They voted for Trump — now his Medicaid cuts could leave their clinics and coverage at risk.
In rural parts of California’s Central Valley, where sun-baked highways connect towns with few doctors and even fewer hospitals, majorities of voters supported Donald Trump in the 2024 election. Now, after the passage of the “Big Beautiful Bill” — Trump’s signature federal budget reform — some of those voters are at risk of losing access to health care.
That’s because the bill includes some of the deepest cuts to Medicaid in a generation. In California, where the program is called Medi-Cal, millions of low-income residents could feel the impact. Clinics, hospitals and safety net providers across the state are bracing for what comes next.
Signed into law by President Trump on July 4, the “Big Beautiful Bill,” officially called 2025 Federal Budget Reconciliation Bill, allows for sweeping cuts to federal spending — mostly to fund the extension of tax cuts passed during Trump’s first term. While Medicare and Social Security remain relatively untouched in the bill, Medicaid is a primary target. And with almost 15 million Californians, more than a third of the population, enrolled in Medi-Cal, the consequences could be massive.
Three key changes could hit Medi-Cal enrollees especially hard:
• Work requirements: The bill requires adults without disabilities or dependents under the age of 13 to prove each month that they’re working or actively seeking work to stay enrolled. Analysts warn that red tape and reporting failures could push hundreds of thousands of patients off the rolls — especially those in unstable jobs or caregiving positions.
• Penalties for immigrant coverage: The law penalizes states for using their own funds to cover undocumented immigrants through Medicaid. In response, California may have to reduce spending elsewhere — potentially cutting services such as prenatal and elder care that benefit the broader population.
• Restrictions on funding mechanisms: The new law limits states’ ability to use provider taxes, such as payments from hospitals and other health providers, to trigger matching federal Medicaid funds. As a result, California could face a multibillion-dollar shortfall in its Medi-Cal budget.
Considering the potential impact of such cuts on the health and economic wellbeing of low-income voters, the question becomes, why would so many of them support a candidate whose policies work against their interests?
“So in the United States, people don’t necessarily know that what they get is a social program, and they don’t necessarily connect their benefits to the state,” said Shana Kushner Gadarian, a political scientist at Syracuse University who studies voter behavior. “So Medicaid is one of these programs. It’s not that people don’t know they have Medicaid, but it has different names in different states. And part of that is because the federal government, in order to do policymaking, often does this submerged thing where they make policy without making it clear that they’re taxing people or that people are getting direct benefits.”
In many of California’s congressional districts, Medi-Cal accounts for billions in federal and state health funding. In California’s 22nd congressional district, which includes parts of Bakersfield, for example, total Medi-Cal spending reached nearly $5.8 billion in 2024, according to an analysis by the California Budget and Policy Center.
“That means people are accessing healthcare,” said Adriana Ramos-Yamamoto, Senior Policy Analyst at the Center. “But it also means that there are a lot of hospitals and providers who rely on this funding to meet their bottom lines.”
If the federal funding disappears, the consequences likely won’t be limited to Medi-Cal recipients, according to Ramos-Yamamoto. Rural hospitals, clinics and safety net providers — many of which already operate on thin margins — could be forced to reduce services, lay off staff or shut down altogether. That would threaten access to care for entire communities, regardless of insurance status.
“When we talk about the large-scale cuts, it is going to impact everyone,” Ramos-Yamamoto said. “When people hear it, they might think, ‘Oh, this is going to take away healthcare for people who are undocumented.’ But actually this is going to be a devastating loss to our state budget and would impact so many more people.”
The numbers tell the story.
To understand which areas of California relied most on Medi-Cal, The Intersection analyzed data from all 58 counties — combining 2024 election results with 2023 census figures on poverty, disability and race/ethnicity, as well as 2023 Medi-Cal enrollment records from the California Department of Healthcare Services. Census data is not yet available for 2024.
The results weren’t surprising at first: counties with higher poverty rates and larger Hispanic populations tended to have higher Medi-Cal enrollment rates. Disability rates followed a similar pattern but added only a small amount of clarity relative to the other factors. One finding, however, did stand out: Even after accounting for poverty and Hispanic population share, counties where a majority of voters supported Trump in the 2024 election had higher Medi-Cal enrollment rates than counties that didn’t. This trend is particularly true in the Central Valley, where 16 out of 18 counties across the Sacramento and San Joaquin valleys voted for Trump and show higher Medi-Cal enrollment than counties where he didn’t win.
Here’s how the numbers break down:
• Poverty: A county that is ten percentage points poorer tends to have about 40 percent more of its residents on Medi-Cal.
• Hispanic share: A ten-point rise in Hispanic population corresponds to roughly 7 percent more people on Medi-Cal.
• Trump vote: Even after adjusting for poverty and hispanic share, Trump-voting counties still sign up about 12% more residents for Medi-Cal than counties that didn’t vote for him.
That 12% represents thousands of people in the California counties that voted for Trump. For example, in Fresno County, which has a population of about 1 million residents, that translates to roughly 45,000 more Medi-Cal enrollees than in similar counties where a majority voted against Trump. In other words, even after accounting for Fresno’s higher poverty and Hispanic shares — the factors the model already links to greater Medi-Cal enrollment — about 45,000 additional residents relied on Medi-Cal at the time the data was collected. The numbers highlight a stark paradox: many of the communities that helped reelect Trump depend even more heavily on Medi-Cal than their demographics alone would suggest. These are the same places where budget cuts to the program could hit hardest, threatening the health coverage of thousands of residents.
The Intersection contacted all nine Republican members of California’s congressional delegation twice. Most represent districts heavily dependent on Medi-Cal and all voted for the “Big Beautiful Bill.” Seven of the members did not respond. Rep. David Valadao declined to comment. Rep. Darrell Issa sent a brief written statement voicing strong support for the work requirements in the bill, calling the reforms “on track for extraordinary success” and citing positive feedback from constituents.
Why Voters Support Cuts to Programs They Rely On.
Experts say there’s no easy answer.
At the most basic level, many people simply don’t vote based on specific policies, according to Kushner Gadarian. Instead, she said, most voters make decisions based on party identity first, then adopt policy positions as a consequence.
“You end up having what seems to be a puzzling set of behaviors, which is sometimes people align with a party for reasons that have nothing to do with their economic self-interests,” she said. “They align with the party because it has values that they appreciate because their parents or other people who live around them have those same values.”
Another factor, Kushner Gadarian said, is the message coming from candidates. For example, Trump and most of the Republicans in Congress did not campaign on large cuts to Medicaid ahead of the 2024 election.
“When people vote prospectively, they don’t necessarily know what is going to happen,” she said. “Like, I’m gonna vote for the Republican party because I like their stance on immigration. I generally think we should cut the budget, but I don’t necessarily think they’re going to cut the budget in a way that harms me.”
Even for voters who are enrolled in Medicaid, the threat of health coverage going away may not feel as though it’s directed at them. In fact, many voters simply don’t know which party supports or threatens specific programs.
“On really salient issues, maybe 50% of the public knows where the parties stand,” said Gabriel Lenz, political science professor at UC Berkeley. “And that’s among the people who take surveys — you’re not getting the least-informed people there.”
“People always generally assume that people are going to be voting on policy and voting in their immediate self-interests,” he added. “But we have good research that shows that that’s just rarely true.”
Ramos-Yamamoto described a persistent perception across the electorate that Medicaid primarily serves a narrow demographic, which allows some voters to support restrictions without recognizing the broader impact.
“I think that that sometimes gets lost when Republicans are talking about this and people are understanding this as, ‘Okay, well this is a cut to them, not me,’” she said. “But it’s really not the case. It’s not possible to do that in a healthcare system that is highly integrated like the one we have.”
What Happens Next?
The effects of the “Big Beautiful Bill” won’t be felt all at once. According to the implementation timeline, some provisions will take effect after the 2026 midterm elections. But the biggest changes — including work requirements and stricter eligibility checks — are scheduled to roll out in the lead-up to the 2028 presidential race.
The U.S. Office of Management and Budget forecasts that about 10.8 million Americans nationwide will lose Medicaid between 2025 and 2034, while the California Budget Office puts the potential Medi-Cal losses at up to 3.4 million over the same decade. Some observers say the staggered timing of the cuts may be by design.
“They’re gonna delay it till after the midterms kick in,” said Lenz. “That also confuses things.”
Whether the cuts will lead to political backlash in the midterms remains uncertain.
“Things typically tend to water down,” Lenz noted, “but once in a while, there’s this one hit that registers so deeply that people don’t forget.”
Julia Mayer is a data reporter based in Berlin and a contributor to The Intersection.
