Immigrant access to Medicaid during the second Trump administration: Evidence from Alameda County, California

• In Event: Medicaid Access and Enrollment

Abstract

CONTEXT: With its passage in July 2025, H.R. 1 created new administrative burdens for Medicaid beneficiaries. Even before H.R. 1, immigrants and those living in mixed-status families were already living with additional barriers to program access such as language challenges, the five year bar, broader fears related to immigration enforcement, and a possible expanded public charge regulation. The latter two of these became much more significant concerns for immigrants considering Medicaid enrollment after November 2024. H.R. 1 will exacerbate these barriers with work requirements, more frequent income verification, and Medicaid eligibility limits for qualified noncitizens. California also has a state Medi-Cal option that covers all income-eligible residents irrespective of citizenship status, but enrollment was paused for adults in January 2026. Because of these changes, Medicaid enrollment for immigrants is under serious threat. County governments in California are legally mandated to provide healthcare for those ineligible for federal or state coverage, meaning that these policy changes endanger local government budgets as well. 

METHODS: This research includes two components: 1) a microsimulation model to predict enrollment changes from H.R. 1 in 2026 and 2027 for immigrants and 2) an analysis of data shared by Alameda County on actual Medi-Cal enrollment data from 2024 and 2025. The microsimulation model is based on a literature review of preexisting studies to estimate coverage changes and detailed coverage data from the county and by eligibility group. For the 2024-2025 analysis of actual Medi-Cal enrollment data, we examine whether a relative decline in Medicaid enrollment occurred for those likely without legal status compared to those with legal status through the beginning of the second Trump administration. If found, these changes can be attributed to chilling effects from ramped up enforcement or heightened rhetoric since they pre-date any safety-net policy changes. 

RESULTS: Overall, our micro-simulation model predicts that 18% of Medi-Cal enrollees in Alameda County will lose their coverage by December 2026 and that another 17% of Medi-Cal enrollees in the County will lose their coverage by December 2027. This represents a coverage loss of about 150,000 people. For immigrants, the projected decline is even more precipitous with 71% of the undocumented population predicted to lose coverage by the end of 2027 (which represents a decline of 69,000 from early 2026 levels. Another 11,000 more qualified immigrants with legal status are also projected to lose coverage. The analysis of actual enrollment data from 2024-2025 is on-going, but early information from Alameda County suggests that Medi-Cal enrollment decreased at a faster pace in 2025 compared to 2024 for those without legal status compared to those without it. 

CONCLUSIONS: These results have informed planning by Alameda County, which will need to adjust indigent care funding based on how many residents lose coverage from H.R. 1. The administrative data analysis will also measure the magnitude of coverage losses experienced even before H.R. 1 in a county with a large foreign-born population.

Author

• Jeremy Barofsky, Georgetown University
  Presenting Author