Why Fresno County could hurt more from Medicaid cuts than most of the country

There’s no doubt amongst experts that cutting Medicaid would impact California greatly. 

But for Fresno County, the impacts could be more concentrated than most other parts of the state. 

About 52% of Fresno County residents — more than half a million people — are insured by Medi-Cal, California’s Medicaid program. According to a Fresnoland review of state health data, Fresno has the third highest Medi-Cal enrollment rate out of all 58 California counties. 

“The regions with high enrollees are definitely more vulnerable, at more risk than lower-enrolled regions because it means people have low incomes and they have jobs that don’t have a good private insurance,” said Shalini Mustala, a research associate at the Public Policy Institute of California.

Tulare County has the highest Medi-Cal enrollment rate in the state — around 61.8%. Three other parts of the San Joaquin Valley rank directly after Fresno: Merced, Kern and Madera counties. 

“The whole Central Valley has higher enrollment rates for Medi-Cal, so the whole region is at higher risk,” Mustala said. She added that California has never faced cuts to federal Medicaid funding before, so whatever happens next is uncharted territory.

The exact impacts of Medicaid cuts are unclear right now, as a current budget proposal calls on the House Committee on Energy and Commerce — which oversees the federal Medicaid program — to cut $880 billion over the next 10 years. President Donald Trump and Republican lawmakers have prioritized renewing tax cuts from Trump’s first administration — and they‘ve squarely identified Medicaid as the sacrifice to make it possible.

In the absence of certainty, a number of strategies have been floated over how Medicaid cuts could take shape, spanning from lowering reimbursement rates and further restricting what Medicaid covers to limiting enrollment by instituting a work requirement. 

“Cutting Medi-Cal rates on the order of what's being floated in Washington right now doesn't help people in the Central Valley,” said Kristof Stremikis, the market analysis and insight director at the California Health Care Foundation. “It doesn't help hospitals. It doesn't help clinics.”

This year, Medi-Cal in California was funded to the tune of $161 billion, “roughly half of which is funded by the federal government and the remaining covered by state and local sources,” according to the California Legislative Analyst's Office.

Although many specifics aren’t yet known, Medicaid cuts could leave both patients and health providers in the lurch, according to experts. 

“When you're talking about cuts of this magnitude, it's really going to be harmful,” Stremikis said. “These sorts of reductions in federal funding — that can only mean fewer people eligible for the program or fewer benefits.”

How patients and health providers could be left in the lurch

If Medicaid cuts lead to patients getting kicked off Medi-Cal, and with no health insurance, it would dramatically impact their access to healthcare — which means missing out on obtaining regular health assessments or identifying serious health conditions early. 

“Folks who are not taking care of their conditions in a preventative way will more likely end up in the hospital with something that is very expensive to treat, as opposed to something that could have been prevented,” said Sara Bosse, the Madera County public health director. “We might be going backwards in terms of population health and individual health, but we also might be creating a situation where it's ultimately more expensive.”

Madera County’s health care infrastructure has already been weakened since the closure of Madera Community Hospital more than two years ago. Although the hospital has new operators, it is still dormant to this day, despite hospital leaders moving their reopening target from last summer to this early this year. 

On top of patients foregoing regular visits to the doctor, health providers that mostly provide care to patients on Medi-Cal are heavily dependent on Medi-Cal reimbursements. That includes hospitals, health centers, rural health clinics — any health provider that is mostly treating lower-income populations. 

The fact that more than 50% of residents in Fresno, Tulare, Merced, Kern and Madera counties are covered by Medi-Cal demonstrates that health providers, and the larger health care infrastructure in those counties, greatly depend on Medi-Cal reimbursements as a key revenue source. 

“There's going to be healthcare providers that rely more on Medicaid than others that are going to struggle during these times,” Fresno County Public Health Director David Luchini told Fresnoland. 

For example, at United Health Centers — which has 34 locations across Fresno, Tulare and Kings counties — 60% of its patients depend on Medi-Cal for health insurance, said CEO Justin Preas.

"These are some of the most vulnerable and chronically ill people that live here in our valley," Preas told Fresnoland. “If their insurance through the Medi-Cal program is taken away, they have no health care." 

Preas said he couldn't remember a time over his 20 years at United Health Centers where there was this much uncertainty and lack of information concerning the future of Medicaid.

"It's lives — you're putting people's lives at risk," Preas said of potential Medicaid cuts. "I do believe that people are going to suffer because they do not have health insurance coverage, and they'll go without care until it's too late."

In the Fresno area, most hospitals have considerable patient pools covered by Medi-Cal, according to data from the California Department of Health Care Access and Information. In 2023, about half of all patient days at Community Regional Medical Center in downtown Fresno were covered by Medi-Cal health plans. 

"Any potential Medicaid cuts are extremely concerning as both Medicaid (Medi-Cal) and Medicare are underfunded and government reimbursement for these programs already don’t cover the cost of care,” said Michelle Von Tersch, a senior vice president of Fresno’s Community Health System, in an emailed statement. “It is too early to predict the ramifications of potential payment cuts, but we are in regular communication with our federal representatives on many topics including this one."

Over at Valley Children’s Hospital — just north of Fresno County — almost three quarters of all patient days in 2023 were covered by Medi-Cal. 

“Approximately 75% of the children we care for are covered by Medicaid (Medi-Cal in California),” said Zara Arboleda, a spokesperson for Valley Children's Hospital, over email. “It is a critical program for our region. Right now, we are monitoring what is going on in Congress. It is too early to tell what the impact may be, as Congress has not provided specifics regarding any changes or reductions to this vital healthcare program.”

Additionally, at least 25% of patient days at St. Agnes Medical Center and Clovis Community Medical Center were covered by Medi-Cal health plans in 2023. A spokesperson for St. Agnes Medical Center did not respond to repeated requests for comment.

A political fight waged over the budget in Washington

The central San Joaquin Valley is represented by a handful of electeds: Reps. Jim Costa and Adam Gray are both Democrats. Reps. Tom McClintock, Vince Fong and David Valadao are Republicans. 

The five of them fell along party lines in the Feb. 25 vote considering the budget proposal that called for slashing Medicaid across the country. Costa and Gray voted against the budget proposal, while McClintock, Fong and Valadao voted for it. 

Costa has been vocal about the need to keep Medicaid, and so has Gray, who introduced a budget amendment specifically meant to protect the safety net health insurance program. 

“Is it such a priority to fund tax cuts — for individuals with over $1 billion in net worth — that we would enact devastating cuts to health care for rural and low-income communities?” Gray said inside the U.S. House chambers last month. 

Fong, McClintock and Valadao have all been criticized for their votes, and Republicans at large have been questioned over how they could vote for a budget proposal that would dramatically impact health access and medical care in their own districts. 

Although Valadao voted for the budget proposal in February, he said his congressional district’s residents have one of the highest Medicaid enrollment rates, adding that he “will not support a final reconciliation bill that risks leaving them behind.”

Valadao has also openly dissented with fellow Republicans, citing the importance of Medicaid and the number of his constituents who rely on it. So far, however, his votes haven’t reflected those sentiments. 

Valadao’s congressional district, California’s 22nd, had a 67% Medi-Cal enrollment rate last year — the highest in all of California, per the UC Berkeley Labor Center. Costa’s district was at 64% and Gray’s district was at 59%. 

Fong’s district, which runs from Clovis all the way down to Bakersfield, was at a 37% Medi-Cal enrollment rate. McClintock, who represents most of north Fresno, was at a 30% enrollment rate. 

Congress has until Friday to approve a budget, otherwise the federal government would plunge into a government shutdown. Republicans have a majority in both the House and the Senate.