California nearly achieved universal healthcare. Now, millions are losing coverage

Two years ago, California hit a milestone decades in the making: Nearly every person in the state qualified for health insurance, regardless of immigration status and income, pushing the state's insured rate to a record 95%. Now that progress is unraveling.

Facing budget shortfalls and new federal restrictions, state leaders have begun rolling back the coverage system they built. Analysis at the UC Berkeley Labor Center and UCLA Center for Health Policy Research project California's uninsured rate could nearly double, to almost 15%, by 2030.

"I knew it was going to be bad, but seeing that doubling was shocking to me," said Miranda Dietz, director of the labor center's healthcare program.

An estimated 2.2 million people could lose insurance over the next four years from combined state and federal cuts, the researchers found. The losses will fall hardest on undocumented immigrants and low-income Californians, with the uninsured rate more than doubling among Black and Asian Californians. The southern part of the state will bear the brunt, driven by its larger share of low-income and immigrant residents.

Many Californians remember how difficult it was to get healthcare before the state expanded and improved insurance options.

In 2008, Kandi Hill had just given birth to her third child. When she started throwing up and experiencing irregular menstrual cycles with heavy bleeding she struggled to find a doctor who would run any tests other than an STD panel. In a matter of months, she died from stage four cervical cancer. She was 31.

Cervical cancer has a 91% five-year survival rate if caught and treated early, according to the National Cancer Institute, but back then the Medi-Cal system was bare bones, and doctors didn't seem to take poor Black patients seriously, said her husband, Ramonte Means.

Means was left to raise two small children and an infant alone. He has been the sole provider for his family ever since, often working part-time and frequently without insurance, stitching together multiple jobs — janitorial work, customer service, job coaching — to make ends meet. Usually, Means said, his employers won't give him full-time hours so that they don't have to provide benefits. With multiple part-time jobs, he tries to keep his income low enough to qualify for Medi-Cal and ensure his kids stay covered too. He'd rather get insurance through an employer, but he can't afford a plan out-of-pocket.

"None of us want anything for free. I work two jobs. My kids go to school," Means said. "We're just asking for some dignity."

Today's Medi-Cal isn't perfect, Means says, but it's much better than when his wife died — patients have more benefits and can see specialists.

"I truly believe if all this happened now, she'd have been fine," Means said. "The system failed my kids more than anything — failed the whole family."

Millions gain coverage

When the Affordable Care Act passed in 2010, California quickly expanded its Medicaid program. Previously, the program was reserved for women and children, seniors and people with disabilities. Low-income adults were excluded unless they had dependent children. The law allowed California to open enrollment to childless adults and raised the income limit to 138% of the federal poverty level — about $22,000 for an individual today.

More than 5 million Californians gained coverage, including Means, who had occasionally earned too much money before the change.

"So 138% poverty is not a lot of money in terms of increasing income, but when you talk about how many people actually become eligible it has a significant impact," said Nadereh Pourat, associate director at the UCLA Center for Health Policy Research.

An additional 1.7 million middle-income Californians bought insurance through the commercial Affordable Care Act marketplace known as Covered California.

"That's a huge policy change," said Rachel Linn Gish, spokesperson for Health Access California, a consumer advocacy group. "Millions and millions and millions of Californians covered in 10 years. No other state can say that."

Still, one major group remained uninsured: undocumented immigrants. They account for about 2.3 million residents, according to the Public Policy Institute of California.

Newsom: The healthcare governor

Gov. Gavin Newsom campaigned on a promise to bring single-payer healthcare to the state. He pivoted to expanding access within the existing system — transforming Medi-Cal with new benefits and a focus on high-quality primary care.

The Democratic governor's administration also launched the state's second-largest coverage expansion, phasing in Medi-Cal eligibility for low-income undocumented adults until all adults and children qualified in 2024.

"We're making sure that universal access to healthcare coverage becomes a reality here in California," Newsom said in 2022 when the state allowed undocumented seniors to enroll in Medi-Cal.

At its peak, the state-funded expansion covered 1.4 million adults and 217,000 children and cost more than $10 billion a year.

Republican lawmakers have sharply criticized that price tag, and increasingly, so have moderate Democrats.

"We need to have cost containment," said Sen. Catherine Blakespear, a Democrat from Encinitas, when the state passed last year's budget.

Total Medi-Cal spending has more than doubled since Newsom took office in 2019, growing from about $96 billion to $217 billion this year. The nonpartisan Legislative Analyst's Office attributes most of that growth to higher spending per recipient — added benefits, higher drug prices and some demographic changes — rather than enrollment alone. People are seeing doctors more, and each visit is more expensive.

Medi-Cal cuts loom

Orlando and Lourdes are immigrants from El Salvador. CalMatters is using only their middle names because they fear being identified by immigration officials. Orlando has lived in Los Angeles for more than 20 years and works in construction with a work permit. Lourdes manages a store and is undocumented.

Recent federal immigration raids have already upended their lives. They've had to counsel their 6-year-old daughter that there are "good police" and "bad police." Now Lourdes, who needs radiation therapy for cancer, worries about losing her Medi-Cal insurance.

To slow Medi-Cal's growth, the state froze enrollment for undocumented adults starting in January; roughly 86,000 fewer undocumented immigrants are covered.

Starting next summer, immigrants without legal status will lose dental benefits and face new monthly premiums. These and cuts to coverage for some legal immigrants are expected to push about 800,000 people off insurance, according to the UC Berkeley Labor Center.

"We pay taxes every year. We deserve to have health insurance," Orlando said.

Services have also been curtailed more broadly. Last year, the state dropped coverage of weight-loss drugs like Ozempic for people who are simply overweight, keeping them only for more serious diagnoses like diabetes. This year, lawmakers scaled back wraparound services, including case management and medical meal-delivery services for low-income patients. They also reinstated a wealth test that caps how much savings an enrollee can have, regardless of their income, which advocates say punishes people for building a financial cushion.

The cuts have stirred outcry from lawmakers on the left, some of whom want the state to raise revenue through corporate taxes or other means rather than shrink Medi-Cal.

Sen. Lena Gonzalez, a Democrat from Long Beach and chair of the Latino Caucus, said she pressed Newsom and his team twice to save benefits for undocumented people.

"I said this is legacy work for you, and I don't want you to ever forget that," Gonzalez said. "For this to happen was just really surprising."

Linn Gish credited Newsom with supporting healthcare access "from day one" but called the recent rollbacks disappointing: "We hoped he would be a champion until the end."

Newsom's office declined an interview request. In a statement, the Department of Health Care Services emphasized that the Legislature voted to approve the budget that included the cuts and said Newsom remains committed to "responsibly" supporting universal coverage.

"Gov. Newsom has consistently highlighted California's coverage gains as central to his broader commitment to universal healthcare coverage and a more inclusive safety net," the statement said.

Federal challenges

Many Democrats, Newsom chief among them, blame President Donald Trump, whose One Big Beautiful Bill tax reform law rewrote Medi-Cal rules and cut federal funding to California. The law also let enhanced Affordable Care Act subsidies expire, contributing to a 140,000-person drop in Covered California enrollment. State officials estimate the Medi-Cal program could lose more than $30 billion annually once federal changes fully take effect in 2027.

The biggest change: Many adults must now prove they're working or volunteering at least 80 hours each month. Research has shown most low-income adults already meet requirements but lose coverage anyway because of bureaucratic errors.

"All it takes is one piece of lost mail and all of a sudden you lose coverage … and things can snowball," said Dylan Roby, a health policy researcher and professor at UC Irvine.

Combined with shorter eligibility periods, the state estimates this will cause 1.3 million people to lose insurance in the next four years.

Those losses won't be spread evenly. Los Angeles and other parts of Southern California could see the steepest declines, according to the Labor Center, which also projects that Latino Californians will lose coverage faster than other groups.

Linnea Koopmans, CEO of Local Health Plans of California, which represents Medi-Cal insurers, said the combined cuts will create a two-tiered system of haves and have-nots.

"There's a lot at stake and a lot to be lost," Koopmans said.

But some Republican lawmakers counter that blaming Washington, D.C. is disingenuous. California has run deficits for four straight years, predating most federal restrictions, which haven't even taken effect yet.

Sen. Roger Niello, a Republican from Roseville and vice chair of the budget committee, put the current impact of federal healthcare restrictions at $3 billion out of a $351 billion state budget.

"It's difficult (to argue) that the woes are being caused by the federal government," Niello said, calling the state's spending problem structural. Revenues have grown, but spending has grown faster.

The current budget leaves the toughest healthcare decisions to the next governor.

"Gov. Newsom says he solved the deficit for the next governor. He hasn't," Niello said.