Fresno County Faces $241M Indigent Care Cost Shift + $300M Budget Hole — Central Valley FQHC Catchment Most Exposed in CA

Fresno County is projected to face a $241M indigent care cost shift as 11,000–30,000 residents lose Medi-Cal coverage under H.R. 1 work mandates and 6-month redeterminations — landing on top of a ~$300M county budget hole and a hiring freeze. Public health, behavioral health, and social services are projected to absorb the largest hits. Critical context: Fresno, Tulare, Merced, Kern, and Madera counties exceed 50% Medi-Cal — making the Central Valley the single most FQHC-exposed region in California (more than LA, Bay Area, or San Diego). Strategic implication for Central Valley FQHCs (Clinica Sierra Vista, United Health Centers, Family Healthcare Network, Adventist Health, Camarena Health, Livingstone Community Health): (1) Model FY26-27 cash flow under 30K member loss, (2) Pre-build sliding-fee capacity expansion plans, (3) Coordinate advocacy with Fresno County supervisors on state offset funding requests (already public ask, March 2026), (4) Track CalAIM 1115 waiver renewal — Central Valley ECM contracts disproportionately exposed if waiver lapses Dec 31, 2026.