Today we’re speaking with Faisal Zain, a leading expert in medical technology. While his work often focuses on the cutting-edge devices used in diagnostics and treatment, he brings a unique perspective on how sweeping federal health policy changes impact the very real, on-the-ground ability of communities to deliver care. We’ll be discussing the immense challenge facing county health programs as they prepare for a future with millions more uninsured residents, exploring how dismantled safety nets can be rebuilt, the tough fiscal choices leaders are forced to make, and what this means for the health of our nation’s most vulnerable populations.
The article highlights Placer County going from caring for 3,400 uninsured residents in 2013 to zero after the ACA. With officials now saying their infrastructure is “gone,” what specific, step-by-step measures must a county take to rebuild a safety-net system for an expected 16,000 newly uninsured people?
Rebuilding from scratch is a monumental task, and the word “gone” is not an exaggeration. First, a county has to secure physical locations, a huge challenge since Placer County, for instance, quit operating its own clinics nearly a decade ago. Then comes the staggering logistical hurdle of equipping them; we’re not just talking about desks and chairs, but about repurchasing every single piece of diagnostic and treatment technology that was let go. From there, it’s a race to hire and train staff—doctors, nurses, technicians—who can operate that equipment and manage a patient load that’s ballooned from a theoretical zero to a projected 16,000 people. Finally, they must establish the administrative systems to track patients and manage care, all while the number of uninsured residents is climbing daily. It’s like trying to build a hospital in the middle of a public health emergency.
The “One Big Beautiful Bill Act” is projected to cut Medicaid by over $900 billion. For a place like Doña Ana County, which had expanded services, what does the internal decision-making process look like when choosing between allocating more money or cutting benefits like dental care for seniors?
That’s a heartbreaking decision-making process. Internally, it becomes a painful exercise in cost-benefit analysis where the ‘benefit’ is human well-being. A county board will look at the new, drastically reduced budget projections, stemming from that more than $900 billion federal Medicaid cut, and weigh the cost of every single service. They’ll have to ask, ‘Can we afford the staff and equipment for senior dental care, or does that money need to go toward keeping the primary care clinic’s doors open?’ It often pits essential services against each other, forcing officials like Jamie Michael in Doña Ana to choose between something seen as ‘extra,’ like dental care, and the core services needed to keep people out of the emergency room. It’s a devastating choice with no good answers.
With California facing a potential $30 billion annual loss in federal Medi-Cal funding, what are the most realistic “fiscal restructuring” options for the state to help revive county indigent care programs? Please describe what those fiscal shifts would entail for local governments and taxpayers.
Given that California is facing a potential $30 billion annual loss in federal Medi-Cal funding, “fiscal restructuring” is a very clinical term for what would be a massive and painful reshuffling of state priorities. The most realistic, though politically difficult, option would be a direct state-level bailout of these county programs. This would mean the state finding that money somewhere in its already strained budget, which is facing a nearly $18 billion deficit in the coming fiscal year. For local governments and taxpayers, this could mean either seeing services cut in other areas—education, infrastructure, public safety—to free up funds for indigent care, or state leaders would have to reverse course on their reluctance to raise taxes significantly. Either way, the state would be stepping in to fill a federal hole, shifting the financial burden directly onto Californians because, as experts have noted, local governments simply don’t have the capacity to raise that kind of revenue on their own.
The text describes the old system as a “patchwork” where care was unequal. Drawing from that pre-ACA era, can you share an example of how excluding specialty or behavioral health from an indigent care program directly led to worse outcomes and higher costs for a patient down the line?
I remember that era well, because we’d see the downstream effects in emergency rooms. Let’s take a patient with a chronic but manageable condition, like diabetes, who lives in a county where the indigent care program doesn’t cover specialty endocrinology or behavioral health support for managing their illness. Without regular access to a specialist or counseling, their condition worsens. A simple need for insulin regulation becomes a full-blown crisis, and they end up in the ER with a life-threatening complication that requires advanced, expensive medical technology and an extended hospital stay. The county ultimately pays a far higher price for that emergency intervention than it would have for consistent, preventative specialty care, and worst of all, the patient suffers immensely. That “patchwork” system was a perfect recipe for turning manageable health issues into catastrophic and costly emergencies.
Santa Clara County’s new sales tax is expected to cover only a third of its projected $1 billion annual loss. Beyond local taxes, what are the most innovative strategies you’ve seen counties consider to manage this massive funding gap, and what are the primary obstacles to implementing them?
Santa Clara County’s situation is a stark warning that even in an incredibly affluent area, local taxes aren’t a panacea; that new tax covers only a third of their projected billion-dollar annual loss. Beyond taxes, some of the more innovative strategies I’ve seen counties consider involve forging aggressive public-private partnerships. This could mean negotiating with large hospital systems to provide a certain amount of uncompensated care at a reduced rate in exchange for other incentives, or partnering with tech companies to develop telehealth platforms that can deliver primary and behavioral health care more efficiently. The primary obstacle is always scale and sustainability. A partnership might cover a few thousand people, but not the tens of thousands who are losing coverage, and these agreements are often fragile, dependent on the goodwill and financial health of the private partner, which isn’t a reliable foundation for a public safety net.
What is your forecast for the future of county-level indigent care over the next five years, particularly regarding the disparity in services between states that expanded Medicaid and those that did not?
Looking ahead, my forecast for county-level indigent care over the next five years is frankly grim, and it will be defined by a deepening chasm between states. States that expanded Medicaid are now facing the painful process of ‘unwinding’ that progress, as one advocate put it. They will be scrambling to resurrect ghost infrastructures, leading to a highly ‘unequal, maldistributed program’ where your access to care depends entirely on your zip code. In contrast, states like Texas that never expanded Medicaid are already straining to fund their existing systems. As more people lose coverage nationally and potentially migrate, their already overburdened programs will be pushed past the breaking point. We are heading toward a future of two Americas in healthcare: one where states desperately try to patch together a semblance of the safety net they once had, and another where the existing, inadequate net tears completely.
