After the One Big Beautiful Bill, Free Clinics Are Stepping Up

This story is part of How We Get By, a KQED series exploring how people are coping with rising costs in the Bay Area and California. Find the full series here.

For Marisol, it’s not strange to feel aches and pains all over her body when she comes home after work. She picks and packages fruit for farms in Contra Costa County. Even when temperatures rise over 100 degrees Fahrenheit, she’s out in the field collecting cherries, peaches, nectarines and apricots.

She knows it takes a toll on her body. “Sometimes you’re so exhausted that it feels like there’s something wrong with your body, and you don’t know if you’re actually sick or just tired,” she said in Spanish.

As an undocumented immigrant without employer-provided health insurance, actually finding out if she’s sick is a luxury. KQED is withholding her full name because publishing it could expose her to potential immigration enforcement. “I either pay my rent or I go to the doctor,” she said.

But in the summer of 2023 — when she began to feel several bumps on her breasts — she decided her health could no longer wait. She went to the one place she knew she could get care at no cost: Hijas del Campo.

Every Tuesday afternoon, the Contra Costa County Department of Public Health parks a mobile clinic outside the nonprofit’s Brentwood offices. The clinic offers limited free care to residents like Marisol who qualify. It’s one of dozens of free clinics across the Bay Area that serve low-income and undocumented immigrants who don’t have access to healthcare.

Free clinics across California are bracing for a surge of uninsured patients as provisions in President Donald Trump’s “One Big Beautiful Bill” take effect, eliminating federal subsidies for some Affordable Care Act plans and tightening Medicaid eligibility rules.

About 160,000 Californians have already lost federal subsidies that made their premiums cheaper and in the coming years, state officials estimate that the number of Californians without health insurance — currently around 2 million — could double by 2030, leaving safety-net clinics to absorb the growing demand for care.

The White House has defended the OBBB, arguing that these changes will help eliminate “waste, fraud, and abuse” from the nation’s healthcare system. But doctors and volunteers who staff free clinics are already seeing people who have lost coverage and warn that a growing uninsured population could negatively impact care for all patients.

How free care works

Free clinics have existed for decades across the Bay Area, offering primary care to those without health insurance. Many serve suburban and rural communities far from the medical infrastructure of the region’s larger cities. But even in San Francisco, free clinics serve thousands each year.

The Clinic by the Bay — located in San Francisco’s Excelsior District, one of the most ethnically diverse neighborhoods in the city — sees many patients who are experiencing a transition that left them uninsured, often a layoff, aging out of their parents’ insurance or migrating to the United States.

“And there’s people who are working but cannot afford their healthcare premiums, so they have decided to go without health insurance,” said Katelyn McMeekin-Jackson, executive director of Clinic by the Bay. She knows many patients by their first name, greeting them warmly when they come through the front door.

There are only a few requirements to get care there, McMeekin-Jackson said. A new patient must share a copy of an ID, proof of income and confirm they do not have health insurance.

More than 200 volunteers — many of them retired doctors, resident physicians and medical students — help the clinic offer primary and ongoing care for those living with chronic conditions, like diabetes.

When a patient needs a service that’s not available in-house, staff work with the clinic’s extended network of physicians who are willing to donate their time. Companies like LabCorp also provide a limited number of free screenings, and skilled nursing homes regularly donate surplus medication.

“A big part of the puzzle is figuring out how we can get around the limitations to get free care,” McMeekin-Jackson said, adding that over the past year, volunteer numbers increased by about 30% to keep pace with the growing number of patients.

“We’re anticipating that patient numbers will grow as premiums increase,” she said. “And there are Medi-Cal changes projected in the future.”

Finding the limits

As Congress raced to finalize the details of the OBBB last summer, lawmakers sought to balance the price tag of other Trump policy priorities — reshaping the nation’s tax system and supercharging immigration enforcement — by freeing up funding elsewhere.

Republicans moved to end the subsidies that lowered the costs of healthcare premiums for millions of people nationwide who bought their plan through an Affordable Care Act marketplace, which includes Covered California.

In 2024, the federal government spent nearly $14 billion on subsidies, which helped millions of Americans enroll in a plan. According to the Kaiser Family Foundation, a San Francisco-based public health research nonprofit, the subsidies lowered the annual premium payment in 2024 from about $1,600 to $900 — a difference of about 44%.

On Jan. 1, the majority of Covered California enrollees saw their premiums rise as the federal government pulled back subsidies. But people making above 400% of the federal poverty level — roughly $62,000 for a single person — began paying the full monthly premium for their health insurance. In the Bay Area, some residents have shared that their premiums have gone up by over 150%.

“We’re getting a lot of calls from people who lost their plan because they couldn’t pay these outrageous new premiums,” said Donna Waldman, the executive director of the Santa Rosa-based Jewish Community Free Clinic.

Waldman, along with a handful of doctors and nurses, started the clinic in 2001. The majority of patients are immigrant farmworkers who power Sonoma County’s multimillion-dollar wine industry. Many are seeing a doctor for the first time in years and are coming in for a one-time check-in — a situation that the clinic is well-equipped for, Waldman said.

“We are not set up to do chronic disease maintenance,” she said. “Our system’s not set up to have you come back every three or four months to get your blood pressure checked — that’s not our type of practice.”

Higher premiums are not just forcing people to drop their plan, but also discouraging those who could qualify for a Covered California plan from signing up.

In Sonoma County, new enrollment this year decreased by 33%, with officials reporting a similar drop statewide. And according to some researchers, the first people to drop their Covered California plans are usually younger, healthier individuals who use fewer benefits. Those enrollees help lower the costs of care for everyone else. But with fewer healthier people in the marketplace, premiums could rise even higher.

When folks call in after dropping their plan, Waldman said the clinic can see them in the meantime, but they also work with the patient to see if they qualify for care at a federally qualified health center — which serve patients on a sliding fee scale, but are subject to income limits and potential immigration rules from the Trump administration.

“We have nothing to lose monetarily from the federal government,” Waldman said. “Free clinics play a really important role in the resiliency of the community right now because we are independent organizations.”

‘Influenza doesn’t know if you have insurance or not’

The OBBB’s next big shock to healthcare is expected at the end of this year. By Dec. 31, states must implement stricter eligibility requirements for patients enrolled in Medicaid — known as Medi-Cal in California, which provides free or low-cost care to roughly 15 million lower-income residents.

In 2010, the Obama administration expanded Medicaid eligibility to include adults aged 19-64 with incomes below 138% of the federal poverty level. In the decade that followed, Medi-Cal enrollment soared, with the biggest increase in that newly-eligible group.

Under the OBBB, Medi-Cal recipients will need to renew their eligibility every six months, instead of annually, and those who are able-bodied and without dependents have to either work, go to school or do community service for at least 80 hours each month.

State officials estimated the new requirements would result in up to 3.4 million Californians losing their Medi-Cal coverage. And because federal funding for Medi-Cal is dependent on how many people are enrolled, the state could lose over $30 billion.

That’s unfortunate, said Ashley Tsang, medical director for the San Francisco Free Clinic, because more people on Medi-Cal means fewer people who are uninsured.

“We were hoping that there were going to be fewer people uninsured as Medi-Cal covered more people,” Tsang said. “At some point, our numbers would have actually dropped.”

The clinic currently sees around 1,500 uninsured patients each year with the help of a few dozen physicians and medical students. Tsang — who helps run the Richmond District clinic along with her husband and fellow physician Ian Nelligan — said the team hasn’t yet needed to expand service hours, but that’s something they are thinking about given the political situation.

“COVID-19 taught us that influenza doesn’t know if you have insurance or not, and people will end up at the emergency department one way or the other,” she said. “We all end up paying for patients who have no health insurance.”

A recent report from the state Legislative Analyst’s Office predicts that care providers — including private and public hospitals that treat patients with coverage — may feel greater financial pressure as the uninsured population grows in the coming years.

Many providers, the report finds, “will still provide some care to these populations without receiving reimbursement,” and as these expenses go up, they may negotiate higher rates with private insurance plans.

Pushing back on closed doors

White House officials have argued that other parts of the OBBB — like larger tax deductibles and expanded flexible spending accounts — will make it easier for individuals to pay for health insurance.

But the administration has made clear the changes will limit access to low-cost care for one group of people in particular: undocumented immigrants. Blocking this group from Medicaid is necessary “to preserve it for hardworking Americans who need it,” press secretary Karoline Leavitt said before the bill’s passage.

The OBBB reduced federal funds that helped states provide emergency Medicaid coverage to undocumented immigrants — a White House memo went as far as calling this move “closing the California loophole.”

This change — along with other expected healthcare cuts from the federal government — prompted state lawmakers last year to block new Medi-Cal enrollment for undocumented immigrants aged 19 and older.

That means Marisol can no longer sign up for Medi-Cal, leaving her with only the mobile clinic outside Hijas del Campo for care.

“This is an injustice,” the farmworker said. “Our work is very intense, and it’s what brings food to people’s tables. But this work is not valued.”

When she first felt those bumps on her breasts in 2023, a doctor at the clinic confirmed she had a tumor — but a benign one that was treated thanks to the county program. Marisol still comes to the mobile clinic for follow-ups.

“People are still going to be sick,” said Hijas del Campo co-founder Dorina Salgado-Moraida, who pointed out that there are thousands of undocumented immigrants in other parts of the state who will be left with no options for care.

“We had some learnings from the pandemic, but then at the same time, we didn’t really learn much,” she said. “We didn’t put systems in place to protect those who are the most essential.”