A cloud of fear has hung over the immigrant community of San Bernardino, California, for months, making it difficult for Maria González to do her job as a community health worker in a city where nearly a quarter of the residents are foreign-born.
Construction began this summer following news of immigration raids across Southern California, the Trump administration’s plans to share Medicaid data with Immigration and Customs Enforcement, and the passage of state and federal restrictions on immigrants’ Medicaid eligibility. And in November, the federal government announced a new “public charge” proposal that, if passed, could block certain immigrants and their families from obtaining permanent residency if they use public benefits, including Medicaid.
Many of Gonzalez’s clients and their children, many of whom are U.S. citizens, remain eligible for California’s Medicaid program, known as MediCal, which provides health insurance to more than 14 million residents with low incomes or disabilities. However, an increasing number of people are unwilling to purchase or renew insurance.
“A lot of people don’t want to apply,” she says. “Some people don’t want to go out and water their plants.”
A KFF Health News analysis found that nearly 100,000 immigrants without legal status left Medi-Cal from June to December, the most recent month for which statistics are available, representing about a quarter of all disenrollments during that period, even though this group only represents about 11% of Medi-Cal enrollees.
This marks a reversal of California’s steady increase in enrollment among immigrants without legal status. Since the state opened Medi-Cal to all low-income residents regardless of immigration status in January 2024, enrollment in this group had increased every month through July.
Tessa Outsees, a spokeswoman for the California Department of Health Services, which oversees Medi-Cal, said the drop in enrollment was largely due to the government restarting eligibility screenings that had been suspended during the coronavirus pandemic. In fact, overall Medi-Cal enrollment peaked in May 2023 and has declined by about 1.6 million people since then.
However, two researchers, Leonardo Cuello of Georgetown University’s Center for Children and Families and Susan Baybay of the UCLA Center for Health Policy Research, noted that California and most other states have fully resumed eligibility testing by mid-2024. In other words, that alone doesn’t explain why enrollment has fallen so sharply over the past 12 months or so.
What’s changed, Cuero said, is that the federal government passed the One Big Beautiful Bill Act, which added further changes to encourage deregistration via executive order.
Investigation provides clues
A KFF/New York Times investigation found that immigrant adults across the country, especially parents, are increasingly bypassing government programs that help pay for food, housing and health care to avoid drawing attention to their or their family’s immigration status. This included legal residents and naturalized citizens. Cuero said he is particularly concerned about parents avoiding these programs. That’s because, even though most children in the United States were born in the United States, about one in four children in the United States has an immigrant parent.
Cuero suspects that could explain the roughly 3% decline in enrollment in Medicaid and the Children’s Health Insurance Program nationwide during the first 10 months of last year, including a 5.6% drop in child enrollment in California, according to data compiled by Georgetown colleagues.
During the first Trump administration, the president expanded the criteria for utility bills to include Medicaid and food and housing assistance. As a result, many citizen children and other household members were forced to forgo Medicaid and other programs for which they were eligible. Some people continued to circumvent the program even after several courts blocked its implementation and Democratic President Joe Biden rolled back the rules.
“This has caused tremendous disruption,” said Louise McCarthy, president and CEO of the Los Angeles County Community Clinic Association, which represents about 70 health centers in the Los Angeles area. “Staff at community health centers are still working to reverse the effects of the original rule.”
Projected savings
Currently, only those who rely on cash assistance programs or government-funded long-term institutional care are considered a public charge risk when applying for a visa to enter the country or become a lawful permanent resident. But under the Trump administration’s proposed rules, Medicaid and other non-cash programs could be used to determine whether immigrants are likely to become dependent on the government. Immigration officials would also be given discretion to impose public charges on people.
The Department of Homeland Security’s proposal says the changes are necessary because existing rules impede the department’s ability to make decisions about the risks of immigrants’ dependence on government resources. The public comment period for the proposal ended in December.
DHS did not respond to inquiries about when it plans to make a final decision on the rule. The change is “consistent with long-standing policy that foreign nationals in the United States should be self-reliant and that government benefits should not encourage immigration,” the proposal says.
The agency estimated the change would save federal and state governments about $9 billion a year from people disenrolling or disenrolling from public benefits programs.
KFF’s analysis of the proposed rule estimates that the rule could disenroll between 1.3 million and 4 million people from Medicaid or CHIP, including as many as 1.8 million children.
“It’s clearly been weaponized to create fear and anxiety,” said Benjamin Chao, director of health and public benefits policy at the California Immigration Policy Center. He said the proposal is part of an “attack on legally present immigrants, their families, American citizens, and society in general.”
Concerns about utility costs are also expected to reduce California participation in anti-hunger programs such as the Supplemental Nutrition Assistance Program, known as CalFresh. Mark Lowery, director of the Orange County Food Bank, said this, along with disenrollments related to the One Big Beautiful Bill Act, could overwhelm food reserves because federal nutrition programs make up the majority of food assistance.
“There is no way the emergency food system has the capacity or resources to meet these needs,” he said.
healthcare needs
Fear of enrolling in Medi-Cal does not extend to all immigrants. Juana Zaragoza runs a program in Oxnard that helps farmworkers, primarily indigenous Mexicans, enroll in Medi-Cal. Overall registrations and reregistrations have remained stable over the past few months, she said. Neither she nor members of the community she serves know much about the utility bill proposal, she added.
Their immediate medical needs often take precedence over their concerns.
“We meet a lot of people who are balancing what’s going to benefit them now and what’s going to benefit them later,” she says. “Some people just want to meet their needs in the moment.”
