Two years ago, Gov. Gavin Newsom鈥檚 administration unveiled a new plan to help solve the homelessness crisis: It began using health care providers, funded through Medi-Cal, to help people get and stay housed.
Now, with President-Elect Donald Trump about to take office, some health care organizations, homeless service providers and other stakeholders throughout California worry the program may fall apart just as it鈥檚 starting to make a difference. It鈥檚 one of many potential shake ups they鈥檙e bracing for as they prepare for a new federal administration unlikely to see eye to eye with the Golden State on many of its social welfare policies.
鈥淚t makes us all very nervous,鈥� said John Baackes, outgoing CEO of Medi-Cal provider L.A. Care Health Plan.
CalAIM, , is an expansion of Medi-Cal that allows health insurance to pay for certain things that aren鈥檛 considered traditional medical care 鈥� such as services to help homeless Californians find and keep housing. Proponents say it鈥檚 brought a much-needed infusion of money into the state鈥檚 overburdened homeless services system.
But because states aren鈥檛 typically allowed to spend Medicaid dollars on those types of services, California had to get special permission from the federal government. That permission, in the form of two waivers, expires at the end of 2026.
That means the fate of CalAIM rests in the hands of the Trump administration, which can decide whether to renew the program, scale it back or change it. Trump has yet to give any indication of what he would do (or even whether this specific California program is on his radar) and most stakeholders agree any changes he makes probably wouldn鈥檛 come until 2026. But the uncertainty is compounding the stress on already overburdened homeless service providers, who routinely receive instead of permanent funding, making it difficult to plan for the future.
鈥淐alAIM has been one of the most important and, I think, under-appreciated policies of the Newsom administration, to try to better connect our health system and our housing system,鈥� said Tommy Newman, vice president of public affairs for United Way of Greater Los Angeles. 鈥淎nd the risk of going backwards on that is scary.鈥�
Newsom鈥檚 administration wouldn鈥檛 specify what, if anything, it is doing to safeguard CalAIM.
鈥淐alifornia will continue to work collaboratively with our federal partners to ensure that families in our state are healthy and our communities are vibrant places to live and work,鈥� Anthony Cava, spokesperson for the Department of Health Care Services, said in a statement. 鈥淲hile we don鈥檛 typically speculate on the potential impacts of a new federal administration, we remain committed to protecting Californian鈥檚 access to the critical services and programs they need.鈥�
What is CalAIM?
The goal of CalAIM is to address factors known as 鈥渟ocial determinants of health鈥� for low-income Californians. It鈥檚 hard to stay healthy when you don鈥檛 have access to basic necessities, such as housing and nutritious food, for example. Ultimately, it鈥檚 supposed to save the state and the feds money by helping people avoid expensive emergency room visits.
In 2023, more than 68,600 Californians used the three services known as the 鈥渉ousing trio鈥� under CalAIM. These are services designed to help them find housing, stay housed or pay for move-in costs such as security deposits and first and last month鈥檚 rent, according to the most recent available. Only CalAIM鈥檚 鈥渕edically tailored meals鈥� service (which helps people with conditions such as diabetes access food that meets their dietary needs) was nearly as popular, with nearly 62,700 users.
CalAIM provides a total of 14 of these services, or 鈥渃ommunity supports,鈥� which also include medical respite care for people who recently left the hospital, asthma remediation 鈥� think air filters, dehumidifiers, mold removal 鈥� and sobering centers. CalAIM also provides something called 鈥渆nhanced care management,鈥� which pairs Medi-Cal members with an intensive case manager who can help them access everything from a doctor to a dentist to a social worker.
One-time grants, doled out to health plans as an incentive for them to ramp up CalAIM services, also helped fund the .
Abode Services, a nonprofit that provides shelter, housing and other aid for unhoused people across seven Bay Area counties, serves more than 1,000 Californians through CalAIM, said CEO Vivian Wan. In Napa County, Abode uses CalAIM to provide case management services to help people move from homeless encampments into shelter and housing. In Santa Cruz County, Abode uses CalAIM funds to replace the federal COVID-19 homelessness funds that poured in during the pandemic but have since dried up.
Abode and other nonprofits also use CalAIM funds to fill an important gap often left by other grants: services for formerly homeless people living in subsidized housing. State programs such as Homekey offer money to buy or build homeless housing, and vouchers pay for tenants鈥� rent, but there鈥檚 often nothing left to fund the case management, counseling and more that鈥檚 crucial to help people with physical and mental health conditions, or addictions 鈥� the people Newsom has made a priority in his effort to clear encampments 鈥� hold onto their housing.
鈥淚 shudder to think what would happen if we had all of the mandates from our development side of supporting people through coordinated entry, taking really vulnerable people, and we then reduced the services down to bare bones,鈥� Wan said.
What would Trump do to CalAIM?
It鈥檚 difficult to speculate about what the Trump administration will do with CalAIM. Celebrity physician , Trump鈥檚 pick to run the Centers for Medicare & Medicaid Services, has no prior experience with the agency and therefore no track record that could provide clues as to how he will act.
Any changes likely would be felt at the end of 2026, when California attempts to renew its CalAIM waivers. But it鈥檚 not unheard of for a president to terminate a waiver early. After President Joe Biden took office in 2021, he , authorized by Trump, that had allowed states to require Medicaid recipients to prove they were working or unable to work. But that was an extreme situation, as multiple courts had already shot down those waivers.
鈥淚t鈥檚 not like CalAIM is going away tomorrow, or even in January,鈥� said Sharon Rapport, director of California state policy for the Corporation for Supportive Housing. 鈥淏ut after that, I think that鈥檚 where the questions are: What could happen then? And the fact that it鈥檚 California, and not Trump鈥檚 favorite state, I think makes people worried.鈥�
Plans to expand future coverage also could be at risk. Health plans are rolling out under CalAIM to offer health care to people in jail and prison up to 90 days before they are released. California also has applied to amend one of its federal waivers to add to the services CalAIM offers. If that鈥檚 approved, the state would be allowed to use Medi-Cal to pay for up to six months of rent for homeless and at-risk people who are leaving settings such as jail, prison, the hospital, or an in-patient mental health or substance abuse facility.
But a by conservative think tank the Manhattan Institute questions the use of health care funds to pay for social services 鈥� a potential bellwether that suggests the new administration might not be supportive of programs like CalAIM.
鈥淓ven if a social welfare program is a well-intentioned and wise idea, that does not make it health-care,鈥� wrote Manhattan Institute senior fellow Chris Pope. 鈥淗ealth care costs will not be greatly reduced by expanding the meaning of health care to cover every social service; nor would doing so distribute nonmedical assistance to those who need it most.鈥�
The Trump administration also could change the waivers before renewing them, forcing California to pare down the services CalAIM offers, or add work requirements.
Trump, as well as the Republican-controlled Congress, are likely to support requiring Medicaid recipients to prove they are either working or are unable to work. The last time he was in office, Trump approved 13 state waivers that included work requirements, before the Biden administration later withdrew them. , a conservative governing blueprint written by the Heritage Foundation, also prioritizes work requirements.
Work requirements historically lead to people, especially low-income people and people of color, losing benefits, according to by the progressive think tank Center on Budget and Policy Priorities. It found many recipients are working but have a hard time providing the necessary paperwork to prove it, while others can鈥檛 work due to obligations as full-time caregivers or a lack of child care.
Trump and Congress also could impose more sweeping cuts to Medicaid as a whole, which could affect California鈥檚 ability to continue programs such as CalAIM.
There are ways California could safeguard at least some of its CalAIM services, by baking them into Medi-Cal as permanent benefits, Rapport said. Her organization is pushing for the state to do that with CalAIM鈥檚 three housing services.
Staff at L.A. Care already are thinking about how they could continue offering CalAIM services to their members if the Trump administration cuts the program. It would require some significant rearranging of funds, said Chief Medical Officer Dr. Sameer Amin. His organization has nearly 16,800 people enrolled in CalAIM services to help them find and keep housing.
鈥淢y concern is that the housing crisis in LA County is not something that happened overnight, and it鈥檚 not something that can be corrected overnight,鈥� he said. 鈥淚t really requires a sustained effort over the course of years and a significant amount of investment. And if we don鈥檛 do the investment that we need to do, if we have to reprioritize away from some of these programs, my concern is that these folks are not going to get the health care that they need because they are not housed.鈥�
Staff writer Kristen Hwang contributed to this story.