The Brief

President Donald Trump’s “One Big Beautiful Bill” cuts federal spending on Medicaid and Affordable Care Act marketplaces by about $1 trillion over a decade, according to the nonpartisan Congressional Budget Office, threatening the physical and financial health of tens of millions of Americans.

The bill, which the Senate passed Tuesday, would reverse many of the health coverage gains of the Biden and Obama administrations, whose policies made it easier for millions of people to access health care and reduced the U.S. uninsured rate to record lows.

The Senate plan to slash Medicaid and ACA marketplace funding could lead to nearly 12 million more people without insurance by 2034, the CBO estimates. That in turn would harm the finances of hospitals, nursing homes, and community health centers — which would have to absorb more of the cost of treating uninsured people — and may force them to reduce services and employees, as well as close facilities.

The legislation is nearing Trump’s desk, though first the Senate and House must approve the same version. The House passed its own version in May and is expected to consider the Senate’s version today, according to House Majority Whip Tom Emmer.

Here are five ways the GOP’s plans may affect health care access.

Need Medicaid? Then Get a Job

The deepest cuts to health care spending come from a proposed Medicaid work requirement, which would cut off coverage for millions of enrollees who do not meet new employment or reporting standards.

In 40 states and Washington, D.C., all of which have expanded Medicaid under the Affordable Care Act, some Medicaid enrollees would have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption, such as caring for a young child.

The bill’s requirement would not apply to people in the 10 largely GOP-led states that have not expanded Medicaid.

Health researchers say the policy would have little impact on employment. Most working-age Medicaid enrollees who don’t receive disability benefits already work or are looking for work, or are unable to do so because they have a disability, attend school, or care for a family member, according to KFF.

State experiments with work requirements have been plagued with administrative issues, such as eligible enrollees’ losing coverage over paperwork problems, and budget overruns. Georgia’s work requirement, which officially launched in July 2023, has cost more than $90 million, with only $26 million of that spent on health benefits, according to the Georgia Budget & Policy Institute, a nonpartisan research organization.

“The hidden costs are astronomical,” said Chima Ndumele, a professor at the Yale School of Public Health.

Less Cash Means Less Care in Rural Communities

Belt-tightening that would target states could translate into fewer health services, medical professionals, and even hospitals, especially in rural communities.

The GOP’s plan would curtail a practice, known as provider taxes, that nearly every state has used for decades to increase Medicaid payments to hospitals, nursing homes, and other providers and to private managed-care companies.

States often use the federal money generated through the taxes to pay the institutions more than Medicaid would otherwise pay. (Medicaid generally pays the lowest fees for care, compared with Medicare, the program for people over 65 and some with disabilities, and private insurance.)

Hospitals and nursing homes say they use these extra Medicaid dollars to expand or add new services and improve care for all patients.

Rural hospitals typically operate on thin profit margins and rely on Medicaid tax payments to sustain them. Researchers from the Cecil G. Sheps Center for Health Services Research who examined the House bill concluded it would push more than 300 rural hospitals — many of them in Kentucky, Louisiana, California, and Oklahoma — toward service reductions or closure.

Republican senators tacked a $50 billion fund onto their version of the bill to cushion the blow to rural hospitals.

Harder To Get, and Keep, ACA Coverage

For those with ACA marketplace coverage, the GOP plan would make it harder to enroll and to retain their plans.

Marketplace policyholders would be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll — something more than 10 million people did this year. They would also have less time to enroll; the bill shortens the annual open enrollment period by about a month.

People applying for coverage outside that period — for instance because they lose a job or other insurance or need to add a newborn or spouse to an existing policy — would have to wait for all their documents to be processed before receiving government subsidies to help pay their monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take weeks.

Republican lawmakers and some conservative policy think tanks, including the Paragon Health Institute, say the changes are needed to reduce fraudulent enrollments, while opponents say they’re the latest attempt to undo Obamacare.

The legislation also does not call for an extension of more generous subsidies put in place during the covid pandemic. If Congress doesn’t act, those enhanced subsidies will expire at year’s end, resulting in premiums rising by an average of 75% next year, according to KFF.

On Medicaid? Pay More To See Doctors

Many Medicaid enrollees can expect to pay more out-of-pocket for appointments.

The bill would require states that have expanded Medicaid to charge enrollees up to $35 for some services if their incomes are between the federal poverty level (this year, $15,650 for an individual) and 138% of that amount ($21,597).

Medicaid enrollees often don’t pay anything when seeking medical services because studies have shown charging even small copayments prompts low-income people to forgo needed care. In recent years, some states have added charges under $10 for some services.

The policy would not apply to people seeking primary care, mental health care, or substance abuse treatment. The Senate bill would allow states to enact even higher cost sharing for enrollees who seek emergency room care for nonemergencies. But if Medicaid patients fail to pay, hospitals and other providers could be left to foot the bill.

Cuts for Lawfully Present Immigrants

The GOP plan could cause at least hundreds of thousands of immigrants who are lawfully present — including asylum-seekers, victims of trafficking, and refugees — to lose their ACA marketplace coverage by cutting off the subsidies that make premiums affordable. The restriction would not apply to green-card holders.

Because the immigrants who would lose subsidies under this plan tend to be younger than the overall U.S. population, their exit would leave an older, sicker, and costlier population of marketplace enrollees, further pushing up marketplace premiums, according to marketplace directors in California, Maryland, and Massachusetts and health analysts.

Taking health care access away from immigrants living in the country legally “will do irreparable harm to individuals we have promised to protect and impose unnecessary costs on local systems already under strain,” John Slocum, executive director of Refugee Council USA, an advocacy group, said in a statement.

Both the House and Senate versions of the bill reflect the Trump administration’s restrictive approach to immigration. But because it ran afoul of Senate rules, the legislation won’t include a proposal that would have reduced federal Medicaid payments to states like California that use their own money to cover immigrants without legal status.

KFF Health News chief Washington correspondent Julie Rovner contributed reporting.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

By the time Democrat Xavier Becerra left Washington, D.C., more Americans than ever had health insurance, owing partly to his work over the years to pass, defend and expand the Affordable Care Act.

It's an achievement the former congressman and U.S. Secretary of Health and Human Services often touts as he campaigns for California governor against Republican Steve Hilton, a former Fox News commentator.

But should Becerra cruise to victory in November, as polling suggests, he will face what may be the steepest decline in health insurance coverage in a generation, one that will land especially hard in his home state.

Federal cuts mean more people uninsured

By 2030, the number of uninsured Californians under 65 is expected to nearly double from 2.4 million to 4.6 million as recently enacted state and federal cuts to Medicaid and ACA marketplaces begin to roll back historic gains in health coverage, according to a May analysis by the University of California, Berkeley Labor Center. The anticipated rise in the uninsured population could have broad implications for hospital systems, insurers and the economy.

In February, Miranda Dietz, the labor center's healthcare program director, told legislators the changes could end up costing California about 200,000 jobs, mostly in the healthcare industry.

Hospital executives have begun reporting more unpaid medical bills, and experts warn health plans will raise premiums further as they're left with enrollees who are, on average, sicker and more expensive to cover.

"It's triage," said Jessica Altman, executive director of Covered California, the nation's largest state-run health insurance marketplace. "That's what the next governor is walking into."

California achieved one of the most dramatic drops in its uninsured population in the nation, largely credited to the state's robust adoption of the ACA. If tapped to lead the wealthy, progressive state, Becerra would wrestle with how uninsured Californians get care and who pays as the Trump administration shrinks a federal safety net he once oversaw.

Becerra has some experience pushing back against Washington, D.C. As California attorney general, he successfully defended many provisions of the Affordable Care Act, including access to birth control.

Becerra said he would issue an executive order to keep those affected by federal cuts insured. But he has not detailed how the state would backfill as much as $30 billion in federal funding California stands to lose annually.

At a policy forum hosted by Politico this month, Becerra promised Californians would not lose health coverage despite federal cutbacks, saying he would push the industry to eliminate waste from "attorneys, accountants, pencil pushers" that cost consumers billions.

"I'm going to ask them to help me extract some of that waste and put it into healthcare, which helps us cover the cost of keeping Californians insured," he said.

His opponent, Hilton, is trying to appeal to voters opposed to President Donald Trump, despite receiving the president's endorsement, and has stumped on cutting off coverage for Californians without legal status, which is paid for with state funds. Hilton has vowed to use those savings to issue state income tax breaks, calling it an immediate antidote to high costs.

Steve Hilton, the Republican candidate for governor of California, campaigns at a Sheraton hotel on July 27 in Pomona.

(

Mario Tama

/

Getty Images

)

"We all understand that the healthcare system is a mess and needs major reform," Hilton said in an interview. "The quickest thing we can do on healthcare costs is actually to tax people less."

Left behind?

In 2010, Becerra was part of U.S. House Speaker Nancy Pelosi's leadership team and helped whip up votes to pass the law. He also had a hand in crafting it, though his attempt to include a government-backed coverage option failed.

A decade later, when lawmakers considered him for the nation's top healthcare job, Becerra said his primary mission would be to carry out President Biden's vision to expand access and cut costs under the Affordable Care Act.

Before the ACA, some 50 million Americans — roughly 1 in 6 — were uninsured. Within a few years of the law's passage in 2010, its expansion of Medicaid eligibility and financial aid to lower-income marketplace enrollees helped slash the U.S. uninsured rate by nearly half.

Millions more gained coverage during the COVID-19 pandemic after Becerra implemented a freeze on Medicaid disenrollment and administered generous but temporary tax credits that put the cost of Obamacare plans within reach for more people.

As Biden's health secretary, Becerra launched aggressive public awareness campaigns, loosened enrollment rules and distributed hundreds of millions in grants to pay consumer assistants, also known as healthcare navigators, to help enrollees wade through paperwork.

"One of the common things we would hear from him as a leader was, 'Who's being left behind?'" said Benjamin Sommers, a Harvard health policy professor who was a deputy assistant secretary under Becerra.

Under Biden and Becerra, the percentage of people with health insurance reached a historic high of 92%, or 310 million Americans having health coverage in 2024.

Republican response

But conservatives said those policies inflated enrollment by attracting fraudulent and wasteful coverage. In response, the second Trump administration has tightened enrollment windows and toughened income reporting.

"It's simple and easy to say, well, the numbers are up so the program must be working," said Edmund Haislmaier, a senior research fellow at the Heritage Foundation, a conservative think tank. "My argument would be that's the wrong metric."

Last summer, the GOP-led Congress passed Trump's One Big Beautiful Bill Act, which Republicans argued preserves Medicaid for those who need it most while rooting out fraud and waste. Altogether, the law is expected to cut Medicaid spending by $900 billion-plus over a decade.

Congress also allowed enhanced premium tax credits for Obamacare plans to expire last year, spiking premium payments for middle-income Americans and driving down enrollment by nearly 3 million this year.

"We are now witnessing almost a wholesale reversal of pretty much all those policies" that helped cover millions more Americans, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

For Eric Maciel, the $800 cost of a Covered California plan is too much. To avoid injury, the 28-year-old stays home more and rarely plays pickup soccer at the park — the other players, he added, can get pretty rough.

"That's another car note," Maciel said. "I'd be left with nothing."

Health economists say Maciel is the type of customer insurers need to stabilize their risk pools: young, healthy and less costly.

Hilton criticized state leaders for passing a revised provider tax he asserts will send premiums soaring and said he wants to inject more competition into California's health insurance market — but he offered no specific ideas.

Playing defense

Higher-than-expected state costs coupled with federal cuts have prompted California to retreat on healthcare coverage. Federal funds account for one-third of the state's budget and more than 60% of spending by Medi-Cal, the state's Medicaid program.

Xavier Becerra served in the House of Representatives when the Affordable Care Act passed and as health secretary under President Biden. He's the frontrunner in California's governor's race.

(

Genaro Molina

/

The LA Times via Getty Images

)

Gov. Gavin Newsom has frozen enrollment for immigrants without legal status, enacted monthly premiums for some, and plans to only temporarily backfill federal assistance for legal immigrants and refugees.

Newsom and Democratic lawmakers agreed to delay some cuts until July 2027, leaving the next governor to weigh further rollbacks against increased taxes. Becerra, a California native born to Mexican immigrants, opposes what's known as the billionaire tax, on November's ballot. This month, he said he supported legislative efforts to penalize large corporations whose workers rely on Medi-Cal, arguing that taxpayers are subsidizing employers' low wages and paltry benefits.

County governments, which are legally required to provide healthcare to uninsured residents too poor to afford care, are lobbying lawmakers for funding to treat what they describe as a fresh deluge of patients who need free care.

"It's a pretty big cliff if all this stuff goes into effect," said Dietz, the labor center's healthcare program director. And there's a choice whether to make it less bad and maintain coverage for folks."

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

Writer Aida Salazar did not spend endless hours on devices as a teen. She grew up in the 1980s, way before TikTok and Instagram. But she has raised teens, a boy and a girl. She felt she lost them to their screens during the pandemic.

“To the point where they were harming themselves on different levels,” she said.

The antidote to the overconsumption of screens, she and her husband realized, was found when they spent time outdoors near their home in Oakland.

“We went to the redwoods, or we went to the ocean, or we went somewhere else where they were my kids again,” she said.

Salazar, who has received numerous awards for some of her 10 YA books, has drawn on that experience for her latest work, Stream.

It’s written in first person rhyme in the voices of the two main characters, a teen boy named Elio and Celi, a girl. (Both appear in Salazar's previous YA novels).

In this book they’re both eighth graders who live separately in Oakland. After their parents realize the extent of their tech dependency, they take the drastic action to send them to rural Mexico for an IRL shock.

“To detox digitally in a rancho, or a place that has no running water, no electricity, and of course, no internet,” said Salazar.

Out of their digital element

Salazar was born in the Mexican state of Zacatecas and grew up in Maywood, in Southeast L.A. County, before earning a master’s degree in writing from CalArts.

The rural Mexican setting of Stream is partly based on her mother’s hometown in Zacatecas, where she wrote some of the book. The title is inspired by a vibrant stream there that once sustained the community but is now in the shadow of crumbling adobe homes.

The cover for the YA book Stream, writren by Aida Salazar.

The book begins with Elio’s narration that brims with excitement about his last day of school.

The first page of the YA novel, Stream.

(

Digital book screenshot

)

Celi’s narration of that last day is more dream-like.

A page from the YA novel, Stream.

(

Digital book screenshot

)

In Mexico, out of their digital element, some connection blooms which, Salazar said, may be love.

Adults can read the book, she said, but it’s meant for teens to read in order to see how Elio and Celi struggle to balance digital and in-person relationships as well as connection and disconnection to nature and their families.

“I don't want our young people especially, to lose their understanding of their source, of who we are as natural beings connected to land, to ancestors, to legacy,” she said.

She believes nurturing the stream of connections to those things will go a long way towards helping teens rise above the various social and environmental challenges they will face in their adult lives.

A battle over a first-of-its-kind tax on billionaires is heating up in California, with tech moguls pumping millions of dollars into a campaign to defeat it and union leaders who support the measure insisting the state's very wealthiest residents should pay their fair share.

Voters in November will be asked whether to pass the ballot measure, known as Proposition 40, which imposes a one-time 5% tax on the assets of the nearly 250 billionaires in the state. Backers say the new revenue would mostly fund healthcare services.

The tax was envisioned by union leader Dave Regan, who said millions of the state's neediest patients could lose health insurance in the coming years, driven largely by President Trump's 2025 tax and spending bill. Dubbed by the White House the "One Big Beautiful Bill," the law slashes federal funding to California and other states.

"Proposition 40 was developed specifically to backfill those cuts from the One Big Bill that are scheduled to take effect in the next five years. It is a five-year solution to that plan," said Regan, who is the president of the SEIU United Healthcare Workers West.

If passed, the measure would direct 90% of the tax revenue to fund healthcare services and the other 10% to food assistance and public education across California.

"We're not even talking about the top 1%, we're talking about the top 0.0001%, the billionaires: 250 individuals in California, $2.4 trillion worth of wealth, and that's an amount of money equivalent to the annual income of all Californians who are not billionaires, including extraordinarily wealthy people," Regan said.

But the populist fervor fueling supporters of the measure is being met with a growing coalition of resisters, from tech billionaires to other unions and some state Democrats. That includes Democratic Gov. Gavin Newsom, who has said the tax would hurt the state's economy, which is powered by profitable tech companies in Silicon Valley that have spawned many of the billionaires who would be taxed under the measure.

Opponents of the tax argue it offers a short-term fix to a long-term problem and could ultimately backfire.

"I'm not against taxes. But this is not the right tool. What we need to develop is something that is stable and consistent," said René Bravo, president of the California Medical Association, in an interview with NPR. "Human beings need and deserve health care that is financed in such a way that you're not increasing the insecurity."

Bravo argues Proposition 40, if passed, would make patients more unstable by providing them with bridge coverage now, but no longer-term solution — making it difficult to plan out medical coverage over many years. Bravo also said he does not trust state lawmakers to spend most of the new revenue on healthcare, speculating that they could direct the money to other pet projects.

"Not accurate, not true," responded union leader Regan. He said voters face a choice between more immediate healthcare funding for Californians or none at all, and that a third way being proposed by some critics is not on the ballot.

Will billionaires leave California if wealth tax passes?

Another major rift between both sides of the fight is whether the first-of-its-kind state wealth tax would drive billionaires out of California.

It's a crucial issue, since California's Chamber of Commerce estimates 1% of the state's residents pay nearly 50% of all personal income taxes.

Few disagree that a mass flight of the ultra-rich would throw California's budget into a tailspin, but the measure has sparked a fierce debate about whether billionaires will actually pack up and leave the state.

French economist Thomas Piketty, who has written extensively about disparities in international wealth, has argued that what's known as "capital flight" is often overstated in debates about wealth taxes. "If one builds a fortune while relying on the country's infrastructure, education, and health systems, there is no reason that one should so readily escape the collective obligations that fund these systems," Piketty wrote last year about a proposed wealth tax in France aimed at the ultra-rich.

Adam Michel, who studies tax policy at the libertarian Cato Institute, believes taxing high income earners will be destructive for the state.

"A wealth tax of this magnitude will be bad for California and for California taxpayers. We should expect not just targeted billionaires to leave, but anyone that expects to be a billionaire or expects to be the target of aggressive taxes like this in the future to leave," he said.

Google co-founder Sergey Brin, one of the richest people in the world, agrees.

He has poured $102 million into a group known as Building a Better California, which he co-founded with former Google chief executive Eric Schmidt. The group has also received millions of dollars in funding from venture capitalist John Doerr, crypto executive Chris Larsen and others. Building a Better California's mission is to defeat the effort, in part by supporting a separate ballot measure that would invalidate the wealth tax. Other tech billionaires, including Palantir founder Peter Thiel, who no longer lives in California, have funneled millions of dollars into other groups hoping to topple the measure.

A spokesperson for Building a Better California did not return a request for comment, but Brin told The New York Times: "I fled socialism with my family in 1979 and know the devastating, oppressive society it created in the Soviet Union. I don't want California to end up in the same place."

Brin recently moved to the Nevada side of Lake Tahoe. Critics of the tax say there will only be more billionaires leaving California if voters pass the measure.

Union leader Regan calls Brin's move political theater. He pointed out that the wealth tax applies to California residents who lived in the state in January of this year, so moving out of state would not allow anyone to dodge the tax, nor would relocating after November, if the ballot measure prevails. Bloomberg estimated the tax could personally cost Brin around $13 billion.

Regan said Brin owes his success in part to government-backed research that helped create Google and insisted that a one-time 5% tax would not be overly burdensome for the tech mogul.

"You are now one of the five wealthiest people in the world in the state that made you rich, enormously rich," said Regan as if speaking directly to Brin, noting that California "needs to stabilize its healthcare system."

Some polls show that Californians are nearly evenly split on the tax.
Copyright 2026 NPR

A California Senate committee just gutted one of the state’s most substantial DUI reform bills in years, despite widespread support from other lawmakers and families of drunk driving victims.

The bill would have required in-car breathalyzers for anyone convicted of a DUI, bringing California in line with most states. State law currently only requires the devices, called ignition interlock devices, after repeat offenses or injury crashes.

Sabrina Cervantes, a Democrat from the Inland Empire and chair of the Senate Appropriations Committee, provided a hint of changes last week when she said there were amendments to the bill that had been approved unanimously by the committee. This week, an updated version of the legislation emerged, and it effectively killed a key provision to start requiring the devices for thousands of first-time offenders. Such changes are commonly referred to as “hostile amendments” because they are made without the involvement or support of the bill’s author.

Cervantes was arrested for a DUI in a high-profile incident in Sacramento in May 2025. The District Attorney’s Office did not prosecute her after a blood test showed no drugs or alcohol in her system. Cervantes then sued the city of Sacramento and several of its police officers, alleging that that police fabricated evidence and falsely arrested her. Cervantes’s sister, state Assembly candidate Clarissa Cervantes, has herself been convicted of two DUIs in Southern California, according to media reports.

Sabrina Cervantes did not respond to our request for comment for this story. We will update it if she does.

As news of the bill’s gutting spread this week, Kellie Montalvo was left wondering if there’d been some sort of horrible mistake. Montalvo, whose 21-year-old son Benjamin was killed by an impaired driver in Cervantes’s district in 2020, said she was just in Sacramento two weeks ago lobbying lawmakers – including Cervantes – on a slate of dangerous driving bills. Many of those bills have already failed.

“It’s heartbreaking, and I try to tell myself not to lose hope,” Montalvo said. “I mean, California has got to do something. Our numbers are horrific.”

Alcohol-related roadway deaths in California spiked more than 50% in a decade — an increase more than twice as steep as the rest of the country, federal data shows. More than 1,300 people die each year statewide in drunken collisions.

Over the last two years, a CalMatters investigation has shown how state officials have allowed dangerous drivers to stay on the road and kill, and how elected leaders have looked away even as the death toll skyrocketed.

For years, lawmakers have tried and failed to require in-car breathalyzers for all DUI offenders. Progressive justice reform groups and the DMV have opposed similar bills in the past, citing fears about unfairly penalizing poor DUI offenders, high costs and the DMV’s aging technology.

Montalvo and other advocates thought this year might be different. The DMV has actively participated in state hearings and, she and others said, provided technical advice to make sure the bill was realistic. Gov. Gavin Newsom also instructed lawmakers last year to continue to work on the state’s breathalyzer laws and develop “a lasting program that strengthens public safety.”

It’s unclear why this year’s bill was gutted at the 11th hour. Public records show that Senate Appropriations committee staff recently expressed concern about costs.

The amendment process is opaque even to Sacramento insiders.

“Honestly it’s sometimes a bit of a black box even for us as legislators,” said the bill’s author, Assemblymember Cottie Petrie-Norris, an Orange County Democrat. “I am still trying myself to get to the bottom of it.”

Petrie-Norris, who has spent the past three years trying to pass a version of this bill, said she does not believe Cervantes’ personal experience played a role in the decision to amend the bill. She added that she is still working to re-amend the measure after “unintended consequences” that she says would make the policy unworkable for the DMV and hurt California’s eligibility for federal funding.

Asked for an interview to explain the changes to the bill, Senate President Pro Tem Monique Límon’s office referred questions to Cervantes. Diana Crofts-Pelayo, Newsom’s chief deputy director of communications, also declined to answer questions about the breathalyzer bill, saying the office does not typically comment on pending legislation.

While the bill heads into the final days of negotiations, Montalvo and other victims’ families are grappling with deja vu. It was just about a year ago that they were standing in the Capitol with photos of their loved ones and told the bill was doomed.

She stays busy checking in with the parole officer for the Riverside County driver who killed her son. Last she heard, the driver was trying to get her license back after being released early from prison.