Medicare, Medi-Cal, employer insurance, Covered CA — how the patchwork pays for care and why the cross-subsidy is breaking.
In the UK: one system, one payer, free at point of use. In the US: multiple overlapping programs for different populations, each with different eligibility, funding, payment mechanisms, and benefits. The same hip replacement generates four completely different payments depending on whether the patient has Medicare, Medi-Cal, employer insurance, or nothing.
California's ~39.5 million residents by coverage source
~6.7M Californians. Funded by payroll taxes + premiums + general revenue. Parts A (hospital), B (physician), C (managed care), D (drugs). Why EMTALA exists — accepting Medicare = must treat all emergencies.
~14.5M enrollees (1 in 3 Californians). Income ≤138% FPL (~$20.8K). Jointly federal/state funded. Pays providers significantly less than Medicare or private — many doctors limit Medi-Cal patients.
~17M Californians. Employer + employee split premiums. Average family premium ~$25,572/year nationally (2024). Historical accident from WWII wage freezes.
~2M enrollees (record 2025). For people without employer coverage earning too much for Medi-Cal. Enhanced subsidies expired Dec 2025 — premiums roughly doubled for 2026.
~2.5M Californians (6.4%). Rely on EMTALA for emergencies, FQHCs for primary care, county programs. Can't access specialists, elective surgery, or consistent chronic care.