Medi-Cal cuts could take health care away from Los Angeles’ homeless

from Kristen HuangCalMatters

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On a brisk January morning, assistant professor Brett Feldman scoured the streets of Los Angeles for patients, knocking on car windows and peering into tents. It was the day after a winter storm drenched the city, and many of the homeless people Feldman usually treated had moved to find somewhere dry.

Feldman leads the Street Medicine Team at USC Keck School of Medicine, providing primary care to thousands of homeless people in Los Angeles. Many have chronic illnesses, mental disorders, wounds or other medical problems; are in desperate need of health care.

But Feldman and other street drug providers across the state worry that changes to Medi-Cal eligibility made by President Donald Trump’s “One Big Beautiful Bill” will cause most homeless people to lose insurance, limiting their options for care.

“It’s very possible that over 90 percent of people experiencing unsheltered homelessness will lose insurance,” Feldman said of his patients in Los Angeles.

Medi-Cal, also known as Medicaid at the federal level, provides health insurance for low-income and disabled people. The new law requires states starting in 2027 to verify that working-age adults under 65 without dependent children meet 80 or more hours of work each month to qualify for Medicaid. It also requires states to verify income and other eligibility criteria every six months, rather than once a year.

Civil servants rate up to 2 million people — about 14 percent of the state’s 14 million Medi-Cal recipients — will lose coverage either because they don’t meet the work requirements or because they’re overwhelmed by the paperwork.

Meeting those requirements will be particularly challenging for the state’s roughly 180,000 homeless people. They often don’t have phones or internet to fill out a job application. They have limited access to food, showers or clean clothes. They usually struggle with addiction or mental illness and often lack the ability to work. Research shows that homeless people have much worse health outcomes and life expectancy nearly 20 years shorter than the general population.

Often, those who need health care the most are those who are least able to work, Feldman said.

Without insurance, people who are not housed will not be able to get medication or find primary care providers. Their health will deteriorate and they will become more reliant on emergency departments.

“It’s going to be a huge problem for the unhoused,” Kelly Bruno-Nelson said, executive director of CalOptima, an Orange County Medi-Cal plan that provides health insurance to about 11,000 members with unstable housing.

Release from work

The law provides exceptions for people who cannot work: those with substance use disorders, debilitating mental illnesses, complex medical conditions and other disabilities. Children, pregnant people, foster youth and people with disabilities are also exempt, although they will be required to renew their Medi-Cal eligibility every six months.

On paper, many homeless Californians likely qualify for work relief. Almost half of homeless Californians you have a complex behavioral health need, including regular drug or heavy alcohol use, hallucinations, or recent psychiatric hospitalization, according to recent reports from the UCSF Benioff Housing and Homelessness Initiative. For 60% reported at least one chronic illnessand approximately one-third have conditions that make bathing, dressing, or eating difficult.

But to request an exception, the patient needs a doctor to certify. Only half of insured and uninsured Californians regularly receive care, and only 39 percent have a primary care provider, Benioff’s data shows.

In Los Angeles, even fewer homeless people have a primary care provider. Just 7% of the population saw a provider in the past year between 2022 and 2023, according to study published by the USC Street Medicine Programmeaning very few people will have medical exemptions certified under the new law.

That means many eligible people could lose Medi-Cal: people like Samantha Randolph.

The 37-year-old has been living on the streets of LA for more than five years. She wouldn’t even know where to start looking for a job if she had to, she said. Her ID snapped in half and she threw it away. Someone stole her phone months ago, and she has no recent work experience.

“I’m alone. I’m doing this alone,” Randolph said that January morning.

Randolph, who is seven months pregnant, will be eligible for a work exemption in 2027. Feldman’s team also checks in on her regularly to monitor the baby and can certify an exemption if necessary. But even that’s no guarantee that Randolph won’t inadvertently lose Medi-Cal.

Her health insurance expired six weeks before Feldman’s visit because the county enrollment office mailed the documents to an address where Randolph did not live. Without Medi-Cal, which pays for the city’s maternity housing, Feldman can’t get her inside.

“I’d love to get you out of here as soon as possible,” Feldman told Randolph as he listened to her breathing and examined the bump on her head. “I’d love to get you somewhere safe and comfortable.”

His benefits team worked diligently behind the scenes to re-enroll Randolph in Medi-Cal. Without ID and other documents, it was a slow process.

The state is trying to automate eligibility checks

Medi-Cal state officials are working on it run an eligibility verification system which will automatically check for compliance with work requirements and exceptions. They hope to save the roughly 3.5 million Californians like Randolph who will have to comply with the law’s new requirements the headache of having to prove their qualifications on paper.

“This is a top priority for us at the department, really looking to minimize harm to members as much as possible,” said Tyler Sadwit, state director of Medicaid for the Department of Health Services.

The department is looking to buy workforce data that will capture gig workers and more timely income information than tax returns. The state already uses data from the IRS and information from other welfare programs like food stamps and cash assistance programs to check if you qualify for Medi-Cal.

To exempt income-eligible students, the department wants to pull information from state universities and colleges. And it works to identify medical diagnosis codes that can be used to exempt people with disabilities or other qualifying conditions such as mental health or substance use disorders.

If the state can link all the data together, some qualified and exempt Medi-Cal recipients will not have to provide additional information.

“They won’t have to take action. They’ll get a notification that they’ve been successfully renewed,” Sadwit said.

But there are gaps that will be difficult for the state to fill with automated data and questions left unanswered by the federal government. Evidence of volunteer work, for example, doesn’t exist in a major database, and it’s unclear whether the federal government will require medical diagnosis codes that could signal a qualified exemption to be verified by a provider every six months. If they do, many unhoused Californians who don’t seek a provider in time could still be kicked out of Medi-Cal.

Department officials also acknowledge that in states that have previously tried to impose work requirements, eligible people always fail.

Matt Beer, a street medic in Kern County, said falling through the cracks is the norm for unsheltered people. Already, people like Randolph lose Medi-Cal all the time.

The new requirements of the law will only make this more likely.

Even street drug providers who work daily to locate and track missing patients cannot guarantee they can find them. Camp purges, serious crime and the weather force people to move frequently.

“The cost of falling through the cracks is probably human life,” Beer said.

Homeless people can lose access, housing

California has invests heavily in street medicine teams in the last five years.

Street teams provide comprehensive first aid services wherever homeless people are: under bridges, on the side of the road, in camps. They administer antipsychotic shots and contraceptives, provide wound care, deliver medications, and help treat substance use disorders. Perhaps most importantly, they often travel with welfare counsellors, social workers and housing specialists.

This and other Medi-Cal investments have helped the state address its homelessness problem.

But with droves of patients expected to drop out of Medi-Cal, some providers predict that street medical teams could disappear as well, worsening the chance that unhoused Californians will have a provider who can certify their exemption from work requirements.

“It’s going to be very fiscally difficult for these programs to be able to sustain themselves,” CalOptima’s Bruno-Nelson said.

Without Medi-Cal, homeless people would not be able to see specialists, get diagnostic tests, or get most medications. They will rely more on emergency departments. And since California policymakers have tied some housing and other social services to Medi-Cal, many experts worry that members of this vulnerable population will lose their best chance for stability.

“These people are spinning through — some with 50 emergency room visits a year because they’re so sick — a vortex,” said Gray Miller, CEO of Titanium Healthcare, a case management company that helps Medi-Cal recipients coordinate health screenings, find housing and manage chronic illnesses.

Back in Los Angeles hours after finding Randolph again, Feldman takes the call and smiles. The county finally approved her Medi-Cal application, meaning Randolph now qualifies for maternity housing. He sends a colleague to pick her up.

“I’m so happy we got Sam in.”

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a cost they can afford. Visit www.chcf.org to learn more.

This article was originally published on CalMatters and is republished under Creative Commons Attribution-NonCommercial-No Derivatives license.