Hooked on Coverage, Counties Question Funding Options
The Struggle for Health Care Access in a Post-Affordable Care Era
In 2013, before the Affordable Care Act (ACA) helped millions gain health insurance, California’s Placer County provided limited health care to around 3,400 uninsured residents who couldn’t afford medical care. For several years, that number has been zero in this predominantly white, rural county stretching from Sacramento’s eastern suburbs to the shores of Lake Tahoe.
However, this trend may not last much longer. County health officials across the country are preparing for an estimated 10 million newly uninsured patients over the next decade due to the Republican-led One Big Beautiful Bill Act. This act, signed into law by President Donald Trump, is expected to reduce Medicaid spending by more than $900 billion over the same period.
“This is the moment where a lot of hard decisions have to be made about who gets care and who doesn’t,” said Nadereh Pourat, director of the Health Economics and Evaluation Research Program at UCLA. “The number of people who are going to lose coverage is large, and a lot of the systems that were in place to provide care to those individuals have either gone away or diminished.”
This situation presents a particular challenge for states like California and New Mexico, where counties are legally required to assist their poorest residents through indigent care programs. Under the ACA, both states were able to expand Medicaid, reducing the burden on local programs that previously offered minimal services.
Placer County, which estimates that 16,000 residents could lose health care coverage by 2028, ceased operating its own clinics nearly a decade ago.
“Most of the infrastructure that we had to meet those needs is gone,” said Rob Oldham, Placer County’s director of health and human services. “This is a much bigger problem than it was a decade ago and much more costly.”
In December, county officials requested to join a statewide association that provides care to small, rural counties, citing an expected rise in the number of uninsured residents.
New Mexico’s Doña Ana County, the state’s second-most populous, added dental care for seniors and behavioral health benefits after many of its poorest residents qualified for Medicaid. However, federal cuts could force the county to reconsider these benefits.
“At some point we’re going to have to look at either allocating more money or reducing the benefits,” said Jamie Michael, Doña Ana’s health and human services director.
Straining State Budgets
Some states, such as Idaho and Colorado, have abandoned laws requiring counties to be providers of last resort for their residents. In other states, uninsured patients often delay care or receive it at hospital emergency rooms or community clinics. These clinics are typically supported by a mix of federal, state, and local funds, according to the National Association of Community Health Centers.
Even in Texas, which opted not to expand its Medicaid program, rising health care costs are straining local budgets.
“As we have more growth, more people coming in, it’s harder and harder to fund things that are required by the state legislature, and this isn’t one we can decrease,” said Windy Johnson, program manager with the Texas Indigent Health Care Association. “It is a fiscal issue.”
California lawmakers face a nearly $18 billion budget deficit in the 2026-27 fiscal year, according to the state’s nonpartisan Legislative Analyst’s Office. Governor Gavin Newsom, who has acknowledged he is considering a White House run, has rejected several efforts to significantly raise taxes on the ultra-wealthy. Despite criticizing the Republican bill as a “complete moral failure” that gutted health care programs, Newsom rolled back Medi-Cal benefits for seniors and immigrants without legal status in 2025 due to rising costs.
H.D. Palmer, a spokesperson for the state’s Department of Finance, said that the Newsom administration is still refining its fiscal projections and that it would be “premature” to discuss potential budget solutions.
Newsom will unveil his initial budget proposal in January. State officials have said California could lose $30 billion a year in federal funding for Medi-Cal under the new law, as much as 15% of the state program’s entire budget.
No Easy Fixes
It’s not clear how many people are currently enrolled in California’s county indigent programs, as the state doesn’t track enrollment and utilization. However, enrollment in county health safety net programs dropped dramatically in the first full year of ACA implementation, going from about 858,000 people statewide in 2013 to roughly 176,000 by the end of 2014, according to a survey by Health Access California.
“We’re going to need state investment,” said Michelle Gibbons, executive director of the County Health Executives Association of California. “After the Affordable Care Act and as folks got coverage, we didn’t imagine a moment like this where potentially that progress would be unwound and folks would be falling back into indigent care.”
In November, voters in affluent Santa Clara County approved a sales tax increase, in part to backfill the loss of federal funds. But even in the home of Silicon Valley, where the median household income is about 1.7 times the statewide average, that is expected to cover only a third of the $1 billion a year the county stands to lose.
Health advocates fear that, absent major state investments, Californians could see a return to the previous patchwork of county-run programs, with local governments choosing whom and what they cover and for how long.
In many cases, indigent programs didn’t include specialty care, behavioral health, or regular access to primary care. Counties can also exclude people based on immigration status or income. Before the ACA, many uninsured people who needed care didn’t get it, which could lead to them winding up in ERs with untreated health conditions or even dying, said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.
Rachel Linn Gish, interim deputy director of Health Access California, a consumer advocacy group, said that “it created a very unequal, maldistributed program throughout the state.”
“Many of us,” she said. “including counties, are reeling trying to figure out: What are those downstream impacts?”
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