This article is adapted from an episode of our podcast, “Civic.” Click the audio player below to hear the full story.
On most mornings, 77-year-old retired teacher Carol Crooks begins her day with the help of Florence Owens, her in-home care provider. Owens cooks, assists with showers and takes her to medical appointments.
Crooks, who lives in Section 8 housing in Oakland and survives on just $1,000 a month from Social Security, depends on Medi-Cal, California’s Medicaid program, to fund her in-home care.
“Not everybody has family members that can do it,” Crooks said.
In-home support services enable people with disabilities, chronic illness or age-related conditions to live independently. For Crooks, it has been the difference between a fulfilling life and an intolerable one. She said the prospect of being forced into a nursing home felt unbearable after short stays post-surgery left a lasting impression of long waits for assistance, lost laundry and random roommates.
“It’s got a warehousing aspect to it,” she said. “Just the idea of it makes me ill.”
This episode of “Civic” examines how federal cuts to Medicaid could affect local patients, long-term care workers, and the city’s healthcare safety net — with voices from those fighting to protect services that are essential to survival.
Crooks’ level of fear and uncertainty underscores the stakes for more than 250,000 San Francisco residents who rely on Medi-Cal ever since the Trump administration’s new federal budget called for more than $1 trillion in Medicaid cuts over the next decade. That’s nearly one-third of the city’s population, and it includes 52,000 children and 35,000 seniors and disabled adults.
Unlike Medicare, the federal health insurance program for seniors and some people with disabilities, Medicaid is a state-federal partnership designed to serve low-income residents and those with significant medical needs.
President Trump had repeatedly vowed not to cut Medicaid, citing a sole focus on eliminating “waste, fraud, and abuse.”
“Here’s what I want on Medicaid, we’re not touching anything,” he said in a statement in May.
But congressional budget instructions directed the reductions to help offset the cost of extending the 2017 Tax Cuts and Jobs Act, which the Center on Budget and Policy Priorities has shown chiefly benefits corporations and high-income households.
The cost of care
California receives more than $81 billion annually in Medicaid funding, which covers about two-thirds of the state’s cost of care through Medi-Cal. San Francisco’s share is $2.1 billion, underpinning the city’s safety-net services and public health programs while supporting jobs and fueling a major segment of the local economy.
At a San Francisco Health Commission meeting in June, Tangerine Brigham, chief operating officer of the San Francisco Health Network, said the Medicaid cuts will have a “devastating impact.”
“Critical programs will be underfunded,” Brigham said. “We don’t know which ones at this point.”
Medi-Cal’s role is outsized when it comes to in-home care services, where even small reimbursement reductions can make services unsustainable. San Francisco has about 29,000 in-home care recipients supported by more than 28,000 caregivers. For most of them, Medi-Cal is the only way to afford such services since they are largely not covered by private insurance or Medicare.
When Medicaid is cut, in-home support is often the first service to go, because it’s considered optional. Gov. Gavin Newsom has floated proposals to cap in-home provider hours, cut undocumented adults from the program and reinstate asset tests. Though lawmakers rejected those measures in this year’s budget negotiations, advocates said they could resurface under deeper federal cuts.
Health experts warn that such cuts threaten to worsen the severe shortage of care workers, make jobs less secure and drive meager wages even lower.
“This is a workforce that, for the most part, lives in poverty,” said Arnulfo De La Cruz, president of Service Employees International Union Local 2015, the largest union in California, representing over half a million long-term care workers.
Loss of funding would destabilize and even endanger the lives of San Francisco’s in-home care recipients, De La Cruz said.
“There’re not enough skilled care beds in San Francisco County to be able to house the roughly 29,000 authorized recipients for home care,” he said. “There’s no scenario we imagine that this bill doesn’t have a deadly, deadly impact.”
Boxinett King, a veteran in-home caregiver and SEIU Local 2015, Region 5, leader, said workers feel like their decades of effort are constantly under siege.
“It’s like déjà vu. When the system is working, they come back and they want to tear it up,” he said. “How could they? We’re supposed to be helping one another. They keep tearing it down.”
Healthcare barriers increase costs
Brigham cited three ways to cut a health care program: Restrict eligibility, reduce what’s covered or pay providers less. The federal plan, she said, targets all three, with particular emphasis on narrowing eligibility through work requirements and burdensome paperwork rules.
Beginning in 2027, Medicaid recipients will have to prove eligibility every six months instead of once a year — a change critics call “death by paperwork.” For Crooks, those bureaucratic hurdles loom large.
“As soon as I get paperwork wanting me to update, I’m going to turn it in right away,” Crooks said. “Because they’re going to be swamped, and I don’t want to get disqualified.”
Beginning in 2028, new rules will also impose $35 copays on adults covered under the Affordable Care Act’s Medicaid expansion — those earning just above the poverty line. Children, seniors and people with disabilities are exempt, but experts warn the copays will deter low-income adults from seeking routine care, pushing them toward more expensive emergency visits.
Research backs that up: A Georgetown University study found even modest cost-sharing reduced care among low-income patients, which can result in more serious health conditions and ultimately, higher long-term healthcare costs.
Lawmakers have also proposed work requirements that could strip coverage from millions. Under the measure, adults between ages 19 and 64 would need to prove at least 80 hours of work each month to remain on Medicaid, unless they qualified for an exemption.
House Speaker Mike Johnson (R-La.) told CNN that Medicaid should support “single mothers with two small children” rather than “29-year-old males sitting on their couches playing video games.”
But health experts and local officials say that image doesn’t match reality. Brigham cited research showing that 63% of California’s Medicaid enrollees already work, while others face legitimate obstacles such as school, caregiving or disability. In San Francisco, 87,000 Medi-Cal recipients are working adults.
“So, we’re not talking about a population for which people believe are undeserving or lazy,” Brigham said.
Opponents argue that work requirements create expensive bureaucracy without increasing employment, while studies show that health coverage actually helps people stay employed. In Arkansas, the first state to impose the policy, more than 18,000 people lost coverage, not because they refused to work but because confusing reporting systems caused them to miss deadlines.
Barriers to care also increase public costs in the long run. In San Francisco alone, nearly 7,000 hospitalizations in 2022 could have been avoided with better outpatient treatment which, based on the average hospital stay, cost the system $128 million, according to state data.
The fight ahead
The San Francisco Community Clinic Consortium is mobilizing against the federal plan. The consortium is a partnership of 12 health centers with 29 sites across the city that last year served about 110,000 patients. High-profile leaders, including House Speaker Emerita Nancy Pelosi and state Sen. Scott Wiener, have joined the organization’s local rallies and online awareness campaigns to denounce the cuts.
But the bill’s design complicates resistance. Many provisions are delayed until after the midterms and phased in over a decade, a structure critics say mutes public backlash and gives lawmakers political cover.
Crooks, meanwhile, is doing what she can.
“I’ve been answering a lot of emails where they ask for signatures or letters,” she said. “I’ve talked to people that are open to it. A lot of people just don’t want to think about it, but they’re going to pay for that.”
CORRECTION 9-8-25: Service Employees International Union Local 2015 is the largest union in California, representing over half a million long-term care workers. An earlier version of this story misstated the number of the SEIU branch.