01/14/2026
With Medicaid & ACA Cuts, Counties Face Daunting Care Challenge
Summary: With huge reductions in federal funding for health insurance programs, leading to a surge In the uninsured, local jurisdictions in many states will be required to fill the gap. This poses massive, highly burdensome or infeasible, funding challenges. (Read online here.)
On the Hook for Uninsured Residents, Counties Now Wonder How They’ll Pay
KFF Health News
By Christine Mai-Duc and Claudia Boyd-Barrett
January 6, 2026
Health Officials in California’s Placer County and across the country are bracing for an estimated 10 million newly uninsured patients over the next decade in the wake of Republicans’ One Big Beautiful Act. The act, which President Donald Trump signed into law this past summer, is also expected to reduce Medicaid spending by more than $900 billion over that period.
This is the moment where a lot of 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 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.”
It’s an especially thorny challenge for states like California 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 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
“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.”
“State leaders, if they choose to prioritize it, need to decide where they’re going to find the funding that would be needed to help those who are going to lose health care as a result of these federal funding and policy cuts,” said Scott Graves, a director at the independent California Budget & Policy Center.
Reviving county-based programs in the near term would require “considerable fiscal restructuring“ through the state budget, the Legislative Analyst’s Office said.
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.
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. 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.”
Comment by Don McCanne
The United States is the only industrialized nation that does not guarantee accessible and affordable health care to essentially all of its residents. Because we have attempted to correct these deficiencies through fragmented, incremental programs, we ended up with the most expensive system on earth, with deficiencies that place us at the bottom of wealthy nations in the performance of our health care system.
With recent Republican control of Congress and the White House, the situation has worsened. Low-income individuals will see a dramatic reduction of coverage from Medicaid. The government also failed to extend premium subsidies for the Affordable Care Act, which will leave millions of individuals and families unable to pay for insurance plans in the ACA exchanges. In addition, Medicare funding will likely suffer, due to budget deficits. These cuts will cause financial hardship or even bankruptcy for far too many, and, worse, inability to obtain care to prevent disabilities and even death. These problems are on top of the serious insurance deficiencies we already have.
Before programs were established to provide health insurance for much (if not all) of the population, medical care was often provided for the indigent through government facilities such as county hospitals and community health centers. As insurance coverage expanded, especially through the Affordable Care Act, these publicly-funded facilities were scaled back or even disappeared. But with the new austerity measures being put in place, there is a desperate need to replace such facilities and programs. That process will be quite complex, partly because funding will need to come from local, county, state and potentially federal sources. Also, regions controlled by conservatives will likely be stingier in providing the needed resources.
Republicans have indicated that they may change their mind and make ACA subsidies more available again. However, they have said that they will do this only if Health Savings Accounts are made part of our health care financing. The problem is that HSAs are designed to benefit wealthier, healthier individuals and families who can afford to fund them and can take advantage of the tax benefits designed for those with higher incomes. HSAs help purchase high-deductible health plans which will not adequately cover the health care costs of those with expensive illness and more modest incomes. Although the previous system offered poor performance at high cost, the most the Republicans offer now will set us further back in trying to bring a high performance health care system to everyone.
Conservatives tell us that a single payer system, such as Medicare for All, would cause prolonged waiting times for health care with inadequate resources to provide needed care. Unfortunately, that is true in some settings, where countries with universal health care systems have, in recent years, been controlled by conservative governments that deliberately under-resource their systems, partly to force a shift to private, market-driven systems. This shift drives more health care dollars to profits for middlemen (private insurers, private equity, etc.) by using funds that should go to patient care.
So what is the solution? A well-designed single payer insurance program that is comprehensive, equitably accessible, and funded based on ability to pay by using progressive income and wealth taxes. Ownership of the system should be by public provisioning – either government or nonprofit providers (eg community health centers and hospitals). Also the legislators and government administrators we put in place must believe in the moral and ethical concepts that would make affordable, comprehensive care accessible to everyone. Taxes should pay for legitimate costs (providing care!) while eliminating the middlemen who serve only to create personal wealth.
Simple. Elect legislators and a president who, deep down inside, truly believe that everyone should have high quality health care when needed. Design, enact, and implement a single payer, improved Medicare for All. Continue to keep in office government officials who sincerely believe that they are there for the people, rather than for the billionaires.
With huge reductions in federal funding for health insurance programs, leading to a surge In the uninsured, local jurisdictions in many states will be required to fill the gap. This poses massive, highly burdensome or infeasible, funding challenges.
