By the time Democrat Xavier Becerra left Washington, D.C., more Americans than ever had health insurance, owing partly to his work over the years to pass, defend, and expand the Affordable Care Act.
It's an achievement the former congressman and U.S. secretary of Health and Human Services often touts as he campaigns for California governor against Republican Steve Hilton, a former Fox News commentator.
But should Becerra cruise to victory in November, as polling suggests, he will face what may be the steepest decline in health insurance coverage in a generation, one that will land especially hard in his home state.
Federal cuts mean more people uninsured
By 2030, the number of uninsured Californians under 65 is expected to nearly double from 2.4 million to 4.6 million as recently enacted state and federal cuts to Medicaid and ACA marketplaces begin to roll back historic gains in health coverage, according to a May analysis by the University of California, Berkeley Labor Center. The anticipated rise in the uninsured population could have broad implications for hospital systems, insurers, and the economy.
In February, Miranda Dietz, the labor center's healthcare program director, told legislators the changes could end up costing California about 200,000 jobs, mostly in the healthcare industry.
Hospital executives have begun reporting more unpaid medical bills, and experts warn health plans will raise premiums further as they're left with enrollees who are, on average, sicker and more expensive to cover.
"It's triage," said Jessica Altman, executive director of Covered California, the nation's largest state-run health insurance marketplace. "That's what the next governor is walking into."
California achieved one of the most dramatic drops in its uninsured population in the nation, largely credited to the state's robust adoption of the ACA. If tapped to lead the wealthy, progressive state, Becerra would wrestle with how uninsured Californians get care and who pays as the Trump administration shrinks a federal safety net he once oversaw.
Becerra has some experience pushing back against Washington, D.C. As California attorney general, he successfully defended many provisions of the Affordable Care Act, including access to birth control.
Becerra said he would issue an executive order to keep those affected by federal cuts insured. But he has not detailed how the state would backfill as much as $30 billion in federal funding California stands to lose annually.
At a policy forum hosted by Politico this month, Becerra promised Californians would not lose health coverage despite federal cutbacks, saying he would push the industry to eliminate waste from "attorneys, accountants, pencil pushers" that cost consumers billions.
"I'm going to ask them to help me extract some of that waste and put it into healthcare, which helps us cover the cost of keeping Californians insured," he said.
His opponent, Hilton, is trying to appeal to voters opposed to President Donald Trump, despite receiving the president's endorsement, and has stumped on cutting off coverage for Californians without legal status, which is paid for with state funds. Hilton has vowed to use those savings to issue state income tax breaks, calling it an immediate antidote to high costs.
"We all understand that the healthcare system is a mess and needs major reform," Hilton said in an interview. "The quickest thing we can do on healthcare costs is actually to tax people less."
Left behind?
In 2010, Becerra was part of U.S. House Speaker Nancy Pelosi's leadership team and helped whip up votes to pass the law. He also had a hand in crafting it, though his attempt to include a government-backed coverage option failed.
A decade later, when lawmakers considered him for the nation's top healthcare job, Becerra said his primary mission would be to carry out President Biden's vision to expand access and cut costs under the Affordable Care Act.
Before the ACA, some 50 million Americans — roughly 1 in 6 — were uninsured. Within a few years of the law's passage in 2010, its expansion of Medicaid eligibility and financial aid to lower-income marketplace enrollees helped slash the U.S. uninsured rate by nearly half.
Millions more gained coverage during the COVID-19 pandemic after Becerra implemented a freeze on Medicaid disenrollment and administered generous but temporary tax credits that put the cost of Obamacare plans within reach for more people.
As Biden's health secretary, Becerra launched aggressive public awareness campaigns, loosened enrollment rules, and distributed hundreds of millions in grants to pay consumer assistants, also known as healthcare navigators, to help enrollees wade through paperwork.
"One of the common things we would hear from him as a leader was, 'Who's being left behind?'" said Benjamin Sommers, a Harvard health policy professor who was a deputy assistant secretary under Becerra.
Under Biden and Becerra, the percentage of people with health insurance reached a historic high of 92%, or 310 million Americans having health coverage in 2024.
Republican response
But conservatives said those policies inflated enrollment by attracting fraudulent and wasteful coverage. In response, the second Trump administration has tightened enrollment windows and toughened income reporting.
"It's simple and easy to say, well, the numbers are up so the program must be working," said Edmund Haislmaier, a senior research fellow at the Heritage Foundation, a conservative think tank. "My argument would be that's the wrong metric."
Last summer, the GOP-led Congress passed Trump's One Big Beautiful Bill Act, which Republicans argued preserves Medicaid for those who need it most while rooting out fraud and waste. Altogether, the law is expected to cut Medicaid spending by $900 billion-plus over a decade.
Congress also allowed enhanced premium tax credits for Obamacare plans to expire last year, spiking premium payments for middle-income Americans and driving down enrollment by nearly 3 million this year.
"We are now witnessing almost a wholesale reversal of pretty much all those policies" that helped cover millions more Americans, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.
For Eric Maciel, the $800 cost of a Covered California plan is too much. To avoid injury, the 28-year-old stays home more and rarely plays pickup soccer at the park — the other players, he added, can get pretty rough.
"That's another car note," Maciel said. "I'd be left with nothing."
Health economists say Maciel is the type of customer insurers need to stabilize their risk pools: young, healthy, and less costly.
Hilton criticized state leaders for passing a revised provider tax he asserts will send premiums soaring and said he wants to inject more competition into California's health insurance market — but he offered no specific ideas.
Playing defense
Higher-than-expected state costs coupled with federal cuts have prompted California to retreat on healthcare coverage. Federal funds account for one-third of the state's budget and more than 60% of spending by Medi-Cal, the state's Medicaid program.
Gov. Gavin Newsom has frozen enrollment for immigrants without legal status, enacted monthly premiums for some, and plans to only temporarily backfill federal assistance for legal immigrants and refugees.
Newsom and Democratic lawmakers agreed to delay some cuts until July 2027, leaving the next governor to weigh further rollbacks against increased taxes. Becerra, a California native born to Mexican immigrants, opposes what's known as the billionaire tax, on November's ballot. This month, he said he supported legislative efforts to penalize large corporations whose workers rely on Medi-Cal, arguing that taxpayers are subsidizing employers' low wages and paltry benefits.
County governments, which are legally required to provide healthcare to uninsured residents too poor to afford care, are lobbying lawmakers for funding to treat what they describe as a fresh deluge of patients who need free care.
"It's a pretty big cliff if all this stuff goes into effect," said Dietz, the labor center's healthcare program director. And there's a choice whether to make it less bad and maintain coverage for folks."
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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