Mia Angulo, who is pregnant and due in May, is living in a tent with her boyfriend in the predominantly Latino neighborhood of Boyle Heights.
Lingering pain from a car crash two months ago, on top of an already hardscrabble life, has Angulo worried about her pregnancy. So, she was relieved when a mobile street medicine van from St. John's Community Health pulled up near her encampment last month.
"Thank God that we have them," she said.
St. John's, which operates 28 clinics, mostly in L.A. County, is part of the nation's network of nonprofit community clinics that care for the poorest Americans. Around 80% of its 144,000 patients, including Angulo, have Medi-Cal, California's version of the Medicaid program for people with low incomes or disabilities.
But federal cuts to Medicaid spending under the Republican-passed One Big Beautiful Bill Act, compounded by fiscal belt-tightening in Sacramento, could cost St. John's up to one-third of its $240 million annual revenue, requiring cuts to services that might include street medicine, said Jim Mangia, the president and CEO.
Smaller, more cash-strapped clinics in L.A. County could face harsher consequences, including closure, if the lost funding is not replaced.
That's why Mangia, along with a coalition of community clinics, health care workers, and advocates, is pushing for a five-year, half-cent sales tax in the nation's most populous county to help backfill the projected loss of federal and state dollars. St. John's has contributed at least $2 million to the campaign so far.
Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, said there aren't a lot of options to save the health care system from disaster.
"Our backs are up against the wall," she said. "This has the potential to be a game changer. It will be an absolutely significant offset to the losses."
The L.A. County Board of Supervisors approved the proposal last month for inclusion on the June 2 primary ballot, over the objection of some cities within the county. Their leaders argued the tax would put a strain on consumers and business owners. Most of an estimated $1 billion in annual revenue generated would be used to protect safety-net health care at community clinics, hospitals, and schools.
Scrambling to stay afloat
Nationally, the GOP budget law is expected to cut federal Medicaid spending by $911 billion over 10 years, and it could lead to an increase of over 14 million in the number of people left uninsured. The L.A. ballot proposal is among many local and state initiatives nationwide, as clinics, hospitals, health care workers, advocates, and legislators scramble for new money to help offset the spending cuts.
In Michigan, where the federal law is projected to cost the state $32 billion over 10 years, Democratic Gov. Gretchen Whitmer's office has proposed new or increased taxes on tobacco, vape products, online gambling, sports betting, and digital advertising, which it projects would raise hundreds of millions of dollars annually.
In Rhode Island, a group of state legislators hopes to ease some of the pain caused by the federal cuts with a package of bills that includes a tax on digital ads and a 3% surcharge on taxable incomes above roughly $640,000.
"The goal is not to replace the revenue; it's to mitigate the damage," said Democratic state Rep. Brandon Potter, one of the legislators involved.
In Washington, Democratic state Rep. Shaun Scott recently introduced legislation to address the loss of federal dollars with a 5% payroll tax on large companies, applied to employee salaries exceeding $125,000 a year.
In California, the GOP law will slash the federal contribution to Medi-Cal by an estimated $30 billion a year, or 25%. Enrollment in Medi-Cal could drop by 3 million by 2028 as a result of the federal and state spending cuts, according to an analysis by the UCLA Center for Health Policy Research and the University of California-Berkeley Labor Center.
In July, California will slash Medi-Cal payments that community clinics receive for certain services provided to patients with "unsatisfactory" immigration status by about $1 billion a year. Those patients include permanent residents in the country for less than five years, refugees, asylees, and other lawfully present people.
Bracing for a 'new reality'?
Advocates and health care experts say finding new revenue is the only way to avoid a crisis in California's health care system.
"Are we going to let the gaps created by federal policies and state budget cuts leave millions of people uninsured?" said Laurel Lucia, deputy executive director of programs at the UC Berkeley Labor Center. "I think a lot of that question comes down to revenues."
Some medical professionals say that new revenue is needed in the short term but that the country needs to address its notoriously expensive health care system.
"This new reality is that we have to do our work with less money going into the future," said Hector Flores, president-elect of the Los Angeles County Medical Association. "So, this is an opportunity for us to look at how we can do things better."
In the meantime, efforts to raise taxes for health care abound.
Voters in Santa Clara County, home to Silicon Valley, last November approved a five-year 0.625% sales tax increase to offset federal Medicaid cuts. A similar measure will be on the June ballot in Contra Costa County.
The best-known initiative, and a hotly contested one, is a union-sponsored ballot proposal in California for a one-time 5% tax on the state's more than 200 billionaires. Democratic Gov. Gavin Newsom strongly opposes it; Sen. Bernie Sanders (I-Vt.) stumped for it in California recently and has promised to introduce a national version in Congress.
Proponents of the temporary wealth tax say it would raise $100 billion, which would mostly be used to backfill lost federal and state dollars in Medi-Cal and other safety-net programs. Proponents are trying to collect nearly 875,000 signatures needed to get it on the November ballot.
"We are on the precipice of a collapse of our health care system. So the most fortunate among us pay a modest tax that will hold us over and allow us to figure out a long-term solution," said Suzanne Jimenez, chief of staff for Service Employees International Union-United Healthcare Workers West, the measure's chief sponsor. "They would still be incredibly wealthy after that."
Billionaires push back
The plan has stirred considerable controversy, not just in the Golden State but nationwide, and has generated strong resistance from billionaires and others.
Critics argue the measure could prompt billionaires to leave California, putting a damper on innovation, jobs, and tax receipts. And, some warn, the measure could end up in a legal quagmire, as those deemed liable to pony up challenge it on multiple fronts.
"If this passed, you would expect it to be tied up in court for some time," said Jared Walczak, a visiting fellow at the California Tax Foundation. "It is fairly plausible that no revenue could come in for a number of years, if there's ever any revenue at all."
The prospect of such complications has led some health care advocates to focus instead on local initiatives that could start generating revenue more quickly, such as the proposed sales tax in L.A. County.
That one has critics too, including leaders of multiple cities within the county who pleaded with supervisors to reject a proposal they argued would add to the affordability worries of consumers and put a strain on businesses.
Kathryn Barger, a Republican and the only L.A. County supervisor to oppose putting the measure on the June ballot, said in a statement that the proposed tax would make the county "less affordable for families and less appealing for consumers to shop and businesses to operate."
But supporters say safety-net health care is already feeling the impact of diminished funding. Last month, for example, L.A. County's Department of Public Health announced it was closing seven clinics due to $50 million in federal, state, and local funding cuts.
Medi-Cal enrollees are worried, too. "We get a lot of calls from panicked patients afraid they're going to lose their Medi-Cal. Dozens of calls a day, hundreds of calls a week," said St. John's Mangia.
"We tell them that we're working on a solution and hopefully we'll have that solution come June."
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