Sacramento County is warning that approximately 15,000 local residents are expected to lose health coverage as new federal Medicaid work requirements take hold, a shift county officials say could saddle the county with tens of millions of dollars in new costs and push more uninsured patients into already strained emergency rooms.
The county made the warning in a social media post this week, stating that H.R. 1 is expected to create around $17 million in new costs for Sacramento County in the current fiscal year and roughly $58 million in new costs next fiscal year, according to Sacramento County. Counties across California are legally required to serve as health care providers of last resort for low-income, uninsured residents who have no other source of medical coverage, a mandate rooted in California Welfare and Institutions Code Section 17000. That means as Medi-Cal enrollees are dropped from the state and federal rolls, the burden of caring for them does not disappear — it shifts to local governments.
The federal law behind the disenrollment wave, H.R. 1, was enacted in July 2025 and requires Affordable Care Act Medicaid expansion adults ages 19 to 64 to complete 80 hours per month of work, education, or community service to keep their coverage starting January 1, 2027, according to the Center for Health Care Strategies. The law also shortens Medicaid expansion redetermination intervals from twelve months to six months, meaning enrollees must prove their eligibility twice as often. The California Department of Health Care Services estimated in May that 4.8 million Medi-Cal enrollees statewide are subject to the new work requirements, and the department projects roughly 1.1 million Californians will lose coverage by fiscal year 2029–30, per the California Health Care Foundation. State health policy experts note that many enrollees will lose benefits due to complex administrative paperwork rather than actual income ineligibility.
County Asks State for Emergency Bridge Funding
Sacramento County and other California counties are asking the state for $100 million in one-time bridge funding, which the county says it plans to use to provide indigent care to affected communities. Sacramento County has warned that emergency rooms could become overwhelmed and local health systems could come under strain if that funding does not materialize.
The request echoes a broader push from county leadership statewide. In June, a joint coalition of local government groups — including the California State Association of Counties and the County Health Executives Association of California — urged state leaders to establish a state-funded emergency Medi-Cal benefit to prevent disenrolled residents from flooding county indigent programs, according to Lassen News. County leaders warned that without state bridge funding, local governments would be forced to divert money from public safety and behavioral health services to cover the gap.
The scale of the potential fiscal shock is significant. The California State Association of Counties reported in February that federal safety-net cuts under H.R. 1 could cost California local governments up to $9.5 billion annually, including $5.5 billion per year for uncompensated indigent health care alone, per California City News. That crisis traces back in part to 2013, when Assembly Bill 85 redirected dedicated county indigent care funding to the state after the Affordable Care Act expanded Medi-Cal — leaving counties with less of a cushion now that federal rules are pushing residents back off coverage.
How Sacramento County Delivers Indigent Care
Sacramento County fulfills its Section 17000 obligation through the County Medically Indigent Services Program, known as CMISP, which provides medically necessary primary, specialty, emergency, and pharmacy care as a last resort for uninsured adults earning up to 138% of the federal poverty level. CMISP applications are evaluated by the county's Department of Human Assistance, with clinical services anchored at the Sacramento County Health Center.
The county also runs the Healthy Partners program, which offers primary and limited specialty care at the Sacramento County Health Center for low-income adult residents who do not qualify for full-scope Medi-Cal because of their immigration status. Healthy Partners works alongside restricted-scope Medi-Cal to provide preventive care and manage chronic conditions for residents excluded from traditional federal coverage.
Neighboring Counties Face the Same Squeeze
Sacramento County is not alone in scrambling to respond. Neighboring Placer County's Board of Supervisors approved an emergency agreement on June 30 to join the County Medical Services Program in order to manage an estimated 7,000 local residents expected to lose Medi-Cal coverage over the coming year, according to Gold Country Media. Placer County leaders similarly warned that local taxpayers cannot absorb rising indigent care costs without cutting other municipal services.
At the state level, Assemblymember Pilar Schiavo has submitted a 2026–27 budget request for $574 million to support county Medi-Cal eligibility workers and help residents navigate complex federal paperwork to avoid losing coverage. Legislative advocates argue that keeping county enrollment staff funded prevents residents from falling into uncompensated emergency room care instead.
The long-term picture painted by researchers is stark. A February study by the UCLA Center for Health Policy Research and the UC Berkeley Labor Center projected that up to 2.98 million fewer Californians will be enrolled in full-scope Medi-Cal by 2028 due to H.R. 1 mandates and state budget adjustments, with the UC Berkeley Labor Center calculating that work requirements alone account for 1.87 million of that projected statewide loss. Sacramento County says it and other California counties will determine the full scope of H.R. 1's impacts as the changes continue to unfold.
