What H.R.1 means for Medi-Cal in San Diego: the losses are no longer a projection

When Congress passed H.R.1 in 2025, analysts began projecting how many Californians would lose Medi-Cal coverage under its work-requirement and eligibility provisions, compounded by the state's own 2025-26 budget changes. In San Diego County, the projections have already been overtaken by the enrollment reports. The decline is happening now, and it is visible in the county's own monthly accounting.

The observed curve

San Diego County HHSA publishes "Eligibility Services By The Numbers" monthly:

• December 2025: 854,006 Medi-Cal recipients.
• July 2026: 785,814 — down 10.98% year over year.

That is roughly 68,000 fewer recipients in about six months, and about 97,000 fewer than a year earlier. The same report shows the strain is not Medi-Cal-only: CalFresh is down 8.78% year over year (365,235 recipients), CalWORKs down 6.01%.

The projected curve

The UC Berkeley Labor Center's county-level analysis (February 2026) projects the combined effect of federal H.R.1 and the enacted 2025-26 state budget by 2028:

• San Diego County: 210,000 fewer full-scope Medi-Cal enrollees.
• Statewide: 2.98 million fewer.

Two caveats the researchers themselves attach: these are high-end estimates, and they count people losing full-scope Medi-Cal — not necessarily people who end up uninsured (some will move to employer or individual-market coverage).

Read together: San Diego is roughly halfway to the projected 2028 loss, in 2026.

Why this is a behavioral health story

Medi-Cal is the payer for nearly everything this series has documented — the crisis teams, the CSUs, the hospitalizations, the new PHP/IOP slots, all of it billed at the rates in part 3. The population losing coverage overlaps heavily with the population those services exist for: in FY 2023-24, 57% of the county system's adult mental health clients had a co-occurring substance use disorder, and 35% of its SUD-treatment clients were homeless at admission (part 2 sources). Coverage loss for this population does not usually mean care stops — it means care moves back to the most expensive door in the building: the emergency department and the 5150 hold. Our housing support for Medi-Cal clients exists precisely for this overlap.

There is a structural irony in the timing. The county's first adult PHP/IOP capacity (part 1) opens in the same year its payer base is shrinking by six figures.

If your coverage is at risk: what to know

• Renewals are the main event. Most losses occur at renewal, often for paperwork rather than eligibility reasons. Respond to any mail or online notice from the county — renewal packets have deadlines.
• Check and update your contact information with San Diego County Self-Sufficiency Services (BenefitsCal.com or the ACCESS line, 1-866-262-9881) so renewal notices reach you.
• Behavioral health exemptions exist. People meeting certain criteria — including some with serious mental illness or substance use disorders in treatment — may be exempt from H.R.1 community-engagement (work) requirements as they phase in. If you are in treatment, tell your provider you want help documenting an exemption.
• Losing Medi-Cal is appealable, and coverage can often be restored retroactively if eligibility continued. Legal Aid Society of San Diego (1-877-534-2524) assists with Medi-Cal appeals at no cost.
• County behavioral health crisis services do not check insurance at the door. The Access & Crisis Line (888-724-7240) and 988 remain available regardless of coverage.