healthcare

For decades, Californians have generally said immigrants, who make up more than a quarter of the state’s population and a third of its labor force, are beneficial to the state and its economy. But budget instability and concerns about rising costs are spilling into a debate over the controversial and expensive policy of allowing low-income immigrants without legal status to receive state-funded health coverage.

Now, Democrat Xavier Becerra and Republican Steve Hilton present a stark choice to voters in the race to be the next governor at a moment when public support for the state’s generous safety net is starting to fray.

Both frame the choice as an economic one.

Becerra, former secretary of Health and Human Services under President Biden, has said it would be “foolish” to exclude the poorest immigrants from routine care and push them into expensive emergency rooms on the taxpayer’s dime. Hilton, a conservative commentator backed by President Trump, has promised to eliminate their coverage and has echoed national Republicans who have skewered California’s expansions to bolster their claims of fraud and abuse in the Medicaid program.

With voters nationwide worried about inflation and the rising cost of living, some Californians might feel less inclined to provide full healthcare coverage to those lacking legal status. What the state does next could have profound implications for its healthcare system and sprawling economy.

Over the past decade, California lawmakers used state dollars to expand Medi-Cal, offering all low-income residents comprehensive coverage regardless of immigration status. But enrollment surpassed initial projections, as did the cost. Medi-Cal coverage of immigrants without legal status costs the state roughly $10 billion a year, according to California’s nonpartisan Legislative Analyst’s Office, more than double the initial estimates.

California lawmakers and Democratic Gov. Gavin Newsom, who championed the program, have approved major rollbacks of benefits for those residents. They said the state can’t afford ballooning healthcare costs amid massive federal cuts from the GOP tax-and-spending law known as the One Big Beautiful Bill Act; the California Health and Human Services Agency projected up to 3.4 million Medi-Cal enrollees could lose coverage and the state could lose more than $30 billion a year in federal funding under the law, causing major disruptions in the safety net health program.Medi-Cal’s budget for fiscal year 2026-27 is $217 billion, and the program serves more than 14 million Californians.

Meanwhile, many legal U.S. residents and citizens have seen their health premium payments skyrocket this year after Congress let enhanced federal Affordable Care Act subsidies expire at the end of December.

As the state grappled with a deficit last year, a majority of likely voters in California said — for the first time in nearly a decade — they opposed providing health insurance to immigrants without legal status, according to a poll by the Public Policy Institute of California.

“The state faces major challenges, and healthcare is one of the major expenditures,” said Mark Baldassare, the institute’s survey director. “People have become more selective about how they want to see those limited healthcare dollars spent.”

Hilton, running on a platform of affordability and lowering taxes, has seized on the sentiment, casting health coverage for immigrants without legal status as deeply unfair and a direct threat to the state’s ability to help citizens.

“Stop taking money from California taxpayers who can barely afford their healthcare to give free healthcare to citizens of other countries who shouldn’t even be here,” Hilton said in a Facebook video the morning of the June 2 primary.

In campaign stump speeches, Hilton promised to use the savings to lower healthcare costs for other Californians without detailing how. Hilton did not respond to requests from KFF Health News for comment.

“Their messaging is very, very simple: It’s an us vs. them,” said Roger Salazar, a Democratic political consultant who represents a coalition of healthcare advocates who argue providing coverage to people who can’t afford it strengthens the workforce and, as a result, the economy. “It’s just a question of convincing the average voter that it’s much better economically.”

A son of immigrants, Becerra for decades pushed to extend safety net benefits in Congress and has made a similar pitch in his campaign for governor. He did not respond to requests for comment.

“Immigrants, whether documented or not, work hard. They pay taxes, and sometimes they get injured on the job or their children get sick,” Becerra said during a debate last month. “It would be foolish to tell a family that they don’t have access to the pediatrician or the family doc.”

Becerra, who could become California’s first elected Latino governor, objected last year when Newsom and legislative leaders decided to freeze Medi-Cal enrollment for adults without legal status, cut benefits, and impose monthly premiums.

“Stop treating coverage as a budget variable that expands in good years and contracts when revenue dips,” Becerra wrote last month in response to an Orange County Register candidate questionnaire. He has vowed to pursue new, steady revenue to fund basic services, such as by upping taxes on corporations and the wealthiest Californians.

In 2023, California was home to about 2.3 million people without legal status, representing roughly 8% of the state’s labor force, according to the Pew Research Center. And 1 in 5 California children live in a family that includes at least one member without legal status, according to the California Department of Education. Healthcare economists say giving people access to preventive healthcare saves taxpayers money in the long run by keeping the workforce healthy and relieving pressure on an overburdened system.

That, Baldassare said, wasn’t a hard argument to make during the COVID-19 pandemic, when immigrants were celebrated as essential workers and the link between individual well-being and public health was more obvious.

But Medi-Cal costs to cover roughly 1.4 million immigrants have ballooned, according to the latest estimates from the Department of Health Care Services. Because only some lawfully present immigrants are eligible for federal Medicaid benefits, states like California that cover other populations must do so exclusively with state funding.

California’s budget experts have warned that maintaining full Medi-Cal coverage for immigrants without seeking additional revenue would destabilize the state’s long-term fiscal outlook.

In a legislative hearing last year, Republican Assemblymember Carl DeMaio questioned whether California taxpayers would prioritize the expansions, saying he doubted “illegal immigrant healthcare in the general fund would be at the top of their list.”

After lawmakers approved the spending reductions, support for immigrant health coverage dropped, Baldassare said. Now lawmakers and Newsom are negotiating further cuts.

David Hayes-Bautista, who has spent his career studying the economic contributions of Latinos and immigrants, said Californians without legal status have higher labor force participation and tend to work in industries and occupations that don’t offer employer-based health insurance. As a result, many resort to Medi-Cal, saddling the state with the healthcare costs instead of employers.

“California, as a state, has the world’s fourth-largest GDP, which is true thanks to Latinos,” Hayes-Bautista, director of the Center for the Study of Latino Health and Culture at UCLA, said. Without contributions from Latinos, many without legal status, it drops to eighth place, about the size of Italy’s economy, he added.

Immigrant advocates hope to have a more vocal champion in Becerra, the favorite to become governor in a state where Democrats outnumber Republicans nearly 2 to 1.

“He will fight, he will push back, he will do all that he can,” said state Sen. María Elena Durazo, a former labor leader who has championed the immigrant healthcare expansions. “That’s the most we could expect.”

Mai-Duc writes for KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling, and journalism.

Proponents of a tax on California billionaires vowed on Thursday to move forward with their November ballot measure despite mounting opposition from many of the state’s most powerful political forces.

A labor union spent $31 million gathering signatures to qualify the measure for the ballot in an effort to offset federal healthcare funding cuts that will affect millions of California’s most vulnerable residents. A representative for the campaign supporting the ballot measure pushed back at opposition to the effort as self-entitled wealthy Californians and entrenched Sacramento interests.

“While a few morally bankrupt billionaires and their buddies in Sacramento want to see California’s hospitals close, and tax breaks for billionaires protected — I assure you, the vast majority of voters do not,” said Debru Carthan, a spokesperson for the Billionaire Tax Now Coalition, which is funded by the Service Employees International Union-United Healthcare Workers West, the sponsor of the proposal.

The California secretary of state is expected to officially certify the measure for the Nov. 3 ballot on Thursday evening.

Carthan said their effort has support in public opinion polls, and from lawmakers, unions, community organizations and volunteers across the state, “something the billionaires and their buddies will never have.”

However, a coalition of healthcare, education, public safety, housing, business and labor leaders opposed to the proposal warned that it would make the state’s notoriously unstable budget even more unpredictable.

“The dangerous wealth tax directly threatens vital funding for education and schools, healthcare and clinics, public safety, and infrastructure projects by making California’s revenue even more volatile,” the leaders of the California Medical Assn., the California Primary Care Assn. and the California School Boards Assn. said in a statement. “That’s why so many leaders – both Democrats and Republicans – are joining us and saying NO. We look forward to ensuring voters have the facts, know the stakes, and resoundingly reject this reckless experiment in November.”

Supporters of the one-time proposed 5% tax on the assets of the state’s wealthiest residents pitched the effort as a stop-gap measure to offset devastating federal healthcare funding cuts passed by the GOP-led Congress and signed by President Trump nearly one year ago. The federal legislation is expected to result in $100 billion in cuts that would affect California’s most vulnerable residents.

The proposed tax, which would be retroactive to billionaires who lived in the state as of Jan. 1, drew predictable opposition from the wealthy, notably Silicon Valley tech leaders.

But it notably divided liberals. While Sen. Bernie Sanders (I-Vt.) and Rep. Ro Khanna (D-Fremont) supported the proposal, Gov. Gavin Newsom was among the Democrats who opposed it because of fears about the potential impact on the state’s volatile budget.

Despite being the fourth largest economy in the world — the home of Hollywood and Silicon Valley — California’s budget is extremely dependent on the state’s most prosperous residents.

Newsom and others who generally support increasing taxes on the wealthiest Americans also argued that the proposed billionaire tax in California was poorly crafted and that any such levies ought to be enacted nationally, because varying state policies would be ineffective.

Opponents also argued that the political priority in the 2026 midterm election should be squarely focused on efforts to make sure Democrats regain control of Congress to serve as a counter balance during the final two years of Trump’s presidency.

“It’s disappointing. This is a critical election where we need to concentrate on flipping the house and undoing the damage that was done” by Trump’s legislation that led to the healthcare funding cuts, said Jodi Hicks, chief executive and president of Planned Parenthood Affiliates of California. The wealth tax “is short term and doesn’t address what is the long-term problem. And I’m not even sure the policy is a viable solution. It’s so critical to be sending the right message — holding Congress accountable and how we need to find long-term solutions to make sure Californians have access to healthcare.”

Rob Lapsley, co-chair of Californians Against Tax Increases and president of the California Business Roundtable, argued that the proposed wealth tax would ultimately affect every Californian.

“Strip away the spin, and this measure forces every California taxpayer, not just billionaires, to file a sworn declaration of their net worth with the Franchise Tax Board under penalty of perjury,” Lapsley said in a statement. “And it hands the Legislature the power to extend the wealth tax to all Californians and every kind of property, including home equity, retirement savings without ever returning to the voters – effectively gutting” voter-approved caps on property tax increases.

Supporters of the tax submitted nearly 1.6 million signatures in April to qualify the proposal for the ballot, roughly double the number required. However, support for the effort has grown increasingly shaky. Newsom’s team created a broad coalition of opponents, including healthcare and education activists, that undercut the foundational argument for the tax.

The union that crafted the proposal responded last week by proposing a legislative alternative that would create a 2% tax on billionaire’s assets. It was flatly refused by the Newsom administration. No deal was reached by the Thursday evening deadline for the union to withdraw the proposal from the November ballot.

Two efforts that were crafted to sink the proposed billionaire tax — dubbed as poison pills — also qualified for the Nov. 3 ballot, according to the California Secretary of State’s office. One would bar new state taxes on personal property, while the other prohibits any new taxes being exempted from existing state spending rules and to be regularly audited. If the billionaire tax proposal is approved by voters but either of the other proposals receives more votes, the tax measure would be voided.

The proposed billionaire tax would apply to more than 200 Californians, some of whom proactively left the state or moved their companies out of California because of the proposal.

The prospect of the wealthy fleeing the state is among the reasons that prominent Democrats such as Newsom opposed it, given California’s budget being so reliant on the state’s most prosperous residents.

Sergey Brin, a co-founder of Google, is among the billionaires who have reportedly moved out of California because of the tax proposal. He donated at least $82 million to an organization that is funding efforts to invalidate the proposed billionaire tax.

Ballot measure proponents had a Thursday evening deadline to withdraw their proposals.

Other policy proposals that will appear on the Nov. 3 ballot include:

• Requiring government-issued voter identification to cast ballots in elections.
• Reforming the California Environmental Quality Act, once a third-rail in Democratic politics that has become increasingly scrutinized in the rebuilding in the aftermath of the Palisades and Eaton wildfire.
• Creating a $11.3-billion affordable housing bond.

Two notable proposals were pulled off the ballot after negotiations between the California Hospital Assn. and labor unions:

• An effort to limit healthcare executives’ compensation.
• A union proposal by the same union backing the billionaire tax that would have required many healthcare clinics to spend 90% of their revenue to serve low-income and underserved residents.

June 23 (UPI) — Acting Attorney General Todd Blanche announced Tuesday that 455 people have been charged in a variety of healthcare fraud schemes totaling $6.5 billion.

Blanche held a press conference to discuss what he called the “2026 national healthcare fraud takedown.” He said 455 people have been charged since June 8 across 56 U.S. attorney’s offices and 45 states and territories.

“These individuals participated in healthcare fraud schemes involving more than $6.5 billion in false claims submitted to Medicare, Medicaid and other healthcare programs,” Blanche said.

Blanche highlighted some of the indictments, including one of a corporate executive in Arizona who was charged for being involved in a $1 billion fraud scheme involving wound grafts.

“This alleged scheme cost Medicare over $1 million per patient,” Blanche said. “In total, our indictment charges 11 defendants for over $2 billion in fraudulent claims in connection to alleged wound care schemes.”

Blanche adds that the money fraudulently claimed in these schemes was used to purchase “multi-million-dollar homes,” cars, jewelry and the construction of a $4.6 million seaside hotel on in the Philippines.

“We’re taking back the money, the luxury cars, the jewelry, and these alleged fraudsters will face justice,” Blanche continued.

Blanche said nine task forces, 57 U.S. attorney’s offices and 41 state attorney general’s offices partnered to investigate healthcare fraud schemes.

Blanche also announced the creation of the West Coast Strike Force and the deployment of more federal prosecutors to bring charges against 295 defendants in Medicaid fraud cases.

A controversial proposal to tax California billionaires to fund healthcare has tenatively qualified for the November ballot, setting the stage for a more intense and expensive battle over whether the state should squeeze the ultra-rich.

Supporters say the proposed tax is crucial to compensate for federal healthcare funding cuts, approved by President Trump and the Republican-controlled Congress, that will harm millions of the state’s most vulnerable residents.

In April, supporters of the billionaire tax submitted nearly 1.6 million signatures, roughly double the number needed to qualify. The California secretary of state’s office on Wednesday declared that enough valid signatures were submitted. The initiative will officially qualify for the Nov. 3 ballot on June 25 unless the proponents withdraw it beforehand.

The initiative would impose a one-time tax of up to 5% on taxpayers and trusts with assets valued at more than $1 billion, with some exceptions, such as property. The levy could be paid over five years. Ninety percent of the revenue would fund healthcare programs, and the remaining funds would be spent on food assistance and education programs. The proposal would cost the state’s richest residents about $100 billion if a majority of voters support it.

Opponents of the measure say the proposal is an ineffective attempt to address the long-term effects of the healthcare cuts and would destroy California’s economy and budget.

The state budget in California is already largely dependent on income taxes paid by its highest earners. Because of that, revenues are prone to volatility, hinging on capital gains from investments, bonuses to executives and windfalls from new stock offerings, and are notoriously difficult for the state to predict.

The proposal already triggered a fierce debate, accentuating the divide between the rich and poor in a state that’s expensive to live in.

The Service Employees International Union-United Healthcare Workers West and other supporters of the billionaire tax say that it would raise $100 billion, offsetting federal funding cuts to healthcare as well as funding education and state food assistance.

But supporters face strong opposition from billionaires with deep pockets. Tech executives and other business leaders oppose the idea and have threatened to move to other states. Opponents say taxing billionaires would harm California’s economy while not addressing underlying financial issues.

The proposal also has divided politicians within the Democratic Party. California Gov. Gavin Newsom spoke out against the billionaire tax, expressing fears that billionaires would move out of the state. But U.S. lawmakers such as California Rep. Ro Khanna and Vermont Sen. Bernie Sanders have backed a billionaire tax, saying the rich should pay their fair share to fund essential services.

Business executives have already poured millions of dollars into groups that oppose the billionaire tax or are promoting alternative solutions to wealth inequality.

Tech executives, venture capitalists and business leaders have donated roughly $118 million to a nonprofit called Building a Better California, according to data on the secretary of state’s website. Most of the funding comes from Google co-founder Sergey Brin, who has given more than $82 million to the group. Executives from DoorDash, Ripple, Stripe and other companies also have contributed.

The group says it supports policies such as expanding access to affordable housing, protecting innovation, requiring government transparency and securing more stable education funding.

PayPal and Palantir co-founder Peter Thiel has contributed $3 million to the California Business Roundtable, which opposes the tax. Former Google Chief Executive Eric Schmidt donated $1 million to that group as well.

California would probably collect tens of billions of dollars from the wealth tax if it passed, but it could also lose other tax revenue, a December letter from the state legislative analyst’s office said. The office also mentioned that it’s tough to predict the exact amount the state would collect because of factors that can affect a billionaire’s wealth such as fluctuating stock prices.

California billionaires who were residents of the state as of Jan. 1 would be affected by the ballot measure if it passes. Some wealthy residents announced plans to moves out of state. On Dec. 31, venture capitalist David Sacks announced that he was opening an office in Austin, Texas, the same day Thiel publicized his firm had opened a new office in Miami.

Mangione would face lighter sentencing if jury accepts he was in a state of ‘extreme emotional disturbance’ during act.

Luigi Mangione, the man suspected of fatally shooting United Healthcare CEO Brian Thompson in New York City, will argue a psychiatric defence during his trial.

Judge Gregory Carro said on Wednesday that Mangione’s lawyers informed him that they will assert that their client was in a state of “extreme emotional disturbance” when he allegedly carried out the shooting in December 2024.

New York state allows murder defendants to make the case that they cannot be held fully responsible for their actions because they were in a state of extreme emotional disturbance at the time of the killing.

Thompson’s slaying, which took place outside a hotel in midtown Manhattan, shocked the United States public. Grainy footage of the act quickly spread across social media.

It also drew attention to the widespread anger over sky-high healthcare prices. Police have said that the terms “delay”, “deny”, and “depose” were written on the suspect’s ammunition, a reference to how health insurance companies avoid paying claims.

If the jury concludes that Mangione was emotionally disturbed at the time of the alleged act, it could move to convict him of manslaughter rather than murder. Such a conviction generally results in a lighter sentence.

Relying on a claim of emotional disturbance means that Mangione would effectively admit that he carried out the act, but that he did so under circumstances of impaired judgement. It differs from an insanity plea, which would allow Mangione to serve his sentence in a psychiatric facility rather than a prison.

Mangione, who sat between two of his lawyers dressed in a blue suit, is set to go to state trial on September 8. The 28-year-old has previously pleaded not guilty to state and federal charges in connection to the killing.

His federal trial, which includes stalking charges, is set to begin on October 13. He faces a potential life in prison if convicted in either case.

US District Judge Margaret Garnett, who is overseeing the federal case, threw out murder and weapons charges against Mangione on technical grounds in January. That ruling eliminated the possibility of Mangione facing the death penalty.

The looming impact of federal Medicaid cuts has reignited a long-simmering, costly battle between California’s medical industry and one of its largest health worker unions.

SEIU-United Healthcare Workers West, with about 120,000 members, has put forward two ballot initiatives to cap the pay of medical executives and require community clinics to spend the bulk of their revenues on patient care.

The California Hospital Assn. has responded with its own ballot proposal that would make it tougher for unions to spend money on political initiatives in the future. It would require approval by a union’s rank-and-file membership for any spending of $1 million or more on statewide measures, or $100,000 or more on local ones.

The competing measures, which have drawn enough verified signatures to qualify for the November ballot, come at a time when the rising cost of healthcare is emerging as a top voter concern.

The Service Employees International Union affiliate has seized upon affordability angst to resurrect a proposal for a cap on healthcare executive compensation, which it has failed to achieve multiple times before. The proposed measure garnered more than 1 million petition signatures.

“This initiative reflects the serious crisis we face and that affordability is a real thing,” said Vikas Saini, president of the Lown Institute, a Massachusetts-based healthcare think tank. “I think it also reflects grassroots anger and a desire to do something.”

Mikey Vaughn, a certified nursing assistant at Cedars-Sinai Medical Center, said the hospital often lacks supplies and staffing levels that he and his colleagues need in order to do their jobs effectively and without undue stress, despite its reputation as the go-to place for the rich and famous.

“The executive pay initiative would, I hope, be used to hire staff and to actually provide better resources for our patients,” he said. Vaughn is also a member of SEIU-UHW’s executive board and political committee.

Thomas Priselac, then-president and CEO of Cedars-Sinai Medical Center, made $8.8 million in fiscal year 2024, according to the organization’s most recent available federal tax filing. Kaiser Permanente’s CEO, Gregory Adams, made nearly $13 million in 2024. Warner Thomas, head of Sutter Health, made just under $12 million.

Cedars-Sinai spokesperson Duke Helfand said the hospital would be unable to recruit and retain physicians, nurses, and specialists if the measure passed, dramatically impairing its ability to provide healthcare.

“Such a scenario would be disastrous not only for Cedars-Sinai but for hospitals across Los Angeles and California,” Helfand said.

The union wants to cap compensation at $450,000 a year for senior hospital and medical group executives, as well as other administrative and managerial staff. However, the initiative does not stipulate how dollars diverted from payroll must be spent.

The union has dubbed the latest proposal the Health Care Executive Compensation Act of 2026. A coalition of medical industry heavyweights opposing it — hospitals, physicians, and clinics, among others — has rebranded it the Health Care Endangerment Act.

Carmela Coyle, CEO of the hospital association, called the measure a cynical political ploy.

“It’s bad policy and it’s going to have bad consequences across California,” she said.

Glenn Melnick, a healthcare economist at the University of Southern California, said even if the initiative were fully implemented and pay cuts enacted, he doubts it would reduce the cost of healthcare for patients.

SEIU-UHW does not have an estimated total amount the initiative would claw back from pay packages that exceed the limit.

Opponents of the initiative note that it doesn’t just target executive pay; it would affect medical practitioners who are also managers. That could include chief medical officers and chief nursing officers, as well as heads of surgery, emergency rooms, oncology, obstetrics, cardiology and other specialties, they say.

It would be up to each hospital, health system and physician group to report which staff members exceed the cap and by how much.

Ultimately, who is subject to the pay cap “probably will have to be battled out in court,” Coyle said . “That’s why we are throwing everything we can at it.”

The second SEIU-UHW ballot initiative, on community clinics, is already in court. The California Primary Care Assn., which represents clinics, filed a federal lawsuit in April seeking to invalidate it before it reaches the November ballot.

The proposed measure would require federally designated community clinics to spend at least 90% of their revenues on activities directly related to their mission of providing care for low-income populations. If it were to pass, more than 90% of those clinic organizations would be on the hook for penalties totaling $1.7 billion in the first year alone and “would face similarly crippling penalties every year,” according to a report commissioned by the primary care association and conducted by the Berkeley Research Group, an international consulting company.

Louise McCarthy, president and CEO of the Community Clinic Assn. of Los Angeles County, said many pivotal services the clinics provide — such as translation and transportation — would likely not be counted toward the spending requirement.

“They are targeting a group of what they see as employers and we see as the safety net,” she said.

The lawsuit cites the harm to clinics and claims the proposed spending requirement would interfere with federal authority.

Renée Saldaña, a spokesperson for SEIU-UHW, characterized the lawsuit against the initiative as “a really desperate attempt by the clinic industry to try and avoid accountability.”

SEIU-UHW, proud of its political activism, is also behind a controversial billionaire tax proposal that would impose a one-time 5% levy on California residents with fortunes over $1 billion to backfill the funding gap created by federal cuts coming down the pike under Republicans’ One Big Beautiful Bill Act. The law, passed last July and signed by President Trump, is projected to squeeze nearly $1 trillion from the Medicaid health coverage program for low-income people by 2034, including as much as $30 billion annually in California.

The hospital association, the community clinic group and the California Medical Assn., which represents physicians, are neutral on the wealth tax proposal thus far. But Saldaña said all three of the union’s ballot proposals tie into an overarching strategy to counter the widening healthcare disparities caused by the federal law.

“We believe the primary concern of healthcare providers, including executives, should be to serve the community, heal patients, and not be in healthcare just to enrich themselves,” she said on the proposed pay cap.

Over the years, the union has submitted dozens of local and statewide ballot initiatives, including ones to cap the pay of hospital executives, regulate dialysis clinics, and raise the minimum wage of healthcare workers.

The hospital association calculates that SEIU-UHW has spent nearly $125 million on local and statewide initiatives since 2012. But healthcare industry groups have spent far more opposing them. The hospital association data shows that the union spent nearly $36 million on three ballot proposals to regulate the dialysis industry, but dialysis companies poured in $302 million to defeat them, according to state campaign finance records.

The union’s ongoing political efforts “threaten patient access to quality health care,” according to the hospital association’s ballot initiative, which could limit how much unions spend on future ballot measures.

Saldaña hinted at a possible lawsuit should that measure pass, saying “we don’t see the legal viability” of it. The proposal, she said, is an attempt “to silence the front-line healthcare workers.”

Ultimately, a ballot initiative won’t cure the ills that plague healthcare in the United States, said the Lown Institute’s Saini. What’s needed, he said, is “an evaluation and reimagination of healthcare.”

Wolfson writes for KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling, and journalism.

Supporters of a half-cent sales tax proposed to help fund health services in Los Angeles County declared victory Tuesday after days of steadily gaining ground as more ballots were counted.

The latest results show the “yes” camp ahead by a slim margin, with just more than 50% of the vote. The measure needs a simple majority to win.

“Today, Angelenos sent a clear message: we take care of each other,” said Jim Mangia, chief executive of St. John’s Community Health and a spokesperson for the campaign, in a statement. “For months, we watched Washington make decisions that stripped healthcare away from hundreds of thousands of our neighbors — and today, Los Angeles County answered.”

The campaign said it would be organizing a news conference Wednesday to celebrate the “historic win.”

The proposal, on the ballot as Measure ER, had gained traction since election night, when results showed the tax had failed to gain a majority of support among early voters. Voters have not rejected a sales tax hike in L.A. County since 2012, when a transportation measure fell just short of a needed two-thirds majority with 66.1% support.

Approval of Measure ER would impose a new sales tax of half a penny of every dollar spent in the county, with the proceeds going to local hospitals and clinics that say they’re bleeding funding after federal cuts. Officials anticipate it will bring in $1 billion annually to patch the holes in the health services network.

The tax, which was championed by a coalition of healthcare advocates, takes effect Oct. 1 and will last for five years.

Los Angeles County’s half-cent sales tax to fund healthcare services was trailing Tuesday, with early returns showing a majority of voters rejecting the measure.

The tax — a half-penny of every dollar spent in the county — is meant to prop up local hospitals and clinics that are hemorrhaging funding after recent federal cuts.

The sales tax, which needs a simple majority to pass, would take effect Oct. 1 and last five years. Officials say it would pull in $1 billion annually to help plug the budget holes hitting local hospitals and clinics.

L.A. County health officials anticipate the One Big Beautiful Bill Act, signed into law by President Trump last summer, will slash more than $2 billion from the county’s health services budget within the next three years. Due to eligibility changes, the county will no longer be able to get reimbursements for many Californians who have lost Medi-Cal.

The measure was championed by a coalition of healthcare advocates called Restore Healthcare for Angelenos who warned that mass layoffs and emergency room closures could be imminent if new funding didn’t come fast. The Department of Public Health recently closed seven clinics — a grim sign, supporters said, of service cuts to come.

Voters haven’t rejected a sales tax hike since 2012, when a transportation measure fell just short with 66.1% support. It needed 66.7% to pass.

A majority of county supervisors had supported the new tax proposal, voting 4 to 1 this February to put it on the ballot. But the measure faced significant opposition from local cities, with opponents arguing the sales tax hike would unfairly burden the poorest county residents and encourage people to spend their dollars across the county line.

Supervisor Kathryn Barger, the board’s lone opponent of the tax, said she was concerned it was a “general” tax, meaning the money wouldn’t be earmarked for healthcare costs. Instead, she argued, politicians would have final say over how the money gets spent.

The supervisors have created a plan for spending the tax money, with the largest chunk of the money meant to cover the costs for patients without insurance. The measure also asked voters to sign off on a nine-member oversight committee.

The county currently has a base sales tax rate of 9.75%, and cities impose local taxes on top of that.

BAKERSFIELD — The southern Central Valley is home to one of California’s few remaining congressional battlegrounds, where Democrats are itching to oust longtime Republican incumbent Rep. David Valadao.

Last year’s voter-approved Proposition 50 redrew the lines of this Latino-majority district slightly in Democrats’ favor. Two top Democratic candidates are battling over who is the best choice to face Valadao (R-Hanford) in November.

Valadao is particularly vulnerable after he voted last year to cut Medicaid spending, a critical resource for many in this poor, rural area. Two-thirds of residents in the district are enrolled in the federally funded low-income health insurance program, and more than 60,000 are expected to lose coverage when work requirements and other federal rules take effect next year.

Rep. David Valadao (R-Hanford) leaves a meeting of the House Republican Conference at the Capitol Hill Club on March 17.

(Tom Williams/Getty Images)

National Democratic infighting has overshadowed a classic moderate vs. progressive primary race since House Democrats’ campaign arm threw its support behind one candidate, Assemblymember Jasmeet Bains (D-Delano), over Randy Villegas, a school board trustee backed by progressives including Sen. Bernie Sanders (I-Vt.).

The race was already tense when the Democratic Congressional Campaign Committee added Bains, a family doctor and two-term assemblywoman, to its “Red to Blue” program, which provides staff and fundraising support to Democrats running against vulnerable Republican incumbents. Local party leaders said they had received assurances from national Democrats that they would stay out of the race, which further angered Villegas and his supporters.

“This is another example as to why people’s faith in the Democratic Party and party leadership is at an all-time low,” Villegas said in an interview with The Times. “In many ways, it’s a badge of honor to not be the insider candidate and to say that I’m actually going to fight for community members here and not D.C. elites.”

DCCC chair, Rep. Suzan DelBene of Washington, cited Bains’ background as a family doctor and her track record in the Legislature fighting to expand access to healthcare.

Randy Villegas, running for California’s 22nd Congressional District, said his campaign manager wants him to take frequent selfies for their social media while walking neighborhoods in Bakersfield.

(Myung J. Chun/Los Angeles Times)

“We only weigh in on primaries when we feel that one candidate stands out as the strongest possible nominee to ensure that we win in the general election,” DelBene said in a recent interview on CBS’ “Face the Nation.” “This is a district that has been devastated by cuts to healthcare, a large Medicaid population, so she’s an incredible candidate and definitely can speak to the issues needed on health care.”

For Democrats, the outcome of the primary could have national significance. With President Trump’s popularity at a low point nationwide — and especially in California — the party hopes to win enough seats in the 2026 election to oust the Republicans from power in the U.S. House of Representatives.

Valadao, who was first elected to Congress in 2012, has been a perpetual target for Democrats, who have held a sizable registration advantage in his district. A moderate Republican, Valadao had emphasized his support for immigration reform, a departure from his party. Still, Democrats ousted Valadao in the blue wave of 2018, only for him to win back the seat in 2020 and remain in office ever since.

Both Villegas and Bains promote themselves as the Democrats’ best option to topple Valadao once again.

Villegas, the son of Mexican immigrants, is endorsed by the House Hispanic and progressive caucuses and has painted Bains as a corporate-backed candidate who would bend to special interests.

Jasmeet Bains, running for California’s 22nd Congressional District, speaks with Mary Jimenez during a campaign canvassing walk in Bakersfield.

(Myung J. Chun/Los Angeles Times)

“We can’t just offer that we’re not Trump. The Democratic Party actually needs to stand for something,” he said. “To me that means fighting for universal healthcare, universal childhood education, banning members of Congress from trading stocks, getting rid of corporate PAC money. Those things may make Democratic leadership uncomfortable, and I’m OK with that.”

Bains is campaigning on her experience as a physician in a region known for its poor environmental and health outcomes. After medical school, she returned to Kern County, where she completed her residency and continued working at clinics that primarily serve low-income patients in the region.

She decided to run for the seat after Valadao voted in favor of H.R. 1, the Republican spending bill Trump signed into law last year that cut nearly $1 trillion in Medicaid funding to pay for tax cuts, which Bains described as a “betrayal.”

“In the Valley, your word is your bond,” she said in a phone interview as she drove the 250-mile journey from her district to the state Capitol in Sacramento. “In the beginning he kept telling everyone that he wasn’t going to vote for it, and I took him for his word.”

Jasmeet Bains brings 8-month-old, Chiquita, as she campaign walks a neighborhood in Bakersfield.

(Myung J. Chun/Los Angeles Times)

Bains is the daughter of Indian immigrants and was the first South Asian woman elected to the California Legislature. She continues to work weekend shifts at a clinic in Delano.

“I thought the healthcare disparities of people losing their private insurance and having to transfer to Medicaid” was bad, Bains said. “With the trillion dollars cut from Medicaid federally, I’m now in a position where I’m transferring my patients from Medicaid to nothing. The problem in the Valley for healthcare has gotten worse and worse and worse.”

It’s the reason labor unions including SEIU Local 521, which represents workers in public, nonprofit and healthcare sectors in Kern and other counties around the state, are backing Bains.

“Within my own union, the members that I represent in Kern County, in certain ZIP Codes they have a 15-year less life expectancy than my union members living in Monterey County, which is a very similar community” with rural agricultural interests, said Riko Mendez, the union’s chief elected officer.

He said Bains understands the region’s unique health challenges and has used her perch in the Legislature to address them, including pushing for funding to research and treat valley fever, an infection caused by fungal spores in the region’s soils.

“We think her experience, her profile, her message is one that we agree with, and that has the best chance of winning in the runoff against Valadao,” he said.

Bains’ time commitments in Sacramento and working at the clinic leave her little time for a traditional campaign knocking doors and showing up to community events. Some voters backing Villegas have noticed.

Randy Villegas takes a phone call in the shade while walking neighborhoods in Bakersfield.

(Myung J. Chun/Los Angeles Times)

“For us, showing up is one of the most important things, and he’s the only candidate who has been doing that consistently,” 18-year-old Vanessa Orozco Romero said after a recent candidate forum in Bakersfield. Though nearly a dozen candidates for various offices were invited, Villegas and two other Democrats running for legislative seats were the only ones to attend.

Orozco Romero called the DCCC’s decision to back Bains “stupid and morally not OK,” especially since neither of the candidates earned enough delegate support to win the state party endorsement earlier this year.

Bains and Villegas have similar backgrounds as children of immigrants who grew up in the southern Central Valley. Though they both went on to earn high-level degrees, each is adamant about staying in Kern County to improve life for its residents.

The district is anchored in the eastern side of Bakersfield, home to California’s once-thriving oil fields, and stretches northward toward Fresno to include swaths of agricultural lands and small farming towns.

While there are more than twice as many registered Democrats in the district as Republicans, Democratic candidates often underperform in the Central Valley and independent voters play a crucial role picking winning candidates. Even under the new Proposition 50 lines that favor Democrats, President Trump would have beat former Vice President Kamala Harris by nearly 2 points.

Though nearly two-thirds of voters in the district are Latino, turnout is usually low among Spanish-speaking voters who are often discouraged by negative attack ads, Democratic activists said.

Save for the 2018 midterms during Trump’s first term, Valadao, a dairy farmer, has frustrated Democrats by continually winning over enough independents to hold onto the seat. Though the three candidates are competing in an open primary, Valadao is expected to advance to the general election as a longtime incumbent and the only Republican on the ballot.

“As he does in every primary election, Congressman Valadao is working hard to earn the vote of all Democrats, Independents, and Republicans,” Robert Jones, a consultant for Valadao’s campaign, wrote in an email. “We trust that the voters of the Central Valley will send the two best candidates to the general election in November.”

When Congress passed the big, ugly bill known as HR 1 last year, most Americans understood it meant cuts to Medicaid, the safety net program millions rely on for medical insurance.

But few Californians realized just how much it will affect the Golden State when its provisions really kick in, starting after the midterms (the Republicans aren’t that dumb) and continuing on in cascading cuts for the next few years.

Millions of Californians — not just low-income folks — are going to feel the effects, whether through a loss of insurance, fewer providers able to keep their doors open, or rising premiums and costs.

“This problem trickles up,” state Senate leader Monique Limón (D-Goleta) told me. “This is not just going to impact the people that have a public healthcare plan. When you see a hospital close, when you see medical providers no longer being able to practice, it is absolutely going to impact everybody, the middle class included.”

Added to the loss of federal funds, Gov. Gavin Newsom’s most recent budget plan (which the Legislature has to debate in coming weeks) includes cuts at the state level. This is in part to contend with the loss of federal money, but also because healthcare costs keep rising and even in this wealthy state, we can’t afford the bills — at least not without some changes.

What those changes are — and who should bear the brunt of them — is a complicated and largely ignored debate happening right now. While our candidates for governor have been grilled on whether they support single-payer healthcare or not, (Becerra is a sort-of, Steyer is a yes) the real question isn’t how is the next governor going to expand access to care — but how are we going to keep the whole system from collapsing right now.

“This is not hypothetical, this is what’s coming down the line,” Limón said.

The problem

About 15 million adults and children, or about 1 in 3 of our state’s residents, rely on Medi-Cal, which is what California calls its Medicaid program.

Through a creative bit of state financing called the Managed Care Organization, or MCO, tax, the federal government has been paying for a big chunk of the costs of that insurance, about $7 billion a year. President Trump’s HR 1 makes that money go bye-bye by greatly reducing the MCO, leaving the state to figure out how to backfill that cash. And that’s just one of the ways the big, ugly bill hurts California. Yes, it’s complicated.

The number of Californians losing health insurance coverage could roughly double in the next four years. Above, a patient undergoes treatment for tongue cancer at Ronald Reagan UCLA Medical Center on March 6, 2026.

(David McNew / Getty Images)

Newsom’s budget plan relies in a not-small way on restructuring the MCO tax to fit HR 1’s new rules. But here’s the problem with that — any fix will require approval from the Trump administration, which has repeatedly shown the welfare of Californians is not a high priority. In fact, the Trump administration in March rejected California’s request to update another fee related to hospitals that also generates billions for Medi-Cal.

So maybe Newsom will be able to negotiate a plan that saves the MCO and California healthcare. But wouldn’t it be much better for the GOP, with a presidential election looming, to watch California (and her presidential-contender governor) tumble off a healthcare cliff? Few states rely on an MCO tax the way ours does, which means our pain is going to be far more visible and profound if we lose this funding.

That means if Newsom’s budget is approved by the state Legislature with the MCO fix, the state is taking a gamble. If the feds don’t approve some new version of the MCO tax, “it would have major implications,” Adriana Ramos-Yamamoto told me. She’s a senior policy fellow with the nonpartisan California Budget and Policy Center.

Sort-of solutions

What’s the fourth-largest economy in the world to do? Limón would like to see the state stop subsidizing corporations who pay so meagerly that their employees qualify for Medi-Cal.

“We don’t have the luxury of being able to provide these tax subsidies,” Limón said.

Turns out, 42% of Medi-Cal enrollees are full-time workers, according to a new report by the UC Berkeley Labor Center. Although most big corporations offer some sort of health insurance, it’s often tied to working a certain number of hours (which they then make sure not to schedule) or it has prohibitive costs or other barriers.

In 2022, the Labor Center found, 34% of low-wage workers received their health insurance through employers, compared with 69% of higher wage workers — meaning California is picking up insurance costs because low-wage employers are finding ways out of them.

“Over the decades, Medi-Cal has really undergone a significant transformation. It’s shifted from a program that primarily served the disabled and indigent and elderly folks to one that largely supports folks that work in low-wage industries,” Tia Orr, the executive director of SEIU California, told me. “Medi-Cal has now become a program where folks that work every single day have to rely on it. The idea that someone can work every day and qualify for food stamps and Medi-Cal, it should be eye-opening to folks.”

Right now, she points out, California taxpayers are paying about $7,800 a year for each person on Medi-Cal.

“The corporations that they work for don’t have to pay one dollar of that, right?”

Limón and her Senate colleagues would like to change that. They have proposed the “Fair Share” plan that would impose a tax on the state’s largest and wealthiest corporations whose employees rely on public assistance. It’s more of an idea than a fleshed-out policy at this point, but as ideas go, it ain’t a bad one. It’s been done in Massachusetts, and New Jersey’s governor has suggested it.

In California, it deserves more attention than it’s currently being given.

To be fair, Newsom’s plan also would also limit state corporate tax credits to $5 million, as my colleague Taryn Luna points out, or 50% of a firm’s tax liability, whichever is greater. That change could bring in $850 million next year to state coffers and grow to $1.8 billion by the end of the decade. That’s still not nearly enough to cover healthcare costs.

To add to the drama, the California Legislative Analyst’s Office predicts all this will get worse — that the number of Californians losing health insurance coverage could roughly double in the next four years. The Newsom administration projects federal Medi-Cal changes could push off 44,000 people in 2026-27, growing to 1.3 million people by 2029-30.

That means more people getting sick and dying because they can’t afford a doctor. It means more doctors, clinics and hospitals losing income vital to keeping their doors open, and more emergency rooms being overloaded because it’s the only option.

“The worst is yet to come,” Rachel Linn Gish, interim deputy director at Health Access California, a consumer healthcare advocacy coalition, told me. “If you wait to take action until it gets bad, it’s already going to be way too late.”

She’s right, and however you look at it, a fix should include corporations paying their fair share.

What else you should be reading

The must-read: Justice Department sues UCLA for the third time, alleges antisemitism against students
The deep dive: The $400 Million Showdown Between a Billionaire and a California Mayor
The L.A. Times Special: Garden Grove crisis exposes Southern California’s hidden industrial risks

Stay Golden,
Anita Chabria

Was this newsletter forwarded to you? Sign up here to get it in your inbox.

Hundreds marched in Buenos Aires against President Javier Milei’s austerity policies and cuts to Argentina’s healthcare system. Protesters said funding cuts and rising costs are worsening access to healthcare and medicines and pushing the public health system into crisis.

SACRAMENTO — Human rights advocates on Tuesday rallied outside the state Capitol to push back on Gov. Gavin Newsom’s proposed budget plan to reduce state-sponsored healthcare coverage for undocumented immigrants.

“We are here to demand a budget that protects California’s values,” said Kiran Savage-Sangwan, executive director of California Pan-Ethnic Health Network. “We are fighting for a budget that rejects Medi-Cal cuts, seeks new revenues and strengthens our safety net reserve to keep families whole.”

Newsom last week unveiled his revised budget proposal, which would further move away from his previous policy to provide free healthcare coverage to all low-income undocumented immigrants.

His proposal would require monthly premiums for undocumented immigrants receiving coverage from Medi-Cal, the state’s version of the federal Medicaid program. It would also continue to block new adult applications, a cutback imposed last year.

The governor has explained that his original policy was more costly than expected and that difficult decisions must be made as the state could soon face an economic downturn.

Speakers at Tuesday’s rally argued this was unacceptable.

The cuts would force many immigrants to choose between putting food on the table or visiting a doctor, said Savage-Sangwan. She said certain groups, including refugees, older adults and those with disabilities, would be left especially vulnerable.

“These are the kinds of actions we would expect from a federal government that scapegoats immigrants and sends violent ICE forces to terrorize our community,” she said. “Instead, these proposals were made by our own governor in a state that claims to value immigrant communities. We know California is better than this.”

The governor’s office did not respond to a request for comment about the rally.

The event drew about 100 attendees, including Anahi Araiza, a policy researcher with Imperial Valley Equity and Justice. She told The Times that many immigrants in their community struggle to afford medical care and subsequently put off doctor visits.

“They wait until it’s an absolute emergency,” she said. “We’ve heard stories where people delay care and then get diagnosed with Stage 4 cancer.”

The event was supported by several organizations, including California Pan-Ethnic Health Network, Survivors of Torture International, Communities Organized for Relational Power in Action, Health4All Coalition, and Organizing Rooted in Abolition, Liberation and Empowerment.

One man carried a large sign with an image of the Virgin Mary that read “Safety Net For All.” Other marchers donned flowing monarch butterfly wings. The orange-and-black insect became a symbol for the pro-migrant movement years ago because it travels long distances between Mexico and the United States.

Meanwhile, another group gathered outside the Capitol for a news conference to raise awareness about the instability caused by federal healthcare cuts.

Assemblymembers Patrick Ahrens (D-Sunnyvale), Robert Garcia (D-Rancho Cucamonga) and Tina S. McKinnor (D-Hawthorne) joined several doctors and nurses to call for a $500-million state investment into public hospitals.

“Public hospitals are the backbone of our healthcare system,” Ahrens said. “It is estimated that federal cuts will strip over $3 billion a year from the California public hospital system — we cannot balance our budget on the backs of the most vulnerable Californians.”

The Republican-backed “Big Beautiful Bill” signed by President Trump last year shifted federal funding away from safety-net programs and toward tax cuts and immigration enforcement. During a legislative hearing this year, healthcare professionals warned state lawmakers the cuts would harm all patients, including those with private insurance.

It’s been years since Los Angeles County voters met a sales tax they didn’t like.

They agreed to pay half a cent more at the cash register to fund buses, trains and pothole fillings in 2016. The next year, they gave a quarter-cent more to fund homeless services. In 2024, voters bumped it up to a half–cent.

But with the electorate in a dour mood and reeling from rocketing gas prices, some speculate voters’ willingness to tax themselves may be dwindling as ballots arrive for the June 2 primary election.

“This is going to be a tougher year for taxes than prior years,” said former supervisor Zev Yaroslavsky, who pushed through a property tax ballot measure in 2002 to fund the county’s trauma care network. “There’s a limit to the tolerance people have for increasing their own taxes.”

Los Angeles County voters will soon decide whether they want to pay a temporary half-cent sales tax to shore up the region’s public healthcare system, which is facing dramatic federal funding cuts. Officials estimate the county will lose more than $2 billion in healthcare funding over the next three years.

The county currently has a base sales tax rate of 9.75%, and cities impose additional local taxes on top of that. If approved, the tax would take effect Oct. 1 and last for five years. The exact tax rate would vary depending on the city.

Voters haven’t said no to a sales tax hike since 2012, when a transportation measure fell just short with 66.1% support. It needed 66.7% to pass.

The healthcare sales tax has a lower bar to clear. The supervisors voted to put the measure on the ballot as a general tax, which gives them more leeway with how the money is spent and only requires a simple majority to pass.

But even that threshold may prove difficult. Polling from March suggested the measure was losing among L.A. city voters, who are often more generous than county voters at large. Angelenos will also find their ballot crowded with other tax hike proposals, which may leave some voters feeling picky.

“People have a very discerning instinct,” said Yaroslavsky. “They will pick and choose what they think is important.”

Despite no organized opposition, a flurry of cities, as well as the editorial board of the Los Angeles Daily News, have loudly spurned the idea, arguing it will make the region even less affordable.

“It’s just terrible timing,” said Paul Little, the head of the Pasadena Chamber of Commerce. “Costs are going through the roof for everything.”

With weeks to go until election day, healthcare workers and advocates supporting the measure have gone full steam ahead with mailers, marches and a social media campaign depicting a wallowing penny finding its lost sense of purpose with the measure. The campaign’s top funders are St. John’s Community Health and SEIU, who frame the measure as life or death for thousands of uninsured residents.

“Think about that person you know in your family who is asthmatic and relies on that inhaler, who has rheumatoid arthritis, who is diabetic,” said Supervisor Holly Mitchell at a recent town hall held in support of the measure. “And think about whether or not you’re willing to spend a half a penny — 50 cents on every hundred dollars — to make sure that that family, friend or neighbor gets what they need to be healthy.”

The supervisors voted 4-1 to put the sales tax on the ballot. Supervisor Kathryn Barger was the lone no vote.

Supporters say the One Big Beautiful Bill Act, signed by President Trump last July, is an existential threat to the public health system, leaving the county without reimbursement for the medical care of many Californians who are losing Medi-Cal coverage. The looming multibillion-dollar hole in the budget raises the prospect of hospital cutbacks, staff layoffs and possible emergency room closures, they say.

When Gavin Newsom ran for California governor in 2018, his support for a state-run single-payer healthcare system was considered a risky move and earned him hefty labor endorsements.

Today, leading Democrats in the wide-open race to succeed Newsom have embraced single-payer healthcare as a political necessity, an answer to voters fed up with rising premiums and other spiraling healthcare costs.

But with no clear front-runner, they are sparring among themselves in debates and political ads over who is most committed to a government-run model. No candidate has outlined how California would fund comprehensive health coverage for its 40 million residents, leaving voters unable to discern which candidate has a concrete plan for the nation’s most populous state.

Healthcare and political experts said the concept of single-payer has shifted from progressive pipe dream a decade ago to today’s mainstream talking points in a state where Democrats outnumber Republicans nearly 2 to 1. Democrats have pledged the model as the best way to lower costs in an attempt to woo voters worried about affordability as ballots arrive for the June 2 primary. The top two Republicans, meanwhile, have dismissed government-run healthcare as a “disaster” and “socialism.”

“In many ways, single-payer healthcare has become a progressive litmus test,” said Larry Levitt, a former White House policy advisor and a healthcare expert at KFF, a health information nonprofit that includes KFF Health News.

Few voters fully understand the term single-payer, let alone expect the next governor to achieve it, Levitt said. Rather, he added, the term has become more of a signal to voters about a candidate’s approach to healthcare reform.

Xavier Becerra, the former U.S. Health and Human Services secretary, who for decades backed single-payer healthcare in Congress, has come under criticism from opponents for a nuanced but clear shift away from single-payer. It came after Becerra secured an endorsement from the California Medical Assn., a powerful group representing doctors and a longtime opponent of single-payer healthcare bills in California.

At a May 5 debate put on by CNN, Becerra declared his support for “Medicare for All,” a proposal for a federally run system that’s been stalled for years, but he declined to say whether he’d pursue a California-led effort. He said his immediate focus would be on mitigating the drastic federal cuts expected to hit low-income and disabled enrollees in Medi-Cal, the state’s Medicaid program, which covers more than a third of residents.

Becerra is counting on voters not to distinguish between the often-confused terms single-payer, Medicare for All, and universal coverage, noting during the debate that “Californians don’t care what you call it, so long as they have affordable healthcare.”

“A lot of people aren’t clear what single-payer is, and they need a metaphor to understand it,” said Celinda Lake, a Democratic strategist and one of the lead pollsters for former President Biden’s 2020 campaign.

Billionaire activist Tom Steyer, who’s touted his self-funding as a signal he can’t be bought, has emerged as the race’s most vocal advocate of single-payer after opposing it during a short-lived 2020 presidential bid. As governor, Steyer has said, he would pass legislation backed by the California Nurses Assn. that has failed to come to fruition under Newsom’s tenure. Pressed on how he would cover the estimated $731.4-billion cost, Steyer told KFF Health News that “God is going to be in the details.”

At a forum last year, former U.S. Rep. Katie Porter said she didn’t believe achieving such a system was realistic in the near term, but the Orange County Democrat later told party delegates that she would “deliver single-payer.” Former Los Angeles Mayor Antonio Villaraigosa and San Jose Mayor Matt Mahan, Democrats who are trailing their competitors in the polls, don’t support single-payer. The top two vote-getters — regardless of party — advance to the November general election.

Some of the most seasoned politicians have failed to deliver single-payer. Newsom, who campaigned on the promise of being a “healthcare governor,” dialed back his ambitions upon taking office, choosing instead to pursue “universal access” to health coverage under a series of Medi-Cal expansions and efforts to contain healthcare spending.

The campaign bus for billionaire activist Tom Steyer, who has made single-payer healthcare a central pillar of his run for governor, in downtown Oakland.

(Christine Mai-Duc/KFF Health News)

Vermont, which remains the only state to pass a single-payer healthcare law, reversed course when leaders there couldn’t identify a funding source.

To enact single-payer, California would need permission from the federal government to redirect billions of dollars from Medicaid, Medicare and other funding that currently flows to the system — approval not likely to come from the Trump administration.

More than half of adults nationally say healthcare costs will have a major impact on whom they vote for in November, according an April KFF poll.

Danielle Cendejas, a Los Angeles-based Democratic consultant who works with state legislative candidates, said single-payer healthcare increasingly appears on candidate questionnaires from small-business advocates as well as hyperlocal Democratic clubs, in state legislative races and national union endorsements. What most California voters want to hear, Cendejas said, is how candidates plan to give them more immediate relief from higher premiums, expensive drug costs and long waits to access care.

The high price tag doesn’t faze Jennifer Easton, a 63-year-old Democrat from Oakland, who said other countries with similar models have proved they can lower costs. She said she supports a single-payer health system because it’s clear to her that Americans have reached the limits of working within the existing system. But she isn’t expecting any of the current candidates to succeed in implementing one, and she hasn’t decided whom to support.

“No one can in four years,” she said. Seeing a candidate enthusiastically support the concept gives her a good idea of their philosophy. “It is, if we’re lucky, a 20-year, 25-year plan.”

Rob Stutzman, a Republican political consultant who advised former Gov. Arnold Schwarzenegger, said while Americans may be supportive of single-payer in polls, focus groups suggest that approval drops quickly when voters realize it could mean losing their current doctor or insurance plan.

At the CNN debate, Steve Hilton, the Republican candidate President Trump has endorsed, said Californians would end up with subpar patient care and “taxes sky high to pay for it,” like in his native United Kingdom. Instead, Hilton suggested the state stop providing “free healthcare for illegal immigrants who shouldn’t even be in the country in the first place.”

Mai-Duc writes for KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism.

SACRAMENTO — One of Gavin Newsom’s top goals as he winds down his final year as California governor is to leave the state with a balanced budget.

After years of the state spending more money than it brings in, it’s Newsom’s last opportunity to fix a chronic deficit or dump the problem on the next governor.

How far he goes to solve the state’s structural spending imbalance will define his legacy as a steward of trillions in taxpayer dollars. As a potential candidate for president in 2028, he could also have a political incentive to do as little as possible.

“Any cuts you make are going to cause people to scream,” said Darry Sragow, a veteran Democratic strategist. “Any increases in taxes are going to cause people to scream and in terms of what’s best for a presidential run, it would be nice if people weren’t screaming.”

As California’s 40th governor, Newsom expanded publicly funded healthcare to income-eligible undocumented immigrants, increased state-subsidized child-care slots and provided free meals for schoolchildren among a wishlist of progressive wins since he took office in 2019.

His achievements have helped struggling Californians live in an increasingly unaffordable state and given him bona fides to tout to voters if he launches a bid for the White House.

But the state could never afford to pay for existing services and the new programs that Newsom and Democratic lawmakers enacted, according to an analysis of ongoing state spending since before the pandemic released by the Legislative Analyst’s Office last week.

Spending from the state’s principal operating fund has grown about $100 billion since Newsom’s first full fiscal year in office in 2019-20, mostly due to the growing cost of existing programs that he inherited. State spending has outpaced California’s strong revenue growth by about 10%, creating a perennial budget shortfall — a structural deficit — that Newsom and the Democratic-led Legislature solve with largely temporary fixes each year.

Instead of making across-the-board program cuts or raising taxes to align spending with revenue, Democrats have tapped into reserves designed to preserve social services for the state’s most disadvantaged communities during economic downturns.

While the California economy remains stable and state revenue has increased, Newsom and lawmakers have taken $12.2 billion from the rainy day fund. Democrats have borrowed $28 billion more from other state funds to cover their spending in recent years, according to the LAO.

“Taken together, these trends raise serious concerns about the state’s fiscal sustainability,” Legislative Analyst Gabriel Petek wrote in a review of Newsom’s January budget proposal.

Fiscal watchdogs have warned that the spending trends will leave California in a precarious position if the stock market tanks and tax receipts bottom out.

Personal income taxes are driving higher-than-expected revenue now, which analysts attribute to an artificial intelligence boom on Wall Street, and suggest the state could have no deficit in the upcoming year. In January, the Newsom administration anticipated significant operating deficits in the years ahead: $27 billion in 2027-28, $22 billion in 2028-29 and $23 billion in 2029-30.

The LAO, the Legislature’s nonpartisan fiscal advisor, said the state has already solved $125 billion in budget problems over the last three years with mostly short-term solutions.

“This issue is really whether they’re going to take seriously the structural deficit that is several years in the making now, where the spending has outpaced revenue, and to address that, they’re going to either have to make some fairly deep cuts or raise revenue and or both,” said former state Controller Betty Yee, who worked as a budget aide under Gov. Gray Davis and recently dropped her own campaign for governor. “But they have to be real. I think resorting to these one-time solutions has really exacerbated the problem.”

How Newsom wants to address the state’s financial challenges will be revealed on May 14 when he is expected to present his revised budget plan in Sacramento. His January budget proposal did not include any significant reductions or cuts to programs.

H.D. Palmer, a spokesperson for the California Department of Finance, said the governor is looking to solve the budget problem with more than a temporary fix.

“Although he is still finalizing his proposal that he’ll put forth to the Legislature, as he has said, he wants those solutions to be durable, and he wants them to have an impact beyond a single fiscal year,” Palmer said.

To stabilize California’s budget, Democrats will probably have to raise taxes or fees to generate new revenue and cut programs, according to the LAO. At least 40 cents for every dollar in revenue is dedicated to education under the state Constitution, requiring policymakers to find between $30 billion and $60 billion annually in additional revenue to cover projected shortfalls in 2027-28 and beyond if relying on new taxes alone.

President Trump’s cuts to healthcare are adding to the problem.

HR 1 will add $1.4 billion in state costs to the general fund. Newsom’s January budget proposal did not include a plan to help millions of low-income Californians who are expected to lose access to healthcare under the federal cuts.

To temper those cuts in California, other groups proposed a new tax on billionaires that appears poised to qualify for the November ballot.

Spearheaded by Service Employees International Union-United Healthcare Workers West, the initiative would apply a one-time 5% tax on taxpayers with assets exceeding $1 billion. If approved by voters, the tax would generate roughly $100 billion, which would fund healthcare programs.

The measure has divided unions and Democrats at the state Capitol.

Newsom has criticized the initiative, citing concerns that increasing taxes on the wealthy will have the opposite intended effect and drive the highest earners out of California. Under a progressive tax structure, the state budget is dependent on income taxes paid by the ultra-rich on earnings largely from capital gains.

Larry Page and Sergey Brin, the co-founders of Google, have already purchased residences in Florida, along with others looking to escape the tax if it goes through in November. Billionaires launched their own ballot measure campaign to undercut the tax proposal.

State lawmakers are also considering avenues to raise revenue, which include repealing a “water’s edge” tax break. Under the change, multinational companies would no longer be allowed to shield the income of their foreign subsidiaries from state taxes. California loses about $3 billion in revenue from the tax break each year.

In its budget plan released in April, the state Senate proposed a new fee on the largest corporations in the state to provide $5 billion to $8 billion annually for Medi-Cal.

The upper house said 42% of Medi-Cal enrollees are full-time workers who are not enrolled in their company’s healthcare plan because their wages are low enough to qualify for state-subsidized healthcare. As a result, corporations aren’t paying for healthcare for many of their employees and instead taxpayers are picking up the bill through Medi-Cal.

SEIU California, the powerful state union council representing over 700,000 workers, endorsed the plan. The union said Trump’s tax policy will reduce corporate taxes by $900 billion, while 3 million Californians lose healthcare.

“In this urgent moment, California’s workers need to see our leaders show us what they’re made of,” said Tia Orr, executive director of SEIU California. “The Senate is showing the courage to demand corporations pay their fair share, rather than making working people pay with their lives.”

The change is being described as a more politically palatable “fee” and not a tax.

“We explored multiple revenue options, and this was the one that felt more narrow, it felt more focused, and it also felt like it was directly going for the subsidy that’s being lost because of the Trump HR 1 cuts,” said Senate President Pro Tem Monique Limón (D-Goleta), who leads the upper house of the Legislature.

Limón said her caucus believes it’s important to address potential revenue streams because of the depth of federal healthcare reductions.

“If we don’t address the structural deficit, we are looking at severe cuts,” she said. “You are looking at people without health insurance. You are looking at hospitals closing down. You are looking at medical providers not being able to take more patients. You are looking at our emergency rooms over capacity, with not enough medical providers. I mean, you’re looking at a place that’s really, really, really difficult, and we feel like we have to, at least, look at what are viable options that are conditional on these cuts coming.”

Newsom has not commented publicly on the Senate’s plan. As governor, he’s been reluctant to embrace new taxes and fees.

Newsom could reject all the proposals for new taxes or fees and continue what he’s done before: take advantage of higher-than-expected tax collections, shift funds around, delay program implementation and borrow money to knock the deficit down to zero, or forecast a surplus, for his last budget year that begins July 1.

If he doesn’t take on California’s larger budget imbalance, then the problem would be the next governor’s to solve. A stock market crash, or economic recession, could force his successor to make drastic cuts across the board with limited reserves to support programs.

Kicking the can again would cement Newsom’s fiscal legacy as a governor who championed bold headline-making policies that bolstered the safety net for low-income Californians, but who failed to provide a solution to pay for his agenda.

“Not only has he not come up with a plan, he has pretended we don’t need one,” said Patrick Murphy, a professor of public affairs at the University of San Francisco.

Newsom’s interest in running for president could seemingly discourage him from slashing the budget and raising attention to the state’s financial woes, Sragow said. Newsom is setting himself up as a potential front-runner for his party. He has said he remains undecided about officially launching a 2028 campaign.

As a Democrat from California, his opponents would automatically label him as financially irresponsible and tax-happy. Calling out the massive budget problem on the horizon, raising taxes and making painful cuts will give them ammunition.

“There’s a long list of things that he’s going to be charged with, and this is likely to be one more,” Sragow said. “But I guess the question is, is he going to be charged with a political misdemeanor or a political felony?”

Former state Sen. Steve Glazer said Newsom is standing on political quicksand either way. State budget projections are based on assumptions about the future that often don’t bear out, leaving his choices exposed to criticism that he went too far, didn’t do enough, and everything in between.

“Whatever the governor decides to do in his May revise and in his final budget, it’s fraught with political risks, because it can be manipulated so easily by all sides,” Glazer said.

If Newsom ignores the spending problem, his successor could blame him for California’s financial woes when they take office in January and provide their own outlook of the state’s fiscal future. At the time, Newsom could be trying to convince America to make him the nation’s next president.

Murphy said Newsom has championed major policies and been reluctant to back off them later when revenue doesn’t pencil out.

In terms of spending, he’s governed similarly to the men who led California before him, with the exception of Jerry Brown, who cut programs to reduce a deficit he inherited in his second stint in the governor’s office and left Newsom with a surplus.

“It’s not all that different than most of the governors have done, which is finding it very hard to say no and finding it very hard to take on a tough choice of going to the ballot to ask for more money or raise taxes,” Murphy said.

On taxation, Newsom is perhaps most similar to former Gov. George Deukmejian, who opposed general tax increases for most of his administration.

Deukmejian left a budget disaster for his successor, Gov. Pete Wilson. Deukmejian publicly claimed he passed a balanced budget in his final year and blamed an economic downturn for the problems Wilson encountered.

When Wilson announced a record $13-billion budget deficit early in his first year in office in 1991, he said the Persian Gulf War, an economic downturn and natural disasters added to a structural deficit in the budget.

The Legislature and Deukmejian, Wilson said, had “papered over” the problem.

Supervisor Kathryn Barger was the only supervisor against it. She pointed to the fact that the tax was a “general” tax, meaning the money won’t be earmarked for healthcare costs. That means politicians have final say over how the money gets spent rather than voters, she said.

Some cities within L.A. County say they’re also rattled over the tax, unleashing a stream of opposition letters against the tax. The California Contract Cities Assn. argues a sales tax hike would “disproportionately burden the very residents the County seeks to protect.” Shoppers near the county line, they warn, likely would start crossing it to shop.

Some of these cities say they have the trust issues when it comes to county ballot measures. When voters approved Measure B in 2002 to fund the county’s trauma center network, an audit years later found the county couldn’t account for whether the money actually had been spent on emergency medical services. And some cities feel they never got their fair share of funds from Measure H, the homelessness services tax measure passed in 2017.