Since the One Big Beautiful Bill Act (OBBBA) passed in July 2025, California hospitals have been preparing for major changes to Medicaid funding and eligibility. In less than three months, some of those changes will take effect, creating new challenges for patients, hospitals, and the communities we serve.
But the warning signs are already here.
Recently, our regional partner, the Hospital Association of San Diego & Imperial Counties, shared some startling data from San Diego County: Between August 2023 and September 2026, Medi-Cal enrollment fell from nearly 1 million to about 781,000. That represents nearly 220,000 fewer Medi-Cal recipients, a staggering 21.9% decline.
Similar trends are happening across Northern California, including Contra Costa, San Joaquin, San Mateo, Santa Clara, and San Francisco counties, although not to the same degree. Medi-Cal managed care plans are also reporting enrollment declines earlier than anticipated.
Although these declines began before the new federal law passed, they underscore the growing challenges facing California’s health care safety net.
And we have not yet experienced the full impact of OBBBA’s changes.
The reality is simple: Losing health coverage does not mean losing the need for health care.
Patients will continue arriving at emergency departments. Families will still need maternity services. Individuals experiencing behavioral health crises will still need treatment. Hospitals will continue providing care, even as the financial resources supporting that care become increasingly uncertain.
Fortunately, communities across Hospital Council’s 50-county territory are not waiting for the consequences to unfold.
Local governments, hospitals, health plans, and community partners are already taking action by:
- Supporting local funding initiatives: Communities are pursuing ballot measures and other funding strategies to preserve essential health care services, including Measure B in Contra Costa County.
- Planning for Medi-Cal transitions: Partnership HealthPlan of California is preparing to transition approximately 85,000 members with unsatisfactory immigration status to Medi-Cal Fee-for-Service beginning Jan. 1.
- Strengthening local safety nets: Counties, including Sonoma and Sacramento, are exploring strategies to preserve access to care for uninsured and vulnerable residents.
- Measuring the impact: Health systems such as Sharp HealthCare are tracking Medi-Cal enrollment alongside hospital self-pay trends to better understand the consequences for patients and providers.
These efforts show what we have seen repeatedly: When hospitals, government, and community partners work together, we accomplish far more than any of us can alone.
But preparation alone will not be enough.
We must identify the communities most at risk, document the impact of coverage losses, strengthen local partnerships, and ensure policymakers understand the consequences of their decisions.
The challenges ahead are significant. There is no benefit in pretending otherwise.
Yet we remain optimistic.
California hospitals have navigated extraordinary challenges, from a global pandemic to natural disasters, workforce shortages, and financial pressures. Time and again, hospital leaders and their teams have demonstrated remarkable resilience, innovation, and an unwavering commitment to their communities.
Hospital Council, working alongside the California Hospital Association, will continue advocating for the resources and policies necessary to protect access to care.
We cannot control every challenge coming our way. But we can control how we prepare, how we collaborate, and how we respond.
If our history has taught us anything, it is that California’s hospitals are strongest when we stand together.