Personal Connection to Public Healthcare
When the head of the nation’s largest publicly operated health plan expresses concern about looming federal cuts to Medicaid, it transcends professional responsibility—it’s deeply personal. Martha Santana-Chin, daughter of Mexican immigrants, grew up relying on Medi-Cal, California’s version of Medicaid, the government-run health care program designed for people with low incomes and disabilities.
Her lived experience with public healthcare shaped her understanding of how safety net programs can break cycles of poverty and create opportunities for advancement. “If it weren’t for safety nets like the Medi-Cal program, I think many people would be stuck in poverty without an ability to get out,” she explained. “For me personally, not having to worry about health care allowed me to really focus on what I needed to focus on, which was my education.”
Leading California’s Largest Medicaid Plan
L.A. Care’s Unprecedented Scale
Today, Santana-Chin serves as CEO of L.A. Care, which operates by far the biggest Medi-Cal health plan in the nation, serving more than 2.2 million enrollees. This enrollment figure exceeds the combined Medicaid and Children’s Health Insurance Program (CHIP) enrollments in 41 states, demonstrating the massive scale of healthcare delivery in Los Angeles County alone.
Dual Mission Challenges
The insurer provides both Medi-Cal coverage and Affordable Care Act marketplace plans through Covered California, creating a comprehensive safety net for the region’s most vulnerable populations while navigating complex regulatory and financial landscapes.
Federal Cuts Threaten Vulnerable Populations
As Santana-Chin begins her second year steering L.A. Care, she grapples with unprecedented federal and state spending cuts that significantly complicate her mission of providing quality health care to poor and medically vulnerable enrollees. These cuts threaten not only the financial stability of the organization but also the health outcomes of millions of Californians who depend on Medicaid coverage.
Impact of HR 1 on California
Catastrophic Enrollment Losses Projected
Santana-Chin warns that the GOP’s One Big Beautiful Bill Act, enacted last year and also known as HR 1, could result in 650,000 enrollees falling off L.A. Care’s Medi-Cal rolls by the end of 2028. This represents more than a quarter of the plan’s current Medi-Cal enrollment—a devastating reduction that will severely strain the organization’s finances as revenues decline from the current $11.7 billion in the last fiscal year.
Statewide Financial Impact
HR 1 is expected to cut more than $900 billion from Medicaid over the next 10 years nationally. In California alone, the Department of Health Care Services, which runs Medi-Cal, anticipates cuts of $30 billion or more. These reductions will fundamentally reshape California’s healthcare delivery system and force difficult decisions about coverage and services.
State-Level Budget Constraints
California’s Response to Deficits
Like other states facing substantial budget deficits, California has already reduced its Medicaid spending through measures including freezing new enrollments for immigrants without legal status and reintroducing asset limits for eligibility. These cuts occurred before the state must reckon with the additional spending reductions required by the withdrawal of federal dollars under HR 1.
Compounding Pressures
The combination of federal funding cuts and state budget constraints creates a perfect storm for Medicaid providers, threatening the sustainability of the safety net healthcare system that millions of Californians depend on for essential medical services.
Leadership Through Crisis
Bringing Private Sector Experience
Santana-Chin oversaw Medi-Cal and Medicare operations for the for-profit insurer Health Net before taking the helm of L.A. Care in January 2025. Her experience in both public and private healthcare systems provides valuable perspective on efficiency, quality improvement, and sustainable operations.
Navigating Regulatory Challenges
She assumed leadership nearly three years after state regulators fined L.A. Care $55 million over violations they said compromised the health and safety of its members. L.A. Care paid $27 million in penalties to the state and agreed to contribute $28 million to community health projects, demonstrating commitment to correcting past deficiencies.
Childhood Experiences Shape Current Mission
Understanding Member Struggles
Santana-Chin’s personal connection to Medicaid fundamentally shapes her leadership approach. “What really motivates me is knowing that many of the people that we’re serving are just like my family,” she shared. “They’ve struggled and have had to have their own children translate things that were very difficult to translate. I remember doing that for my own mother.”
Human Dignity and Healthcare Access
Her experiences inform her core belief that healthcare access is a fundamental human right. “Basic human dignity requires that you have access to health care,” she emphasized, recognizing that health security enables families to focus on education, employment, and building better futures.
Transportation Access Remains Critical
Childhood Barriers Inform Current Priorities
Santana-Chin vividly recalls how lack of transportation coverage complicated her family’s healthcare access. “Back then they didn’t cover transportation, and we didn’t have a vehicle,” she explained. Today, transportation remains a critical issue for L.A. Care members.
Modern Transportation Solutions
“One of the issues we’ll hear from our members is the need to make sure we have trustworthy transportation that shows up on time, where the drivers treat them with respect,” she noted. “Had I had that, had my mother had that, life would have been much easier.”
Devastating Delivery System Impact
Beyond Enrollment Numbers
“It’s going to devastate the delivery system,” Santana-Chin warned about HR 1’s impact. “The state obviously isn’t going to be able to make up for the shortfalls in federal funding, and over the course of the next several years, funding is going to be less and less, and the people we cover are going to decrease significantly.”
Ripple Effects Throughout Healthcare
The reductions in payment and rise in uncompensated care will destabilize hospitals and other healthcare providers, forcing service closures or site reductions. “It’s going to impact access. And it’s not only going to impact those that lose coverage,” she emphasized, noting that healthcare infrastructure degradation affects entire communities.
Strategic Response and Efficiency
Technology-Driven Solutions
Facing significant revenue drops, L.A. Care is focused on operational efficiency and creative technology deployment. “We are looking at creative ways to use technology to empower our people to do higher-level work,” Santana-Chin explained. This includes supporting call center agents with smarter technology for faster problem resolution and automating claims payment processes.
Maintaining Quality While Reducing Costs
The challenge lies in improving efficiency without compromising the quality of care that vulnerable populations desperately need, requiring strategic investments in infrastructure and workforce development.
Congressional Concerns and Unintended Consequences
Point of Inflection
“We are at a point of inflection in the health care delivery system,” Santana-Chin stated. “And we have to recognize that some of the components of HR 1 will have long-term unintended consequences — maybe they were intended; I’ve got to believe that some of these things are not.”
Work Requirements Create Coverage Barriers
She specifically cited work requirements as problematic: “Work requirements are an example of something that many people did believe was the right thing to do to be good stewards of the health care dollar. It is very complex and is going to cause people to lose coverage that actually do qualify. It’s unfortunate, and that would be something that I would urge folks to reconsider.”
Immigration Status and Healthcare Access
Universal Human Need
Santana-Chin firmly opposes restricting healthcare based on immigration status. “It doesn’t matter what immigration status you are. If you are a human being and you need health care, you’re going to try to access health care wherever you can,” she explained.
System Strain from Uninsured Populations
California’s decision to freeze Medi-Cal enrollment for immigrants without legal status will create additional strain on the delivery system as uninsured individuals seek emergency care, ultimately costing the system more while producing worse health outcomes.
Infrastructure Improvements and Compliance
Addressing the 2022 state concerns about delayed care authorizations and patient grievance handling, L.A. Care has made substantial investments. “There has been quite a bit of investment in the L.A. Care infrastructure over the last several years — our IT platforms, our data,” Santana-Chin noted. The organization has added capacity and bandwidth to support teams, demonstrating commitment to regulatory compliance and member service.
Immigration Raids Create Healthcare Barriers
Chilling Effect on Care Seeking
Federal immigration raids in Los Angeles have created severe barriers to healthcare access. “It absolutely has had a chilling effect. Families are afraid to come in. They’re not taking their children to get vaccinated,” Santana-Chin reported.
Life-Threatening Consequences
Healthcare providers have witnessed dramatic drops in patient volume. “I’ve had numerous providers in emergency departments say that they have experienced a drop in the volume of individuals coming in,” she shared. Most disturbingly, “One of our case managers was really distraught because there was an individual that decided to forgo serious lifesaving treatment because of fear.”
This fear-driven avoidance of necessary medical care creates public health risks that extend far beyond immigrant communities, threatening vaccination rates, disease control, and emergency response systems.
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