SACRAMENTO, Calif. — State Sen. Akilah Weber Pierson anticipates that California’s sprawling Medicaid program, known as Medi-Cal, may need to be dialed back after Gov. Gavin Newsom releases his latest budget, which could reflect a multibillion-dollar deficit.

Even so, the physician-turned-lawmaker, who was elected to the state Senate in November, says her priorities as chair of a budget health subcommittee include preserving coverage for the state’s most vulnerable, particularly children and people with chronic health conditions.

“We will be spending many, many hours and long nights figuring this out,” Weber Pierson said of the lead-up to the state’s June 15 deadline for lawmakers to pass a balanced budget.

With Medicaid cuts on the table in Washington and Medi-Cal running billions of dollars over budget due to rising drug prices and higher-than-anticipated costs to cover immigrants without legal status, Weber Pierson’s dual responsibilities — maintaining a balanced budget and delivering compassionate care to the state’s poorest residents — could make her instrumental in leading Democrats through this period of uncertainty.

President Donald Trump has said GOP efforts to cut federal spending will not touch Medicaid beyond “waste, fraud, and abuse.” Congressional Republicans are considering going after states such as California that extend coverage to immigrants without legal status and imposing restrictions on provider taxes. California voters in November made permanent the state’s tax on managed-care health plans to continue funding Medi-Cal.

The federal budget megabill is winding its way through Congress, where Republicans have set a target of $880 billion in spending cuts over 10 years from the House committee that oversees the Medicaid program.

Health care policy researchers say that would inevitably force the program to restrict eligibility, narrow the scope of benefits, or both. Medi-Cal covers 1 in 3 Californians, and more than half of its nearly $175 billion budget comes from the federal government.

One of a handful of practicing physicians in the state legislature, Weber Pierson is leaning heavily on her experience as a pediatric and adolescent gynecologist who treats children with reproductive birth defects — one of only two in Southern California.

Weber Pierson spoke to KFF Health News correspondent Christine Mai-Duc in Sacramento this spring. She has introduced bills to improve timely access to care for pregnant Medi-Cal patients, require developers to mitigate bias in artificial intelligence algorithms used in health care, and compel health plans to cover screenings for housing, food insecurity, and other social determinants of health.

This interview has been edited for length and clarity.

Q: You’re a state senator, you practice medicine in your district, and you’re also a mom. What does that look like day to day?

A: When you grow up around someone who juggles a lot, that just kind of becomes the norm. I saw this with my mom [former state Assembly member Shirley Weber, who is now secretary of state].

I’m really happy that I’m able to continue with my clinical duties. Those in the health care profession understand how much time, energy, effort, and money we put into becoming a health care provider, and I’m still fairly early in my career. With my particular specialty, it would also be a huge void in the San Diego region for me to step back.

Q: What are the biggest threats or challenges in health care right now?

A: The immediate threats are the financial issues and our budget. A lot of people do not understand the overwhelming amount of dollars that go into our health care system from the federal government.

Another issue is access. Almost everybody in California is covered by insurance. The problem is that we have not expanded access to providers. If you have insurance but your nearest labor and delivery unit is still two hours away, what exactly have we really done for those patients?

The third thing is the social determinants of health. The fact that your life expectancy is based on the ZIP code in which you were born is absolutely criminal. Why are certain areas devoid of having supermarkets where you can go and get fresh fruits and vegetables? And then we wonder why certain people have high blood pressure and diabetes and obesity.

Q: On the federal level, there’s a lot of conversation happening around Medicaid cuts, reining in the MCO tax, and potentially dropping Affordable Care Act premium subsidies. Which is the biggest threat to California?

A: To be quite honest with you, all of those. The MCO tax was a recognition that we needed more providers, and in order to get more providers, we need to increase the Medi-Cal reimbursement rates. The fact that now it is at risk is very, very concerning. That is how we are able to care for those who are our most vulnerable in our state.

Q: If those cuts do come, what do we cut? How do we cut it?

A: We are in a position where we have to talk about it at this point. Our Medi-Cal budget, outside of what the federal government may do, is exploding. We definitely have to ensure that those who are our most vulnerable — our kids, those with chronic conditions — continue to have some sort of coverage. What will that look like?

To be quite honest with you, at this point, I don’t know.

Q: How can the state make it the least painful for Californians?

A: Sometimes the last one to the table is the first one to have to leave the table. And so I think that’s probably an approach that we will look at. What were some of the more recent things that we’ve added, and we’ve added a lot of stuff lately. How can we trim down — maybe not completely eliminate, but trim down on — some of these services to try to make them more affordable?

Q: When you say the last at the table, are you talking about the expansion of Medi-Cal coverage to Californians without legal status? Certain age groups?

A: I don’t want to get ahead of this conversation, because it is a very large conversation between not only me but also the [Senate president] pro tem, the Assembly speaker, and the governor’s office. But those conversations are being had, keeping in mind that we want to provide the best care for as many people as possible.

Q: You’re carrying a bill related to AI in health care this year. Tell me what you’re trying to address.

A: It has just exploded at a speed that I don’t know any of us were anticipating. We are trying to play catch-up, because we weren’t really at the table when all of this stuff was being rolled out.

As we advance in technology, it’s been great; we’ve extended lives. But we need to make sure that the biases that led to various discrepancies and health care outcomes are not the same biases that are inputted into that system.

Q: How does Sacramento policy impact your patients and what experience as a physician do you bring to policymaking?

A: I speak with my colleagues with actual knowledge of what’s happening with our patients, what’s happening in the clinics. My patients and my fellow providers will often come to me and say, “You guys are getting ready to do this, and this is why it’s going to be a problem.” And I’m like, “OK, that’s really good to know.”

I work at a children’s facility, and right after the election, specialty hospitals were very concerned around funding and their ability to continue to practice.

In the MCO discussion, I was hearing from providers, hospitals on the ground on a regular basis. With the executive order [on gender-affirming care for transgender youth], I have seen people that I work with concerned, because these are patients that they take care of. I’m very grateful for the opportunity to be in both worlds.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

After narrowly passing a budget resolution this spring foreshadowing major Medicaid cuts, Republicans in Congress are having trouble agreeing on specific ways to save billions of dollars from a pool of funding that pays for the program without cutting benefits on which millions of Americans rely. Moderates resist changes they say would harm their constituents, while fiscal conservatives say they won’t vote for smaller cuts than those called for in the budget resolution. The fate of President Donald Trump’s “one big, beautiful bill” containing renewed tax cuts and boosted immigration enforcement could hang on a Medicaid deal.

Meanwhile, the Trump administration surprised those on both sides of the abortion debate by agreeing with the Biden administration that a Texas case challenging the FDA’s approval of the abortion pill mifepristone should be dropped. It’s clear the administration’s request is purely technical, though, and has no bearing on whether officials plan to protect the abortion pill’s availability.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Maya Goldman of Axios, and Sandhya Raman of CQ Roll Call.

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Among the takeaways from this week’s episode:

• Congressional Republicans are making halting progress on negotiations over government spending cuts. As hard-line House conservatives push for deeper cuts to the Medicaid program, their GOP colleagues representing districts that heavily depend on Medicaid coverage are pushing back. House Republican leaders are eying a Memorial Day deadline, and key committees are scheduled to review the legislation next week — but first, Republicans need to agree on what that legislation says.
• Trump withdrew his nomination of Janette Nesheiwat for U.S. surgeon general amid accusations she misrepresented her academic credentials and criticism from the far right. In her place, he nominated Casey Means, a physician who is an ally of HHS Secretary Robert F. Kennedy Jr.’s and a prominent advocate of the “Make America Healthy Again” movement.
• The pharmaceutical industry is on alert as Trump prepares to sign an executive order directing agencies to look into “most-favored-nation” pricing, a policy that would set U.S. drug prices to the lowest level paid by similar countries. The president explored that policy during his first administration, and the drug industry sued to stop it. Drugmakers are already on edge over Trump’s plan to impose tariffs on drugs and their ingredients.
• And Kennedy is scheduled to appear before the Senate’s Health, Education, Labor and Pensions Committee next week. The hearing would be the first time the secretary of Health and Human Services has appeared before the HELP Committee since his confirmation hearings — and all eyes are on the committee’s GOP chairman, Sen. Bill Cassidy of Louisiana, a physician who expressed deep concerns at the time, including about Kennedy’s stances on vaccines.

Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who co-reported and co-wrote the latest KFF Health News’ “Bill of the Month” installment, about an unexpected bill for what seemed like preventive care. If you have an outrageous, baffling, or infuriating medical bill you’d like to share with us, you can do that here.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: NPR’s “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured,” by Andrea Hsu. 

Maya Goldman: STAT’s “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph. 

Anna Edney: Bloomberg News’ “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare,” by Zachary R. Mider and Zeke Faux. 

Sandhya Raman: The Louisiana Illuminator’s “In the Deep South, Health Care Fights Echo Civil Rights Battles,” by Anna Claire Vollers. 

Also mentioned in this week’s podcast:

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CRESTWOOD, Mo. — The prospect of sweeping federal cuts to Medicaid is alarming to some Missourians who remember the last time the public medical insurance program for those with low incomes or disabilities was pressed for cash in the state.

In 2005, Missouri adopted some of the strictest eligibility standards in the nation, reduced benefits, and increased patients’ copayments for the joint federal-state program due to state budget shortfalls totaling about $2.4 billion over several prior years. More than 100,000 Missourians lost coverage as a result, and the Federal Reserve Bank of Philadelphia reported that the changes led to increases in credit card borrowing and debt in third-party collections.

A woman told NPR that year that her $6.70-an-hour McDonald’s job put her over the new income limits and rendered her ineligible, even though she was supporting three children on about $300 a week. A woman receiving $865 a month in disability payments worried at a town hall meeting about not being able to raise her orphaned granddaughter as the state asked her to pay $167 a month to keep her health coverage.

Now, Missouri could lose an estimated $2 billion a year in federal funding as congressional Republicans look to cut at least $880 billion over a decade from a pool of funding that includes Medicaid programs nationwide. Medicaid and the closely related Children’s Health Insurance Program together insure roughly 79 million people — about 1 in 5 Americans.

“We’re looking at a much more significant impact with the loss of federal funds even than what 2005 was,” said Amy Blouin, president of the progressive Missouri Budget Project think tank. “We’re not going to be able to protect kids. We’re not going to be able to protect people with disabilities from some sort of impact.”

At today’s spending levels, a cut of $880 billion to Medicaid could lead to states’ losing federal funding ranging from $78 million a year in Wyoming to $13 billion a year in California, according to an analysis from KFF, a health information nonprofit that includes KFF Health News. State lawmakers nationwide would then be left to address the shortfalls, likely through some combination of slashing benefits or eligibility, raising taxes, or finding a different large budget item to cut, such as education spending.

Republican lawmakers are floating various proposals to cut Medicaid, including one to reduce the money the federal government sends to states to help cover adults who gained access to the program under the Affordable Care Act’s provision known as Medicaid expansion. The 2010 health care law allowed states to expand Medicaid eligibility to cover more adults with low incomes. The federal government is picking up 90% of the tab for that group. About 20 million people nationwide are now covered through that expansion.

Missouri expanded Medicaid in 2021. That has meant that a single working-age adult in Missouri can now earn up to $21,597 a year and qualify for coverage, whereas before, nondisabled adults without children couldn’t get Medicaid coverage. That portion of the program now covers over 329,000 Missourians, more than a quarter of the state’s Medicaid recipients.

For every percentage point that the federal portion of the funding for that group decreases, Missouri’s Medicaid director estimated, the state could lose $30 million to $35 million a year.

But the equation is even more complicated given that Missouri expanded access via a constitutional amendment. Voters approved the expansion in 2020 after the state’s Republican leadership resisted doing so for a decade. That means changes to Medicaid expansion in Missouri would require voters to amend the state constitution again. The same is true in South Dakota and Oklahoma.

So even if Congress attempted to narrowly target cuts to the nation’s Medicaid expansion population, Washington University in St. Louis health economist Timothy McBride said, Missouri’s expansion program would likely stay in place.

“Then you would just have to find the money elsewhere, which would be brutal in Missouri,” McBride said.

In Crestwood, a suburb of St. Louis, Sandra Smith worries her daughter’s in-home nursing care would be on the chopping block. Nearly all in-home services are an optional part of Medicaid that states are not required to include in their programs. But the services have been critical for Sandra and her 24-year-old daughter, Sarah.

Sarah Smith has been disabled for most of her life due to seizures from a rare genetic disorder called Dravet syndrome. She has been covered by Medicaid in various ways since she was 3.

She needs intensive, 24-hour care, and Medicaid pays for a nurse to come to their home 13 hours a day. Her mother serves as the overnight caregiver and covers when the nurses are sick — work Sandra Smith is not allowed to be compensated for and that doesn’t count toward the 63-year-old’s Social Security.

Having nursing help allows Sandra Smith to work as an independent podcast producer and gives her a break from being the go-to-person for providing care 24 hours a day, day after day, year after year.

“I really and truly don’t know what I would do if we lost the Medicaid home care. I have no plan whatsoever,” Sandra Smith said. “It is not sustainable for anyone to do infinite, 24-hour care without dire physical health, mental health, and financial consequences, especially as we parents get into our elder years.”

Elias Tsapelas, director of fiscal policy at the conservative Show-Me Institute, said potential changes to Medicaid programs depend on the extent of any budget cuts that Congress ultimately passes and how much time states have to respond.

A large cut implemented immediately, for example, would require state legislators to look for parts of the budget they have the discretion to cut quickly. But if states have time to absorb funding changes, he said, they would have more flexibility.

“I’m not ready to think that Congress is going to willingly put us on the path of making every state go cut their benefits for the most vulnerable,” Tsapelas said.

Missouri’s congressional delegation split along party lines over the recent budget resolution calling for deep spending cuts, with the Republicans who control six of the eight House seats and both Senate seats all voting for it.

But 76% of the public, including 55% of Republicans, say they oppose major federal funding cuts to Medicaid, according to a national KFF poll conducted April 8-15.

And Missouri Sen. Josh Hawley, a Republican, has said that he does not support cutting Medicaid and posted on the social platform X that he was told by President Donald Trump that the House and Senate would not cut Medicaid benefits and that Trump won’t sign any benefit cuts.

“I hope congressional leadership will get the message,” Hawley posted. He declined to comment for this article.

U.S. House Republicans are aiming to pass a budget by Memorial Day, after many state legislatures, including Missouri’s, will have adjourned for the year.

Meanwhile, Missouri lawmakers are poised to pass a tax cut that is estimated to reduce state revenue by about $240 million in the first year.