Counties across the United States are preparing for a surge in uninsured residents following federal healthcare policy changes, threatening the infrastructure of care for the poorest Americans. The One Big Beautiful Bill Act, signed into law this past summer, is expected to result in approximately 10 million newly uninsured patients over the next decade and reduce Medicaid spending by more than $900 billion over that period. States and counties legally required to provide indigent care face mounting pressure to revive programs that have largely been dismantled since the Affordable Care Act expanded coverage.
California’s Struggling System
California counties face particularly acute challenges due to state law requiring them to help their poorest residents. Placer County, which provided care to 3,400 uninsured residents in 2013, estimates that 16,000 residents could lose health care coverage by 2028. The county dismantled its own clinics nearly a decade ago when Medicaid expansion reduced demand. Rob Oldham, Placer County’s director of health and human services, stated that the infrastructure to meet these needs is “gone” and the problem is “much bigger and much more costly” than a decade ago. Enrollment in county health safety net programs dropped dramatically in the first full year of ACA implementation, falling from about 858,000 people statewide in 2013 to roughly 176,000 by the end of 2014.
California faces an estimated loss of $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. In 2025, Governor Newsom rolled back state Medi-Cal benefits for seniors and for immigrants without legal status after the program was forced to borrow $4.4 billion from the state’s general fund. California faces a nearly $18 billion budget deficit in the 2026-27 fiscal year according to state estimates.
Nationwide Implications
New Mexico’s Doña Ana County, the state’s second-most-populous county, expanded dental care for seniors and behavioral health benefits when residents qualified for Medicaid, but now faces potential reductions. Some states, including Idaho and Colorado, abandoned laws requiring counties to be providers of last resort. Even Texas, which did not expand Medicaid, continues to rely on counties to care for many uninsured residents, with officials citing rising health care costs as a fiscal burden. In November, voters in affluent Santa Clara County approved a sales tax increase partly to backfill federal funding losses, though officials expect this to cover only a third of the $1 billion a year the county stands to lose.
This article is an AI-assisted summary. All facts and figures are drawn from the original report: https://kffhealthnews.org/news/article/indigent-care-uninsured-medicaid-aca-obamacare-one-big-beautiful-bill-california/