Contra Costa, Santa Clara, Alameda and San Francisco are expanding county-run care programs for people expected to lose coverage in 2027, but the documents behind those plans show the money covers only a fraction of the need.
In two Bay Area boardrooms this week, county officials took up the same problem from opposite ends of the region and arrived at similar answers.
In Martinez on Tuesday, Contra Costa County supervisors heard a proposal to widen a little-used county health program that dates to 2002, so that it could absorb residents expected to lose Medi-Cal starting in January. In San Jose, Santa Clara County supervisors approved replacing their primary care program for the uninsured with a broader plan, called Valley Care, that would cover hospital stays and specialists as well as checkups.
Neither program is health insurance, and officials in both counties said so plainly. They are county-run programs meant to keep people connected to doctors and prescriptions while they try to regain coverage, or after they lose it for good. They are also a return, more than a decade after the Affordable Care Act shrank them, to a model in which California counties carried much of the cost of caring for people without coverage.
What has changed is the scale of the coverage loss now expected, and its source. Federal changes under H.R. 1, the budget law President Trump signed in 2025, and a series of cuts in California’s own budget are arriving at the same time. A review of county board documents, state budget analyses and accounts of this week’s meetings shows that Bay Area counties are preparing for those losses with programs sized for thousands of people, while their own estimates of those at risk run to the tens of thousands per county.
What is changing, and when
The federal law requires most adults who gained Medi-Cal through the Affordable Care Act expansion to show 80 hours a month of work, school or community service, and to renew their eligibility every six months instead of once a year. Both requirements take effect in California in January 2027.
California has added its own changes. The 2025-26 state budget froze new enrollment in full-scope Medi-Cal for undocumented adults starting in January 2026, and set a $30 monthly premium, beginning in July 2027, for adults ages 19 to 59 with what the state calls “unsatisfactory immigration status” who keep their coverage. This year’s budget directs the administration to set that premium between $30 and $50 a month, according to the Legislative Analyst’s Office, which estimated that a $50 premium would save about $427 million from the state’s general fund in 2027-28.
The 2026-27 budget also moves all Medi-Cal services for that population out of managed care plans and into the state’s fee-for-service system beginning in January 2027. The administration estimated the change would save $525 million in 2026-27 and $1.3 billion a year after that, the analyst’s office reported, citing “lower utilization of certain services” and the elimination of some administrative costs. The analyst’s office said the change implements a federal limit, under H.R. 1, on states’ ability to pay for emergency Medicaid for this population through managed care plans.
The UC Berkeley Labor Center and the UCLA Center for Health Policy Research project that 2.98 million fewer Californians will be enrolled in full-scope Medi-Cal by 2028 as a result of the federal and state changes. The largest share, 1.87 million, comes from work requirements. The enrollment freeze accounts for 550,000, six-month renewals for 270,000 and the premiums for 95,000. The researchers describe the figures as “the high end of potential Medi-Cal coverage losses” and note that they count people losing Medi-Cal, not people becoming uninsured, since some will find job-based or other coverage.
Contra Costa: an old program, widened
The Contra Costa plan was presented to the Board of Supervisors on Oct. 20, according to an account of the meeting by Contra Costa News. Contra Costa Health officials told the board that as many as 93,000 county residents could become uninsured by 2031 because of Medi-Cal eligibility changes, work requirements, copayments and more frequent renewals. About 47,500 residents with certain immigration statuses are expected to move from managed care to fee-for-service Medi-Cal on Jan. 1, officials said.
The county’s Basic Health Care Program has existed since 2002. Under the proposal, eligibility would extend to residents with incomes up to 300 percent of the federal poverty level who cannot get other coverage, including those between 0 and 138 percent of the poverty line who are generally excluded today. Participants would pay no annual fee, and prescription copayments would be capped at an estimated $15. Community clinics including La Clínica, LifeLong Medical Care and Brighter Beginnings would continue as partners.
Dr. Caleigh Stenger of Contra Costa Health estimated that the redesigned program could serve about 6,000 people, and called it “exactly the kind of cushion we need right now,” as well as a “bridge.” Lavonna Martin, a health department official, emphasized that the program is a health access program, not insurance.
The current program is small. Officials clarified that the county’s figure of about 3,100 participants includes people served through community clinics’ CARES program; only about 100 to 120 are enrolled in the traditional Basic Health Care Program.
Dr. Grant Colfax, the county’s health director, told supervisors that coverage losses would lead to “increases in preventable illness and death” and “tremendous county financial exposure.” He added: “What doesn’t change is that the emergency department remains open to everyone as a last resort. And unfortunately, if that’s the last resort for people, people will go to the emergency room when they’re sicker.”
The gap in Contra Costa’s numbers
Andrew Murrell, Contra Costa Health’s chief financial officer, put the program’s cost at about $13.5 million, according to Contra Costa News. Of that, $7.5 million represents services the county health system already provides. The remaining $6 million, including about $2 million for primary care contracts with community clinics, has no identified funding source. Murrell said the program would not require new doctors or clinics, but also cautioned that Contra Costa Health faces a cumulative deficit approaching $800 million over the next five years.
Supervisor John Gioia suggested the board consider emergency funding, pointing to an earlier authorization of about $20 million to cover possible interruptions in federal food aid, of which about $1 million was ultimately spent, according to County Administrator Monica Nino. Gioia floated about $12 million to support the health program for two years. “We felt it was an emergency that people should have food I think it’s an emergency that people should have healthcare,” he said.
Other supervisors asked staff to return first with a fuller financial plan. Supervisor Candace Andersen said she had not been told the program could move forward only by tapping emergency reserves, but added that if a funding crisis came, “we can consider that um as we would with any other emergency.” Supervisor Diane Burgis noted that the program would reach up to 6,000 of the as many as 93,000 people the county expects to lose coverage, because of its eligibility limits. Supervisor Ken Carlson asked for quarterly reports.
The board accepted the report and took no other action, Contra Costa News reported; the item will return. Some early accounts, including KALW’s, described the program as already updated. Health officials proposed phased implementation starting before Jan. 1, with contracts and systems completed through March.
The ratio is the central fact of the Contra Costa plan: a program sized for about one in 15 of the residents the county itself expects could lose coverage by 2031, with about $6 million of its estimated $13.5 million cost not yet funded.
Santa Clara: a broader plan, paid for from within
Santa Clara County is moving further. Its Primary Care Access Program, known as PCAP, offers primary and preventive care to uninsured adults with household incomes up to 650 percent of the poverty level. Membership more than tripled over the past year, to 4,537 by August, according to a report to the board from Paul Lorenz, chief executive of Santa Clara Valley Healthcare, as summarized by SaratogaCA.city. The report tied that growth to H.R. 1, state health care cuts and the expiration of enhanced federal premium tax credits for Covered California at the end of 2025.
Valley Care, which the supervisors approved this week, according to KALW, would take effect Jan. 1, 2027. It would cover primary, specialty, emergency and hospital care plus pharmacy, through the county’s hospitals and clinics, for uninsured residents up to 650 percent of the poverty level who cannot get Medi-Cal, Medicare or other coverage, as well as residents under 400 percent who cannot get subsidized Covered California plans. There would be no monthly premium. Patients would pay set fees based on income, such as $5 for specialty or urgent care, $15 for an emergency visit and $45 for a hospital stay, with the emergency fee waived if the patient is admitted.
The health system’s current budget includes $66.4 million for PCAP and charity care. It said it could absorb up to $25 million in new costs without additional general fund money, enough for about 10,000 more participants this fiscal year by its projections, and would return at midyear with budget transfers from Valley Health Plan, the county’s health plan. Current members are to be notified between mid-November and early December.
“These are challenging times, and we will always serve our patients during challenging times,” Amy Carta, director of government relations and special projects at Santa Clara Valley Health System, told KALW. The Labor Center estimates that 70,000 people in Santa Clara County could lose coverage in 2027, KALW reported.
The report also notes a limitation: Valley Care would not count as qualifying coverage under state and federal insurance mandates, so participants could still face penalties.
San Francisco and Alameda: older programs, new pressure
The two Bay Area counties with the longest-running programs for the uninsured are already absorbing the first wave.
Healthy San Francisco, created in 2007 and paid for mainly from the city’s general fund plus patient fees, enrolled more than 54,000 people at its peak in 2010-11, then fell below 3,000 by the end of 2025 as residents moved into Affordable Care Act coverage, Mission Local reported. Enrollment has grown 39 percent since January 2026, which Tangerine Brigham, chief operating officer of the San Francisco Health Network, attributed at a Sept. 14 City Hall hearing to the state’s freeze on new enrollment for undocumented adults. The city estimates 25,400 to 50,500 residents are at risk of losing Medi-Cal by the end of 2027, and has approved more than $25 million in additional funding for nonprofit clinics that see Healthy San Francisco patients, expecting 5,000 to 7,000 new enrollees by year’s end, according to Mission Local. Like the Contra Costa program, it works only inside city limits.
Alameda County’s program, HealthPAC, enrolled 90,000 people under a federal waiver before 2014, when more than 40,000 of them moved to Medi-Cal, according to a July 24 letter from Alameda County Health to the Board of Supervisors. The letter asked supervisors to approve, at their Aug. 4 meeting, $29.4 million in contracts with nine community clinics to serve HealthPAC patients through June 2027, financed by Measure A, the county’s half-cent health care sales tax, along with county general funds and one-time bridge money. From July 2025 through May 2026, the letter said, HealthPAC covered 10,018 primary care visits.
The state’s side of the ledger
The Legislative Analyst’s Office describes the state’s Medi-Cal changes as “budget solutions,” part of how the Legislature and the governor closed shortfalls, with savings that run into the billions of dollars over several years. The state has also sent money toward counties: the 2026-27 budget includes $197 million from the general fund, or $709 million in total funds, for county workload in carrying out the H.R. 1 eligibility changes, and $250 million in one-time grants to county and University of California hospitals, according to the analyst’s office.
That county administration money pays for processing renewals and eligibility checks. It does not pay for the care counties will provide to people who lose coverage, which is the cost the Contra Costa and Santa Clara plans are trying to estimate.
What happens next
The schedule is fixed. On Jan. 1, work requirements and six-month renewals begin for expansion adults, and Medi-Cal for people with unsatisfactory immigration status moves to fee-for-service. In July 2027, the monthly premium for those adults begins; the administration will propose its amount, between $30 and $50, in next May’s budget revision.
Contra Costa’s staff is expected to return with a funding plan, and the board will decide whether to treat the program as an emergency expense, as Gioia proposed. Santa Clara will return at midyear with budget transfers. Alameda’s HealthPAC clinic contracts run through June 2027.
The county programs share another limit. Each serves only its own residents, and none replaces insurance. Burgis made the point at Tuesday’s meeting: “This is the county making an attempt to adapt to the federal and state actions that are taking away revenues and support for folks that need health care,” she said. “If you have coverage, don’t lose it.”
Desmond Akers covers the cities and counties of the greater Bay Area, from Oakland and San Jose to the Peninsula, the North Bay and the East Bay suburbs, for Around the Region. More from Desmond Akers
