In Los Angeles, physician assistant Brett Feldman starts each day searching for patients on the streets and in tents, looking for people he said need care the most and often have the hardest time reaching it. On a brisk January morning, Feldman and his USC Keck School of Medicine street medicine team found that many of the people they usually treat had moved after a winter storm, complicating outreach and follow-up. Feldman said he and other street medicine providers across California fear that changes to Medi-Cal eligibility tied to President Donald Trump’s Medicaid work mandate—part of his “One Big Beautiful Bill” proposal—could cause many unhoused Californians to lose insurance, limiting what medical teams can do.

The proposal would require states starting in 2027 to verify that able-bodied adults younger than 65 without dependent children are performing 80 hours or more of work each month in order to qualify for Medicaid. It would also require states to verify income and other eligibility criteria every six months rather than once per year. In California, state officials estimated that up to 2 million people—about 14% of the state’s 14 million Medi-Cal recipients—could lose coverage, either because they do not meet the work requirements or because they get overwhelmed by the paperwork.

For people experiencing unsheltered homelessness, the practical obstacles are likely to go beyond completing paperwork. Feldman said many of his patients do not have phones or internet to apply for jobs and have limited access to meals, showers or clean clothes. He said many face addiction or mental health conditions and may not have the ability to work, and that health conditions often track to the same people least able to meet new work-activity rules. “It’s very possible over 90% of people experiencing unsheltered homelessness will lose insurance,” Feldman said.

Medi-Cal’s exemptions for people who cannot work are central to the debate over how many people could be affected. The law carves out exemptions for people who can’t work, including those with substance use disorders, disabling mental health conditions, complex medical conditions and other disabilities. It also exempts children, people who are pregnant, foster youth and those with disabilities, though Feldman and other providers say frequent re-verification could still create problems for those whose eligibility depends on documentation.

On paper, many homeless Californians could qualify for exemptions, according to reports cited by street medicine clinicians. Nearly half of homeless Californians have a complex behavioral health need, including regular drug or heavy alcohol use, hallucinations or recent psychiatric hospitalization, according to recent reporting from the UCSF Benioff Housing and Homelessness Initiative. The same reports cited by street medicine providers said about 60% have at least one chronic condition, and roughly a third have conditions that make bathing, dressing or eating difficult. But Feldman’s team said that to claim an exemption, a patient needs a doctor to certify it—and that could be a high bar for people who rarely get regular care.

The Benioff Housing and Homelessness Initiative data cited in the reporting also suggested only about half of insured and unhoused Californians regularly get care, and that only 39% have a primary care provider. In Los Angeles specifically, a USC Street Medicine program study cited in the story said just 7% of the population had seen a provider in the past year between 2022 and 2023, meaning few people could have exemptions medically certified in time. That concern shows up in individual cases: the story described Samantha Randolph, a 37-year-old who has lived on the streets of Los Angeles for more than five years, saying she would not know where to start finding work if required.

Randolph’s situation illustrates how administrative errors can compound medical fragility. The reporting said Randolph’s ID was damaged and she threw it away, and that someone stole her phone months earlier, leaving her with no recent work experience. The story said Randolph is seven months pregnant and would qualify for an exemption from the work requirements once the changes take effect in 2027. Even so, her Medi-Cal coverage expired six weeks before Feldman’s visit because the county enrollment office mailed paperwork to an address where Randolph does not live, according to the reporting. Without Medi-Cal, which the story said pays for maternity housing in the city, Feldman could not get her inside.

Feldman described the effort to fix Randolph’s coverage as slow and contingent on missing documents. His benefits team worked to re-enroll her, the story said, but Randolph faced the kind of documentation bottlenecks that can derail eligibility in programs that depend on paper verification. Feldman told Randolph during the visit that he wanted to get her somewhere safe and cozy, and the story reported that after the county approved her application later the same day, Randolph qualified for maternity housing.

California officials are trying to reduce those disruptions by building an eligibility verification system that can automate compliance checks and exemptions. Tyler Sadwith, the state Medicaid director at the Department of Health Care Services, said California is treating the work as a top priority and seeking to minimize harm to members. The state, the story said, is looking to purchase workforce data to capture gig workers and more timely information about income than tax returns, and it already uses IRS data and information from other welfare programs such as food stamps and cash assistance to verify Medi-Cal eligibility.

The state is also seeking additional data sources to support exemption categories. The reporting said California wants to use information from state universities and colleges to exempt income-eligible students, and it is identifying medical diagnosis codes that could be used to exempt people with disabilities or other qualifying conditions such as mental health or substance use disorders. State officials said that if the data can be linked, some eligible and exempt recipients might be renewed without providing additional information, and might receive a notification that they have been successfully renewed.

Still, the reporting described gaps that could be hard to fill with automation. Evidence of volunteer work does not exist in large databases, the story said, and it is unclear whether federal requirements would mandate that diagnosis-code based exemptions be reverified by a provider every six months. Officials also acknowledged that in states that have previously implemented work requirements, eligible people still fell through the cracks. Matt Beare, a street medicine physician in Kern County, said falling through the cracks is the norm for people who are unhoused, adding that people already lose Medi-Cal coverage “all the time,” and that the new requirements would make it more likely.

Concerns extend beyond insurance cards to access to the care and housing supports that can hinge on coverage. The story said California has invested in street medicine teams over the past five years, with teams delivering primary care wherever people are living, providing wound care, medications and help with substance use disorder treatment. The teams also often include benefits counselors, social workers and housing specialists, and the reporting said those Medi-Cal investments have helped chip away at homelessness. But some providers predict that if large numbers of patients lose Medi-Cal, street medicine teams may become financially harder to sustain.

Kelly Bruno-Nelson, an executive director with CalOptima, said it would be “very fiscally difficult” to sustain programs that support people if coverage drops. Gray Miller, chief executive of Titanium Healthcare, described a pattern in which people without Medicaid coverage end up cycling through emergency rooms, saying they can spin through care while remaining unable to stabilize. In the final reporting on Randolph, the story described Feldman returning to Los Angeles hours after he found her and smiling after the county approved her Medi-Cal application—an outcome the providers say shows how coverage decisions can shift rapidly when documentation barriers are overcome, but also how fragile those outcomes can be for people without consistent access to paperwork.

Sources list:

  • Associated Press (Kristen Hwang/CalMatters), distributed through partnership with The Associated Press.