In-home care services provided through Medi-Cal, California’s Medicaid program, have become essential for many vulnerable residents, including 77-year-old retired teacher Carol Crooks, who relies on her caregiver Florence Owens for support with daily tasks and medical appointments.
Living on a fixed income of $1,000 a month from Social Security, Crooks, who resides in Section 8 housing in Oakland, fears the consequences of potential federal cuts to Medicaid that could strip away crucial in-home support.
“Not everybody has family members that can do it,” she emphasized, illustrating the importance of these services for individuals in similar situations.
For Crooks, the ability to live independently at home, as opposed to being placed in a nursing facility, has made a monumental difference in her quality of life.
Short experiences in nursing homes after surgery left her with vivid memories of long wait times, misplaced laundry, and unwanted roommates.
The thought of being forced into such environments is terrifying for her and many others relying on these essential services.
This article draws from the podcast “Civic,” as it navigates the frontline impact that potential Medicaid cuts could have on patients, caregivers, and local healthcare systems.
The stakes are particularly high for the over 250,000 San Francisco residents relying on Medi-Cal, especially with recent proposals from President Donald Trump’s administration for more than $1 trillion in Medicaid cuts over the next decade.
This demographic represents nearly one-third of San Francisco’s population, encompassing 52,000 children and 35,000 seniors and individuals with disabilities.
The fundamental difference between Medicaid and Medicare is significant; while Medicare serves seniors and certain disabled individuals, Medicaid is a state-federal partnership aimed at supporting low-income residents and those with heightened medical needs.
Despite President Trump’s assurances that his administration would not cut Medicaid, stating in May, “Here’s what I want on Medicaid, we’re not touching anything,”
the congressional budget has instructed these reductions as a means to bolster the cost of the 2017 Tax Cuts and Jobs Act, a policy that primarily benefits corporations and affluent households.
California receives upwards of $81 billion each year for Medicaid, covering approximately two-thirds of the costs associated with Medi-Cal.
Moreover, San Francisco’s allocation stands at $2.1 billion, which is critical for supporting the city’s safety-net services, public health programs, and job creation, thriving as a significant section of the local economy.
At a recent San Francisco Health Commission meeting, Tangerine Brigham, chief operating officer of the San Francisco Health Network, expressed concerns over the devastating impact of the potential Medicaid cuts.
“Critical programs will be underfunded,” Brigham warned, highlighting the uncertainty regarding which specific services will be affected.
In-home care services are particularly vulnerable to funding cuts, as they are often considered optional in the spectrum of necessary medical assistance.
San Francisco currently has around 29,000 in-home care recipients supported by over 28,000 caregivers, with Medi-Cal being the primary funding source since private insurance or Medicare rarely cover such services.
If Medicaid funding is diminished, in-home support is typically the first service to be impacted, leading to a potential crisis for many of San Francisco’s residents in need.
Governor Gavin Newsom has already proposed measures aiming at capping hours for in-home care providers, excluding undocumented adults from Medi-Cal, and reinstating asset tests.
While these proposals were rejected in negotiations for this year’s budget, advocates are bracing for their reemergence amid deeper federal cuts.
With the prospect of losing funding, health experts warn that the critical shortage of care workers may worsen further, jeopardizing job security and potentially driving wages lower for these essential workers.
Arnulfo De La Cruz, president of Service Employees International Union Local 15, explained that for many long-term care workers, the job is one they undertake while battling poverty.
Loss of Medicaid funding threatens not only the stability of these jobs but also the lives of in-home care recipients.
According to De La Cruz, “there’re not enough skilled care beds in San Francisco County to be able to house the roughly 29,000 authorized recipients for home care.”
It is troubling to think that the proposed cuts could lead to a dangerous situation for many.
In discussing healthcare program cuts, Brigham cited three potential methods: restricting eligibility, reducing coverage, or lowering provider payments.
She noted that the federal plan targets all three strategies, with keen attention on narrowing eligibility through complicated paperwork and work requirements.
Starting in 2027, Medicaid recipients may face a new requirement to demonstrate eligibility every six months instead of yearly, a change deemed “death by paperwork” by critics.
For Crooks, the looming bureaucratic challenges are concerning, prompting her to act quickly whenever she receives requests for documentation updates.
Her fear hinges on not wanting to risk disqualification due to administrative backlogs.
As of 2028, newly proposed rules will impose a $35 copay on adults who are part of the Medicaid expansion under the Affordable Care Act, a policy that could deter low-income individuals from pursuing essential healthcare services.
While children, seniors, and people with disabilities are exempt from copays, experts contend that the added costs will push low-income adults towards more expensive emergency care instead of preventive measures.
Research conducted by Georgetown University supports these concerns, showing that even minimal cost-sharing has led to reduced healthcare access among low-income patients, ultimately resulting in more severe health challenges and higher long-term healthcare expenses.
Future proposals include work requirements that may strip Medicaid coverage from millions.
Under the proposed measures, adults ages 19 to 64 must prove at least 80 hours of work each month to maintain their Medicaid status unless they meet specific exemptions.
House Speaker Mike Johnson (R-La.) articulated the argument around Medicaid, stating it should primarily support “single mothers with two small children” rather than “29-year-old males sitting on their couches playing video games.”
However, studies demonstrate that this perception misrepresents the reality for many individuals.
Brigham highlighted that 63% of California’s Medicaid recipients are already working, while others contend with challenges like education, caregiving, or disabilities.
In San Francisco, there are approximately 87,000 working adults who receive Medi-Cal, dispelling assumptions surrounding eligibility.
The opposition to work requirements argues they create costly bureaucracies that do not lead to increased employment rates, while research indicates that health coverage supports individuals in maintaining steady employment.
In Arkansas, the first to implement such a policy, more than 18,000 people lost coverage not because they chose not to work, but due to the confusion surrounding reporting requirements and deadlines.
Providing better access to care is crucial, especially considering that nearly 7,000 hospitalizations in San Francisco during 2022 were avoidable with better outpatient treatment, costing the system a staggering $128 million based on average hospitalization expenses.
As advocates in San Francisco, including the San Francisco Community Clinic Consortium, prepare to oppose impending federal legislation, they recognize the uphill battle they face.
The consortium, comprising 12 health centers with 29 locations across the city, served around 110,000 patients last year and is mobilizing efforts against the federal cuts.
High-profile supporters, including House Speaker Emerita Nancy Pelosi and state Senator Scott Wiener, have joined local rallies and initiatives to raise awareness about the impacts of the cuts.
However, the design of the bill complicates resistance efforts.
Many provisions are set to roll out after the midterms and phase in gradually over a decade, which critics argue dilutes public outrage and grants lawmakers the step-back needed from backlash.
In the meantime, Crooks remains proactive and committed to advocating for the preservation of services.
“I’ve been answering a lot of emails where they ask for signatures or letters,” she shared, emphasizing her efforts to raise awareness.
She has conversations with individuals open to discussions about the matter, and her resolve stands firm against those who simply wish to ignore these looming challenges.
As thousands of San Francisco residents face an uncertain future, Crooks and her supporters continue to rally against the proposed cuts, advocating for a healthcare system that prioritizes dignity and support for all.
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