Background: Historically, counties have provided indigent care to low‑income Californians who lacked any other source of health coverage. These county indigent care programs are required to furnish only basic, subsistence‑level medical services—not comprehensive health insurance. The obligation to provide this care is mandated by state law under Welfare and Institutions Code Section 17000.
To support these state‑mandated services, counties were allocated funding through the 1991 Realignment. Following the Affordable Care Act’s expansion of Medi‑Cal in 2014, California enacted Assembly Bill 85, which redirected a significant portion of those realignment dollars away from county indigent care to support other state priorities. While the expansion allowed California to scale up Medi‑Cal coverage and substantially reduce reliance on county indigent care, counties experienced sharp declines in caseloads, leading many to downsize infrastructure or restructure care delivery. Provisions included in H.R. 1 are expected to narrow coverage through new Medicaid work requirements and more frequent redeterminations, resulting in coverage losses for many Californians.
As a result, counties will require significant new resources to rebuild the infrastructure necessary to meet the anticipated increase in the uninsured population. As part of the H.R. 1 County Multi-Year Budget Request, counties are requesting $761 million in FY 2026-27 and $2.4 billion to provide care to eligible individuals returning to county indigent programs.
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