Agricultural workers harvest onions in a California field in this Library of Congress photo. Immigrants in the state face a dual threat from cuts to federal Medicaid and state Medi-Cal health coverage, as well as federal enforcement actions and deportation threats for undocumented immigrants. Photo: Carol M. Highsmith Archive, Library of Congress.

Undocumented, low-income immigrants in California who are covered by Medi-Cal health insurance are likely to face challenges moving forward – a combination of budget cuts coming down from the state and federal levels.

And the ongoing immigration enforcement and mass deportations under the Trump administration also are stoking worries among migrants that are keeping some from accessing health care.

“The fear, especially in our rural locations, it’s really been at an all time high,” said Justin Preas, CEO of Fresno-based United Health Centers of the San Joaquin Valley, referring to patient apprehension over the prospect of immigration raids and federal threats of mass deportations. “I’ve been here 20 years and you see these things kind of happen, and then they kind of calm down, and then they kind of happen. But it’s never been like it is now, ever.”

Shortly after President Trump took office in January, federal Immigration and Customs Enforcement agents turned up at a UHC clinic in Dinuba looking for a specific person, but it turned out they were at the wrong location. And while that spurred a flurry of false rumors on social media about a larger raid, Preas said there have been no repeat visits by ICE to any United Health Centers locations.

Still, he said, the combination of cuts and fear poses a formidable threat to health and wellbeing  of the region’s immigrant communities and California’s critical agriculture workforce.

“It’s really unfortunate that where we’re going, where things are going right now, that we’re disregarding so many people that are just a fabric of our communities,” he said. “If we think that just because we’re going to take away their Medi-Cal cards, (that) they still won’t need health care, then that’s a terrible misconception.”

Medi-Cal is California’s incarnation of the federal Medicaid program for low-income and disabled people. California is one of only seven states in the U.S., plus the District of Columbia, that offers public health coverage to some or all low-income adults regardless of immigration status, and one of 14 states plus D.C. that provide medical coverage for children regardless of their immigration status, according to KFF, an independent health policy and information organization.

CalMatters, a nonprofit, nonpartisan news organization, reports that about 1.6 million undocumented immigrants in California are enrolled in Med-Cal.

That coverage is being targeted, however, as Congress and the Trump administration seek to cut Medicaid spending and curtail or eliminate public benefits to undocumented immigrants. Meanwhile, California looks to ease its own state budget woes.

Those effects are likely to be magnified in the San Joaquin Valley, a region in which poverty, unemployment and reliance on Medicaid/Medi-Cal are far higher than California as a whole. The region is also dominated by agriculture, an industry that includes a workforce that’s largely Hispanic or Latino.

Even before California expanded its offer of Medi-Cal coverage to undocumented adults in 2024, two-thirds of the 1.1 million San Joaquin Valley patients receiving care at clinics under the Federally Qualified Health Center program were Medi-Cal enrollees, according to data from the U.S. Health Resources & Services Administration for 2023, the most recent full calendar year for which information is available. About 31% of the clinics’ patients were either agricultural workers or their family members.

Budget actions will pare services

California expects to spend almost $197 billion on Medi-Cal in 2025-26, according to the state Health and Human Services Agency. Well over half of that will come from the federal Medicaid program.

But in the face of budget woes, California is tightening its purse strings for Medi-Cal, particularly from the general fund portion of the state’s overall budget.

The new state budget adopted by the California Legislature, which took effect July 1, incorporates several significant provisions that will limit or eliminate some health services for residents with “unsatisfactory immigration status” – bureaucratic jargon for undocumented immigrants who are not eligible for federal Medicaid coverage.

Among those actions under the state Health and Human Services Agency’s budget:

 

• Freezing new enrollments for full-scope Medi-Cal coverage for undocumented immigrants ages 19 and older, starting no earlier than January 2026. This measure is projected to create almost $78 million in general fund savings to the state in 2025-26 and up to $3.3 billion by 2028-29.

• Eliminating full-scope dental benefits for undocumented enrollees ages 19 to 54 starting in July 2026. Emergency and restricted-scope dental coverage would still be available to such patients. This change is estimated to save the state’s general fund $308 million in 2026-27 and $336 million annually in following years.

• Eliminating a “prospective payment system” covering care funded only by the state to undocumented immigrants starting in July 2026, instead shifting to a system in which care providers are reimbursed on a fee-for-service basis. The shift is projected to save the state $1 billion in 2026-27 in general fund spending, and $1.1 billion each year in subsequent years.

• Charging a $30-per-month premium for Medi-Cal coverage for undocumented enrollees ages 19 to 54, starting in July 2027. The estimated general fund savings are $695.7 million in 2027-28 and $675 million annually in subsequent years.

• Putting in place a program to seek pharmacy drug rebates for the state for undocumented immigrants, resulting in general fund savings of about $370 million in 2025-26 and $600 million in 2026-27 and beyond. Additional savings from minimum rebates for HIV/AIDS and cancer drugs are estimated at $75 million in 2025-26 and $150 million in following years.

 

Those state Medi-Cal changes are on top of what Preas, the United Health Centers CEO, believes could be additional punitive actions against California by the Trump administration over coverage for undocumented immigrants.

“What is the funding going to be like from the federal government to the state?” Preas said in a recent interview with the Central Valley Journalism Collaborative. “Obviously they (the Trump administration) are trying to push the state to no longer insure undocumented people at all or provide any kind of public benefits to undocumented people.”

“And if California does, they’re going to be penalized by less (federal) funding and matching for the program, even if state dollars are used only for the undocumented, which is the current situation,” he added.

The federal Medicaid program is already in for significant spending cuts under terms of a whopping budget-reconciliation bill, the One Big Beautiful Bill Act, narrowly approved by Congress and signed into law earlier this month by President Donald Trump. That legislation slices more than $1 trillion in spending from Medicaid over the next 10 years.

Current U.S. law already bars undocumented immigrants from eligibility for federally-funded Medicaid coverage in most instances. Among the notable provisions in the new federal law is a restriction on Medicaid eligibility for some lawful immigrants who are eligible under current law. Those who will no longer be eligible include refugees, people who have been granted asylum and abused spouses and children.

KFF Health News reports that the new law also imposes on states, including California, rules for a work or service requirement of at least 80 hours per month for people ages 19 to 64 to be eligible for Medicaid unless they are medically frail or are parents who have children under 13; and to begin charging $35 per service for covered adults for certain services in California and 39 other states where Medicaid coverage was expanded under the Obama-era Affordable Care Act.

Between reductions to Medicaid and the Affordable Care Act, the nonpartisan Congressional Budget Office estimates that about 11 million people nationwide will lose health insurance coverage by 2034.

Immigration enforcement fears abound

The federal Medicaid cuts and the state Medi-Cal changes aren’t the only things confronting undocumented immigrants in the Valley and California. Highly publicized enforcement raids by U.S. Immigration and Customs Enforcement, or ICE, to round up undocumented people have many migrants scared, to the point where they are passing up already scheduled medical appointments at health clinics in the Valley.

At United Health Centers, which operates about three dozen individual clinic sites in Fresno, Kings and Tulare counties, there’s been a 10% to 15% increase in no-shows by patients for their appointments in recent months.

“We hear these things in the news (that) it’s not just undocumented people that are being detained, and it’s people that have authorized work permits, that are actually here legally, that are getting swept up in these things,” Preas said of recent ICE raids.

Earlier this year, after President Trump took office in January, his administration rescinded a policy that largely prevented federal immigration agents from conducting enforcement activities, including arrests or detentions, at healthcare facilities, churches, schools and other “sensitive” locations.

Shortly after the president was sworn in, ICE agents turned up at a UHC clinic in Dinuba looking for a specific person, but it turned out they were at the wrong location. And while that spurred a flurry of false rumors on social media about a larger raid, Preas said there have been no repeat visits by ICE to any United Health Centers locations.

Of five other nonprofit FQHC organizations based in Fresno, Kings, Tulare and Madera counties, four did not respond to queries about whether ICE agents had shown up at any of their clinics or how appointment no-show rates have changed over fear of immigration raids.

Graciela Soto-Perez, CEO of Tulare-based Altura Centers for Health, told CVJC that there had been no ICE raids at any of its seven physical or mobile clinics. Soto acknowledged that no-shows were up this summer, but added that “visits usually drop in the summer, slightly, so I don’t know if it’s due to the surrounding raids.”

Clinics including those operated by United Health Centers, Golden Valley Health Centers headquartered in Merced and Stockton-based Community Medical Centers are working to make sure patients know that they are doing what they can to protect their privacy, including information about immigration status.

“We’re doing everything we can to work with them and reassure our patients that they’re in a safe place and when they come to see us, and that when they come in, their health information is private,” Preas said. “We don’t release their information to anybody. We don’t allow people into non-patient care areas that shouldn’t be there and don’t have a right to be there.”

“And our site management staff is very well trained and versed on how they would handle those things if somebody wants to come in that wants access to certain things,” he added.

The overall situation is one that has Preas worried about the political treatment of Valley’s migrant community, particularly agricultural workers.

“Especially in our rural communities … we have the privilege of taking care of the people that are there, and the work that they do is basically feeding the world,” Preas added. “The least we can do is take care of them and make sure that they are healthy and their families are healthy, because they’re doing work that not everybody would do. … We owe them that gratitude for the work they do every day.”

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Tim Sheehan is the Health Care Reporting Fellow at the nonprofit Central Valley Journalism Collaborative. The fellowship is supported by a grant from the Fresno State Institute for Media and Public Trust. Contact Sheehan at tim@cvlocaljournalism.org.