San Francisco has more than 200,000 residents who rely on Medi-Cal, California’s public health insurance for low-income residents. City officials say at least 25,000 of them could lose coverage in the next year and a half.
Mayor Daniel Lurie and other local leaders have known this was coming ever since Republicans in Congress passed HR 1, the so-called “big beautiful bill,” last July. The mayor and supervisors recently shifted $34 million in emergency funds to help keep people covered, either through Medi-Cal or another insurance or safety net.
Last month, the city’s public health director Daniel Tsai told supervisors, “We are going to provide healthcare coverage and support to our neighbors who lose their Medi-Cal because of their immigration status.”
But doing so will be an enormous feat. After Tsai’s bold pledge, city officials have shared plans with The Frisc that will only cover a fraction of those who could lose insurance.
The stakes are high. Uninsured people are likely to delay doctor visits until they have an emergency. Less insurance is also bad for SF’s fiscal health as it picks up the bills that Medi-Cal once covered. The Department of Public Health (DPH) anticipates losing $65 million this year and $196 million next year from lost Medi-Cal reimbursements, reaching $400 million by 2038.
Immigrants with unsatisfactory immigration status (UIS) — refugees, asylum-seekers, or people fleeing domestic abuse and human trafficking — are the main target of the cuts. California has already frozen new Medi-Cal enrollment for them, and next year, those enrolled will be kicked off full coverage and reduced to only bare-bones care.
HR 1 will also require most able-bodied adults to work to keep their benefits.
Advocates had hoped California would hold the line against the cuts. Gov. Gavin Newsom’s new state budget is complicated, helping or buying time in some ways but also introducing some new barriers. The new Medi-Cal eligibility rules are also complicated, which some advocates say is a strategy to discourage the public from using the benefits.
Meanwhile, the landscape is evolving rapidly. (For instance, the Trump administration last week froze a sliver of California’s Medicaid dollars over “suspected fraud,” but analysts say this won’t affect the new policies).
San Francisco’s $34 million emergency funds are one part of the response. The agencies in charge — DPH and the Human Services Agency (HSA) — are also conducting outreach, but many residents don’t speak English or are wary of government contact because of immigration enforcement and even violence. They’ve begun enrolling some people to the city’s own low-cost healthcare program, Healthy San Francisco, if they don’t qualify for insurance.
The agencies caution that rules for eligibility aren’t one-size-fits-all; they’ll need to counsel people on a case-by-base basis. Through interviews with advocates, policy analysts, and agency officials, The Frisc has created a snapshot of where the policies stand, who will be most affected, what San Francisco has pledged to do — and where the city might fall short.
Rolls already frozen
California spends about $150 billion a year on Medi-Cal. In its most recent report, a state analyst said “more than half” of those dollars came from the federal government.
Between HR 1 and new state restrictions, HSA estimates that 25,000 to 50,000 San Franciscans may lose Medi-Cal by the end of 2027. The changes are happening in phases. (See chart below.)
Some changes have already taken effect. On Jan. 1, 2026, California froze new enrollment for UIS immigrants in response to funding losses from HR 1. The Legislative Analyst’s Office said the freeze would save the state $10.6 billion. Despite the freeze, San Francisco still encourages everyone to apply in case they can find a loophole.
Those already on Medi-Cal, even with UIS status, won’t risk being kicked off until next year. But this October, the feds will stop paying Medicaid bills for UIS immigrants. California will pick up the tab — but only for nine months.
“This new [federal] provision really narrow[s] who’s eligible: US citizens, US nationals, and a very small group of immigrants,” says California Budget and Policy Center analyst Hannah Orbach-Mandel.
She notes that all taxpayers, including UIS immigrants, have contributed to the program: “Now they’re getting that coverage taken away from them, even though [some] have been paying into the program for years.”
While the state is only covering UIS immigrant adults for nine months, it will continue to cover kids regardless of immigration status via the Children’s Health Insurance Plan (CHIP), according to Orbach-Mandel.
Proof of work in 2027
On Jan. 1, 2027, new work requirements will kick in for anyone aged 19 to 64, not just immigrants. Exceptions include pregnant and disabled people, or parents with kids 14 and younger. The state says it will send a warning letter to those affected.
Just like recent changes to CalFresh food stamp eligibility, there’s a three-month grace period. In March 2027, people will start to lose health insurance if they fail to show they’re working, volunteering, or training 20 hours per week or 80 hours per month.
Also early next year, adults aged 19 to 64 who got Medi-Cal through the Affordable Care Act (ACA) expansions must start re-enrolling every six months instead of annually, which means twice as many chances for people’s coverage to lapse, advocates say. (The state says this new re-enrollment clock starts in March, but HSA says to start preparing in January.)
The city is planning a Community Works Program to help folks get the work hours, which are already required for CalFresh.
On July 1, 2027, California will stop covering full Medi-Cal and dental for UIS immigrants. They will only be covered for emergencies and pregnancy-related services. Some (but not all) immigrants will have to pay a monthly premium to stay on full Medi-Cal, or be moved to barebones coverage.
We’ll cover them through Healthy SF. We will absorb all of that.
SF department of public health director daniel tsai
Also on July 1, 2027, the state will lower the amount of assets (bank accounts, property, cars) recipients can own to qualify. Most people 65 and older with $21,000 or more in assets will lose coverage; the prior limit was $130,000. This applies to everyone, not just immigrants.
Amid this dizzying array of changes in the next 12 months, San Francisco’s first line of defense is to keep as many people as possible on Medi-Cal. For immigrants and others who cannot stay on, there’s an alternative option: Healthy San Francisco.
The San Francisco plan
The emergency $34 million will pay for more than 150 new workers to help San Franciscans navigate changing requirements for Medi-Cal and CalFresh. An HSA spokesperson said via email that “this funding will help support increased capacity to process extra paperwork, assist with redeterminations, and connect thousands of clients to employment opportunities.”
For immigrants who can’t stay on insurance, “we will cover them through Healthy SF,” DPH director Tsai said last month. “We’ll make sure our clinics, community clinics, and [nonprofit partners] are able to see those folks. We will absorb all of that.”
Healthy SF currently covers about 3,000 people. It is only for adults 18 and older who do not qualify for any insurance program, including Medi-Cal. They must live in the city and earn no more than five times the federal poverty level.
Though Healthy SF covers some medical costs, it is not insurance. It has member fees, and some services aren’t covered, including dental, vision, fertility services, gender-affirming surgery, and any services beyond city limits.
“If I personally had a choice between Healthy SF and Medi-Cal, I would use Medi-Cal,” says Adrienne Sabety, assistant professor of health policy at Stanford University. “But for people who don’t qualify for Medi-Cal, I think Healthy SF is a really great option.”
City Hall has boosted the Healthy SF budget by $41.6 million through 2029-30 to cover expenses at participating sites, according to DPH.
When asked how many people could move to Healthy SF, DPH said in a statement it projects adding about 8,000 more — a minority of the 25,000 to 50,000 whom HSA estimates are at risk — “because many San Franciscans who lose Medi-Cal coverage will still qualify for other programs or will not meet Healthy SF eligibility criteria.”
One reason for the gap: people who don’t meet upcoming Medi-Cal work requirements won’t automatically qualify for Healthy SF, according to an HSA spokesperson: “This is because they would still qualify for other programs, or could become eligible again if they returned their paperwork or got connected to work.”
The work requirements will be the “largest projected impact” of all the HR 1 cuts, the spokesperson added.
DPH representatives did not respond to questions about plans for the thousands of people who may lose Medi-Cal and not qualify for Healthy SF.
Every channel possible
The total number of people impacted will remain a moving target. “At the end of the day, it’s really difficult to estimate because a lot depends on how some of these changes are implemented,” says Orbach-Mandel of the California Budget and Policy Center.
Getting the word out is difficult — and important, as demonstrated in Arkansas when mandatory Medicaid work requirements hit in 2018. So many people lost coverage and delayed medical care that a federal judge ended the policy.
Research later showed that more than 70 percent of Arkansans were unsure whether the policy was in effect. “My hope is that California does a better job trying to message around it,” says Stanford’s Sabety.
HSA says it’s working with community organizations and using snail mail, radio, text messages, social media — basically every channel available and in multiple languages. They’ve even created a benefits center on wheels. (Picture an ice cream truck offering public benefits.) “We’re doing whatever we possibly can to reach our clients,” said the HSA spokesperson.
HSA emphasizes that people shouldn’t drop Medi-Cal for fear of the government having their information. It’s already in the hands of the state, which shares it with federal agencies. San Francisco is also required to share information with the state.
Officials stress that it’s better to have healthcare than to go without. Otherwise, emergency care becomes people’s first and only option. This puts them in medical jeopardy. It also puts more strain on the city’s health system and budget. And ultimately, it puts to the test the bold promises officials have made about San Francisco’s safety net.
