Health clinics that serve more than 1.1 million patients up and down the San Joaquin Valley are bracing for the prospect of budget cuts and other fallout in the wake of the passage of President Donald Trump’s “One Big Beautiful Bill” budget act, narrowly approved by Congress and signed into law on July 4.

The Congressional Budget Office reports that House Resolution 1, which squeaked through the U.S. Senate and House of Representatives in rushed votes, includes  just over $1 trillion in spending cuts over 10 years to Medicaid, the federal health insurance program for low-income patients. Throughout the eight Valley counties – Fresno, Kern, Kings, Madera, Merced, San Joaquin, Stanislaus and Tulare – almost seven out of 10 patients rely on MediCal, California’s incarnation of Medicaid.

Many of those patients live in poverty and most are ethnic or racial minorities. Some could face the prospect of cuts to primary-care health services available through about 340 clinics operated by nonprofit organizations under the Federally Qualified Health Centers program as a result of the bill’s passage.

“We’re very concerned about what is in there, and I think it’s a foregone conclusion there’s going to be some kind of cuts in there,” said Justin Preas, CEO of Fresno-based United Health Centers of the San Joaquin Valley, in an interview before the bill’s final passage. “We still don’t really have a clear picture of how deep it’s going to go, and they’re trying to just shove this thing through.” United Health Centers operates three dozen clinic sites serving about 180,000 patients in Fresno, Kings and Tulare counties.

The bill’s passage in Congress was almost squarely along party lines. In the U.S. Senate, Vice President J.D. Vance broke a 50-50 tie in the July 1 vote after two Republican senators joined all 47 Democrats and one independent who opposed the bill. On July 3, the House of Representatives passed the Senate version of the bill in a close 218-214 vote. All 212 Democrats in the House voted against the bill, along with two Republicans.
Both of California’s senators, Democrats Alex Padilla and Adam Schiff, voted against the bill. House members representing the San Joaquin Valley were divided along party lines: Republicans Tom McClintock of El Dorado Hills, David Valadao of Hanford and Vince Fong of Bakersfield voted to pass the bill; Democrats Josh Harder of Tracy, Adam Gray of Merced and Jim Costa of Fresno voted against it.

Among the bill’s notable provisions, according to KFF Health News, an independent health news organization, are:

  • A rule that states impose a work or service requirement of at least 80 hours per month for people ages 19 to 64 to be eligible for Medicaid. Parents of children age 13 and under, and people who are medically frail, are exempt from the work requirement.
  • A requirement to begin charging $35 per service for covered adults for certain services in 40 states, including California, where Medicaid coverage was expanded under the Affordable Care Act.
  • A requirement that states reassess Medicaid eligibility every six months for people covered under Medicaid expansion. Current law calls for eligibility renewal every 12 months.
  • A limit on retroactive Medicaid coverage to costs that occur either one or two months prior to a person’s application for coverage. Current law includes retroactive coverage going back three months.
  • Bars Medicaid funds from being paid to nonprofits that primarily provide family planning or reproductive services, including abortions, and received $800,000 or more in Medicaid payments in 2023.
  • 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. Current law bars undocumented immigrants from eligibility for federally-funded Medicaid coverage.

Between reductions to Medicaid and the Affordable Care Act, the nonpartisan Congressional Budget Office estimates that almost 12 million people will lose health insurance coverage by 2034.

The CBO also estimates that the bill – which also would make permanent tax cuts put in place during President Trump’s first term – would add about $3.4 trillion to the federal deficit by 2034, despite cuts or reductions to a wide range of programs.

In Fresno, Kings, Madera and Tulare counties, the nonprofits that operate almost 200 clinic sites under the FQHC program rely on Medicaid for as much as 70% or more of their annual revenue.

Operators of such clinics, including United Health Centers, are worried about their ability to maintain some of the services they provide.

Preas said that in 2024, United Health Centers provided care for about 180,000 patients across 37 clinic sites in Fresno, Kings and Tulare counties. Medi-Cal enrollees account for about two-thirds of those patients.

Between the federal legislation and California’s own budget woes and efforts to curb federal benefits for undocumented immigrants, “I’m guessing it’s going to be at least probably 20% to 25% of our patients are going to no longer qualify for the Medi-Cal program,” Preas said. “That’s a lot of people that are going to be uninsured and are going to not be accessing primary care (at clinics) and showing up in our (hospital) emergency rooms that already can’t handle the volume they have, and driving up the cost of care.”

Rationale for their votes

Two of the Valley’s Republican representatives in Congress, Rep. David Valadao of Hanford and Rep. Vince Fong of Bakersfield, both voted to pass the bill. Each issued only prepared statements to explain their votes.

Valadao said he voted for the bill despite misgivings over how it will be implemented. But, he added, “ultimately, I voted for this bill because it does preserve the Medicaid program for its intended recipients – children, pregnant women, the disabled and elderly.”

Fong’s staff said the bill “restores integrity to Medicaid … and other safety net programs by rooting out waste and strengthening them for those they are intended to serve, including seniors, children, mothers and the disabled.” Fong’s staff did not respond to follow-up questions about specific examples of a lack of integrity or waste in the program.

Fong’s staff also ignored questions submitted by CVJC about whether they had assessed how many people in their district may lose benefits or no longer qualify for Medicaid as a result of the cuts or the work requirements; whether they had evaluated the impact of the bill on FQHCs serving their district; or likely impacts on the district from a long-term increase in the federal deficit.

Among Valley Democrats in the House, Rep. Jim Costa of Fresno and Rep. Adam Gray of Merced voted against the bill and, in prepared statements, expressed disappointment at its passage. 

Gray described the legislation as “a partisan spending bill that will blow up our federal deficit, increase our national debt, raise health care premiums on Valley families and put our rural hospitals at risk.”

Costa, said the bill comes at “the expense of the people of the San Joaquin Valley.”

“Healthcare is essential as the majority of the people that I represent rely on Medicaid (and other safety net programs),” he added. “These vital safety nets ensure families can access food (and) healthcare …. But this bill guts those services and puts rural hospitals at risk of closure. …”

Whatever the legislators’ reasoning, “I think the ultimate goal from who’s supporting this bill (and) how they’re going to make cuts is they’re going to push people off the program,” said Preas.

Preas said that FQHCs, such as United Health Centers and others across the Valley, are likely to confront financial challenges that will limit the services they offer.

“There are so many things that we provide that are not necessarily funded, things like patient transportation, things like enrollment and case-management services, enabling-type services,” Preas said.

Representatives of several other major FQHC nonprofits in Fresno, Kings, Madera and Tulare counties did not respond to CVJC’s requests for comment on the legislation, including Camarena Health in Madera which operates 27 clinic sites serving more than 63,000 patients; Visalia-based Family HealthCare Network with 47 clinic sites and almost 240,000 patients, and Aria Community Health, a Lemoore-based nonprofit with 30 clinic sites and more than 35,000 patients.

Federal efforts to eliminate benefits for undocumented immigrants, currently provided under California’s Medi-Cal program, could cut even deeper into services. 

Preas said he believes the Trump administration is “trying to push the state to no longer insure undocumented people at all or provide any kind of public benefits to undocumented people.”

Preas also said that services that are not mandatory under federal Medicaid coverage, including adult optometry and other benefits, could fall by the wayside. 

“Things are very much at risk for the future,” he said. “It’s a very challenging time right now, because we’re kind of getting hit from all sides with everything that’s going on.”

Polling reveals public distaste for the bill

A KFF Health tracking poll conducted in June – before the Senate voted to approve even deeper cuts than the original House version passed in May – showed that nationwide about two-thirds of Americans opposed the “One Big Beautiful Bill Act.”

Most of those supporting the legislation were Republicans, including those who identify as supporters of the Make America Great Again movement. But polling showed that support has waned.

“Among both Republicans and MAGA supporters, support drops at least 20 percentage points, with less than half of each group viewing the law favorably after hearing it would increase the country’s uninsured rate and decrease funding for local hospitals,” KFF reported.

The president of the American Medical Association, Bobby Mukkamala M.D. of Michigan, issued a statement on July 3, when the House passed the final version of the bill. 

“Today is a sad and unnecessarily harmful day for patients and health care across the country and its impact will reverberate for years,” Mukkamala said. “Care will be less accessible, and patients may simply forego seeing their physician because the livelines of Medicaid and CHIP (Children’s Health Insurance Program) are severed.”

“This bill moves us in the wrong direction,” he added. “It will make it harder to access care and make patients sicker. It will make it more likely that acute, treatable illnesses will turn into life-threatening or costly chronic conditions. That is disappointing, maddening and unacceptable.”

The California Medical Association and other health organizations likewise expressed their opposition to the legislation.

“This vote does more than cut funding to Medicaid – it will directly result in the loss of health care for millions and will jeopardize the health and safety of people across the country,” said CMA President Shannon Udovic-Constant, M.D., a pediatrician in San Francisco.

“This legislation will do nothing to save costs in the long run. It will result in patients delaying care, illnesses going undetected, increased emergency room visits and, ultimately, in more patient deaths,” Udovic-Constant added. “As someone who has dedicated decades to saving lives, I can say with certainty that the cuts to Medicaid will only have negative consequences.”

Alan Morgan, CEO of the Missouri-based National Rural Health Association, declared that “this legislation will limit access to care for all rural patients by ending healthcare coverage for rural residents nationwide and putting financial strain on rural facilities who care for them.”

The National Rural Health Association includes a range of constituency groups including FQHCs, such as those providing care in far-flung areas of the San Joaquin Valley.

Tim Sheehan is the Health 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. CVJC student research assistant Lauren Aiello contributed to this report. Contact Sheehan at tim@cvlocaljournalism.org.