BAKERSFIELD — In 2021, Bakersfield resident Elizabeth Ramirez’s mother broke three bones in a fall, leaving Ramirez with a new set of responsibilities: cooking and cleaning for her mom, bathing her and driving her to appointments.
“So I was caregiving for her on top of my kids,” Ramirez said. “It was just a lot.”
After a few years of juggling, Ramirez became a registered care provider for her mother through the state’s In-Home Supportive Services, a program provided through Medi-Cal.
“So the work I put into making sure she’s safe and healthy, I get paid for it now,” Ramirez said. “It’s such a good support system that keeps people from drowning.”
No congressional seat in California relies more on Medi-Cal than the 22nd District, which follows Interstate 5 and Highway 99 as they stretch southeast from Avenal and Delano, through almond and pistachio orchards, to Bakersfield.
Two-thirds of residents are enrolled in Medi-Cal, the state’s Medicaid program, which provides health care to low-income residents, people with disabilities and those living in nursing homes or need of a personal caregiver.
The 22nd District is also experiencing an intense political shift.
Back in 2020, voters here supported Joe Biden over Donald Trump in the presidential election by a 55%-42% margin. In November, Trump won the 22nd District, 52%-46% over Kamala Harris. The 19-point shift between 2020 and 2024 was the largest in California, securing incumbent Rep. David Valadao a comfortable victory that helped the GOP maintain control of the House of Representatives.
Connie Conway, the chair of the Republican Party of Tulare County, said Trump drew support from new voters — enough to start a young Republicans chapter in the county — and disaffected Democrats.
“I say this to people all the time, and I know because I’m a lifelong Central Valley girl, ‘We’re pretty conservative no matter what your party registration is,” Conway said.
Across California, Trump made his largest gains in districts like the 22nd — inland, working class, majority-Latino and, according to a KQED analysis, heavily reliant on Medi-Cal.
“We’re not known for our excess wealth, at least in our part of the Central Valley. We’re just hard-working people that share a lot of the same values: family, faith,” Conway said. “I think in this past election, that really resonated with a lot of folks.”
Now, Republicans in Congress are moving ahead with plans to slash the health care program.
House Republicans passed a budget resolution in February that set a goal of $2 trillion in spending cuts. It was the first step toward passing a budget that party leaders hope will include over $4.5 trillion in new spending and tax cuts.
Top Republicans ruled out reductions to Social Security, Medicare and defense, leaving Medicaid as the most expensive program on the chopping block.
The path to achieving the centerpiece of Trump’s legislative agenda could go straight through the pocketbooks of the voters who powered GOP progress in 2024. Cuts to Medicaid, which has enjoyed bipartisan support, could imperil representatives like Valadao and give new life to Democrats looking for ways to reverse their decline in California’s working class communities.
“I don’t want to say that there is an opportunity, since nothing good will come out of this budget, but the opportunity to clarify and define what we as a party are doing in this term of Trump is going to be critical,” said Orrin Evans, a Democratic strategist who has worked on multiple House campaigns in the state. “We have to be united in standing against this.”
KQED cross-referenced district-by-district Medicaid enrollment numbers from the UC Berkeley Labor Center with presidential vote totals from the 2020 and 2024 elections in each of the state’s 52 congressional districts, compiled by the California Target Book.
Of the 13 seats with the largest shift toward Trump in 2024 — the top quartile of districts — eight were among the top quartile in Medi-Cal reliance. Twelve of the 13 had Medi-Cal populations above the state average.
While Valadao voted for the budget resolution, he has expressed concerns for his constituents who benefit from Medi-Cal and said he would not vote for a final budget bill “that risks leaving them behind.” It’s unclear how the party would offset the costs of tax cuts without targeting Medicaid.
Doing so could bring political risk for California Republicans beyond just vulnerable incumbents like Valadao. The GOP made significant inroads in communities still represented by Democrats in Congress — in the Central Valley, Inland Empire and along the state’s southern border — which fueled Republican gains further down the ballot in 2024.
The shifts reflect the acceleration of a yearslong political realignment along educational lines. During the Trump era, Democrats have gained ground in highly-educated suburban areas, such as coastal Orange and San Diego counties, and lost support in more working-class counties further inland.
In November, Republicans scored two shocking victories in state Assembly districts long held by Democrats in Imperial and Riverside counties.
Valadao’s Bakersfield seat fits the profile of these areas in political transition. According to estimates from the U.S. Census’ American Community Survey, nearly 60% of the citizen voting-age population is Latino, the most of any district in California. Meanwhile, fewer than one in 10 residents over age 24 hold a college degree, the lowest share of any district in the state.
“That particular district, President Trump did far better than other Republican candidates had done at the top of the ticket,” said Tal Eslick, Valadao’s former chief of staff, on KQED’s Political Breakdown. “So I think this is an example of a district that’s changing, especially among, I would say, Hispanic males.”
Eslick and Conway attributed the GOP’s 2024 turnaround in the area to a mix of economic concerns, such as the cost of living, and social issues, including the debate over transgender rights.
“If you can imagine a 70-year-old Hispanic female from Corcoran, I don’t think the trans issues or other issues like that resonated with her,” Eslick said. “I think [Democrats] lost many of those folks, and those folks went towards President Trump.”
But it’s exactly in these areas of the state that the health care coverage provided by Medi-Cal is a lifeline for residents, said Scott Graves, budget director at the California Budget & Policy Center.
“In the more rural areas of the state, in farming communities, they’re doing some pretty backbreaking jobs,” Graves said. “They’re not getting very well compensated for it, and they’re very unlikely to be offered a health coverage plan.”
The federal government covers roughly half of most Medicaid costs in California, splitting the expense with the state government. Under the Affordable Care Act, Medicaid expanded to cover Californians making up to 138% of the federal poverty level ($21,597 for a single adult in 2025), with the federal government covering 90% of the new costs.
Medi-Cal dollars are inextricably woven into the local economy in this part of the state. Kaweah Health Medical Center in Visalia is the largest hospital in Tulare County. It’s also the county’s largest employer.
The hospital receives more than 30% of its revenue through Medi-Cal, according to Gary Herbst, Kaweah’s CEO, compared to less than 20% from private insurance. When Herbst first arrived at Kaweah in 1992, that ratio was reversed.
Herbst has begun planning for various scenarios of cuts to Medicaid. If the federal government were to lower its cost-sharing to 45% for both traditional and expansion Medi-Cal enrollees, the loss for Kaweah would be around $60 million a year.
“If we were to lose 50, 60 million dollars a year in Medi-Cal funding, then where would I cut? How many hundreds of people would I have to lay off? How many services would I have to close?” he said. “We’ve never faced losses of this magnitude.”
Doctors and nurses at Kaweah would still be required to provide emergency services to anyone who shows up at the hospital, regardless of their ability to pay. So the cuts could potentially come to services such as colonoscopy screenings, surgeries for hip and knee replacements or primary care visits.
“It’s not possible to cover a $50- to $60-million reduction in funding and say, ‘Oh, we’re just going to stop providing services to Medi-Cal patients,’” Herbst said. “We would literally be forced to close an entire service, probably multiple services, so it would affect all patients that are receiving those services.”
The consequences appeared to be on Valadao’s mind when he spoke on the House floor before voting to advance the GOP budget framework.
“I’ve heard from countless constituents who tell me the only way they can afford health care is through programs like Medicaid, and I will not support a final reconciliation bill that risks leaving them behind,” he said.
Valadao said Congress is faced with “a historic opportunity to advance the key priorities of this administration.” By cutting spending, Congress would be able to extend crucial provisions of the 2017 Tax Cuts and Jobs Act, such as the doubling of the standard deduction and the child tax credit.
After Valadao spoke, Rep. Steve Scalise, the House Majority Leader, said California’s 22nd District “is going to have a very loud voice as this process moves forward.” He said Medicaid could be strengthened by weeding out “waste, fraud and abuse,” without providing details on where that exists in the program.
Valadao declined an interview for this story. Longtime allies such as Eslick and Conway were skeptical that Republicans in Congress would actually carry out large cuts to Medicaid.
“I don’t see a scenario in which Republicans, or for that matter any politician, go after an entitlement program that is pretty popular and obviously a key issue for a large swath of people,” Eslick said.
It seems impossible for Republicans to achieve their ambitious goals for cutting spending without touching Medicaid. The budget plan passed by the House called for $880 billion in cuts over the next 10 years from programs overseen by the Committee on Energy and Commerce. Just $581 billion of spending under the committee’s jurisdiction is for programs other than Medicaid, according to the Congressional Budget Office.
Valadao is a political survivor, one of just two Republicans left in the House who voted to impeach Trump in 2021, but he’s not immune to the high-stakes politics of health care. In 2017, he voted to repeal the Affordable Care Act. A year later, he lost his campaign for re-election.
“David Valadao has a very clear choice: he can vote on behalf of his district or he can take another step towards a successful lobbying career which he will assume as soon as he is defeated,” said Evans, the Democratic strategist. “Voting for this draconian budget, there is no argument in how it would advance or help constituents in his district.”
Another clue about Medicaid’s political potency lies in a little-noticed ballot measure passed in November by California voters. Proposition 35 extended a state tax on providers of health care plans and restricted the revenue to fund Medi-Cal.
The initiative passed overwhelmingly with 68% of the vote — outpacing other ballot measures with similar levels of bipartisan support — and it tallied 70% approval in those 13 seats that saw the largest shift toward Trump.
Dustin Corcoran, CEO of the California Medical Association, which represents physicians in the state, said Medicaid is often a blind spot for policymakers and elected officials, who typically receive health coverage on the private market.
Corcoran saw a different reality as he traveled the state as co-chair of the Proposition 35 campaign. One stop took him to the campus of the UC Merced, in the heart of the 13th Congressional District, which has the third-highest Medi-Cal population and fourth-largest shift toward Trump.
He asked this icebreaker: Who knows what Medicaid is?
“Every hand went up,” Corcoran said. “Every single hand in the room.”
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