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Blog Post · January 31, 2024

The Affordable Care Act Has Expanded Community Clinics in California

photo - Nurse Using Stethoscope during Medical Examination

As the state continues to expand the Medi-Cal program to more low-income Californians, making sure coverage translates into access to health care providers is crucial. Community clinics provide primary and preventive healthcare services to underserved and low-income Californians with and without health insurance—here, we focus on roughly 1,200 state-licensed primary care clinics. These clinics have long been key components of Medi-Cal provider networks, with many serving as primary care providers responsible for coordinating health care for Medi-Cal enrollees. After the ACA Medi-Cal expansion, clinics have become even more important especially for new enrollees.

In the lead-up to ACA implementation, many observers were concerned that expanding Medi-Cal to most low-income adults would divert newly insured patients from community clinics to other providers. Instead, clinics have experienced sustained growth, supported both by the boost in revenue resulting from more patients with insurance (mostly Medi-Cal, which contributes about 70% of clinics’ net revenue) and by additional federal funding through the ACA. Visits to community clinics along with the share of visits covered by Medi-Cal increased steadily until the onset of the pandemic.

While Medi-Cal visits to primary care clinics increased throughout California, there was some variation across regions. The Inland Empire—home to 13% of the state’s Medi-Cal eligible population—saw the biggest surge, followed by the San Diego region, the Sacramento region, and the Central Valley. Before the ACA expansion, the Inland Empire had low access to clinics; the substantial increase in Medi-Cal visits following the expansion suggests that clinic access has improved. Medi-Cal visits to clinics increased less sharply in the Central Coast region, despite substantial growth in both Medi-Cal enrollment and the number of clinics.

Medi-Cal expansion has not erased financial and other challenges at community clinics. Many California clinics were facing slowing revenue growth and increasing expenses driven largely by personnel costs heading in to 2020. The onset of the pandemic and the associated decline in visits heightened the financial challenges faced by clinics across the state. Clinic visits in the Inland Empire, Far North, and San Diego region remained lower in 2022 (the most recent data available) compared to 2019. Some clinics have transitioned to operating intermittently with limited services as part of larger systems and others have closed. In addition, long-term staffing shortages also worsened during the pandemic and continue to be a key challenge for community clinics. Recent investments in health workforce training programs could help, though many have been delayed or reduced to respond to the state’s worsening budget situation.

Community clinics are an essential point of access to health services for Medi-Cal enrollees, especially as the program has expanded over the past decade. With the new expansion to all low-income residents regardless of immigration status, community clinics are poised to contribute significantly to outreach efforts and enrollment support, and some may benefit from having more patients with insurance. At the same time, those gaining coverage may have substantial health needs—especially for behavioral health services—which could put further strain on struggling clinics. Monitoring the financial stability and capacity of clinics to maintain their key role in serving Medi-Cal enrollees will be important moving forward.


Affordable Care Act coronavirus COVID-19 Health & Safety Net health care Medi-Cal Medi-Cal expansion health care access Poverty & Inequality safety net