Trump's Medicaid work mandate could kick thousands of homeless Californians off coverage

On a brisk January morning, physician assistant Brett Feldman searched the streets of Los Angeles for patients, knocking on car windows and peering into tents. It was the day after a winter storm had doused the city, and many of the unhoused people Feldman usually treats had moved to find somewhere dry.

Feldman leads the street medicine team at the USC Keck School of Medicine, providing primary care to thousands of L.A.'s homeless individuals. Many have chronic conditions, mental health disorders, wounds or other medical issues; they need health care desperately.

But Feldman and other street medicine providers across the state are worried that changes made to Medi-Cal eligibility by President Donald Trump's "One Big Beautiful Bill" will cause a majority of unhoused people to lose insurance, limiting their options for care.

"It's very possible more than 90 percent of people experiencing unsheltered homelessness will lose insurance," Feldman said of his L.A. patients.

Medi-Cal, also known as Medicaid federally, provides health insurance for low-income people and those with disabilities.

The new law requires states starting in 2027 to verify that able-bodied adults younger than 65 without dependent children are performing 80 hours or more of work each month in order to qualify for Medicaid. It also requires states to verify income and other eligibility criteria every six months as opposed to once per year.

State officials estimate up to 2 million people – about 14 percent of the state's 14 million Medi-Cal recipients – will lose coverage, either because they don't meet the work requirements or because they get overwhelmed by the paperwork.

Meeting those requirements will be particularly challenging for the state's roughly 180,000 homeless people. They often have no phones or internet to complete a job application. They have limited access to meals, showers or clean clothes. They commonly struggle with addiction or mental health conditions and often don't have the ability to work. Research shows that homeless individuals have far worse health outcomes and a lifespan nearly 20 years shorter than the general population.

Often those who need health care the most are the ones who are least able to work, Feldman said.

Without insurance, people who are unhoused won't be able to pick up medications or find primary care providers. Their health conditions will worsen, and they'll rely on emergency rooms more.

"This is going to be a huge issue for the unhoused," said Kelly Bruno-Nelson, an executive director with CalOptima, an Orange County Medi-Cal plan that provides health insurance for an estimated 11,000 members with unstable housing.

Work exemptions

The law carves out exemptions for people who can't work: those with substance use disorders, disabling mental health conditions, complex medical conditions and other disabilities. Children, people who are pregnant, foster youth and those with disabilities are also exempt from working, though they will be required to renew their Medi-Cal eligibility every six months.

On paper, many homeless Californians likely qualify for work exemptions. Nearly half of homeless Californians have a complex behavioral health need, including regular drug or heavy alcohol use, hallucinations or recent psychiatric hospitalization, according to recent reports from the UCSF Benioff Housing and Homelessness Initiative. About 60 percent report at least one chronic condition, and roughly a third have conditions that make bathing, dressing or eating difficult.

But to claim an exemption, a patient needs a doctor to certify it. Only half of insured and unhoused Californians regularly get care and only 39 percent have a primary care provider, Benioff data shows.

In L.A., even fewer unhoused people have a primary care provider. Just 7 percent of the population had seen a provider in the past year between 2022 and 2023, according to a study published by the USC Street Medicine program, meaning very few people would have medical exemptions certified under the new law.

That means many eligible people could lose Medi-Cal: people like Samantha Randolph.

The 37-year-old has lived the streets of L.A. for more than five years. She wouldn't even know where to begin finding a job if she had to, she said. Her ID cracked in half, so she threw it away. Someone stole her phone months ago, and she has no recent work experience.

"I'm on my own. I'm doing this by myself," Randolph said on that same January morning.

Randolph, who is seven months pregnant, would qualify for an exemption from the work requirements come 2027. Feldman's team also checks on her regularly to monitor the baby and could certify an exemption if necessary. But even that's no guarantee that Randolph wouldn't inadvertently lose Medi-Cal.

Her health insurance expired six weeks prior to Feldman's visit because the county enrollment office mailed the paperwork to an address where Randolph doesn't live. Without Medi-Cal, which pays for maternity housing in the city, Feldman can't get her inside.

"I'd love to get you out of here as soon as possible," Feldman said to Randolph as he listened to her breathing and examined a bump on her head. "I'd love to get you somewhere safe and cozy."

His benefits team has been working diligently in the background to re-enroll Randolph in Medi-Cal. Without identification and other documents, it has been a slow process.

State tries to automate eligibility checks

State Medi-Cal officials are working to launch an eligibility verification system that will automatically check for work requirement compliance and exemptions. They hope to spare the estimated 3.5 million Californians like Randolph who will need to comply with the law's new requirements the headache of having to prove their qualifications on paper.

"This is a top priority for us in the department, really seeking to minimize the harm to members to the greatest extent that we can," said Tyler Sadwith, state Medicaid director at the Department of Health Care Services.

The department is looking to purchase workforce data that will capture gig workers and more timely information about income than tax returns. The state already uses IRS data and information from other welfare programs like food stamps and cash assistance programs to verify Medi-Cal eligibility.

To exempt income-eligible students, the department wants to pull information from the state's universities and colleges. And it is working to identify medical diagnosis codes that could be used to exempt people with disabilities or other qualifying conditions like mental health or substance use disorders.

If the state can link all of the data together, some qualifying and exempt Medi-Cal recipients won't need to provide additional information.

"They won't have to take action. They will receive a notification that they have been successfully renewed," Sadwith said.

But there are gaps that will be difficult for the state to fill with automated data and questions left unanswered by the federal government. Evidence of volunteer work, for example, doesn't exist in a large database, and it's unclear if the federal government will require the medical diagnosis codes that could signal a qualifying exemption be reverified by a provider every six months. If they do, many unhoused Californians who don't see a provider in time could still get kicked off of Medi-Cal.

Department officials also acknowledge that in states that have previously tried to implement work requirements, eligible people always fall through the cracks.

Matt Beare, a street medicine physician in Kern County, said falling through the cracks is the norm for people who are unhoused. Already, people like Randolph lose Medi-Cal all the time.

The law's new requirements will only make that more likely.

Not even street medicine providers who work daily to find and follow up with unhoused patients can guarantee that they can locate them. Encampment sweeps, violent crime and weather force people to move frequently.

"The cost of falling through the cracks is likely human life," Beare said.

Homeless could lose access, housing

California has invested significantly in street medicine teams over the past five years.

Street teams deliver comprehensive primary care services wherever unhoused people are: under bridges, on the side of the road, in encampments. They administer antipsychotic injections and contraceptives, provide wound care, deliver medications and help with substance use disorder treatment. Perhaps most importantly, they often travel with benefits counselors, social workers and housing specialists.

That and other Medi-Cal investments have helped the state chip away at its homelessness problem.

But with droves of patients expected to fall off of Medi-Cal, some providers predict that street medicine teams may also disappear, worsening the chance that unhoused Californians have a provider who can certify their work requirement exemptions.

"It's going to be very fiscally difficult for those programs to be able to sustain themselves," Bruno-Nelson with CalOptima said.

Without Medi-Cal, unhoused people won't be able to see specialists, get diagnostic testing or obtain most medications. They'll rely more on emergency rooms. And because California policymakers have tied some housing and other social services to Medi-Cal, many experts worry members of this vulnerable population will lose their best chance at stability.

"These people are spinning through — some with 50 emergency room visits a year because they're so sick — a vortex," said Gray Miller, chief executive of Titanium Healthcare, a case management company that helps Medi-Cal recipients coordinate health appointments, find housing and manage chronic conditions.

Back in L.A. hours after he found Randolph again, Feldman takes a call and smiles. The county has finally approved her Medi-Cal application, which means Randolph now qualifies for maternity housing. He sends a colleague to pick her up.

"I'm so happy we got Sam inside."

California Health Care Foundation

Supported by the California Health Care Foundation, which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.