Democrat Xavier Becerra frequently highlights his legacy of expanding healthcare access as he campaigns to succeed two-term Governor Gavin Newsom. By the time the former congressman and U.S. Secretary of Health and Human Services left Washington, D.C., more Americans than ever had health insurance, thanks in part to his years of work to pass, defend, and expand the Affordable Care Act. However, if Becerra wins the November election, he will inherit a steep decline in healthcare coverage that is projected to hit his home state exceptionally hard.
By 2030, the number of uninsured Californians under the age of 65 is projected to nearly double, rising from 2.4 million to 4.6 million, according to a May analysis by the University of California, Berkeley Labor Center. This anticipated surge is driven by recently enacted state and federal cuts to Medicaid and the Affordable Care Act marketplaces, which are beginning to dismantle historic gains in health coverage. The sharp increase in the uninsured population could have severe consequences for hospital networks, insurance providers, and the broader economy.
The impact of these cuts is already reverberating through the system. In February, Miranda Dietz, the healthcare program director for the UC Berkeley Labor Center, informed state legislators that the policy shifts could ultimately cost California approximately 200,000 jobs, primarily within the healthcare sector. Hospital executives are already reporting an increase in unpaid medical bills, and policy experts warn that insurance plans will raise premiums as their risk pools are left with enrollees who are, on average, sicker and more expensive to cover. Jessica Altman, the executive director of Covered California, the nation's largest state-run health insurance marketplace, described the incoming administration's challenge bluntly: "It's triage. That's what the next governor is walking into."
California previously achieved one of the most significant drops in its uninsured population in the country, largely due to its enthusiastic implementation of the Affordable Care Act. If elected to lead the state, Becerra will have to manage how uninsured residents receive care and who covers the costs as the Trump administration scales back the federal safety net he once managed. Becerra has a history of challenging Washington; during his tenure as California's attorney general, he successfully defended numerous provisions of the Affordable Care Act, including access to birth control.
To combat the impending crisis, Becerra has stated he would issue an executive order to keep those affected by federal cuts insured. However, he has not yet detailed how California would replace the up to $30 billion in federal funding the state stands to lose annually. Speaking at a policy forum hosted by Politico, Becerra promised that Californians would not lose their coverage despite the federal scale-back. He suggested he would pressure the healthcare industry to eliminate administrative waste from "attorneys, accountants, pencil pushers" that costs consumers billions of dollars. "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," Becerra said.
His Republican opponent, former Fox News commentator Steve Hilton, is campaigning on a different approach. Despite receiving an endorsement from President Donald Trump, Hilton is attempting to appeal to voters who oppose the president. Hilton has focused his platform on cutting off state-funded healthcare coverage for California residents without legal status. He has pledged to redirect those savings into state income tax breaks, framing the move as an immediate solution to high living 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." Hilton has also criticized state leaders for passing a revised provider tax that he claims will cause premiums to soar, calling for more competition in the insurance market, though he has not provided specific details on how to achieve this.
Becerra's deep ties to federal healthcare policy date back to 2010, when he was a member of U.S. House Speaker Nancy Pelosi's leadership team and helped secure the votes to pass the Affordable Care Act. He also assisted in drafting the legislation, though his effort to include a government-backed public option failed. A decade later, during his confirmation process for the nation's top healthcare post, Becerra pledged to execute President Joe Biden's goal of expanding access and lowering costs under the law.
Before the Affordable Care Act, roughly 50 million Americans—about 1 in 6—lacked health insurance. Following its passage, the expansion of Medicaid eligibility and financial subsidies for lower-income marketplace enrollees cut the national uninsured rate nearly in half. During the COVID-19 pandemic, millions more gained coverage after Becerra implemented a freeze on Medicaid disenrollment and distributed temporary tax credits that made insurance plans more affordable. As health secretary, Becerra also launched public awareness campaigns, extended enrollment periods, and distributed hundreds of millions of dollars in grants to fund healthcare navigators who assist consumers with enrollment paperwork. Under the Biden-Harris administration, the U.S. insured rate reached a record high of 92% in 2024, representing 310 million covered Americans. Benjamin Sommers, a Harvard health policy professor who served as a deputy assistant secretary under Becerra, recalled that the secretary frequently asked his team, "Who's being left behind?"
Conservatives, however, argue that these policies artificially inflated enrollment by enabling fraud and waste. Edmund Haislmaier, a senior research fellow at the Heritage Foundation, argued that high enrollment numbers are the wrong metric for success. "It's simple and easy to say, well, the numbers are up so the program must be working. My argument would be that's the wrong metric," Haislmaier said. Last summer, the Republican-led Congress passed Trump's One Big Beautiful Bill Act, which supporters argued protects Medicaid for those who need it most while targeting waste. The law is projected to cut federal Medicaid spending by more than $900 billion over the next decade. Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, observed that the federal government is now executing "almost a wholesale reversal of pretty much all those policies" that previously expanded coverage.
For some residents, the rising costs are already unsustainable. Eric Maciel, a 28-year-old Californian, said the $800 monthly cost of a Covered California plan is unaffordable. To avoid injuries that could lead to medical debt, Maciel has started staying home more often and rarely plays pickup soccer. "That's another car note," Maciel said of the premium. "I'd be left with nothing." Health economists note that young, healthy individuals like Maciel are exactly the types of consumers insurance companies need to balance risk pools and stabilize premium costs.
Amid rising state costs and federal reductions, California has already begun pulling back on some healthcare spending. Federal funds represent one-third of the state's overall budget and cover more than 60% of spending for Medi-Cal, California's Medicaid program. Governor Newsom has frozen enrollment for undocumented immigrants, introduced monthly premiums for certain enrollees, and plans to only temporarily backfill federal assistance for legal immigrants and refugees. Newsom and Democratic lawmakers agreed to delay some of these spending cuts until July 2027, passing the decision on further rollbacks or potential tax increases to the next governor.
Becerra, a California native born to Mexican immigrants, opposes the "billionaire tax" on the November ballot. However, he recently expressed support for legislative measures that would penalize large corporations whose employees rely on Medi-Cal, arguing that taxpayers should not have to subsidize low wages and poor benefits. Meanwhile, county governments, which are legally mandated to provide healthcare to low-income uninsured residents, are lobbying state lawmakers for emergency funding to manage an expected wave of patients seeking free care. "It's a pretty big cliff if all this stuff goes into effect," Dietz warned. "And there's a choice whether to make it less bad and maintain coverage for folks."
