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When Congress allowed covid-era subsidies for health insurance to expire, California used its own funds to offset the hike in Obamacare premium costs for residents with low incomes.

But the reach has been limited.

As Gov. Gavin Newsom negotiates his last budget with the legislature, the Democrat wants to offer financial help to more than 1 in 4 enrollees in Covered California, the nation’s largest state-run health insurance marketplace. Democratic lawmakers, who hold a supermajority, are still debating the plan.

“My budget proposal would KEEP $0 monthly plans for low-income Californians to help clean up the financial disaster Trump created,” Newsom , where he often chides the president and GOP Congress.

have put up their own funds to keep Affordable Care Act plans affordable and residents insured as the rising cost of healthcare has emerged as a among voters. Newsom’s $300 million proposal would make California’s program among the most generous, but even the nation’s richest state can’t patch a left by the expiration of enhanced subsides at the end of last year.

“The gap between what people can pay in their monthly budget and what health insurance costs is so big that it’s a lot for states to take on,” said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. “They’re going to have to figure out how they can finance that.”

New Mexico lawmakers have of the lost federal subsidies with state money. It seems to have worked; New Mexico saw in marketplace enrollment this year, but state analysts that the subsidy program isn’t sustainable.

and , which, like California, tax residents , are also spending hundreds of millions of dollars to try to keep premium payments low. Their hope, healthcare experts say, is to avoid the exodus seen in states such as Georgia that didn’t offer enrollees help.

Since the enhanced subsidies expired, have seen their premium payments increase by $65 a month on average.

Conservatives including have long argued that the subsidy expansion was too generous to high-income enrollees and .

“There are never enough subsidies to make health insurance affordable because subsidies are the problem,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute. “They are causing people to turn a blind eye to fraud and waste and excessive prices because it’s someone else’s money that they’re spending, not their own.”

Helping the Poorest?

People who earn too much to qualify for Medicaid got relief starting in January after Newsom and legislators softened the blow for about 300,000 of the lowest-income enrollees. They offset lost federal premium tax credits for individuals who last year and partially filled the gap for those who earned up to $25,823.

The governor now wants to expand subsidies to those who earn up to $31,920 this year for an individual and $66,000 for a family of four — an estimated 218,000 additional people.

Veronica and William Walter, who live in the San Francisco Bay Area, earn less than $40,000 a year in one of the nation’s most expensive regions. They’re counting on a more generous state healthcare tax credit if they have to pay for health insurance next year.

A car accident two years ago left William temporarily disabled, qualifying the couple for Medi-Cal, the state’s Medicaid program.

Now he’s back at work as a security guard, and Veronica said she’s worried they’ll be kicked off Medi-Cal. She’s even more worried about how they’ll get by with federal premium tax credits not nearly as generous as before.

“Without it, we’re going to be facing worse problems than we have now,” she said. Under Newsom’s proposal, Veronica and others in the highest eligible income bracket could receive an average monthly subsidy of $36 a person.

“For them, $36 a month is the sort of thing that can make a difference between keeping coverage and losing coverage,” said Peter Lee, former executive director of Covered California. “We can’t fix everything with that gap, but we can focus the dollars on those who need it most.”

The Walter family, though, may still face a nearly $200 monthly premium payment to cover both of them, $130 more than they previously paid for healthcare and prescriptions through Covered California.

“I can’t afford that, not really,” said Veronica, a pet sitter who works part-time at a school. “A giant state like this with this many people, and this many resources? You can’t just leave the people with nothing for healthcare or healthcare they can’t afford.”

California policy researchers and health advocates acknowledge the limits of a partial subsidy but say that concentrating funds on those who earn less is the most efficient way to maximize impact. People who drop coverage are , healthier, and less likely to have high healthcare costs — all factors that help stabilize the insurance risk pool. Without coverage, Lee said, they’re also more likely to experience debt from medical emergencies or leave unpaid hospital bills that strain the .

Cary Sanders, senior policy director at the California Pan-Ethnic Health Network, a health advocacy group, said the state’s move last year kept low-income enrollment in Covered California steady and reduced racial disparities in coverage.

“It’s working; it’s just that it’s not enough,” Sanders said. “We need the federal subsidies back.”

Still No Help for Many

When Congress passed enhanced subsidies in 2021, it capped monthly premium payments for even the highest earners at 8.5% of income. Those temporary enhancements allowed about 8 million Americans to choose robust plans with no monthly premium payment last year and helped double Obamacare enrollment to of 24 million.

At the end of last year, 22 million of them lost that help when the GOP-led Congress blocked the extension.

The pressures on Obamacare enrollees don’t stop at premiums. Federal legislation Republicans passed last summer known as the also shortens enrollment windows, tightens income verification requirements for subsidies, and requires enrollees who earn more than they projected to pay back the full amount.

Even if Newsom’s proposal passes, most Covered California customers won’t get state help. Nearly 1 million enrollees — 52% — earn above the $31,300-a-year individual earning cutoff.

Victoria Garzouzi was one of many middle-income retirees hit with one of the most extreme premium increases: The monthly payment for her low-level bronze plan jumped eightfold to $1,600.

To make ends meet, she came out of retirement and dipped into her savings. “I’m working to pay for my insurance,” she said. “I am an army of one.”

Despite a $6,000 deductible, her health insurance premium payment is more than the mortgage on her two-bedroom house. She’s putting off a needed cataract surgery until October, when she turns 65 and qualifies for Medicare.

While GOP leaders have not publicly weighed in on the state subsidies, some Democratic lawmakers have questioned why more help hasn’t been proposed.

Assembly member Dawn Addis, who chairs the chamber’s budget subcommittee on health, suggested Newsom could tap an additional $230 million from a fund for healthcare cost relief — money raised from a state penalty levied on those who can afford to enroll in health insurance but choose not to.

Lawmakers have previously criticized state officials for socking away much of the penalty revenue, which was supposed to go toward healthcare affordability. After California discontinued its premium subsidies thanks to increased federal assistance, the Newsom administration said the state was saving to help consumers once those temporary subsidies expired. Instead, California borrowed from the subsidy fund to cover state budget shortfalls, to the tune of $771 million. Starting this year, the subsidy fund should see an influx of cash as the state pays back the loan.

At a May legislative hearing, Joseph Donaldson, then a Department of Finance analyst, said maintaining the reserve was a prudent and financially sustainable approach.

Dylan Roby, a public health professor at the University of California-Irvine who consults for Covered California, said the focus on lower-income enrollees is deliberate. They qualify for federal subsidies that higher earners don’t, maximizing federal investment and strengthening the broader system.

“You end up with more advanced premium tax credits flowing into the state that you would have been leaving on the table,” he said.

State lawmakers have until June 15 to pass a state budget. Then, Covered California’s board would decide eligibility and benefit amounts, a decision that could come this summer, with new subsidies starting Jan. 1.

Even with the extra help, Walter and her husband worry they won’t be able to afford a potential $200 monthly premium payment. Walter said she’d likely have to rely on free clinics or ration medications.

“I take so many pills, I rattle,” she said. “That, on top of the $200? For us, it really adds up.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage?ÌýClick here  to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

This <a target="_blank" href="/insurance/covered-california-aca-obamacare-insurance-premium-subsidies-affordability/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Today, leading Democrats in the wide-open race to succeed Newsom have embraced single-payer as a political necessity, an answer to voters fed up with rising premiums and other spiraling healthcare costs.

But with no clear front-runner, they are sparring among themselves in debates and political ads over who is most committed to a government-run model. No candidate has outlined how California would fund comprehensive health coverage for its 40 million residents, leaving voters unable to discern which candidate has a concrete plan for the nation’s most populous state.

Healthcare and political experts said the concept of single-payer has shifted from progressive pipe dream a decade ago to today’s mainstream talking points in a state where Democrats outnumber Republicans nearly 2 to 1. Democrats have pledged the model as the best way to lower costs in an attempt to woo voters worried about affordability as ballots arrive for the June 2 primary. The top two Republicans, meanwhile, have dismissed government-run healthcare as a “disaster” and “socialism.”

“In many ways, single-payer healthcare has become a progressive litmus test,” said Larry Levitt, a former White House policy adviser and a healthcare expert at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

Few voters fully understand the term single-payer, let alone expect the next governor to achieve it, Levitt said. Rather, he added, the term has become more of a signal to voters about a candidate’s approach to healthcare reform.

Xavier Becerra, the former U.S. Health and Human Services secretary, who for decades backed single-payer healthcare in Congress, has come under criticism from opponents for a nuanced but clear shift away from single-payer. It came after Becerra secured an endorsement from the California Medical Association, a powerful group representing doctors and a longtime opponent of single-payer healthcare bills in California.

At a May 5 debate put on by CNN, Becerra for “Medicare for All,” a proposal for a that’s been stalled for years, but he declined to say whether he’d pursue a California-led effort. He said his immediate focus would be on mitigating the drastic federal cuts expected to hit low-income and disabled enrollees in Medi-Cal, the state’s Medicaid program, which covers more than a third of residents.

Becerra is counting on voters not to distinguish between the often-confused terms single-payer, Medicare for All, and universal coverage, noting during the debate that “Californians don’t care what you call it, so long as they have affordable healthcare.”

“A lot of people aren’t clear what single-payer is, and they need a metaphor to understand it,” said Celinda Lake, a Democratic strategist and one of the lead pollsters for former President Joe Biden’s 2020 campaign.

Billionaire activist Tom Steyer, who’s touted his self-funding as a , has emerged as the race’s most vocal advocate of single-payer after during a short-lived 2020 presidential bid.

As governor, Steyer has said, he would pass legislation backed by the California Nurses Association that has failed to come to fruition under Newsom’s tenure. Pressed on how he would cover the estimated , Steyer told Ñî¹óåú´«Ã½Ò•îl Health News that “God is going to be in the details.”

At a , former U.S. Rep. Katie Porter said she didn’t believe achieving such a system was realistic in the near term, but the Orange County Democrat later told party delegates that she would “.” Former Los Angeles Mayor Antonio Villaraigosa and San Jose Mayor Matt Mahan, Democrats who are trailing their competitors in the polls, don’t support single-payer. The top two vote-getters — regardless of party — advance to the November general election.

Some of the most seasoned politicians have failed to deliver single-payer. Newsom, who campaigned on the promise of being a “healthcare governor,” dialed back his ambitions upon taking office, choosing instead to pursue “” to health coverage under a series of Medi-Cal expansions and efforts to contain healthcare spending.

Vermont, which remains the a single-payer healthcare law, when leaders there couldn’t identify a funding source.

To enact single-payer, California would from the federal government to redirect billions of dollars from Medicaid, Medicare, and other funding that currently flows to the system — approval not likely to come from the Trump administration.

More than half of adults nationally say healthcare costs will have a on whom they vote for in November, according to an April KFF poll.

Danielle Cendejas, a Los Angeles-based Democratic consultant who works with state legislative candidates, said single-payer healthcare increasingly appears on candidate questionnaires from as well as , in and .

What most California voters want to hear, Cendejas said, is how candidates plan to give them more immediate relief from higher premiums, expensive drug costs, and long waits to access care.

The high price tag doesn’t faze Jennifer Easton, a 63-year-old Democrat from Oakland, who said other countries with similar models have proved they can lower costs. She said she supports a single-payer health system because it’s clear to her that Americans have reached the limits of working within the existing system. But she isn’t expecting any of the current candidates to succeed in implementing one, and she hasn’t decided whom to support.

“No one can in four years,” she said. Seeing a candidate enthusiastically support the concept gives her a good idea of their philosophy. “It is, if we’re lucky, a 20-year, 25-year plan.”

Rob Stutzman, a Republican political consultant who advised former Gov. Arnold Schwarzenegger, said while Americans of single-payer , focus groups suggest that approval drops quickly when voters realize it could mean losing their current doctor or insurance plan.

At the CNN debate, Steve Hilton, the Republican candidate President Donald Trump has endorsed, said Californians would end up with subpar patient care and “taxes sky high to pay for it,” like in his native United Kingdom.

Instead, Hilton suggested the state stop providing “free healthcare for illegal immigrants who shouldn’t even be in the country in the first place.”

This <a target="_blank" href="/health-care-costs/california-governor-race-single-payer-healthcare-becerra-cma-steyer/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

She and her husband, Charles, a former high school teacher who goes by Chaz, planned to retire comfortably in the three-bedroom house where they raised their kids about 60 miles northwest of Sacramento.

But early last year, the 63-year-old became unsteady on her feet. One morning in May, she woke up with slurred speech and landed in the hospital, then rapidly lost the ability to move the right side of her body.

In August, as doctors continued to puzzle over a possible diagnosis, the couple received a notice saying that on Jan. 1 their combined health care premium payments through the state insurance exchange would shoot up from $540 a month to $3,899 a month. The reason: Federal enhanced premium subsidies expiring at the end of last year would no longer offset their payment.

They immediately canceled a monthlong cruise they’d been planning with friends and looked through their retirement accounts.

“Now, instead of thinking about where we can go in our retirement, we’re asking the question, ‘Are we still going to be able to stay where we are because of the health care costs?’” said Chaz, who retired in 2021 at age 59.

Then they received more bad news. In October, at the age of 63, Jean was diagnosed with ALS, a debilitating disease that will eventually leave her unable to speak, swallow, or breathe on her own. But Jean’s condition allowed her to enroll in Medicare, the federal health insurance program that covers adults 65 and older and people with disabilities. The diagnosis saved them roughly $1,600 a month in premiums — little comfort as Jean lost her ability to walk, bathe, and dress herself.

“It’s kind of morbid that, because of my diagnosis, I got put on Medicare right away, so at least we don’t have to pay that out-of-pocket,” Jean said, sitting in a wheelchair in her living room, a quilt draped over her legs to guard against the intense chills she now often gets. “We’re not going to get buried under this.”

Yet the premiums for Chaz’s plan and her Medicare remain a significant strain on their finances. The $2,300 a month they now owe, which includes roughly $342 in premium payments for Jean’s Medicare supplemental insurance, is higher than their monthly mortgage and eats up more than a quarter of their budget.

The Franklins are among the across the nation facing greater financial pressure after Congress chose not to extend 2021 enhanced federal subsidies. That assistance helped more than double enrollment in Obamacare plans to over 24 million.

The Congressional Budget Office estimated in 2024 that, without an extension of the tax credits, the number of uninsured Americans would climb by 2.2 million this year alone. , nationwide enrollment in ACA plans was down about 1.2 million year over year, though experts say it could be months before the full effects of rising premiums are known, as people miss payments and lose coverage.

The groups hit hardest will be , , and people living in high-cost states, said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. The Franklins are all three.

“They fell off what we call a subsidy cliff,” Pogue said. “It’s very, very shocking, the amount that a person would have to absorb.”

That’s because the expanded tax credits made the biggest difference for people nearing retirement age who sat just above thresholds, Pogue said. People such as the Franklins, who likely wouldn’t have qualified for financial help before expanded credits were implemented, are now losing that support at a time when insurers have responded to the uncertainty by dramatically raising rates.

Roughly half of people who were expected to lose eligibility for premium tax credits were ages 50 to 64, according to an , a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

A Retired Couple Faced a Huge Health Premium Increase. Her Terminal Diagnosis Saved Them Money.

Jean Franklin, 63, and Chaz Franklin, 64
Colusa, CaliforniaÌý

Chaz and JeanÌýFranklin thoughtÌýthey’dÌýsaved enough to retire comfortably. But when they found out the premium payment for their “silver” Affordable Care Act plan would soon rise from $540 a month to $3,899, they had to reevaluate. A couple of months later, Jean was diagnosed with ALS, a debilitating neurodegenerative illness that qualified her for Medicare. Her premium payment dropped to $342 a month. The couple still pays a combined $2,300 a month in premiums, more than a quarter of their budget. “It’s the terrible irony that because my wife got a disorder, I’m saving money, and a lot of it,” Chaz said.

Republicans who opposed the extension have said the premium assistance went directly to insurance companies rather than consumers, incentivizing fraud and wasteful coverage. They also say the enhanced subsidies, which had no upper income limit for eligibility, were far too generous in capping premium payments at 8.5% of income, no matter how much an enrollee made.

“Most Americans would agree that taxpayers should not be subsidizing the health insurance of someone making $250,000,” U.S. Rep. , a California Republican who an extension in January, wrote in an . “I cannot accept the simple extension of a program that will line the pockets of insurers and is riddled with fraud at the expense of the American taxpayer.”

Patient advocates say the premium increases and expiration of subsidies have forced people into difficult choices. “The young people who are healthy are the first to say, I’m going to roll the dice” and forgo coverage, said , executive vice president of policy and programs at the National Patient Advocate Foundation. “Those who are remaining in the system — because they have no choice — are holding off care, they’re holding off their meds, they’re going without necessary food.”

While the Franklins are getting by, they have relied on their sons to pay for a motorized recliner to assist with lifting Jean and a handicap van to transport her. Chaz, who broke a tooth a year ago, delayed fixing it because a crown would cost him $1,000.

This year, the couple will draw $36,000 more than they had anticipated from their retirement savings, most of it to cover Chaz’s insurance premiums.

“I have a nest egg,” Chaz said. “But there’s a lot of people around here who don’t.”

For a while, he was outraged.

“I wish Congress would get off their butts and solve this issue,” said Chaz, who is a registered Republican but blames both sides of the aisle. “You’re so busy bickering over stupid crap and it’s both parties pointing fingers and blaming. Where was this discussion two years ago?”

Now, Chaz said, he’s focused on making Jean, his wife of 27 years, as comfortable as possible.

Before she got sick, they did practically everything together — hiking, traveling, tai chi, amateur photography, and bug-hunting. One of her favorite specimens was the rain beetle, a fuzzy scarab-like insect that can’t feed as an adult, relying solely on fat stores from its larval stages.

In the mornings, Chaz and their sons, Charlie and Louis, take turns lifting Jean, dressing her, and helping her use the bathroom. It’ll be fodder for the counselor, she jokes to her sons, when they inevitably need therapy later in life.

Most days, Jean’s outdoor adventures rarely extend beyond being wheeled to her back patio, where she loves to watch their backyard chickens bobble around. Chaz’s stubbornness makes him a great patient advocate. Charlie always seems to know exactly when she needs a big hug, and Louis tells jokes that can still make her snort with laughter.

“I don’t know what I would do without my boys making me laugh,” she said.

In December, Chaz will turn 65, old enough to qualify for Medicare himself. “After this year — knock on wood — we should be OK,” Jean said, before pausing and shooting her husband a wry smile.

“Well, you’re gonna be OK.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage?ÌýClick here  to contact Ñî¹óåú´«Ã½Ò•îl Health News and share your story.

This <a target="_blank" href="/health-care-costs/insurance-premium-payments-terminal-diagnosis-aca-subsidies-covered-california/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

TheÌýCaliforniaÌýDemocratÌýcame into office promising to fight forÌý“,”Ìýand he came close to achieving it. Really close. But as it turns out,Ìýthat’sÌýeasier said than done whenÌýyou’reÌýjugglingÌý,Ìý,ÌýandÌýshrinking federal support.Ìý

Now he’s walking the fine line between keeping his  and being tarred as a reckless state executive who has stretched California’s spending . 

After years of political infighting, Newsom and the Democratic-controlled legislature in 2024 broadened California’s Medicaid program, Medi-Cal, to  regardless of immigration status. 

Now, he’s rolling back those expansions in the name of “fiscal prudence.” 

This year, California froze Medi-Cal enrollment for most adults without legal status, just two years after . On July 1, immigrants not eligible for federal Medicaid â€” both legal residents and those without authorization â€” will lose access to state dental coverage. Next year, they’ll have to start paying monthly premiums. 

Last month, Newsom proposed letting roughly 200,000 legal immigrants â€” asylees, refugees, and others â€” get cut off from Medi-Cal after Sept. 30, when the federal government will stop paying for them. 

Advocates are livid. 

ProgressivesÌýsayÌýNewsom’s political ambitionsÌý—Ìýand perceived need to distance himself from theÌýpolarizedÌýtopic of immigrant health careÌý—Ìýgo againstÌýhis earlyÌýpledges.Ìý

“You’re clouded by what Arkansas is going to think, or Tennessee is going to think, when what California thinks is something completely different,” said California state Sen. Caroline Menjivar, chair of the budget subcommittee on health and human services. 

Meanwhile, Republicans and fiscal hawks have painted Newsom as a  Democrat prioritizing use of limited state funds on free health care for noncitizens. And Newsom has taken hits from the Trump administration accusing California of “” to use federal funds for immigrant health services. 

He’s not the only governor grappling with this dilemma. And all 50 states, which are currently required to provide health coverage to refugees, asylees, and others, will have to decide whether to backfill that coverage for some 1.4 million legal immigrants starting Oct. 1, when  of the One Big Beautiful Bill Act kicks in and leaves states without federal reimbursement for their care.

This <a target="_blank" href="/insurance/the-week-in-brief-gavin-newsom-california-immigrant-health-policy-presidential-bid/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

For a second year, the Democrat has asked state lawmakers to roll back coverage for some immigrants in the face of federal Medicaid spending cuts and a roughly that if the artificial intelligence bubble bursts. Newsom has proposed that the state not step in when, starting in October, the federal government stops providing health coverage to an estimated 200,000 legal residents — comprising .

Progressive legislators and activists said the cost-saving measures are a departure from Newsom’s , while Republicans continue to skewer Newsom for using public funds to cover any noncitizens.

Newsom’s latest move would save an estimated $786 million this fiscal year and $1.1 billion annually in future years in a proposed budget of $349 billion, according to the Department of Finance.

State Sen. Caroline Menjivar, one of two Senate Democrats who voted against Newsom’s immigrant health cuts last year, said she worried the governor’s political ambition could be getting in the way of doing what’s best for Californians.

“You’re clouded by what Arkansas is going to think, or Tennessee is going to think, when what California thinks is something completely different,” said Menjivar, who said previous criticism got her from a key budget subcommittee. “That’s my perspective on what’s happening here.”

Meanwhile, Republican state Sen. Tony Strickland criticized Newsom for glossing over the state’s , which state officials say could balloon to $27 billion the following year. And he slammed Newsom for continuing to cover California residents in the U.S. without authorization. “He just wants to reinvent himself,” Strickland said.

It’s a political tightrope that will continue to grow thinner as federal support shrinks amid ever-rising health care expenses, said Guian McKee, a co-chair of the Health Care Policy Project at the University of Virginia’s Miller Center of Public Affairs.

“It’s not just threading one needle but threading three or four of them right in a row,” McKee said. Should Newsom run, McKee added, the priorities of Democratic primary voters — who largely mirror blue states like California — look very different from those in a far more divided general electorate.

Americans are deeply divided on whether the government should provide health coverage to immigrants without legal status. In a last year, a slim majority — 54% — were against a provision that would have penalized states that use their own funds to pay for immigrant health care, with wide variation by party. The provision was left out of the final version of the bill passed by Congress and signed by President Donald Trump.

Even in California, support for the idea has waned amid ongoing budget problems. In a by the Public Policy Institute of California, 41% of adults in the state said they supported providing health coverage to immigrants who lack legal status, a sharp drop from the 55% .

, Vice President JD Vance, , and congressional Republicans have repeatedly accused California and other Democratic states of using taxpayer funds on immigrant health care, a red-meat issue for their GOP base. Centers for Medicare & Medicaid Services Administrator Mehmet Oz has of “” to receive more federal funds, freeing up state coffers for its Medicaid program, known as Medi-Cal, which has enrolled roughly 1.6 million immigrants without legal status.

“If you are a taxpayer in Texas or Florida, your tax dollars could’ve been used to fund the care of illegal immigrants in California,” he said in October.

California state officials have denied the charges, noting that only state funds are used to pay for general health services for those without legal status because the law prohibits using federal funds. Instead, Newsom has made it a “” that California has opened up coverage to immigrants, which his administration has noted and helps them avoid costly emergency room care often covered at taxpayer expense.

“No administration has done more to expand full coverage under Medicaid than this administration for our diverse communities, documented and undocumented,” Newsom told reporters in January. “People have built careers out of criticizing my advocacy.”

Newsom warns the federal government’s “carnival of chaos” passed Trump’s One Big Beautiful Bill Act, which he said puts 1.8 million Californians at risk of losing their health coverage with the implementation of work requirements, other eligibility rules, and limits to federal funding to states.

Nationally, 10 million people could lose coverage by 2034, according to the Congressional Budget Office. higher numbers of uninsured patients — particularly those who are relatively healthy — could concentrate coverage among sicker patients, potentially increasing premium costs and hospital prices overall.

Immigrant advocates say it’s especially callous to leave residents who may have fled violence or survived trafficking or abuse without access to health care. Federal rules currently require state Medicaid programs to cover “qualified noncitizens” including asylees and refugees, according to Tanya Broder of the National Immigration Law Center. But the Republican tax-and-spending law ends the coverage, affecting legal immigrants nationwide.

With many state governors yet to release budget proposals, it’s unclear how they might handle the funding gaps, Broder said.

For instance, Colorado state officials estimate roughly 7,000 legal immigrants could lose coverage due to the law’s changes. And Washington state officials refugees, asylees, and other lawfully present immigrants will lose Medicaid.

Both states, like California, expanded full coverage to all income-eligible residents regardless of immigration status. Their elected officials are now in the awkward position of explaining why some legal immigrants may lose their health care coverage while those without legal status could keep theirs.

Last year, spiraling health care costs and state budget constraints prompted the Democratic governors of , potential presidential contenders JB Pritzker and Tim Walz, to pause or end coverage of immigrants without legal status.

California lawmakers last year voted to eliminate dental coverage and freeze new enrollment for immigrants without legal status and, starting next year, will charge monthly premiums to those who remain. Even so, the state is slated to spend $13.8 billion from its general fund on immigrants not covered by the federal government, according to Department of Finance spokesperson H.D. Palmer.

At a press conference in San Francisco in January, Newsom defended those moves, saying they were necessary for “fiscal prudence.” He sidestepped questions about coverage for asylees and refugees and downplayed the significance of his proposal, saying he could revise it when he gets a chance to update his budget in May.

Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network, pointed out that California passed a law in the 1990s requiring the state to cover when federal Medicaid dollars won’t. This includes green-card holders who haven’t yet met the five-year waiting period for enrolling in Medicaid.

Calling the governor’s proposal “arbitrary and cruel,” Savage-Sangwan criticized his choice to prioritize rainy day fund deposits over maintaining coverage and said blaming the federal government was misleading.

It’s also a major departure from what she had hoped California could achieve on Newsom’s first day in office seven years ago, when he declared his support for single-payer health care and proposed extending health insurance subsidies to middle-class Californians.

“I absolutely did have hope, and we celebrated advances that the governor led,” Savage-Sangwan said. “Which makes me all the more disappointed.”

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For several years, that number has been zero in the predominantly white, largely rural county stretching from Sacramento’s eastern suburbs to the shores of Lake Tahoe.

The trend could be short-lived.

County health officials there and across the country are bracing for an newly uninsured patients over the next decade in the wake of Republicans’ One Big Beautiful Bill Act. The act, which President Donald Trump signed into law this past summer, is also expected to reduce Medicaid spending by over that period.

“This is the moment where a lot of hard 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 at 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 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 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.

Placer County, which estimates that 16,000 residents could lose health care coverage by 2028, quit operating its own clinics nearly a decade ago.

“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.”

In December, county officials that provides care to mostly small, rural counties, citing an expected rise in the number of uninsured residents.

New Mexico’s second-most-populous county, Doña 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, Doña Ana’s health and human services director.

“At some point we’re going to have to look at either allocating more money or reducing the benefits,” Michael said.

Straining State Budgets

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 Association of Community Health Centers.

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 health care costs are straining local budgets.

“As we have more growth, more people coming in, it’s harder and harder to fund things that are required by the state legislature, and this isn’t one we can decrease,” said Windy Johnson, program manager with the Texas Indigent Health Care Association. “It is a fiscal issue.”

California lawmakers face a nearly in the 2026-27 fiscal year, according to the latest estimates by the state’s nonpartisan Legislative Analyst’s Office. Gov. Gavin Newsom, who has acknowledged he is , has rebuffed to significantly raise taxes on the ultra-wealthy. Despite blasting the bill passed by Republicans in Congress as a that guts health care programs, in 2025 the Democrat 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’s general fund.

H.D. Palmer, a spokesperson for the state’s 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.

Newsom will unveil his initial budget proposal in January. State officials have said California a year in federal funding for Medi-Cal under the new law, as much as 15% of the state program’s entire budget.

“Local governments don’t really have much capacity to raise revenue,” said Scott Graves, a director at the independent California Budget & Policy Center with a focus on state budgets. “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.”

Reviving county-based programs in the near term would require “considerable fiscal restructuring” through the state budget, the Legislative Analyst’s Office said in .

No Easy Fixes

It’s not clear how many people are currently enrolled in California’s county indigent programs, because the state doesn’t track enrollment and utilization. But enrollment in county health safety net programs dropped dramatically in the first full year of ACA implementation, going from about 858,000 people statewide in 2013 to roughly 176,000 by the end of 2014, at the time by Health Access California.

“We’re going to need state investment,” said Michelle Gibbons, executive director of the County Health Executives Association of California. “After the Affordable Care Act and as folks got coverage, we didn’t imagine a moment like this where potentially that progress would be unwound and folks would be falling back into indigent care.”

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 , that is expected to of the $1 billion a year the county stands to lose.

Health advocates fear that, absent major state investments, Californians could see a return to the previous , with local governments choosing whom and what they cover and for how long.

In many cases, indigent programs didn’t include specialty care, behavioral health, or regular access to primary care. Counties can also exclude people or income. 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, said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.

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.”

“Many of us,” she said. “including counties, are reeling trying to figure out: What are those downstream impacts?”

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But there was one glaring omission that LGBTQ+ advocates and political strategists say is part of an increasingly complex dance the Democrat faces as he curates a more centrist profile for a potential presidential bid.

Newsom that would have required insurers to cover, and pharmacists to dispense, 12 months of hormone therapy at one time to transgender patients and others. The proposal was a for trans rights leaders, who said it was crucial to preserve care as gender-affirming services under White House pressure.

Political experts say highlights how charged trans care has become and, in particular, for Newsom, who as San Francisco mayor engaged in civil disobedience by allowing gay couples to marry . The veto, along with his lukewarm response to anti-trans rhetoric, they argue, is part of an alarming pattern that could damage his credibility with key voters in his base.

“Even if there were no political motivations whatsoever under Newsom’s decision, there are certainly political ramifications of which he is very aware,” said Dan Schnur, a former GOP political strategist who is now a politics lecturer at the University of California-Berkeley. “He is smart enough to know that this is an issue that’s going to anger his base, but in return, may make him more acceptable to large numbers of swing voters.”

Earlier this year on Newsom’s podcast, the governor told the late conservative activist Charlie Kirk that trans athletes competing in women’s sports was “,” triggering a backlash among his party’s base and LGBTQ+ leaders. And he has as a “major problem for the Democratic Party,” saying Donald Trump’s were “devastating” for his party in 2024.

Still, in a conversation with YouTube streamer ConnorEatsPants this month, Newsom “as a guy who’s literally put my political life on the line for the community for decades, has been a champion and a leader.”

“He doesn’t want to face the criticism as someone who, I’m sure, is trying to line himself up for the presidency, when the current anti-trans rhetoric is so loud,” said Ariela Cuellar, a spokesperson for the California LGBTQ Health and Human Services Network.

Caroline Menjivar, the state senator who introduced the measure, described her bill as “the most tangible and effective” measure this year to help trans people at a time when they are being singled out for what she described as “targeted discrimination.” In a legislature in which Democrats hold supermajorities in both houses, lawmakers sent the bill to Newsom on a party-line vote. Earlier this year, Washington to enact a state law extending hormone therapy coverage to a 12-month supply.

In a on the California bill, Newsom cited its potential to drive up health care costs, impacts that an found would be negligible.

“At a time when individuals are facing double-digit rate increases in their health care premiums across the nation, we must take great care to not enact policies that further drive up the cost of health care, no matter how well-intended,” Newsom wrote.

, federal agencies have been to gender-affirming care for children, which Trump has referred to as “chemical and surgical mutilation,” and from or of institutions that provide it.

In recent months, , , and have reduced or eliminated gender-affirming care for patients under 19, a sign of the chilling effect Trump’s executive orders have had on health care, even in one of the nation’s most progressive states.

California wide coverage of gender-affirming health care, including hormone therapy, but pharmacists can currently dispense only a 90-day supply. Menjivar’s bill would have allowed 12-month supplies, modeled after that allowed women to receive an annual supply of birth control.

Luke Healy, who at an April hearing that he was “a 24-year-old detransitioner” and no longer believed he was a woman, criticized the attempt to increase coverage of services he thought were “irreversibly harmful” to him.

“I believe that bills like this are forcing doctors to turn healthy bodies into perpetual medical problems in the name of an ideology,” Healy testified.

The California Association of Health Plans opposed the bill over provisions that would limit the use of certain practices such as prior authorization and step therapy, which require insurer approval before care is provided and force patients and doctors to try other therapies first.

“These safeguards are essential for applying evidence-based prescribing standards and responsibly managing costs — ensuring patients receive appropriate care while keeping premiums in check,” said spokesperson Mary Ellen Grant.

An analysis by the California Health Benefits Review Program, which independently reviews bills relating to health insurance, concluded that annual premium increases resulting from the bill’s implementation would be negligible and that “no long-term impacts on utilization or cost” were expected.

Shannon Minter, legal director for the National Center for LGBTQ Rights, said Newsom’s economic argument was “not plausible.” Although he said he considers Newsom a strong ally of the transgender community, Minter noted he was “deeply disappointed” to see the governor’s veto. “I understand he’s trying to respond to this political moment, and I wish he would respond to it by modeling language and policies that can genuinely bring people along.”

Newsom’s press office declined to comment further.

Following the podcast interview with Kirk, Cuellar said, advocacy groups backing SB 418 grew concerned about a potential veto and made a point to highlight voices of other patients who would benefit, including menopausal women and cancer patients. It was a starkly different strategy than what they might have done before Trump took office.

“Had we run this bill in 2022-2023, the messaging would have been totally different,” said another proponent who requested anonymity because they were not authorized to speak publicly on the issue. “We could have been very loud and proud. In 2023, we might have gotten a signing ceremony.”

Advocates for trans rights were so wary of the current political climate that some also felt the need to steer clear of promoting a separate bill that would have expanded coverage of hormone therapy and other treatments for menopause and perimenopause. , authored by Assembly member Rebecca Bauer-Kahan, who has spoken movingly about her struggles with health care for perimenopause, .

In the meantime, said Jovan Wolf, a trans man and military veteran, patients like him will be left to suffer.

Wolf, who had taken testosterone for more than 15 years, tried to restart hormone therapy in March, following a two-year hiatus in which he contemplated having children.

Doctors at the Department of Veterans Affairs told him it was too late. Days earlier, the Trump administration it would phase out hormone therapy and other treatments for gender dysphoria.

“Having estrogen pumping through my body, it’s just not a good feeling for me, physically, mentally. And when I’m on testosterone, I feel balanced,” said Wolf, who eventually received care elsewhere. “It should be my decision and my decision only.”

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She hesitated. The procedure was part of a clinical trial, and she’d heard about a federal freeze on . She wanted to know: Would this study be at risk, potentially affecting her care?

Those worries put unnecessary pressure on a patient facing the loss of roughly 2 million nerve cells every minute that treatment was delayed, said , a neurologist and longtime stroke researcher.

“To then have to worry about what’s happening with the funding from the federal government is a needless increase in the stress patients are going through,” Saver said.

Patients and researchers such as Saver have found themselves caught in the middle as the Trump administration has accused major universities of , pulling research funds in an attempt to .

Scientists who have spent their lives developing treatments for lung cancer, brain tumors, and Alzheimer’s disease say scientific funding should not be politicized — and warn that patients waiting for lifesaving treatments stand to lose the most. They also worry that funding cuts mired in legal challenges could discourage would-be scientists from entering the field, reducing the chances for medical breakthroughs.

“I would have thought that stroke and Alzheimer’s disease and all these conditions affect Democrats and Republicans alike and would be supported by everyone,” Saver said. “The reasons for the suspension don’t seem to tie into the work we’re doing.”

In July, the National Institutes of Health, the National Science Foundation, and the Energy Department in medical and science research grants to UCLA after the Justice Department said the university had of Jewish students during pro-Palestinian protests. The Trump administration that would require UCLA to pay a $1.2 billion fine and overhaul campus policies on admissions, hiring, and gender-affirming health care to reinstate the grants.

Yet the federal government plays a crucial role in funding lifesaving research that industry has little incentive to back. Saver said treatment discoveries made in the past 15 years have been “transformative” for stroke care. To keep eight clinical trials afloat, Saver said, he and other neurology department faculty members sought outside funding and agreed to salary cuts. But they were close to running out before federal funds were restored.

In the ER, doctors told the stroke patient not to worry. Given the need to study her particular symptoms, they tapped a pot of private donations to cover the procedure. She enrolled and was treated.

Gov. Gavin Newsom, a Democrat who has been challenging President Donald Trump more directly as he builds a national profile, has likened the president’s demands .

And Newsom last week state funding from any California university that Trump put forth that prioritizes federal research funds to institutions that adhere to the administration’s definitions of gender, limit international students, and change admissions policies, among other stipulations. “California will not bankroll schools that sell out their students, professors, researchers, and surrender academic freedom,” Newsom said in a statement.

In September, U.S. District Judge Rita Lin of the Northern District of California ordered frozen NIH grants in the state to flow again, folding UCLA researchers into a lawsuit initially brought by researchers from the University of California-Berkeley and UC-San Francisco in June after federal agencies slashed hundreds of millions in grants to UC campuses.

Some private academic institutions have reclaimed their funding by agreeing to pay hefty fines and changing campus policies, including , which agreed to pay $200 million, and , which settled for $50 million. Meanwhile, last month that the administration’s cancellation of some $2.6 billion in grants to Harvard was illegal.

Still, researchers worry the relief is temporary. Even with the district court’s restoration, the case brought by UC researchers is still pending and could ultimately be decided in Trump’s favor. The White House has the ruling to restore Harvard’s funding, while of the school’s finances.

“We haven’t seen everything play out yet. Lots of scientists and researchers and people who run labs are circumspect, knowing that the near future could be a bit bumpy,” said Jessica Levinson, a constitutional law professor at Loyola Law School. “They should feel like this is a win, but it’s possible that it’s a short-lived one.”

Officials at the U.S. Department of Health and Human Services did not respond to questions about potential harm done to studies while the funds were frozen, or criticisms that they are wrongly politicizing money for potentially lifesaving research.

In a statement about the administration’s campaign targeting antisemitism, HHS spokesperson Andrew Nixon said that “we will not fund institutions that promote antisemitism. We will use every tool we have to ensure institutions follow the law.”

HHS spokesperson Emily Hilliard said in a follow-up statement that the department is “steadfast in its commitment to advancing groundbreaking biomedical research” and that it continues to “invest strategically in research that tackles today’s urgent challenges.”

Most of the UCLA funding freezes affected foundational science that doesn’t directly involve patients but has the potential to vastly improve treatment. David Shackelford, a researcher exploring novel ways to stunt the growth of therapy-resistant lung cancer, said he was nearing a potential breakthrough for treating the disease, which kills 9 in 10 patients within five years of a diagnosis.

“I’m not used to my science being politicized,” Shackelford said. “It’s cancer. We should never even be having this discussion.”

As court battles play out, Democratic state legislators are on next year’s ballot dedicating state funds to continue advances in cancer, stroke, and infectious disease research, among other scientific research. But state bond money, if approved by voters, wouldn’t come close to replacing federal grants, which traditionally finance the lion’s share of biomedical research.

In 2024 alone, for example, roughly flowed to California, with $3.8 billion of that going to universities. And the proposed bond would be broad, one-time funding that could pay for other study areas, such as climate change research, marine ecosystems, or wildfire prevention.

the possibility of even bigger federal cuts to the state’s second-largest employer would have ripple effects across California’s economy.

While other universities have sued the Trump administration, UC leaders have instead engaged in “good faith dialogue” with the Justice Department in hopes of negotiating a settlement, Milliken said.

S. Thomas Carmichael, a neurologist at UCLA, said about 55 grants totaling $23 million from the NIH, including studies of migraines, epilepsy, and autism, were frozen in his department at the David Geffen School of Medicine. As bad as funding cuts are, he warned of the Trump administration’s ability to attack a school’s accreditation, to limit visas for international students, or to launch investigations.

“It’s essentially a complete and total power mismatch to take the federal government on,” Carmichael said. “If you simply give no ground, yield nothing, you won’t win.”

Separately, in mid-September, a group of UC labor unions and faculty associations filed suit against the federal government, claiming the threat to research funds amounted to “financial coercion” to adopt campus policies that would restrict free speech. A hearing in that case is scheduled for December.

Brenda L., a UCLA patient, said she was devastated when a scan in 2021 led to her stage 4 lung cancer diagnosis at age 70. After 18 months on Tagrisso, a drug considered the gold standard for treating this particular cancer, her tumors started growing again. (Brenda declined to provide her full name because she hasn’t disclosed her diagnosis to some family members.)

“I was just feeling like, well, that’s the end of me,” said Brenda, who’s now 75 and lives in Bakersfield. She joined a clinical trial and has been taking another experimental drug alongside Tagrisso for two years. The combination has all but stopped the cancer’s progression.

“I’m the lucky one,” said Brenda, whose current trial has not been impacted. “Other patients, they should have that same chance.”

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The leadership upheavals, which he says will restore trust in federal health agencies, have shaken the confidence many states have in the CDC and led to the fracturing of a national, cohesive immunization policy that’s endured for .

States and medical societies that long worked in concert with the CDC are breaking with federal recommendations, saying they no longer have faith in them amid the turmoil and Kennedy’s criticism of vaccines. Roughly seven months after Kennedy’s nomination was confirmed, they’re rushing to draft or release their own vaccine recommendations, while new groups are forming to issue immunization guidance and advice.

How the new system will work is still being hammered out. Vaccine recommendations from states, medical societies, and other groups are likely to diverge, creating dueling guidance and requirements. Schoolchildren in New York may still generally need immunizations, for example, while others in places such as Florida may not need many vaccines.

There are potential financial ramifications too, because historically, private insurers, Medicaid, and Medicare have generally covered only vaccines recommended by the federal government. If the CDC and its advisory group, which began Sept. 18 in Atlanta, stop recommending certain vaccines, hundreds of millions of people could wind up paying for shots that previously cost them nothing. Some states are already taking steps to prevent that from happening, which means where people live could determine if they will face costs.

“You’re seeing a proliferation of recommendations, and the recommendations by everybody are different from the CDC,” said , a University of Minnesota epidemiologist who launched an ad hoc group that provides vaccine guidance. “States and medical societies are basing their recommendations on science. The recommendations out of CDC are magic, smoke, and mirrors.”

Kennedy has defended changes at the CDC and the revamping of the vaccine committee as necessary, saying previous advisory panel members had and agency leadership botched its pandemic response.

The CDC is “the most corrupt agency at HHS, and maybe the government,” Kennedy said at a . Susan Monarez, the ousted CDC director, testified Sept. 17 at another Senate hearing about how Kennedy told her to preapprove vaccine recommendations from the advisory panel or be fired.

Kennedy has said HHS also plans to investigate vaccine injuries he says are . The CDC investigates injuries that are reported by providers or patients, but Kennedy has said he wants to recast the entire program. The Food and Drug Administration is already who died following covid-19 vaccination.

HHS didn’t return an email seeking comment.

The actions by states, medical societies, and other groups reflect a mounting lack of confidence in federal leadership, public health leaders say, and the break from the CDC is happening at a rapid clip.

The Democratic governors of California, Hawaii, Oregon, and Washington — fashioning themselves as the West Coast Health Alliance — are coordinating to develop vaccine recommendations that won’t necessarily follow those from the CDC. The governors said in a that the CDC shake-up has “impaired the agency’s capacity to prepare the nation for respiratory virus season and other public health challenges” and this week for vaccination against viruses such as covid, influenza, and respiratory syncytial virus.

A group of northeastern states are exploring a similar collaborative.

“The worst thing that could happen is that we have 50 different recommendations for the covid vaccine. That will destroy public health,” said Massachusetts Public Health Commissioner Robbie Goldstein, who has been involved with the effort. He’s also spoken with leaders of the West Coast alliance. “I’m really hopeful that we do come together in larger and larger collaboratives with the same recommendations or very similar recommendations,” he said while speaking to a group of reporters this month.

And medical societies such as the American Academy of Pediatrics are releasing covid vaccine recommendations for the first time from the CDC’s guidance.

Some states are seizing on the split to ensure access to shots. Massachusetts is to cover vaccines recommended by the state health department rather than paying only for those suggested by the CDC, making it the first state to guarantee such continued coverage. AHIP, a trade group representing insurers, that health plans will cover immunizations, including updated formulations of covid and flu vaccines, that were recommended by the CDC panel as of Sept. 1 with no cost sharing through the end of 2026.

Pennsylvania is to give covid vaccines even if they’re not recommended by the federal agency. Instead, they can follow recommendations from the pediatric academy and other medical groups.

Florida, meanwhile, plans to for schoolchildren to get immunizations against chickenpox, meningitis, hepatitis B, and some other diseases. State lawmakers would need to take action to end mandates for all vaccines.

Joseph Ladapo, the state’s surgeon general, said in a that any vaccine requirement is wrong and “drips with disdain and slavery.”

Some doctors criticize the decision as a dangerous step backward.

“This is a terrifying decision that puts our children’s lives at risk,” said , former acting director of the CDC, in an emailed statement.

The first school vaccine mandate was rolled out in the , for smallpox. While all states have vaccine requirements for schoolchildren, immunization rates for kindergarten students declined while cases of vaccine-preventable in 2024 and 2025.

Rochelle Walensky, the Biden administration’s first CDC director, warned of the “polarization” of state-by-state approaches. “It’s like your head is in the oven and your feet are in the freezer and, on average, we’re at 95% vaccination. That doesn’t work in measles — every place has to be at 95% vaccination.” She was referring to the proportion of a population that needs to be vaccinated to provide herd immunity.

Kennedy’s actions have thrust vaccines center stage and made him fodder for comedy. The Marsh Family, a British musical group, on Sept. 7 of Paul Simon’s “Me and Julio Down by the Schoolyard,” with the chorus, “We’ll see measles and polio down in the schoolyard.”

HBO comedian said the CDC could be known by the title “Disease” during a recent episode of his show. And Stephen Colbert used his monologue on “The Late Show with Stephen Colbert” to weigh in on the revamped vaccine advisory group, calling its new members the “.”

President Donald Trump has defended Kennedy, telling reporters “he means very well,” even as Trump said on Sept. 5 that “you have some vaccines that are so amazing.” Trump has repeatedly expressed pride in Operation Warp Speed, a government initiative during Trump’s previous administration that rapidly developed covid vaccines. But he’s also promoted a discredited theory linking vaccines and autism.

The White House did not respond to a request for comment.

The Trump administration already narrowed recommendations for the covid vaccine despite no new safety risks with the shots, although medical societies are continuing to recommend them for most people. The gulf is expected to widen as the agency’s advisory group reviews on a number of pediatric vaccines.

Other groups are also trying to provide vaccine and public health guidance, driven in part by concerns that Kennedy and other federal health leaders will make policy decisions and statements not grounded in science. Kennedy has promoted claims that aluminum, used in many vaccines, is , despite a lack of evidence for the claims. A , in fact, found aluminum was not linked to chronic disease, but Kennedy said the study’s supplemental data indicated it caused harm. The journal that published the study .

Current and former CDC and HHS staffers, along with public health academics and retired health officials, have formed the National Public Health Coalition, a nonprofit to endorse recommendations and provide guidance on policy issues. They plan to partner with state and local health departments.

“A real benefit of the National Public Health Coalition is we are made up of current and former CDC and HHS folks, people who have deep knowledge of what government programs for public health look like, and what improvements are needed,” said Abigail Tighe, the group’s executive director.

Another new group is , which bills itself as a volunteer-led effort to raise awareness about vaccines. And the was launched in April by the University of Minnesota’s infectious disease center, to review evidence for medical societies on the safety and effectiveness of vaccines.

“We’re going to continue to help wherever we can to address misinformation,” said Osterholm, the center’s leader.

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Patients begin lining up before dawn at , an annual five-day health clinic in Texas’ Rio Grande Valley. Many residents in this predominantly spanning the Mexican border lack insurance, making the health fair a major source of free medical care in South Texas for more than 25 years.

Until this year. The Trump administration’s plan to strip in federal public health and pandemic funds from Texas helped prompt just before its scheduled July 21 start.

“Some people come every year and rely on it,” said Hidalgo County Health and Human Services Director Dairen Sarmiento Rangel. “Some people even camp out outside of Border Health so they can be the first in line to receive services. This event is very important to our community.”

States and local governments have made painful program cuts in the wake of major reductions in federal health funding that have already taken effect. Now, they’re sizing up the financial hits to come — some not until late next year or beyond — from the “,” the tax and spending law congressional Republicans passed in July that enacts much of President Donald Trump’s domestic agenda.

Texas, for instance, expects to see its federal Medicaid funds reduced by as much as over 10 years due to new barriers for enrollment, such as more frequent eligibility checks, according to a July analysis by KFF.

Taken together, the reductions amount to a seismic shift in how state health programs are provided and paid for. The administration is, in effect, pushing a significant amount of health costs to states. That will force their leaders to make difficult choices, as many state budgets are already strained by declining tax revenues, a slowdown in federal pandemic spending, and economic uncertainty.

Revenue forecasters have lowered expectations for the coming year, according to a .

“It’s almost inevitable that states will enact a number of cuts to health services because of the fiscal pressure,” said Wesley Tharpe, senior adviser for state tax policy at the left-leaning .

Some are proactively trying to stanch the impact.

Hawaii lawmakers are looking to aid nonprofits that are already contending with federal funding cuts. They’re in grants to health, social service, and other nonprofits hit by federal funding cuts. To get the money, nonprofits must show a termination or drop in funding, or that they have otherwise been harmed by the cuts.

“It is not fair that organizations dedicated to supporting the people of Hawaii are being forced to scale back due to federal funding cuts,” Democratic Gov. Josh Green .

Other states are scaling back projects to contend with cuts. Delaware Gov. Matt Meyer, a Democrat, received notice in March that the Trump administration was in public health funding from the state. The next month, state legislative leaders halted a planned project to upgrade and expand the Capitol complex as a result.

“We recognized that the reckless federal cuts to the social safety nets of thousands of Delawareans called for us to hold back resources to protect our most vulnerable,” said , president pro tempore of the Delaware Senate.

In New Mexico, the state with the , a bipartisan group of lawmakers voted to create a trust fund to boost funding for the program. About 10% of the more than covered by Medicaid and the related Children’s Health Insurance Program could lose their health coverage under the federal spending law, based on .

Some state leaders are warning constituents that the worst may be yet to come.

At an Aug. 18 event at a hospital in the South Bronx section of New York City, New York Gov. Kathy Hochul, a Democrat, stood on stage among health care workers in white coats to skewer Trump’s new law.

“What Republicans in Washington have done through the ‘Big Ugliest Bill’ I’ve ever seen is literally screwing New Yorkers,” she said. The state’s health system is bracing for in annual cuts.

And in California, lawmakers weighed the impact of the coming cuts from the federal law at a general assembly , where some Democratic legislators said state efforts to protect reproductive health services and other programs were in jeopardy.

“We’ve been bracing for this reality: President Trump’s so-called ‘Big, Beautiful Bill’ is now law,” Democratic lawmaker Gregg Hart said at the hearing, calling it a “direct assault on California’s core programs and our values.”

“Sadly, the reality is, the state does not have the capacity to backfill all of these draconian federal funding cuts in the current budget,” Hart said. “We cannot simply write a check and make this go away.”

The sweeping budget law, which passed without any Democratic support, will reduce federal spending on Medicaid by about over the next decade, based on estimates from the . The spending reductions largely come from the imposition of a on people who’ve obtained Medicaid under the Affordable Care Act’s expansion, as well as other new barriers to coverage.

The law will mean more than 7.5 million people will lose Medicaid coverage and become uninsured, according to the Congressional Budget Office, while extending tax cuts for wealthy people who, Democrats say, don’t need them. Republicans and Trump have said the spending package and its accompanying program cuts were necessary to prevent fraud and waste, and to sustain Medicaid, a state-federal program for people with disabilities and lower incomes.

“The One Big Beautiful Bill removes illegal aliens, enforces work requirements, and protects Medicaid for the truly vulnerable,” the White House said in a .

The Medicaid cuts won’t begin until after the midterm elections in November 2026, but other cuts have already hit.

The Trump administration has sought to claw back earmarked to states because of the pandemic, spurring a with a coalition of Democratic-led states. It also in for mental health services in schools, and halted grants from the National Institutes of Health that provided money to more than 90 public universities.

HHS press secretary Emily Hilliard said the agency is prioritizing investments that advance Trump’s mandate to confront chronic disease. She defended some of the cuts and said, erroneously, that the spending law doesn’t cut Medicaid.

“The covid-19 pandemic is over, and HHS will no longer waste billions of taxpayer dollars responding to a crisis that Americans moved on from years ago,” she said.

State leaders say the pandemic funding the administration wants returned was earmarked for other public health measures, such as tracking emerging diseases, outbreak responses, and staffing. State attorneys general in May won a against the administration.

“What we’re seeing now is states anticipating big cuts in Medicaid coming, but they’re also dealing with a whole variety of federal cutbacks in public health programs that are smaller but still quite meaningful,” said , executive vice president for health policy at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.

Part of the challenge for states is simply understanding the changes.

“I think it’s fair to say there is concern, confusion, and uncertainty,” said Kathryn Costanza, a Medicaid expert at the National Conference of State Legislatures.

States are struggling to sort it all out, forming that are , suing to try to block the cuts, and reallocating funding.

In Colorado, lawmakers to let state Medicaid dollars pay for non-abortion care at Planned Parenthood of America clinics after Trump’s law banned federal funding for such care. Whether the ban holds up in court .

The Louisiana Legislature to state universities to make up for cuts to federal research funding, much of which goes to health-related research.

And in South Dakota, the state’s largest food bank has to make up for funding cuts to the U.S. Department of Agriculture.

States must balance their budgets every year, so cuts put many services at risk if state lawmakers are unwilling to raise taxes. The work will begin in earnest in January, when many states begin new legislative sessions.

And the tough choices are likely to continue. Congressional House Republicans are considering legislation that could , including by slashing the generous cost sharing the federal government provides for 20 million adults who enrolled in Medicaid under the ACA’s Medicaid expansion.

Some states will roll back their Medicaid expansions and cut more health programs as a result.

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