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Undocumented, low-income immigrants in California who are covered by Medi-Cal health insurance are likely to face challenges moving forward – a combination of budget cuts coming down from the state and federal levels.

And the ongoing immigration enforcement and mass deportations under the Trump administration also are stoking worries among migrants that are keeping some from accessing health care.

“The fear, especially in our rural locations, it’s really been at an all time high,” said Justin Preas, CEO of Fresno-based United Health Centers of the San Joaquin Valley, referring to patient apprehension over the prospect of immigration raids and federal threats of mass deportations. “I’ve been here 20 years and you see these things kind of happen, and then they kind of calm down, and then they kind of happen. But it’s never been like it is now, ever.”

Shortly after President Trump took office in January, federal Immigration and Customs Enforcement agents turned up at a UHC clinic in Dinuba looking for a specific person, but it turned out they were at the wrong location. And while that spurred a flurry of false rumors on social media about a larger raid, Preas said there have been no repeat visits by ICE to any United Health Centers locations.

Still, he said, the combination of cuts and fear poses a formidable threat to health and wellbeing of the region’s immigrant communities and California’s critical agriculture workforce.

“It’s really unfortunate that where we’re going, where things are going right now, that we’re disregarding so many people that are just a fabric of our communities,” he said. “If we think that just because we’re going to take away their Medi-Cal cards, (that) they still won’t need health care, then that’s a terrible misconception.”

Medi-Cal is California’s incarnation of the federal Medicaid program for low-income and disabled people. California is one of only seven states in the U.S., plus the District of Columbia, that offers public health coverage to some or all low-income adults regardless of immigration status, and one of 14 states plus D.C. that provide medical coverage for children regardless of their immigration status, according to KFF, an independent health policy and information organization.

CalMatters, a nonprofit, nonpartisan news organization, reports that about 1.6 million undocumented immigrants in California are enrolled in Med-Cal.

That coverage is being targeted, however, as Congress and the Trump administration seek to cut Medicaid spending and curtail or eliminate public benefits to undocumented immigrants. Meanwhile, California looks to ease its own state budget woes.

Those effects are likely to be magnified in the San Joaquin Valley, a region in which poverty, unemployment and reliance on Medicaid/Medi-Cal are far higher than California as a whole. The region is also dominated by agriculture, an industry that includes a workforce that’s largely Hispanic or Latino.

Even before California expanded its offer of Medi-Cal coverage to undocumented adults in 2024, two-thirds of the 1.1 million San Joaquin Valley patients receiving care at clinics under the Federally Qualified Health Center program were Medi-Cal enrollees, according to data from the U.S. Health Resources & Services Administration for 2023, the most recent full calendar year for which information is available. About 31% of the clinics’ patients were either agricultural workers or their family members.

Budget actions will pare services

California expects to spend almost $197 billion on Medi-Cal in 2025-26, according to the state Health and Human Services Agency. Well over half of that will come from the federal Medicaid program.

But in the face of budget woes, California is tightening its purse strings for Medi-Cal, particularly from the general fund portion of the state’s overall budget.

The new state budget adopted by the California Legislature, which took effect July 1, incorporates several significant provisions that will limit or eliminate some health services for residents with “unsatisfactory immigration status” – bureaucratic jargon for undocumented immigrants who are not eligible for federal Medicaid coverage.

Among those actions under the state Health and Human Services Agency’s budget:

Freezing new enrollments for full-scope Medi-Cal coverage for undocumented immigrants ages 19 and older, starting no earlier than January 2026. This measure is projected to create almost $78 million in general fund savings to the state in 2025-26 and up to $3.3 billion by 2028-29.

Eliminating full-scope dental benefits for undocumented enrollees ages 19 to 54 starting in July 2026. Emergency and restricted-scope dental coverage would still be available to such patients. This change is estimated to save the state’s general fund $308 million in 2026-27 and $336 million annually in following years.

Eliminating a “prospective payment system” covering care funded only by the state to undocumented immigrants starting in July 2026, instead shifting to a system in which care providers are reimbursed on a fee-for-service basis. The shift is projected to save the state $1 billion in 2026-27 in general fund spending, and $1.1 billion each year in subsequent years.

Charging a $30-per-month premium for Medi-Cal coverage for undocumented enrollees ages 19 to 54, starting in July 2027. The estimated general fund savings are $695.7 million in 2027-28 and $675 million annually in subsequent years.

Putting in place a program to seek pharmacy drug rebates for the state for undocumented immigrants, resulting in general fund savings of about $370 million in 2025-26 and $600 million in 2026-27 and beyond. Additional savings from minimum rebates for HIV/AIDS and cancer drugs are estimated at $75 million in 2025-26 and $150 million in following years.

Those state Medi-Cal changes are on top of what Preas, the United Health Centers CEO, believes could be additional punitive actions against California by the Trump administration over coverage for undocumented immigrants.

“What is the funding going to be like from the federal government to the state?” Preas said in a recent interview with the Central Valley Journalism Collaborative. “Obviously they (the Trump administration) are trying to push the state to no longer insure undocumented people at all or provide any kind of public benefits to undocumented people.”

“And if California does, they’re going to be penalized by less (federal) funding and matching for the program, even if state dollars are used only for the undocumented, which is the current situation,” he added.

The federal Medicaid program is already in for significant spending cuts under terms of a whopping budget-reconciliation bill, the One Big Beautiful Bill Act, narrowly approved by Congress and signed into law earlier this month by President Donald Trump. That legislation slices more than $1 trillion in spending from Medicaid over the next 10 years.

Current U.S. law already bars undocumented immigrants from eligibility for federally-funded Medicaid coverage in most instances. Among the notable provisions in the new federal law is a restriction on Medicaid eligibility for some lawful immigrants who are eligible under current law. Those who will no longer be eligible include refugees, people who have been granted asylum and abused spouses and children.

KFF Health News reports that the new law also imposes on states, including California, rules for a work or service requirement of at least 80 hours per month for people ages 19 to 64 to be eligible for Medicaid unless they are medically frail or are parents who have children under 13; and to begin charging $35 per service for covered adults for certain services in California and 39 other states where Medicaid coverage was expanded under the Obama-era Affordable Care Act.

Between reductions to Medicaid and the Affordable Care Act, the nonpartisan Congressional Budget Office estimates that about 11 million people nationwide will lose health insurance coverage by 2034.

Immigration enforcement fears abound

The federal Medicaid cuts and the state Medi-Cal changes aren’t the only things confronting undocumented immigrants in the Valley and California. Highly publicized enforcement raids by U.S. Immigration and Customs Enforcement, or ICE, to round up undocumented people have many migrants scared, to the point where they are passing up already scheduled medical appointments at health clinics in the Valley.

At United Health Centers, which operates about three dozen individual clinic sites in Fresno, Kings and Tulare counties, there’s been a 10% to 15% increase in no-shows by patients for their appointments in recent months.

“We hear these things in the news (that) it’s not just undocumented people that are being detained, and it’s people that have authorized work permits, that are actually here legally, that are getting swept up in these things,” Preas said of recent ICE raids.

Earlier this year, after President Trump took office in January, his administration rescinded a policy that largely prevented federal immigration agents from conducting enforcement activities, including arrests or detentions, at healthcare facilities, churches, schools and other “sensitive” locations.

Shortly after the president was sworn in, ICE agents turned up at a UHC clinic in Dinuba looking for a specific person, but it turned out they were at the wrong location. And while that spurred a flurry of false rumors on social media about a larger raid, Preas said there have been no repeat visits by ICE to any United Health Centers locations.

Of five other nonprofit FQHC organizations based in Fresno, Kings, Tulare and Madera counties, four did not respond to queries about whether ICE agents had shown up at any of their clinics or how appointment no-show rates have changed over fear of immigration raids.

Graciela Soto-Perez, CEO of Tulare-based Altura Centers for Health, told CVJC that there had been no ICE raids at any of its seven physical or mobile clinics. Soto acknowledged that no-shows were up this summer, but added that “visits usually drop in the summer, slightly, so I don’t know if it’s due to the surrounding raids.”

Clinics including those operated by United Health Centers, Golden Valley Health Centers headquartered in Merced and Stockton-based Community Medical Centers are working to make sure patients know that they are doing what they can to protect their privacy, including information about immigration status.

“We’re doing everything we can to work with them and reassure our patients that they’re in a safe place and when they come to see us, and that when they come in, their health information is private,” Preas said. “We don’t release their information to anybody. We don’t allow people into non-patient care areas that shouldn’t be there and don’t have a right to be there.”

“And our site management staff is very well trained and versed on how they would handle those things if somebody wants to come in that wants access to certain things,” he added.

The overall situation is one that has Preas worried about the political treatment of Valley’s migrant community, particularly agricultural workers.

“Especially in our rural communities … we have the privilege of taking care of the people that are there, and the work that they do is basically feeding the world,” Preas added. “The least we can do is take care of them and make sure that they are healthy and their families are healthy, because they’re doing work that not everybody would do. … We owe them that gratitude for the work they do every day.”

Tim Sheehan is the Health Care Reporting Fellow at the nonprofit Central Valley Journalism Collaborative. The fellowship is supported by a grant from the Fresno State Institute for Media and Public Trust. Contact Sheehan at tim@cvlocaljournalism.org.

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The call that would upend his life came 11 years ago.

His daughter had hanged herself; she was now on life support.

He rushed to her bedside, but eventually the time came when the machine would be turned off.

The father placed his hand on his daughter’s chest, found her heartbeat and willed her to push through.

Her heart slowed and slowed and slowed. Then it stopped.

She was gone.

The anguish crashed down on him like a tank, compounding the despair he carried after another suicide 14 years earlier. He and his brother had found his father, a Vietnam War veteran, dead from a self-inflicted gunshot wound.

In an interview, the 54-year-old suicide prevention case manager with the Department of Veterans Affairs painfully recalled his agonizing journey, which also included beating cancer, as he grappled with a new crisis of his own.

The world he turned to for salvation — returning to school at age 46, specifically to become a social worker so he could work in suicide prevention with veterans — was now in turmoil.

Like the roughly 2 million workers across the federal government, he is watching his colleagues and the veterans he’s trying to help lose their livelihoods or weather a barrage of messages that federal workers have no value — often coming directly from the president and the people he has empowered.

The White House did not return a request for comment.

“When you have a purpose in life and you found your thing, and then all of a sudden it’s being destroyed — you lose all hope,” the suicide prevention manager said, his voice fading. The federal worker, like others quoted in this story, asked that he remain anonymous for fear of reprisal. “I hurt for everybody who’s impacted by it, you know? I mean, I hate to say it, but I work in suicide prevention and I had thoughts. I’ve had thoughts of not wanting to be here anymore.”

NBC News spoke with 20 federal employees across agencies. Spanning the country, these workers lost their jobs, watched co-workers lose them or endured what amounted to a Goliath joyously stomping on David. In interviews, federal workers — many of whom are veterans — told of overwhelming stress, personal crises, suicidal ideation, rapid weight loss, prolonged lack of sleep, panic attacks and visiting the emergency room after a mental breakdown.

They’re facing bombardment from every angle, some showing screenshots to reporters of offensive messages delivered over text and social media, which in turn echo misinformation that billionaire Elon Musk has elevated on his X platform — for example that federal workers are lazy, that they themselves are a source of waste and fraud, and that they don’t bother to come to the office.

Some, particularly veterans or those who assist veterans, expressed fury they’re being denigrated by Musk and a president who never wore a military uniform. Trump, a president for whom some of them voted, even posted an insulting meme about federal workers on his Truth Social account that showed an image of the cartoon character SpongeBob holding a list.

It read, “Got done last week,” an apparent reference to Musk’s request of federal workers that they send an email pointing to five things they did at work. “Cried about Trump. Cried about Elon. Made it into the office for once. Read some emails. Cried about Trump and Elon some more.”

Sarah Boim, a 38-year-old who was fired from her job with the Centers for Disease Control and Prevention in Atlanta, said she grew so distraught that her therapist told her to find a psychiatrist and immediately get on an antidepressant. Boim said she and her husband cannot pay their mortgage on one income and she is desperately searching for work.

“Your career is ripped away from you, with no money to move forward,” Boim said. “I have bipolar. It’ll mess up my life if I have an episode. So we’re just trying to be really careful. I’m hearing stuff like that across the agency.”

“I knew there would be reorganization. I wasn’t expecting this level of chaos,” Boim added. “Taking a sledgehammer approach and having an unelected billionaire in my email is just insane. What are his qualifications for doing this? The government is not a startup; we have been in business since 1776.”

Some who voted for Trump said they regret believing him as a candidate when he said he rejected Project 2025, whose co-author Russell Vought said he wanted to put federal civil servants “in trauma.” Once in office, Trump tapped Vought to lead the Office of Management and Budget, a powerful post.

“We want the bureaucrats to be traumatically affected,” Vought said in a speech in the lead-up to the Nov. 4 election. “When they wake up in the morning, we want them to not want to go to work because they are increasingly viewed as the villains.”

So far, they say, Vought is succeeding.

One Department of Defense employee who did two tours in Iraq said his post-traumatic stress disorder was triggered to the point that he called a suicide hotline, then visited an emergency room at a veterans hospital. The employee said he and colleagues felt unspeakable frustration and anger after relentless mocking by Musk that was supported by Trump, who he said appeared to be delighting in the distress of his own workforce.

The worker said his episode emerged the weekend Musk made a display of joyously lifting a chain saw while appearing at a conservative conference. In that same period, employees were deluged with messaging from Musk’s Department of Government Efficiency, or DOGE, that ranged from termination notices to confusing emails that were often contradicted by supervisors.

“It’s not about the layoffs. It’s about a dehumanization of who we are and what we do,” he said, noting he voted for Trump because he liked what the president did in his first stint in office. Now, he said, he carries guilt over his Trump vote after he watched co-workers and other veterans at the emergency room. “We don’t do it for the applause. We do it to serve our country and serve our community. You get into public service not for the money but because you want to be part of something greater than yourself.”

Katherine Freeman had been working for 10 months as an administrative assistant for the CDC specializing in tuberculosis when she received a mass email saying she had been fired because of her performance. She had received only positive performance reviews and was in line for a promotion.

“This really knocked me off my feet to get a generic letter that is basically a template. It didn’t even have my name on it. It was just attached to an email,” said Freeman. “To tell people who are performing well that they’re being terminated for poor performance and you’re not getting a severance package, that’s just a cruel way to to handle your employees. I think that’s what people are upset about.”

“Everybody understands that the government needs to spend less money, and we get that. But if you’re going to do a layoff, do a layoff the right way.”

One VA worker who was just fired, a mother of three young kids, said colleagues all around her are sinking into hopelessness.

“You wonder what is going to happen in the world, in general. What will that look like for our children?” she said. “For other people’s kids, they say, ‘It’s not just my life, but my children’s lives. Where are we going?’”

A different VA worker who served in the Navy for more than a decade described having dropped 20 pounds in a month and losing her hair. She, like others, described behavior from Musk and Trump as taunting and triggering a sense of powerlessness and anger. Reaching a breaking point, she called a suicide hotline for help.

“Serving my vets is what I live for. They need me. They need an understanding person on the other end of the phone call,” said the woman. “I will be destroyed if they fire me.”

None of the workers opposed cutting excess. But many described what they saw playing out in their agencies as chaotic and haphazard — like rushing to push boxes off a sinking Titanic without looking at what was inside. Some said their abrupt dismissal would leave programs in the lurch, like those that help farmers or facilitate trade for small businesses.

“I’m like so many other government employees I talked to. It’s their f—–g mission in life to help veterans who are struggling. Please quote me on that,” the VA suicide prevention manager said. “I’ve yet to have a person that can, to my face, tell me that my job is not needed. I just tell people what I do and ask them to explain to me: What part of my job is waste or fraud?”

The defense employee, whose job entails refurbishing and updating technology on Navy ships, said the constant attack on federal workers has made him want to walk away, move to the private sector and draw a bigger salary. But he recalled during one of his Army tours in Iraq that his unit needed armor reinforcement on its Humvee. A federal worker came through for him in that perilous moment.

“I get to do that now, with sailors in the Navy. I’m working to help sailors in the Navy be prepared to engage the Chinese if they go after Taiwan,” the defense worker said. “I’m not going to quit, not going to give up. Because I’m not just giving up on my country, I’m giving up on the sailor and the war fighter that is going to be in immense danger if I do that.”

“That’s what a lot of us are remembering: what we do and why we do it, and it’s bigger than this stupid political stuff. This is people’s lives.”

If you or someone you know is in crisis, call or text 988 to reach the Suicide and Crisis Lifeline or chat live at 988lifeline.org. You can also visit SpeakingOfSuicide.com/resources for additional support.