In 2013, before the Affordable Care Act helped millions get health insurance, California\u2019s Placer County provided limited healthcare to some 3,400 uninsured residents who couldn\u2019t afford to see a doctor.<\/p>\n
For several years, that number has been zero in the predominantly white, largely rural county stretching from Sacramento\u2019s eastern suburbs to the shores of Lake Tahoe.<\/p>\n
The trend could be short-lived.<\/p>\n
County health officials there and across the country are bracing for an estimated 10 million<\/a> newly uninsured patients over the next decade in the wake of Republicans\u2019 One Big Beautiful Bill Act. The act, which President Trump signed into law this summer, is expected to reduce Medicaid spending by more than $900 billion<\/a> over that period.<\/p>\n \u201cThis is the moment where a lot of hard decisions have to be made about who gets care and who doesn\u2019t,\u201d said Nadereh Pourat, director of the Health Economics and Evaluation Research Program at UCLA. \u201cThe 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.\u201d<\/p>\n It\u2019s an especially thorny challenge for states such as California<\/a> and New Mexico where counties are legally required to help their poorest residents through what are known as indigent care programs. Under Obamacare, both states were able to expand Medicaid<\/a> to include more low-income residents, alleviating counties of patient loads and redirecting much of their funding for the patchwork of local programs that provided bare-bones services.<\/p>\n Placer County, which estimates that 16,000 residents could lose healthcare coverage by 2028, quit operating its own clinics nearly a decade ago.<\/p>\n \u201cMost of the infrastructure that we had to meet those needs is gone,\u201d said Rob Oldham, Placer County\u2019s director of health and human services. \u201cThis is a much bigger problem than it was a decade ago and much more costly.\u201d<\/p>\n In December, county officials asked to join a statewide association<\/a> that provides care to mostly small, rural counties, citing an expected rise in the number of uninsured residents.<\/p>\n New Mexico\u2019s second-most populous county, Do\u00f1a Ana, added dental care for seniors and behavioral health benefits after many of its poorest residents qualified for Medicaid. Now, federal cuts could force the county to reconsider, said Jamie Michael, Do\u00f1a Ana\u2019s health and human services director.<\/p>\n \u201cAt some point we\u2019re going to have to look at either allocating more money or reducing the benefits,\u201d Michael said.<\/p>\n Straining state budgets<\/p>\n Some states, such as Idaho and Colorado, abandoned laws that required 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. Those clinics are often supported by a mix of federal, state and local funds, according to the National Assn. of Community Health Centers.<\/p>\n Even in states like Texas, which opted not to expand its Medicaid program and continued to rely on counties to care for many of its uninsured, rising healthcare costs are straining local budgets.<\/p>\n \u201cAs we have more growth, more people coming in, it\u2019s harder and harder to fund things that are required by the state Legislature, and this isn\u2019t one we can decrease,\u201d said Windy Johnson, program manager with the Texas Indigent Health Care Assn. \u201cIt is a fiscal issue.\u201d<\/p>\n California lawmakers face a nearly $18-billion budget deficit<\/a> in the 2026-27 fiscal year, according to the latest estimates by the state\u2019s nonpartisan Legislative Analyst\u2019s Office. Gov. Gavin Newsom, who recently acknowledged he\u2019s mulling over a White House run<\/a>, has rebuffed several efforts<\/a> to significantly raise taxes on the ultrawealthy. Despite blasting the bill passed by Republicans in Congress as a \u201ccomplete moral failure\u201d<\/a> that guts healthcare programs, the Democrat this year rolled back state Medi-Cal benefits for seniors and for immigrants without legal status after rising costs forced the program to borrow $4.4 billion from the state\u2019s general fund.<\/p>\n H.D. Palmer, a spokesperson for the state\u2019s 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.<\/p>\n Newsom will unveil his initial budget proposal in January. State officials have said California could lose $30 billion<\/a> a year in federal funding for Medi-Cal under the new law, as much as 15% of the state program\u2019s entire budget.<\/p>\n \u201cLocal governments don\u2019t really have much capacity to raise revenue,\u201d said Scott Graves, a director at the independent California Budget & Policy Center with a focus on state budgets. \u201cState leaders, if they choose to prioritize it, need to decide where they\u2019re going to find the funding that would be needed to help those who are going to lose healthcare as a result of these federal funding and policy cuts.\u201d<\/p>\n Reviving county-based programs in the near term would require \u201cconsiderable fiscal restructuring\u201d through the state budget, the Legislative Analyst\u2019s Office said in an October report<\/a>.<\/p>\n No easy fixes<\/p>\n It\u2019s unclear how many people are enrolled in California\u2019s county indigent programs, because the state doesn\u2019t track enrollment and utilization. But enrollment in county health safety net programs dropped dramatically in the first full year of Affordable Care Act implementation, going from about 858,000 people statewide in 2013 to roughly 176,000 by the end of 2014, according to a survey<\/a> at the time by Health Access California.<\/p>\n \u201cWe\u2019re going to need state investment,\u201d said Michelle Gibbons, executive director of the County Health Executives Assn. of California. \u201cAfter the Affordable Care Act and as folks got coverage, we didn\u2019t imagine a moment like this where potentially that progress would be unwound and folks would be falling back into indigent care.\u201d<\/p>\n 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<\/a>, that is expected to cover only a third<\/a> of the $1 billion a year the county stands to lose.<\/p>\n Health advocates fear that, absent major state investments, Californians could see a return to the previous patchwork of county-run programs<\/a>, with local governments choosing whom and what they cover and for how long.<\/p>\n In many cases, indigent programs didn\u2019t include specialty care, behavioral health or regular access to primary care. Counties can also exclude people based on immigration status<\/a> or income. Before the ACA, many uninsured people who needed care didn\u2019t get it, which could lead to them winding up in emergency rooms with untreated health conditions or even dying, said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.<\/p>\n Rachel Linn Gish, interim deputy director of Health Access California, a consumer advocacy group, said that \u201cit created a very unequal, maldistributed program throughout the state.\u201d<\/p>\n \u201cMany of us,\u201d she said. \u201cincluding counties, are reeling trying to figure out: What are those downstream impacts?\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF,<\/a> the independent source for health policy research, polling and journalism.<\/p>\n","protected":false},"excerpt":{"rendered":"In 2013, before the Affordable Care Act helped millions get health insurance, California\u2019s Placer County provided limited healthcare…\n","protected":false},"author":2,"featured_media":366088,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[2139,179985,15907,16457,179986,159,97,252,18565,253,9746,78845,27290,3590,158575,179987,13109,168920],"class_list":["post-366087","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-affordable-care-act","tag-california-county","tag-care","tag-director","tag-fiscal-year","tag-funding","tag-health","tag-health-care","tag-health-economics","tag-healthcare","tag-law","tag-next-decade","tag-number","tag-people","tag-placer-county","tag-poor-resident","tag-state","tag-uninsured"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/366087","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=366087"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/366087\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/366088"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=366087"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=366087"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=366087"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}