Sonoma County supervisors hear scale of HR 1 impacts; staff recommend three‑year mitigation package

Sonoma County supervisors on April 20 heard a detailed briefing on how the federal HR 1 package could reduce Medi‑Cal and CalFresh coverage, increase administrative work and shift costs onto counties. County staff recommended a three‑year mitigation approach that relies on temporary funding, expanded eligibility staffing and support to community clinics and food providers while state and federal rules remain uncertain.

Staff framed HR 1 as a policy and fiscal reversal that narrows coverage and raises redetermination frequency, increasing administrative churn. “This is going to be a tough budget year,” County Executive Officer Guin said, urging a measured approach. Assistant County Executive Jennifer Salido told the Board the presentation focused on “what we know, what we don’t know, the known unknowns, and how we can position the county to respond thoughtfully, responsibly, and strategically.”

Katie Kavanaugh, a county analyst, said provisions in HR 1 will be implemented in stages through 2028 and will include more frequent eligibility renewals and work requirements for certain adults. Staff said Sonoma County currently has about 132,000 residents enrolled in Medi‑Cal and presented multiple estimates of those who could lose full scope coverage under HR 1: staff cited roughly 8,700 people affected by work requirements, about 12,000 by renewal/administrative barriers and 4,400 tied to immigration‑status changes. Kavanaugh summarized the core mitigation strategy: “The county’s number one method for addressing all of the impacts…is to keep eligible individuals enrolled. Period.”

Staff described the downstream coverage waterfall: residents who lose Medi‑Cal may step into the County Medical Services Program (CMSP) or into a medically indigent category the county must serve under Welfare and Institutions Code §17000. The packet included a high‑end CMSP bill example — if the county were required to pay the full cost for an estimated 11,560 people, the annual figure could be roughly $102 million — but staff stressed that CMSP eligibility and service changes approved by the CMSP board and potential state actions would change that estimate.

To reduce churn and preserve coverage, staff recommended a three‑year package that includes:

- Funding the Human Services Department to hire eligibility staff: an initial request for 38 eligibility positions (a mix of dual‑fill and three‑year limited positions) plus seven time‑limited Job Link positions to support work requirements and case navigation;

- One‑time and short‑term funding for the community health clinic (CHC) network to expand primary care capacity. Staff presented an estimate of about $12.8 million for the first fiscal year and roughly $39.6 million over three years tied to an estimated <15,000 additional clinic patients; staff characterized those clinic figures as more certain than some county estimates but said they will continue to be refined through negotiations with the clinics;

- A $1 million placeholder to support local food providers and a proposal to consider modest increases to county General Assistance (GA) benefits (staff noted GA has not been increased since 2021 and offered a 15–24% example increase as board‑level discretion).

Deputy County Administrator Peter Brueland and Principal Analyst Nick Klein outlined timing: the recommended budget book target date is May 13; hearings materials are to be published May 29 and hearings begin June 9 with final budget adoption expected in June. Klein warned that while some state numbers may improve, much of the state revenue growth is tied to income tax and not sales tax, which remains volatile and is an important driver of county revenue constraints.

Supervisors pressed staff on several points: how multi‑year prepayments to clinics would be structured, whether lump‑sum funding creates expectations of ongoing support, how to measure CHC performance, and which departmental fund balances staff proposed to repurpose if needed. Staff said they favor a prepayment model with quarterly reconciliation rather than a complex reimbursement system that would require substantial HIPAA‑compliant billing capacity. Supervisor Rabbit and others suggested considering performance metrics and longer windows than three years if federal changes persist.

On CalFresh, staff said roughly 42,700 Sonoma County residents are currently enrolled and presented an estimate that up to 13,000 could be subject to work requirements; of that group, staff said roughly 30% (about 3,900 people) may not meet the new requirements, and approximately 762 non‑citizens could lose coverage in 2026–27. The estimated loss of monthly benefits tied to CalFresh reductions was presented as about $1.4 million per month, or $17.3 million annually.

Staff emphasized timing uncertainties and several “known unknowns” — notably the final CMSP cost exposure and the state’s May revision and trailer‑bill actions — and recommended relying on temporary sources and returning with refined numbers in June. “We are recommending setting aside three years to fund this entire system and program,” Kavanaugh said, while noting staff will continue to update the Board as state guidance and clinic negotiations proceed.

The Board did not take action at the workshop; staff emphasized the presentations were informational and that final decisions will occur during budget hearings. The Board asked staff to return with detailed budget materials and clarified scenarios for May/June consideration.