medicaid bajo la One Big Beautiful Bill, la ley aprobada por los republicanos, sumados al en Sacramento, podrían costarle a St. John’s hasta un tercio de sus ingresos anuales de $240 millones. Eso obligaría a recortar servicios que podrían incluir la medicina callejera, dijo Jim Mangia, presidente y director ejecutivo de la organización.

Si no se reemplaza el financiamiento perdido, clínicas más pequeñas y con menos recursos del condado podrían enfrentar consecuencias aun más duras y hasta cierres.

Por eso Mangia, junto con una coalición de clínicas comunitarias, trabajadores de salud y defensores, impulsa por cinco años en el condado más poblado del país para ayudar a cubrir la pérdida proyectada de fondos federales y estatales.

Hasta ahora, St. John’s ha aportado al menos $2 millones a la campaña.

Louise McCarthy, presidenta y directora ejecutiva de la Asociación de Clínicas Comunitarias del Condado de Los Ángeles (Community Clinic Association of Los Angeles County), dijo que no hay muchas opciones para salvar al sistema de salud de un desastre.

“Estamos en una situación crítica y desesperante”, agregó. “Esto tiene el potencial de cambiar el panorama. Compensaría de manera muy significativa las pérdidas”.

La Junta de Supervisores del condado de Los Ángeles en febrero para incluirla en la boleta de las elecciones primarias del 2 de junio, pese a la oposición de algunas ciudades dentro del condado. Sus líderes argumentaron que el impuesto pondría presión sobre los consumidores y los dueños de negocios.

La mayor parte de en ingresos anuales se usaría para proteger la atención médica de la red de seguridad en clínicas comunitarias, hospitales y escuelas.

Luchando por mantenerse a flote

A nivel nacional, se espera que la ley presupuestaria del Partido Republicano reduzca el gasto federal en Medicaid en a lo largo de 10 años. También podría aumentar en más de el número de personas sin seguro médico.

La propuesta en la boleta del condado de L.A. es una de muchas iniciativas locales y estatales en todo el país, mientras clínicas, hospitales, trabajadores de salud, defensores y legisladores buscan nuevas fuentes de dinero para compensar los recortes.

En Michigan, donde se proyecta que la ley federal le costará al estado , la oficina de la gobernadora demócrata Gretchen Whitmer ha propuesto de impuestos sobre el tabaco, productos de vapeo, apuestas en línea, apuestas deportivas y publicidad digital. Calcula que esto generaría cientos de millones de dólares al año.

En Rhode Island, un grupo de legisladores estatales espera aliviar parte del impacto de los recortes federales con un que incluye un impuesto a los anuncios digitales y un recargo del 3% sobre ingresos gravables superiores a aproximadamente $640.000.

“El objetivo no es reemplazar los ingresos, sino reducir el daño”, dijo el representante estatal demócrata Brandon Potter, uno de los legisladores involucrados en estas leyes.

En Washington, el representante estatal demócrata Shaun Scott presentó recientemente una legislación para abordar la pérdida de fondos federales con un impuesto del 5% sobre la nómina de grandes empresas, aplicado a salarios de empleados que superen los $125.000 al año.

En California, la ley republicana reducirá la a Medi-Cal en al año, o 25%. La inscripción en Medi-Cal podría caer en como resultado de los recortes federales y estatales, según un análisis del Centro de UCLA para la Investigación de Políticas de Salud y del Centro Laboral de la Universidad de California-Berkeley.

En julio, California reducirá los pagos de Medi-Cal que reciben las clínicas comunitarias por ciertos servicios brindados a pacientes con estatus migratorio “insatisfactorio” en alrededor de . Estos pacientes incluyen residentes permanentes en el país por menos de cinco años, refugiados, personas con asilo y otras personas legalmente presentes.

Preparándose para una “nueva realidad”

Defensores y expertos en salud dicen que encontrar nuevas fuentes de ingresos es la única manera de evitar una crisis en el sistema de salud de California.

“¿Vamos a permitir que los vacíos creados por las políticas federales y los recortes del presupuesto estatal dejen a millones de personas sin seguro?”, dijo Laurel Lucia, subdirectora ejecutiva de programas del Centro Laboral de UC Berkeley. “Gran parte de esa pregunta se reduce a los ingresos”.

Algunos profesionales de la medicina dicen que se necesitan nuevos ingresos en el corto plazo, pero que el país también debe abordar su sistema de salud, conocido por ser costoso.

“Esta nueva realidad es que en el futuro tendremos que hacer nuestro trabajo con menos dinero”, dijo Hector Flores, de la Asociación Médica del Condado de Los Ángeles. “Así que esta es una oportunidad para ver cómo podemos hacer las cosas mejor”.

Mientras tanto, abundan los esfuerzos por aumentar los impuestos para la atención médica.

Los votantes del condado de Santa Clara, hogar de Silicon Valley, aprobaron en noviembre pasado un aumento de 0,625% en el durante cinco años para compensar recortes federales a Medicaid. Una estará en la boleta de junio en el condado de Contra Costa.

La iniciativa más conocida, y muy disputada, es una propuesta en la boleta de California patrocinada por sindicatos para aplicar una única vez a los más de del estado.

El gobernador demócrata Gavin Newsom se opone firmemente; el senador Bernie Sanders (independiente de Vermont) hizo campaña recientemente en California a favor de la propuesta y presentar una versión nacional en el Congreso.

Los promotores del impuesto temporal a la riqueza dicen que recaudaría , que en su mayoría se usarían para cubrir la pérdida de fondos federales y estatales en Medi-Cal y otros programas de la red de seguridad. Estos promotores intentan reunir cerca de 875.000 firmas necesarias para llevar la medida a la boleta de noviembre.

“Estamos al borde de un colapso de nuestro sistema de salud. Así que las personas más afortunadas entre nosotros pagan un impuesto modesto que nos dará tiempo y nos permitirá encontrar una solución a largo plazo”, dijo Suzanne Jimenez, jefa de gabinete del Sindicato Internacional de Empleados de Servicios–Trabajadores de la Salud Unidos West, principal patrocinador de la medida. “Aun así, seguirían siendo increíblemente ricos”.

Los multimillonarios responden

El plan ha generado gran controversia, no solo en California sino en todo el país, y ha provocado y otros críticos.

Los críticos argumentan que la medida podría hacer que los multimillonarios abandonen California, lo que afectaría la innovación, los empleos y la recaudación fiscal. Algunos también advierten que podría terminar en una batalla legal, ya que quienes tendrían que pagar podrían impugnarla por múltiples vías.

“Si esto se aprobara, se esperaría que quedara frenado en los tribunales por algún tiempo”, dijo Jared Walczak, investigador temporal de la California Tax Foundation. “Es bastante posible que no entre ningún ingreso durante varios años, si es que llega a entrar alguno”.

La posibilidad de estas complicaciones ha llevado a algunos defensores de la salud a enfocarse en iniciativas locales que podrían empezar a generar ingresos más rápido, como el impuesto a las ventas propuesto en el condado de Los Ángeles.

Pero esa medida también tiene críticos, incluidos líderes de varias ciudades del condado que pidieron a los supervisores que rechazaran porque, dicen, aumentaría las preocupaciones por el costo de vida de los consumidores y pondría presión sobre los negocios.

Kathryn Barger, republicana y la única supervisora del condado de Los Ángeles, que se opuso a incluir la medida en la boleta de junio, dijo en un comunicado que el impuesto propuesto haría que el condado fuera “menos accesible para las familias y menos atractivo para que los consumidores compren y las empresas operen”.

Pero los partidarios dicen que la atención médica de la red de seguridad ya está sintiendo el impacto de la reducción de fondos. Por ejemplo, en febrero, el Departamento de Salud Pública del condado anunció que debido a $50 millones en recortes de financiamiento federal, estatal y local.

Los inscritos en Medi-Cal también están preocupados.

“Recibimos muchas llamadas de pacientes en pánico que temen perder su Medi-Cal. Decenas de llamadas al día, cientos de llamadas a la semana”, dijo Mangia, de St. John’s.

“Les decimos que estamos trabajando en una solución y esperamos tener esa solución en junio”.

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Lingering pain from a car crash two months ago, on top of an already hardscrabble life, has Angulo worried about her pregnancy. So, she was relieved when a mobile street medicine van from St. John’s Community Health pulled up near her encampment last month.

“Thank God that we have them,” she said.

, which operates 28 clinics, mostly in L.A. County, is part of the nation’s network of nonprofit community clinics that care for the poorest Americans. Around 80% of its 144,000 patients, including Angulo, have Medi-Cal, California’s version of the Medicaid program for people with low incomes or disabilities.

But federal cuts to Medicaid spending under the Republican-passed One Big Beautiful Bill Act, compounded by in Sacramento, could cost St. John’s up to one-third of its $240 million annual revenue, requiring cuts to services that might include street medicine, said Jim Mangia, the president and CEO.

Smaller, more cash-strapped clinics in L.A. County could face harsher consequences, including closure, if the lost funding is not replaced.

That’s why Mangia, along with a coalition of community clinics, health care workers, and advocates, is pushing for a five-year, in the nation’s most populous county to help backfill the projected loss of federal and state dollars. St. John’s has contributed at least $2 million to the campaign so far.

Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, said there aren’t a lot of options to save the health care system from disaster.

“Our backs are up against the wall,” she said. “This has the potential to be a game changer. It will be an absolutely significant offset to the losses.”

The L.A. County Board of Supervisors last month for inclusion on the June 2 primary ballot, over the objection of some cities within the county. Their leaders argued the tax would put a strain on consumers and business owners. Most of an in annual revenue generated would be used to protect safety-net health care at community clinics, hospitals, and schools.

Scrambling To Stay Afloat

Nationally, the GOP budget law is expected to cut federal Medicaid spending by over 10 years, and it could lead to an increase of in the number of people left uninsured. The L.A. ballot proposal is among many local and state initiatives nationwide, as clinics, hospitals, health care workers, advocates, and legislators scramble for new money to help offset the spending cuts.

In Michigan, where the federal law is projected to cost the state , Democratic Gov. Gretchen Whitmer’s office has proposed on tobacco, vape products, online gambling, sports betting, and digital advertising, which it projects would raise hundreds of millions of dollars annually.

In Rhode Island, a group of state legislators hopes to ease some of the pain caused by the federal cuts with a that includes a tax on digital ads and a 3% surcharge on taxable incomes above roughly $640,000.

“The goal is not to replace the revenue; it’s to mitigate the damage,” said Democratic state Rep. Brandon Potter, one of the legislators involved.

In Washington, Democratic state Rep. Shaun Scott recently introduced legislation to address the loss of federal dollars with on large companies, applied to employee salaries exceeding $125,000 a year.

In California, the GOP law will slash the to Medi-Cal by an a year, or 25%. Enrollment in Medi-Cal could by 2028 as a result of the federal and state spending cuts, according to an analysis by the UCLA Center for Health Policy Research and the University of California-Berkeley Labor Center.

In July, California will slash Medi-Cal payments that community clinics receive for certain services provided to patients with “unsatisfactory” immigration status by about . Those patients include permanent residents in the country for less than five years, refugees, asylees, and other lawfully present people.

Bracing for a ‘New Reality’?

Advocates and health care experts say finding new revenue is the only way to avoid a crisis in California’s health care system.

“Are we going to let the gaps created by federal policies and state budget cuts leave millions of people uninsured?” said Laurel Lucia, deputy executive director of programs at the UC Berkeley Labor Center. “I think a lot of that question comes down to revenues.”

Some medical professionals say that new revenue is needed in the short term but that the country needs to address its notoriously expensive health care system.

“This new reality is that we have to do our work with less money going into the future,” said Hector Flores, of the Los Angeles County Medical Association. “So, this is an opportunity for us to look at how we can do things better.”

In the meantime, efforts to raise taxes for health care abound.

Voters in Santa Clara County, home to Silicon Valley, last November approved a five-year 0.625% to offset federal Medicaid cuts. A will be on the June ballot in Contra Costa County.

The best-known initiative, and a hotly contested one, is a union-sponsored ballot proposal in California for a on the state’s . Democratic Gov. Gavin Newsom strongly opposes it; Sen. Bernie Sanders (I-Vt.) stumped for it in California recently and has a national version in Congress.

Proponents of the temporary wealth tax say it would raise , which would mostly be used to backfill lost federal and state dollars in Medi-Cal and other safety-net programs. Proponents are trying to collect nearly 875,000 signatures needed to get it on the November ballot.

“We are on the precipice of a collapse of our health care system. So the most fortunate among us pay a modest tax that will hold us over and allow us to figure out a long-term solution,” said Suzanne Jimenez, chief of staff for Service Employees International Union-United Healthcare Workers West, the measure’s chief sponsor. “They would still be incredibly wealthy after that.”

Billionaires Push Back

The plan has stirred considerable controversy, not just in the Golden State but nationwide, and has generated strong and others.

Critics argue the measure could prompt billionaires to leave California, putting a damper on innovation, jobs, and tax receipts. And, some warn, the measure could end up in a legal quagmire, as those deemed liable to pony up challenge it on multiple fronts.

“If this passed, you would expect it to be tied up in court for some time,” said Jared Walczak, a visiting fellow at the California Tax Foundation. “It is fairly plausible that no revenue could come in for a number of years, if there’s ever any revenue at all.”

The prospect of such complications has led some health care advocates to focus instead on local initiatives that could start generating revenue more quickly, such as the proposed sales tax in L.A. County.

That one has critics too, including leaders of multiple cities within the county who to reject a proposal they argued would add to the affordability worries of consumers and put a strain on businesses.

Kathryn Barger, a Republican and the only L.A. County supervisor to oppose putting the measure on the June ballot, said in a statement that the proposed tax would make the county “less affordable for families and less appealing for consumers to shop and businesses to operate.”

But supporters say safety-net health care is already feeling the impact of diminished funding. Last month, for example, L.A. County’s Department of Public Health announced it was due to $50 million in federal, state, and local funding cuts.

Medi-Cal enrollees are worried, too. “We get a lot of calls from panicked patients afraid they’re going to lose their Medi-Cal. Dozens of calls a day, hundreds of calls a week,” said St. John’s Mangia.

“We tell them that we’re working on a solution and hopefully we’ll have that solution come June.”

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Martha Santana-Chin, hija de inmigrantes mexicanos, creció con Medi-Cal, la versión californiana de Medicaid, el programa de atención médica administrado por el gobierno para personas con bajos ingresos y discapacidades.

Y hoy es CEO de L.A. Care, que administra lo que es, por lejos, el plan de Medi-Cal más grande, con más de 2,2 millones de beneficiarios, superando el número de inscripciones en Medicaid y en el Programa de Seguro de Salud Infantil (CHIP, por sus siglas en inglés) en .

“Si no existieran redes de apoyo como el programa Medi-Cal, muchas personas estarían estancadas en la pobreza sin posibilidades de salir adelante”, dijo. “En lo personal, no tener que preocuparme por la atención médica me permitió concentrarme en lo que debía: mi educación”.

Al comenzar su segundo año al frente de L.A. Care, Santana-Chin enfrenta recortes presupuestarios federales y estatales que dificultan su misión de brindar atención médica a personas de bajos recursos y en situación de vulnerabilidad médica, inscritas en Medicaid. La aseguradora también ofrece planes de la Ley de Cuidado de Salud a Bajo Precio (ACA, en inglés) a través de Covered California.

Santana-Chin advierte que la ley republicana conocida como One Big Beautiful Bill Act, aprobada el año pasado y también llamada HR 1, podría provocar que 650.000 personas salgan del programa Medi-Cal de L.A. Care antes de que termine 2028. Esto afectará las finanzas del plan debido a la reducción en los ingresos. La aseguradora reportó ingresos de $11.700 millones en el último año fiscal.

Se estima que HR 1 recortará más de $900.000 millones de Medicaid en los próximos 10 años, incluidos en California, según el Departamento de Servicios de Atención Médica del estado, que administra Medi-Cal.

Como otros estados con déficits grandes, California ha reducido su gasto en Medicaid mediante medidas como congelar nuevas inscripciones de inmigrantes sin estatus legal e imponer nuevamente . Todo esto incluso antes de que el estado tenga que afrontar los recortes derivados de la pérdida de fondos federales bajo HR 1.

Santana-Chin estuvo a cargo de las operaciones de Medi-Cal y Medicare para la aseguradora privada Health Net, antes de asumir la dirección de L.A. Care en enero de 2025. Asumió el cargo casi tres años después de que los reguladores estatales multaran a L.A. Care con que, según indicaron, comprometieron la salud y seguridad de sus afiliados. L.A. Care pagó al estado y acordó destinar $28 millones a proyectos comunitarios de salud.

En una amplia entrevista, Santana-Chin habló con Bernard J. Wolfson, corresponsal senior de �������ýҕ�l Health News, sobre los desafíos financieros que enfrenta L.A. Care y por qué considera que la atención médica no debería depender del estatus migratorio de una persona. Esta entrevista fue editada por razones de espacio y claridad.

Usted creció con Medicaid. ¿Cómo ha influido eso en su visión ahora que dirige uno de los planes más grandes del país?Lo que realmente me motiva es saber que muchas de las personas a las que servimos son como mi familia. Han enfrentado dificultades y han tenido que depender de sus propios hijos para traducir cosas muy complicadas. Yo recuerdo haber hecho eso por mi mamá. La dignidad humana básica exige tener acceso a atención médica.

¿Hay algo en su trabajo en Health Net o en L.A. Care que le haya recordado su experiencia infantil con Medi-Cal?En ese entonces no cubrían transporte y no teníamos auto. Hoy, una de las cosas que escuchamos de nuestros afiliados es la necesidad de contar con un transporte confiable, que llegue a tiempo y cuyos conductores los traten con respeto. Si mi mamá y yo hubiéramos tenido eso, la vida habría sido mucho más fácil.

¿Qué impacto cree que tendrá HR 1?Va a devastar el sistema de atención médica. Al estado le será imposible compensar la pérdida de fondos federales, y en los próximos años habrá cada vez menos dinero. Eso hará que el número de personas que cubrimos se reduzca significativamente. Esperamos que entre ahora y fines de 2028, unas 650.000 personas salgan de nuestras listas. Y eso es solo en L.A. Care.

Eso representa más de una cuarta parte de sus afiliados en Medi-CalSí, es muy, muy significativo. La reducción en los pagos y el aumento en la atención no remunerada van a afectar seriamente al sistema. A medida que ese sistema se debilite y hospitales y otros proveedores se vean obligados a cerrar servicios o reducir sus centros, el acceso a la atención se verá afectado. Y no solo para quienes pierdan la cobertura.

¿Cómo responderá L.A. Care?Obviamente vamos a tener una caída significativa en los ingresos. Estamos muy enfocados en operar de la manera más eficiente posible. Y estamos buscando formas creativas de usar la tecnología para que nuestro personal pueda asumir tareas de mayor nivel. Por ejemplo, mejorar nuestras herramientas para que los agentes del centro de llamadas puedan responder más rápido y resolver problemas. También estamos automatizando procesos del área de pagos de reclamos.

¿Qué le diría a los republicanos del Congreso que aprobaron HR 1?Estamos en un punto de inflexión en el sistema de salud. Y debemos reconocer que algunas partes de HR 1 tendrán consecuencias no deseadas a largo plazo, o tal vez sí eran deseadas, pero me cuesta creerlo. Probablemente haya aspectos que valga la pena reconsiderar.

¿Como cuáles?Los requisitos de trabajo son un ejemplo. Muchos pensaron que sería una buena forma de administrar responsablemente el dinero destinado a la salud. Pero es muy complejo y provocará que personas que realmente califican pierdan su cobertura. Es lamentable, y eso es algo que pediría que reconsideraran.

¿Qué impacto tendrá la decisión de California de congelar la inscripción en Medi-Cal para inmigrantes sin estatus legal?No importa cuál sea tu estatus migratorio, si eres un ser humano y necesitas atención médica, vas a buscarla donde puedas. Y eso va a generar presión en el sistema si no tienes seguro.

¿Qué ha hecho L.A. Care para responder a las preocupaciones del estado en 2022 sobre demoras en la autorización de servicios y en la atención de quejas?Se ha invertido mucho en la infraestructura de L.A. Care en los últimos años: en nuestras plataformas de tecnología, en el manejo de datos. También se ha sumado capacidad, se han reforzado muchos equipos y hay más personal para apoyar el trabajo.

¿Cómo han afectado las redadas migratorias federales en Los Ángeles a los afiliados de L.A. Care y a la comunidad en general?Definitivamente han tenido un efecto paralizante. Las familias tienen miedo de ir al médico. No están llevando a vacunar a sus hijos. Muchos proveedores en salas de emergencia nos han dicho que ha bajado el número de personas que llegan. Una de nuestras gestoras de casos estaba muy angustiada porque una persona decidió no recibir un tratamiento que le podía salvar la vida por miedo.

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Martha Santana-Chin, the daughter of Mexican immigrants, grew up on Medi-Cal, California’s version of Medicaid, the government-run health care program for people with low incomes and disabilities. Today, she is CEO of L.A. Care, which runs by far the biggest Medi-Cal health plan, with more than 2.2 million enrollees, exceeding the Medicaid and Children’s Health Insurance Program enrollments in .

“If it weren’t for safety nets like the Medi-Cal program, I think, many people would be stuck in poverty without an ability to get out,” she said. “For me personally, not having to worry about health care allowed me to really focus on what I needed to focus on, which was my education.”

As she begins her second year steering L.A. Care, Santana-Chin is grappling with federal and state spending cuts that complicate her task of providing health care to the poor and medically vulnerable enrollees in Medicaid. The insurer also provides Affordable Care Act marketplace plans through Covered California.

Santana-Chin warns that the GOP’s One Big Beautiful Bill Act, enacted last year and also known as HR 1, could result in 650,000 enrollees falling off L.A. Care’s Medi-Cal rolls by the end of 2028. This will strain the plan’s finances as revenues decline. The insurer had revenues of $11.7 billion in the last fiscal year.

HR 1 is expected to cut more than $900 billion from Medicaid over the next 10 years — including in California, according to the Department of Health Care Services, which runs Medi-Cal.

Like other states facing big deficits, California has reduced its Medicaid spending through such steps as freezing new enrollments for immigrants without legal status and reintroducing an . And that’s before the state reckons with the spending cuts that likely will be required by the withdrawal of so many federal dollars under HR 1.

Santana-Chin oversaw Medi-Cal and Medicare operations for the for-profit insurer Health Net before taking the helm of L.A. Care in January 2025, nearly three years after state regulators over violations they said compromised the health and safety of its members. L.A. Care paid to the state and agreed to contribute $28 million to community health projects.

In a wide-ranging interview, Santana-Chin talked to �������ýҕ�l Health News senior correspondent Bernard J. Wolfson about the financial headwinds facing L.A. Care and why she believes health care shouldn’t be restricted based on a person’s immigration status. This interview has been edited for length and clarity.

Q: You grew up on Medicaid. How has that shaped your views now that you run one of the largest Medicaid plans in the country?

What really motivates me is knowing that many of the people that we’re serving are just like my family. They’ve struggled and have had to have their own children translate things that were very difficult to translate. I remember doing that for my own mother. You know, basic human dignity requires that you have access to health care.

Q: Has anything you’ve dealt with at Health Net or L.A. Care reminded you of your childhood experiences in Medi-Cal?

Back then they didn’t cover transportation, and we didn’t have a vehicle. Today, one of the issues we’ll hear from our members is the need to make sure we have trustworthy transportation that shows up on time, where the drivers treat them with respect. Had I had that, had my mother had that, life would have been much easier.

Q: What do you think the impact of HR 1 will be?

It’s going to devastate the delivery system. The state obviously isn’t going to be able to make up for the shortfalls in federal funding, and over the course of the next several years, funding is going to be less and less, and the people we cover are going to decrease significantly. We are expecting between now and the end of 2028 that we’re going to see 650,000 people drop off the rolls. That’s just L.A. Care.

Q: That’s over a quarter of your Medi-Cal enrollment.

Yes, it’s very, very significant. The reductions in payment and the rise in uncompensated care are really going to impact our delivery system. As the delivery system gets destabilized and hospitals and other health care providers are forced to close services or reduce the number of sites they have, it’s going to impact access. And it’s not only going to impact those that lose coverage.

Q: How will L.A. Care respond?

Obviously, we’re going to see a significant drop in revenue. We’re very focused on making sure that we are operating as efficiently as we can operate. And we are looking at creative ways to use technology to empower our people to do higher-level work. Mostly supporting our call center agents with smarter technology that helps them answer questions and resolve problems more quickly. Some of it is automating processes on the claims payment side.

Q: What do you have to say to congressional Republicans who passed HR 1?

We are at a point of inflection in the health care delivery system. And we have to recognize that some of the components of HR 1 will have long-term unintended consequences — maybe they were intended; I’ve got to believe that some of these things are not. There’s probably a need to reconsider some of the things that were passed.

Q: Such as?

Work requirements are an example of something that many people did believe was the right thing to do to be good stewards of the health care dollar. It is very complex and is going to cause people to lose coverage that actually do qualify. It’s unfortunate, and that would be something that I would urge folks to reconsider.

Q: What impact do you expect from California’s decision to freeze Medi-Cal enrollment for immigrants without legal status?

It doesn’t matter what immigration status you are. If you are a human being and you need health care, you’re going to try to access health care wherever you can. That’s going to put a strain on the delivery system if you’re uninsured.

Q: What has L.A. Care done to address the state’s concerns in 2022 that it delayed authorizing care and addressing patient grievances?

There has been quite a bit of investment in the L.A. Care infrastructure over the last several years — our IT platforms, our data. There’s also quite a bit of investment in adding new capacity, adding bandwidth to many of the teams, more folks to help support the work.

Q: How have federal immigration raids in L.A. affected L.A. Care members and the broader community?

It absolutely has had a chilling effect. Families are afraid to come in. They’re not taking their children to get vaccinated. I’ve had numerous providers in emergency departments say that they have experienced a drop in the volume of individuals coming in. One of our case managers was really distraught because there was an individual that decided to forgo serious lifesaving treatment because of fear.

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California, Massachusetts, Connecticut, and have set caps on health care spending in a bid to rein in the intense financial pressure felt by many families, individuals, and employers who every year face increases in premiums, deductibles, and other health-related expenses.

Hospitals and other health care providers are citing Republicans’ One Big Beautiful Bill Act, signed by President Donald Trump in July, as one more reason to challenge those limits.

The law is expected to reduce federal Medicaid spending by over a decade, which mathematically should help the overall health care system meet the caps. But the law is also expected to increase the number of uninsured Americans, mostly Medicaid beneficiaries, by an estimated . Health care analysts predict hospitals and other providers will raise prices to cover the double whammy of lost Medicaid revenue and the cost of caring for an influx of newly uninsured patients.

Whether regulators in some states will allow providers to justify higher prices and exceed the spending caps is unclear. Only can penalize providers financially if they fail to meet targets.

“Are we going to say, ‘That’s OK’? Or are we going to say, ‘Well, you exceeded the target. We’re still going to penalize you for that’?” said Richard Pan, a former state lawmaker and a member of the California Office of Health Care Affordability’s board. “That has not yet been decided.”

The California Hospital Association, the industry’s main state lobbying group, in October asking a state court to strike down the spending caps, which it argued fail to account for all the cost pressures hospitals face. Those pressures, it said, include an aging, sicker population; the of labor; expensive advances in medical technology; large capital outlays on required seismic retrofitting; and changes in federal policy, including the One Big Beautiful Bill Act. The hospital group’s lawsuit also asserted that the state affordability office, by hastily imposing ill-considered cost-cutting targets, was undermining its other key mission of improving health care access, quality, and equity.

California’s affordability office last year set a five-year target to cap statewide spending growth, starting at 3.5% in 2025 and declining to 3% by 2029. The annual caps apply to a wide range of health care entities, including hospitals, medical groups, insurers, and other payers.

Earlier this year, it imposed much lower spending growth caps — starting at 1.8% in 2026 and declining to 1.6% by 2029 — for .

“The spending caps set by politically appointed bureaucrats could force cuts that result in many Californians traveling farther for care, facing longer emergency room wait times, experiencing more overcrowding, and losing access to critical services,” Carmela Coyle, the hospital association’s president and CEO, said in an October press release.

The California attorney general’s office, which will represent the affordability agency, has not yet filed a response to the hospital group’s complaint and did not respond to a request for comment.

Hospitals’ Pushback

California is not the only state taking a close look at hospital prices, which are widely considered a of health care costs.

“States, armed with information that points to payments to hospitals as a driver of what is way beyond affordable commercial premiums, have begun to take increasingly targeted actions focused on commercial hospital prices,” said Michael Bailit, founder of the Needham, Massachusetts-based consultancy , which has advised multiple states, including California, on ways to tame health care spending. “It is not surprising that the hospital industry is going to oppose such state actions.”��

In its lawsuit, the California Hospital Association said the affordability office’s own report showed that pharmaceutical and insurance companies are largely responsible for high costs.

Hospitals in some states with cost growth limits, including and , have expressed objections similar to the ones raised in the California lawsuit. They could follow their counterparts in California if their lawsuit succeeds, said Peter Lee, who led California’s Affordable Care Act marketplace, Covered California, for and is now a at Stanford Medicine’s Clinical Excellence Research Center.

Lee said the work of California’s affordability office and similar agencies in other states is just about the only systemwide effort being made to cut health care costs. They are basically saying, “‘Look, health care is taking money away from education, it is taking money away from the environment, it is taking money away from everything in the public sector, and in the private sector it is taking money away from wages,’” he said. “‘We don’t know how you, the health system, are going to do it, but it is your job not just to provide quality but to lower costs. Here’s the target.’”

To be sure, achieving the cost savings that California and those other states are seeking is no easy lift. It will ultimately require persuading large, financially powerful players that compete fiercely for health care dollars to adopt a different mindset and begin cooperating to reduce costs instead. And that, in many cases, will mean lower revenue.

But the status quo, as many people know all too well, means continued financial pain for millions.

In early 2020, Estevan Rodriguez, a bartender at California’s Monterey Beach Hotel, had surgery for a staph infection in his leg. The bill came to nearly $168,000. His insurance paid most of it, but he still owed $5,665, which took him two years to pay, more than $200 every month. “It may not be a lot to some people, but it was a lot to me,” Rodriguez said.

He said he dropped his Hulu subscription, switched to a lower-cost cellphone, and got cheaper car insurance. He started going to food banks rather than the grocery store, he said, and had a lot less time with his kids, because he was constantly working to pay off the hospital bill.

, where Rodriguez had his surgery, is one of the seven hospitals identified by California’s affordability office as high-cost. A attributed high hospital prices in Monterey County to a lack of market competition “rather than higher operating costs or superior quality of care.”

The Monterey hospital referred a request for comment about its “high-cost” designation to the California Hospital Association. CHA spokesperson Jan Emerson-Shea declined to comment beyond the language of the lawsuit and Coyle’s press release statement.

Reduced Competition

Health care analysts worry the One Big Beautiful Bill Act will reduce market competition even further by stressing already weak hospitals, leading some to shut services, merge with larger health systems, or close. One study estimates are at risk of closing nationwide.

Less competition, in addition to fewer Medicaid dollars and an increase in uninsured patients, will only strengthen the incentive of health systems with the requisite market clout to raise their commercial prices, increasing premiums for employers and individuals.

“We think commercial prices will continue to increase as health care providers, and hospitals in particular, will seek to preserve or increase their revenue,” said Rachel Block, a program officer at the Milbank Memorial Fund, a foundation that focuses on health equity.

That in turn could pose a challenge to state affordability regulators tasked with overseeing compliance with growth targets for health care spending.

California’s affordability office is required to consider mitigating factors, including changes in federal and state laws. But some of its board members have expressed skepticism about letting hospitals offset Medicaid losses with higher commercial prices.

“There’s a lot of talk about using HR 1 and other federal policies as an excuse to raise prices on commercial payers,” Ian Lewis, an affordability office board member and policy director for UNITE HERE Local 2, a hospitality workers union in the Bay Area, said at the agency’s , referring to the One Big Beautiful Bill. “There’s no more blood to be squeezed from this stone.”

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And, they warn, the economic burden will steer many medical students to lucrative specialties in more affluent, urban areas rather than lower-paying primary care jobs in underserved and rural communities, where doctors are in shortest supply.

“The growing financial barriers may deter some individuals from pursuing a career in medicine, particularly those from low-income backgrounds,” said Deena McRae, a psychiatrist and associate vice president for academic health sciences at University of California Health.

The new federal loan limits, which are enshrined in the GOP legislation signed by Trump on July 4, professional degree students can borrow at $50,000 a year, up to a maximum of $200,000 — well below the average cost of a four-year medical school education.

For students who graduated this year with an MD degree from a four-year medical school in the United States, the median cost of attendance was $318,825, according to Kristen Earle, director of student financial services at the . And for those who entered a U.S. medical school in the 2024-25 academic year, the median first-year cost was $83,700.

Health care experts and politicians on both sides of the aisle agree that medical schools must find ways to lower their costs, but critics of the loan caps say limiting federal lending isn’t the answer. Congressional Republicans, who voted for the caps, say they are intended to stem a sharp rise in federal student lending over the past two decades that has driven the cost of attendance higher.

“Uncapped loan limits gave no incentives for schools to reduce any of their costs, recognizing that taxpayers, students, or students’ families would eventually foot the bill,” said Sara Robertson, a spokesperson for the GOP-controlled House Committee on Education and Workforce. “Our reforms and loan limits will put downward pressure on costs to provide better outcomes and lower debt for all students.”

The budget law brings back caps for graduate and professional education that Congress eliminated in 2006. Since then, students have been able to get federal loans that cover the total cost of their degree programs. Reimposing the caps, along with other changes to federal student loans, is expected to over 10 years, according to the Congressional Budget Office.

Whether the new federal loan policy will push down tuition costs remains to be seen.

Robertson pointed to a by the National Bureau of Economic Research showing that the more generous federal lending policy since 2006 has led to “significantly higher program prices” in graduate education. The study also found that the additional federal support failed to increase enrollment in graduate programs, including for underrepresented students.

However, by the Association of American Medical Colleges shows that cost-of-living increases, not tuition, drove up the expense of studying medicine in recent years.

Students already in medical school who have taken out federal loans before the new rules take effect on July 1 will be exempted from the cap. But students whose loans are capped under the new law will need to make up the difference, in many cases by taking out private sector loans, which typically have less flexible repayment terms and require a strong credit rating — a heavy lift for students from low-income communities.

Robertson cited a 2017 analysis showing that of graduate students could have obtained a private loan at a lower interest rate than any available federal loan. Federal loans, however, come with advantages that private loans don’t. For instance, federal loans can include monthly repayments calibrated to income, and they offer two debt forgiveness paths, including the program, which erases the balance for those who work in a government or nonprofit organization and make their monthly payments for 10 years.

Critics and proponents agree on at least one thing: Now is the time for medical schools to think creatively about lowering costs for students. This might include reduced tuition, more chances for debt forgiveness, and accelerated programs that allow students to graduate in three years rather than four, reducing costs by 25% and getting them more quickly into paid jobs.

“I hope that coming out of this, medical schools and others find a way to seize the moment and help us figure out how to reduce the total cost of medical school,” said Martha Santana-Chin, CEO of L.A. Care. “Maybe this is an opportunity for us to rethink how the system is working.”

Roughly a fifth of medical schools offering an MD degree have accelerated programs, including the University of California-Davis, according to the .

A data analysis of eight medical schools led by the NYU Grossman School of Medicine, whose core MD curriculum is three years, shows that students in three-year programs derive a lifetime financial gain totaling over $240,000 due to the cost savings of less time in medical school, interest not paid on the corresponding amount not borrowed, and faster progression to a salaried position.

In addition to lowering costs, accelerated medical programs seek to address health care workforce shortages by training physicians more quickly. And with the new loan caps about to make it more difficult for many students to finance their medical education, these programs suddenly have a new timeliness.

Students who spend three years in medical school instead of four have lower debt and get to a higher salary sooner, said Caroline Roberts, a family physician and director of rural education at the University of North Carolina’s School of Medicine. UNC offers a three-year track for students who want to be primary care doctors and work in rural areas of the state, where doctor shortages are a major problem.

Zoe Priddy, who is in her second year of UNC’s three-year program, said that if the federal loan limits had been in place at the time she was making plans to attend medical school, she would have needed a job that paid better than the research lab where she worked after completing her undergraduate degree.

“I would have had to change my trajectory if I still wanted to pursue medicine, and I don’t know if it would have been possible for me,” Priddy said. However, the lower debt associated with the three-year track “eased my decision” to go into pediatrics, a lower-paying specialty, she said.

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Analistas del sector salud advierten que significativamente si los legisladores federales no renuevan los subsidios creados durante la pandemia de covid, que el Congreso aprobó en 2021 como complemento a los subsidios de ACA.

Es un tema que tiene apoyo popular. Según una , más de tres cuartas partes de los adultos, incluyendo el 59% de los republicanos, quieren que el Congreso extienda los subsidios mejorados para personas de ingresos bajos y moderados.

Estos subsidios adicionales han reducido las primas mensuales, han ayudado a millones de estadounidenses a pagar los seguros de salud de ACA y han disminuido la

La semana del 6 de octubre, el presidente Donald Trump insinuó que Y la legisladora Marjorie Taylor Greene, republicana de Georgia, alineada desde hace tiempo con el movimiento “Make America Great Again” (MAGA), pareció respaldar una extensión de los subsidios, al publicar que estaba “absolutamente indignada de que las primas de los seguros médicos se DUPLIQUEN si los subsidios expiran este año”.

Sin embargo, los líderes republicanos quieren , mientras que los demócratas buscan que el acuerdo esté incluido en el proyecto de ley para terminar con el cierre.

Si los subsidios adicionales no se extienden más allá de este año, se espera que el costo que pagan estos consumidores por sus planes médicos de ACA suba en promedio.

Eso representaría un fuerte aumento en el costo de vida para más de 24 millones de personas inscritas en los mercados de seguros, incluyendo un 90% de los casi 2 millones que tienen seguro a través de Covered California, . Analistas advierten que la pérdida de estos subsidios mejorados provocaría que millones de personas cancelen su cobertura a nivel nacional, incluyendo a cientos de miles en California.

El cierre del gobierno federal se debe principalmente a un desacuerdo entre los legisladores demócratas, que quieren extender los subsidios, y los republicanos, que se oponen al costo y, en muchos casos, a la propia ley de salud.

Una estimación calcula que la extensión tendría en 10 años. Los demócratas esperan que su postura les ayude a recuperar la Cámara de Representantes en las elecciones intermedias del próximo año, como ocurrió en 2018 tras el fallido intento republicano de derogar ACA.

La temporada de inscripción para los planes de salud de ACA de 2026 comienza el 1 de noviembre en la mayoría de los estados, incluido California, y los inscritos aún no saben si sus primas aumentarán de forma exorbitante el próximo año.

“Las personas necesitan poder comparar planes de salud”, dijo Jessica Altman, directora ejecutiva de Covered California. “Estamos en un momento decisivo”.

En julio, Covered California envió notificaciones a sus consumidores detallando la parte adicional de su subsidio federal que está por expirar. La intención era advertirles cuánto podrían aumentar sus costos si decidían mantener el mismo plan el próximo año.

En el caso de personas de ingresos medios, desaparecería el subsidio completo de $200 al mes. Otro inscrito perdería un tercio de los $600 mensuales que recibía en ayuda, según ejemplos de notificaciones proporcionadas por Covered California.

Los subsidios adicionales han brindado asistencia financiera a muchos compradores de planes medicos, con ingresos medios, que no calificaban para los subsidios originales, y han incrementado la ayuda para muchas otras personas.

El líder de la mayoría en el Senado, John Thune, dijo a finales de septiembre que no descartaba una extensión de los subsidios, pero que “tendría que venir acompañada de algunas reformas”.

Estas podrían incluir cambios para reducir la cantidad de personas que califican para la ayuda adicional, según sus ingresos, y reducir o eliminar los planes sin primas, que se volvieron ampliamente disponibles con la llegada de estos subsidios.

Si se terminan los subsidios mejorados, Covered California estima que quienes los reciben verán aumentar sus primas en un 97% de promedio. Pero los aumentos no serán iguales para todos. Según la edad, los ingresos y la ubicación, algunas personas verán aumentos menores, mientras que otras podrían ver que sus costos de bolsillo se triplican, explicó Altman.

Las personas que viven en , especialmente en los condados del norte, del este y en la región de Monterey Coast, enfrentarán aumentos de costos desproporcionadamente altos, según proyecciones de Covered California. Los inscritos con ingresos superiores a $62.600 perderán toda la ayuda financiera, lo que dejará a algunas personas de entre 55 y 64 años con facturas de primas que podrían representar .

Sin los subsidios mejorados, “veremos a más personas endeudadas por gastos médicos, más personas sin seguro o con seguro insuficiente”, dijo Cary Sanders, directora de políticas de la organización sin fines de lucro California Pan-Ethnic Health Network. “Y esa es la forma más rápida en que una familia puede perder su seguridad económica”.

Covered California estima que unas 400.000 personas abandonarían el mercado de seguros y probablemente se quedarían sin cobertura. Y eso, advierten profesionales y activistas de la salud, solo aumentará la presión —en forma de salas de emergencia y clínicas comunitarias más saturadas— sobre un sistema de salud ya estresado.

Sin embargo, el impacto proporcional en California será menor que en algunos estados liderados por republicanos como Florida, Texas y Georgia. Como esos estados no ampliaron el programa Medicaid de ACA, millones de residentes recurrieron a los planes del mercado de Obamacare, especialmente después de que los subsidios mejorados hicieron que la cobertura fuera mucho más accesible.

Entre 2020 y 2025, la aumentó casi 2.5 veces en Florida, alcanzando los 4,7 millones —más del doble que en California. En Texas, se triplicó a casi 4 millones. En Georgia también se triplicó, alcanzando los 1,5 millones.

California cuenta con aproximadamente $190 millones para 2026 en fondos estatales para ayudar a compensar la pérdida de los subsidios adicionales. Pero ese dinero se usa para ayudar a rebajar los deducibles, copagos y otros gastos de bolsillo de los inscritos. Y es una cantidad pequeña en comparación con los que los inscritos de Covered California reciben hoy día gracias a los subsidios que están por expirar.

“Mucha gente se va a sorprender con lo que viene”, señaló Rachel Linn Gish, vocera de la organización sin fines de lucro Health Access California. “Van a tener que tomar decisiones muy difíciles como: ‘¿Recorto el gasto en comida, en la renta, o me quedo sin seguro?’”.

Muy pronto, Covered California y otros mercados de ACA tendrán que enviar cartas formales de inscripción abierta, notificando a los inscritos exactamente qué esperar para la cobertura de 2026.

Covered California normalmente envía estas cartas el 1 de octubre, pero las ha retrasado hasta alrededor del 15 de octubre con la esperanza de que Washington aclare la situación. Por ahora, la agencia tiene dos versiones listas: una con la extensión de los subsidios y otra sin ellos.

Altman dijo que esperaba una acción del Congreso antes de enviar la versión con los grandes aumentos en las primas. Pero puede que no tenga otra opción.

“Ese es el escenario que tenemos, es decir, lo que ocurrirá si nada cambia”, dijo Altman. “Y también es el peor escenario posible, desafortunadamente”.

Le preocupa que, si Covered California informa a los inscritos de un probable y enorme aumento en sus primas, eso ahuyentará a muchas personas, aunque más adelante el Congreso decida extender los subsidios.

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Health care analysts say the nation’s significantly if federal lawmakers do not agree to renew covid-era tax credits, which Congress authorized in 2021 to supplement ACA subsidies.

They’re popular too. According to a , more than three-quarters of adults, including 59% of Republicans, say they want Congress to extend the enhanced tax credits for people with low and moderate incomes. KFF is a health information nonprofit that includes �������ýҕ�l Health News, the publisher of California Healthline.

The additional credits have lowered premiums, helped millions of Americans afford the cost of ACA insurance, and lowered the .

Last week, President Donald Trump might be in the works. And Republican U.S. Rep. Marjorie Taylor Greene of Georgia, long aligned with the “Make America Great Again” movement, appeared to endorse an extension of the tax credits, saying in that she was “absolutely disgusted that health insurance premiums will DOUBLE if the tax credits expire this year.”

However, Republican leaders want to first, while Democrats want a deal in a bill that ends the shutdown.

If the supplemental subsidies are not extended beyond this year, the amount subsidized consumers pay for their ACA health plans is expected to on average. That would be a painful cost-of-living increase for most of the country’s more than 24 million marketplace enrollees, including almost 90% of the nearly 2 million people in Covered California, the . Analysts say the loss of enhanced credits would lead millions to drop their coverage nationally, including hundreds of thousands in California.

The federal government shutdown stems primarily from a disagreement between Democratic lawmakers, who want to extend the tax credits, and Republicans opposed to the cost and, in many cases, to the landmark health care law itself. One estimate puts the over 10 years. The Democrats hope their stance can help them win back the House in next year’s midterm elections, as they did in 2018 following a failed GOP effort to repeal the ACA.

Open enrollment season for 2026 ACA health plans starts Nov. 1 in most states, including California, and enrollees still have no clue whether their premiums will rise exorbitantly next year.

“People need to be able to shop for health plans,” says Jessica Altman, executive director of Covered California. “We are at a pivotal moment.”

In July, Covered California sent notices to enrollees breaking out the enhanced portion of their federal subsidy that is set to expire. The idea was to give them a warning of how much their costs might rise if they chose to keep the same health plan next year.

In one case, a common scenario for middle-income enrollees, the entire subsidy of $200 a month would go away. Another enrollee stood to lose one-third of a total $600 per month in aid, according to sample notices provided by Covered California.

The additional tax credits have provided financial assistance to many middle-income health plan shoppers who didn’t qualify for the original subsidies and increased the amount of aid for many others.

Senate Majority Leader John Thune in late September left the door open to extending the otherwise-expiring tax credits but said “it would have to come with some reforms.”

Those might include changes that would reduce the number of enrollees eligible for the extra financial aid, based on income, and reduce or eliminate zero-premium plans, which have become widely available with the advent of the additional tax credits.

If the enhanced subsidies end, Covered California projects its enrollees receiving enhanced subsidies will see their premium costs rise an average of 97%. But the increases will not be borne equally. Depending on age, income, and location, some people will see smaller jumps while others could see their out-of-pocket costs triple, Altman says.

, especially in the northern and eastern counties, and along the Monterey Coast, will see disproportionately large cost increases, according to projections from Covered California. Enrollees with incomes over $62,600 will lose financial aid altogether, leaving some who are ages 55-64 with premium bills as high as .

Without the enhanced subsidies, “we’re going to see more people experiencing medical debt, more people being either uninsured or underinsured,” says Cary Sanders, senior policy director at the nonprofit California Pan-Ethnic Health Network. “And that is the quickest way for families to lose their economic security.”

Covered California estimates about 400,000 people would leave the exchange and likely go without insurance. And that, health care professionals and advocates warn, will only heap stress — in the form of more crowded emergency rooms and community clinics — on an already stressed health care system.

But the proportional impact in California will be smaller than in some Republican-led states such as Florida, Texas, and Georgia. Since those states did not embrace the ACA’s Medicaid expansion, millions of residents thronged to Obamacare marketplace plans, particularly after the enhanced tax credits made coverage eminently more affordable.

From 2020 to 2025, grew nearly 2.5 times in Florida to 4.7 million — more than double California’s marketplace enrollment. In Texas, it more than tripled to just under 4 million. Georgia’s tripled, too, to 1.5 million.

California has about $190 million for 2026 in state funds to help offset the loss of the enhanced premium subsidies. But that money is currently used to help offset enrollee deductibles, coinsurance payments, and other out-of-pocket expenses. And it’s a drop in the bucket compared with the in financial aid Covered California enrollees currently receive from the expiring tax credits.

“A lot of people are going to be shocked at what they’re facing,” says Rachel Linn Gish, a spokesperson for the nonprofit advocacy group Health Access California. “They’re going to have to make super hard choices of, ‘Do I cut back on my groceries, or my rent, or do I go uninsured?’”

Very soon, Covered California and other ACA marketplaces will have to send out formal open enrollment letters, notifying enrollees precisely what to expect for 2026 coverage.

Covered California typically sends those letters out Oct. 1 but has delayed them to around Oct. 15 in the hope that Washington will provide clarity. For now, Covered California has two versions of the letter on ice, one with tax credit extensions and one without.

Altman says she is hoping for congressional action before sending the one with whopping premium increases. But she may have no choice.

“That’s the default here, as in the thing that will happen if nothing changes,” Altman says. “It is also the worst-case scenario, unfortunately.”

She fears that if Covered California informs enrollees that their rates will likely rise sharply, it will scare many away, even if Congress later agrees to extend the credits.

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Owlett is one of four residents in the inaugural class of a three-year family medicine residency program run by the local nonprofit . She is the kind of doctor the organization seeks to draw to the far north of California, a region with .

That’s because Owlett knows in her gut what a lack of health care means, having seen family members drive hours to see a specialist or simply forgo care in her hometown of Wellsboro, a hamlet in Pennsylvania. She did rural training at medical school in Colorado. And because her husband attended Chico State, the couple has a strong social network here, making them likely to remain.

“With the growing family medicine residency program here, it’s a great opportunity to bring more doctors into the area, and I’d love to be a part of that,” Owlett said.

Owlett exemplifies what leaders in rural Northern California want more of: doctors trained locally who stay to work in the area. They have ambitious plans to attract more Owletts and expand the medical workforce, but recent state and federal spending cuts will pull dollars out of an already frayed health system, exacerbating the shortage of care and making their efforts more challenging.

“We need help up here, and cutting funding is not going to help us,” said Debra Lupeika, associate dean for rural and community-based education at the University of California-Davis School of Medicine and a family physician at the tribal Rolling Hills Clinic in Red Bluff, about 40 miles northwest of Chico. “We are in dire straits. We need doctors.”

California’s far northern region is a collection of sparsely populated counties stretching from just north of Sacramento all the way up to Oregon and from the Pacific coast to the Nevada border. The shortages are so pervasive that support for one of the costliest solutions — a proposed $200 million health care training campus — transcends partisanship.

“It’s about what are the priorities, right? And health care certainly is a priority — should be a priority,” said California Assembly Republican Leader James Gallagher, who represents Chico and the surrounding area. “I think it’s been pretty bipartisan, this kind of stuff.”

Republicans in Congress, including the nine GOP lawmakers in California’s delegation, voted in July to cut nearly a trillion dollars from Medicaid. Area Rep. Doug LaMalfa said the “those eligible for benefits continue to receive them.” Meanwhile, the Democratic-controlled California legislature has its health care coverage for immigrants who lack legal status.

California’s health care shortage is driven by the struggles of rural hospitals; an aging physician workforce; the inherent appeal to up-and-coming doctors of more urban areas; and the financial pressures of doing business in a region with a high proportion of , especially Medi-Cal, the state’s version of the Medicaid program, for people with low incomes and disabilities.

Almost everyone who lives up here is affected by the shortages, ranging from people with complex medical needs to those with simple, straightforward ones.

When Lupeika’s 24-year-old daughter, Ashley, injured her shoulder this summer, she couldn’t get an MRI for nearly a month, despite her severe pain.

Ginger Alonso, an assistant professor of political science and public administration at Chico State, said she drives 70 miles to Redding for OB-GYN care.

The long waits or distances people must travel often lead them to delay or forgo care. As a result, they show up at emergency rooms, urgent care, or community clinics with illnesses that are more severe than they would have been had they received medical attention sooner.

“We see sicker patients, bottom line,” said Tanya Layne, a primary care physician in Chico who recently closed her private practice for financial reasons and works at an urgent care clinic in town, owned by Enloe Health, which also runs the sole hospital in town.

Patients walk through the door with undiagnosed cancers, uncontrolled asthma, raging diabetes, and severely high blood pressure, Layne said.

In many northern counties, specialists in acutely short supply include neurologists, gastroenterologists, rheumatologists, endocrinologists, OB-GYNs, oncologists, and urologists.

“We have whole areas with no specialists at all, or where specialists are so overworked that the waits are really long, and people are forgoing care,” said Doug Matthews, a Chico-based colorectal surgeon and regional medical director of Partnership HealthPlan, which provides Medi-Cal coverage in 24 northern counties.

The health care shortage in the region grew more acute after the catastrophic 2018 Camp Fire devastated the town of Paradise, 15 miles east of Chico, shuttering and sending dozens of doctors out of the region.

In response, local leaders created , which launched a four-year residency in psychiatry last year followed by the family medicine program this year. The group also runs a program to expose high school students to potential careers in health care, and it is behind early plans for the $200 million “interprofessional” health care campus that would train future doctors, nurses, physician assistants, and others.

The startup cost would likely need to come from California’s state legislature, but lawmakers are limited by severe budget pressures. Nevertheless, James Schlund, a radiologist and board member of the organization, is discussing it with officials from UC Davis and Touro University.

“We are building the coalition,” Schlund said, “to go to the legislature with an empty bucket and ask them to fill it with money at the hardest of possible times.”

Meanwhile, medical and political leaders in Chico and Redding, the two largest cities in California’s far north, are each exploring building a medical school, possibly in collaboration and under the auspices of UC Davis, which considers rural medicine integral to its mission.

A medical school, paired with more residency slots, would keep graduating students in the area long enough for them to establish roots, buy homes, and start families, boosting the supply of local physicians, said Paul Dhanuka, a gastroenterologist and member of the Redding City Council.

But some say the region’s small population makes it a challenge to train more residents.

“The number of residents you can accommodate is limited by the ability to get the right kinds of patients with the right kind of cases that give the residents the training they need,” said Duane Bland, a physician who runs the family practice residency program at Mercy Medical Center in Redding.

Dhanuka said that in sparsely populated areas, a low number of childbirths limits how many residents can be trained in family medicine. But that is not the case with other specialties such as surgery, psychiatry, cardiology, and gastroenterology. And, he said, across the whole northern region, “there are multiple hospitals as well as clinics which absolutely are looking for more residency participation.”

Residency programs are largely funded with federal dollars through Medicare, and that funding is not at imminent risk — though the number of residency slots paid for by Washington has not significantly increased in about 30 years.

However, some graduate medical education is state-funded, and in California many of those slots rely on revenue generated from a tax on Medi-Cal health plans, which California voters earmarked for that and other purposes last fall by passing . That revenue is projected to under changes in the budget law and a similar rule proposed by the Centers for Medicare & Medicaid Services.

its ER and hospital services in October after losing its federal designation as a “critical access” hospital, which afforded it higher payments and more regulatory flexibility.

A $50 billion rural health care fund in the budget law will offset a little more than a third of the money that rural areas are expected to lose because of the Medicaid cuts, from KFF. And it’s not clear how, or to which states, that money will be distributed.

Civic and medical industry leaders in Chico and Redding say the message needs to get out that a robust health care system will serve the interests of everyone, across political lines.

“Health care is such a human need, because we all hurt the same, regardless of race, color,” Dhanuka said. “We can address this. And we don’t need to take sides on this.”

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And presto: You’ve got people dropping coverage; rising costs; and a smaller, sicker group of enrollees, which translates to higher premiums.

The Trump administration and congressional Republicans have just checked that achievement off their list.

They have done it with the sprawling tax and spending law President Donald Trump signed on July 4 and a related set of released by the Centers for Medicare & Medicaid Services that will govern how the ACA marketplaces are run.

Among the many provisions, there’s this: Large numbers of lawfully present immigrants currently enrolled in Obamacare health plans will lose their subsidies and be forced to pay full fare or drop their coverage.

Wait. What?

I understand that proponents of the new policies think the government spends too much on taxpayer subsidies, especially those who believe the ACA marketplaces are rife with fraud. It makes sense that they would support toughening enrollment and eligibility procedures and even slashing subsidies. But taking coverage away from people who live here legally is not health care policy. It’s an echo of the federal immigration raids in Los Angeles and elsewhere.

“It’s creating a very hostile environment for them, especially after having to leave their countries because of some very traumatic experiences,” says Arturo Vargas Bustamante, a professor of health policy and management at UCLA’s Fielding School of Public Health. “For those who believe health care is a human right, this is like excluding that population from something that should be a given.”

In Covered California, 112,600 immigrants, or nearly 6% of total enrollees, stand to lose their federal tax subsidies when the policy takes effect in 2027, according to data provided by the exchange. In the Massachusetts and Maryland marketplaces, the figure is closer to 14%, according to their directors, Audrey Morse Gasteier and Michele Eberle, respectively.

It’s not clear exactly how much financial aid those immigrants currently receive in ACA marketplaces. But in Covered California, for example, the average for all subsidized enrollees is $561 per month, which covers 80% of the $698 average monthly premium per person. And immigrants, who tend to have lower-than-average incomes, are likely to get more of a subsidy.

The immigrants who will lose their subsidies include victims of human trafficking and domestic violence, as well as refugees with asylum or with some temporary protected status. And “Dreamers” will no longer be eligible for ACA marketplace health plans because they will not be considered lawfully present. Immigrants who are not in the country legally cannot get coverage through Covered California or most other ACA marketplaces.

The nearly 540,000 Dreamers in the United States arrived in the U.S. as kids without immigration papers and were granted temporary legal status by President Barack Obama in 2012. Of those, an estimated 11,000 have ACA health plans and would lose them, including 2,300 in Covered California.

Supporters of the policy changes enshrined in the CMS rule and budget law think it’s high time to rein in what they say are abuses in the system that started under the Biden administration with expanded tax credits and overly flexible enrollment policies.

“It’s about making Obamacare lawful and implementing it as drafted rather than what Biden turned it into, which was a fraud and a waste-infused program,” says Brian Blase, president of Arlington, Virginia-based Paragon Health Institute, which produces policy papers with a free-market bent and influenced the Republican-driven policies.

But Blase doesn’t have much to say about the termination of Obamacare subsidies for lawfully present immigrants. He says Paragon has not focused much on that subject.

Jessica Altman, executive director of Covered California, expects most immigrants who lose subsidies will discontinue their enrollment. “If you look at where those populations fall on the income scale, the vast majority are not going to be able to afford the full cost of the premium to stay covered,” she says.

Apart from the human hardship cited by Bustamante, the exodus of immigrants could compromise the financial stability of coverage for the rest of Covered California’s . That’s because immigrants tend to be younger than the average enrollee and use fewer medical resources, thus helping offset the costs of older and sicker people who are more expensive to cover.

shows that immigrant enrollees targeted by the new federal policies pose significantly lower medical risk than U.S. citizens. And a significantly higher percentage of immigrants in the exchange are ages 26 to 44, while 55- to 64-year-olds make up a smaller percentage.

Still, it would be manageable if immigrants were the only younger people to leave the exchange. But that is unlikely to be the case. More red tape and higher out-of-pocket costs — especially if enhanced tax credits disappear — could lead a lot of young people to think twice about health insurance.

The covid-era enhanced tax credits, which have ACA marketplace enrollment since their advent in 2021, are set to expire at the end of December without congressional action. And, so far, Republicans in Congress do not seem inclined to renew them. Ending them would reverse much of that enrollment gain by jacking up the amount consumers would have to spend on premiums out of their own pockets at Covered California and more than .

And by the Congressional Budget Office shows that a consequent exodus of younger, healthier people from the marketplaces would lead to even greater costs over time.

Enhanced tax credits aside, consumers face additional hurdles: The annual enrollment period for Covered California and other marketplaces will be shorter than it is now. Special enrollment periods for people with the lowest incomes will be effectively eliminated. So will automatic renewals, which have greatly simplified the process for a majority of enrollees at Covered California and some other marketplaces. Enrollees will no longer be able to start subsidized coverage, as they can now, before all their information is fully verified.

“Who are the people who are going to decide to go through hours and hours of onerous paperwork?” says Morse Gasteier. “They’re people who have chronic conditions. They have health care issues they need to manage. The folks we would expect not to wade through all that red tape would be the younger, healthier folks.”

California and 20 other states this month challenged some of that red tape in a to stop provisions of the CMS rule that erect “unreasonable barriers to coverage.” California Attorney General Rob Bonta said he and his fellow attorneys general hoped for a court ruling before the rule takes effect on Aug. 25.

“The Trump administration claims that their final rule will prevent fraud,” Bonta said. “It’s obvious what this is really about. It’s yet another political move to punish vulnerable communities by removing access to vital care and gutting the Affordable Care Act.”

This article was produced by �������ýҕ�l Health News, which publishes , an editorially independent service of the .��

�������ýҕ�l Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).