Kathy Wood normally spends her lunch break walking her 6-year-old dog, Bridget Claire. But last month, she spent it thinking about Gov. Gavin Newsom.

Wood, a Franciscan nun and nurse practitioner, provides medical services to low-income Sacramento residents four days a week at her no-cost clinic, Clara’s House. The clinic has 456 immigrant patients, some of whom are on Medi-Cal, and Wood feared that looming budget cuts would reduce their care.

A week later, her worries became law.

Newsom signed a budget with a slew of changes for immigrants on Medi-Cal, like a new monthly premium, a future loss of dental care and an enrollment freeze for those with unsatisfactory immigration status.

State-funded Medi-Cal currently covers 2 million immigrants with UIS — including some permanent residents like recent green card holders. The California Department of Health Care Services estimated that the premiums and enrollment freeze would leave about a million immigrants without access to Medi-Cal.

Since DHCS shared its estimate, state legislators reduced the premium from Newsom’s proposed $100 to $30. But health advocates say premiums are problematic, no matter how high.

“It creates a two-tiered separate but equal health care system where, if you happen to be a citizen, you can get one set of coverage, and if you happen not to have the proper legal documents, you have a whole other set of health care, which is more expensive at $30 a month, with less benefits like the elimination of dental, and, starting in 2026, the inability to even enroll,” said Rachel Linn Gish, director of communications for Health Access California. Her organization has been campaigning for universal Medi-Cal coverage since 2014.

Linn Gish estimated that the vast majority of immigrants will go uninsured and without regular access to care as a result of the new budget. Their only avenue of medical treatment would be an emergency room once something becomes bad enough, Linn Gish said.

Wood offers an alternative. After her lunch break, she provided primary care for three immigrant patients at her downtown Sacramento clinic. The next day, she served six more. She checks patients’ lung capacity and blood sugar levels; she administers their physicals and charts their history. If a patient demands a service Wood cannot provide herself, like surgery, Clara’s House has a network of partners to step in.

But as the state and federal governments reduce their support, Clara’s House may not have room for everyone.

“Things are so crazy right now,” Wood said. “I’m not sure what’s going to happen.”

Comprehensive coverage

Medi-Cal — California’s free or low cost health coverage for low-income residents — became effective in March 1966. Patients on Medi-Cal join managed care plans, using network providers and primary care physicians for medical needs.

But California’s undocumented immigrants, 29% of whom live in poverty, did not qualify for coverage until half-a-century later when, in 2015, then-Gov. Jerry Brown signed legislation to extend coverage to undocumented children.

Beginning in 2020, undocumented young adults between the ages of 19 and 26 were also included, and undocumented seniors, aged 50 and older, were added two years later. In 2024, Medi-Cal was expanded to adults between 26 and 50 — the last gap in service.

Newsom, now responsible for limiting Medi-Cal coverage for immigrants, signed off on three of the expansions. In 2020, he called the coverage of undocumented young adults legislation “we’ve long dreamed of.”

In reality, Wood found that Medi-Cal care was not comprehensive.

Wood spent 30 years as a nurse in Los Angeles, and when she returned to her hometown of Sacramento 15 years ago, she started Clara’s House to support people without health care like undocumented immigrants.

After Medi-Cal coverage expanded, Clara’s House assisted clients with enrollment, and Wood sent patients to Medi-Cal’s health maintenance providers, known as HMOs, for services she did offer at the clinic.

She remembered referring one woman to a Medi-Cal HMO for a pap smear and mammogram — services that screen for cancer. Because the patient was postmenopausal, the pap smear was denied. The mammogram was never taken.

“What seems to be mandated that the HMO provides doesn’t get done,” Wood said.

She tried to request an audit of the facility from Sacramento Congresswoman Doris Matsui’s office to see how care was administered. But her requests at Matsui’s office were denied. Wood was told the audits were confidential.

“So it’s kind of like you just give up, right?” Wood said.

Instead, she grew her services.

Clara’s House ensures its patients receive dental, vision, hearing, and blood work as part of its comprehensive care. Patients are provided with information about nutrition and vaccines, and before a patient leaves, they schedule a follow-up. Since 2010, Clara’s House has served patients across 22,511 appointments.

For specialized medical services, like mammograms, Clara’s House now works with private partners to provide care, Peggy Desmond explained. Desmond has been at Clara’s House since 2014 and does not have an official title, instead working on whatever Wood requests.

“I’m kind of her girl Friday,” Desmond joked.

In addition to Desmond and Wood, Clara’s House has a team of students from a Sacramento State language program to help translate documents and digitize medical charts. Almost everyone working at Clara’s House is a volunteer, and the clinic is supported entirely by private donations. The sole paid staff member coordinates financial assistance with Mercy Medical Group.

Financial assistance allows patients to receive surgery they would otherwise skip. Desmond recalled a patient from Clara’s House who needed a procedure in the beginning of June. The patient is not enrolled in Medi-Cal, and her bill tallied over $100,000. With financial assistance from Mercy, the surgery was free.

Other partners include a local dermatologist and Carrington College’s dental program. Anything patients can get on Medi-Cal, Clara’s House replicates with private providers.

Pitfalls of privacy

The clinic’s model cannot be axed by the governor, but it’s still vulnerable.

Clara’s House had a partnership with Susan G. Komen, the breast cancer advocacy group, to give patients cancer screenings and mammograms. After the COVID-19 pandemic, the money dried up.

The clinic’s current partners can stop donating services at any time, and even maintaining their level of care may not meet the clinic’s demands.

“We sent people to Medi-Cal, and so those patients haven’t been part of this,” Wood said. “But now they’re all coming back.”

Wood welcomes returning clients to the clinic, but prospective patients have to be referred by a partner agency, which includes numerous churches and the Sacramento Food Bank.

With Wood as the sole nurse practitioner, the clinic only offers six appointments per day. Wood cannot conduct more appointments without reducing her time with patients or extending her unpaid workday. The clinic’s universal coverage is limited to the people she can see.

Typically, Wood sees each patient for an hour — back to back to back, from nine in the morning to four in the afternoon.

But three weeks ago, she had an unexpected hour to herself.

“I had a woman’s health appointment,” Wood said, “and the lady didn’t come in because she was too afraid.”

That patient is one of Clara’s House’s immigrant patients, and her absence was not unprecedented. Wood said a cohort of her clients are missing medical care due to fear of U.S. Immigration and Customs Enforcement.

Nationwide, ICE is rapidly increasing detentions. In October 2024, an average of 14,288 immigrants arrested by ICE were in detention each day. By May, that figure more than doubled to 32,771, according to recent detention statistics.

California is the state with the third-highest number of detainees, and in Sacramento, ICE shares an office building with immigration court. Five days before Wood’s patient skipped her appointment, plainclothes officers detained immigrants at their mandatory court hearings.

By keeping patients home, the threat of detention disrupts medical care at Clara’s House. The majority of patients are diabetic and require frequent return visits so Wood can track their blood sugar and prescribe necessary medication. Wood will not prescribe medication over the phone, so missing appointments means missing medicine, too.

More than prescriptions, though, Wood is worried about paperwork.

She recalled when earlier this month the Trump administration ordered personal data on millions of Medicaid enrollees — including those in Medi-Cal, California’s Medicaid program. The data contains the immigration status of individuals, and Wood fears it will be used to arrest her undocumented clients.

“Can we even believe in our government anymore?” she asked.

Wood ended her clinic’s years-long partnerships with Medi-Cal HMOs, no longer sending them patients for medical care. Wood said the lack of government support would increase the strain on Clara’s House, but Desmond is not worried.

“We have a thing at Clara’s house,” explained Desmond. “God will provide.”

“And so far, it’s worked.”