Big bill. big impact.
The newly passed "One Big Beautiful Bill Act" will slash $1 trillion in federal healthcare spending over the next decade. In Santa Clara County, this translates to more than $1 billion in lost funding over the next few years. Community health leaders warn that thousands of residents could lose access to care, while the region's social safety net faces one of its most serious threats in decades.
In the midst of this uncertainty, we brought together a group of American Leadership Forum Silicon Valley Senior Fellows and other top leaders who head major health organizations in Silicon Valley. They spoke candidly about the challenges ahead, as well as how collaboration and shared leadership could help navigate the difficult road forward.
Dr. Tony Iton (CEO, The Health Trust), Sarita Kohli, Class XXXV (President and CEO, Asian Americans for Community Involvement), Michael Elliot, Class XLII (President and CEO, Valley Health Foundation), and Dolores Alvarado, Class XXVII (CEO, Community Health Partnership) joined me in two separate Zoom conversations. They reflected on the fears they hold for their communities and the hopes they carry for the future of health care in Silicon Valley.
Facing Stark Realities
Both conversations carried a sense of gravity, as participants grappled with what they described as potentially catastrophic changes to health care locally.
Dr. Tony Iton, the new CEO of The Health Trust, which advances health equity through programs addressing food security, chronic disease prevention, and access to care, did not mince words about the stakes.
"These cuts to Medicaid are particularly injurious because they impact a part of the social safety net, which is life or death, and that's our clinical services and associated health services to populations that are quite literally hanging on by a thread," he explained.
He went on to frame the crisis in stark systemic terms: "So we're going very much at high speed in the wrong direction, heading towards a cliff of health crisis in this country, and the means that the federal government has to essentially avoid that cliff have essentially been burnt to the ground."
Picking up on his warning, Sarita Kohli, President and CEO of Asian Americans for Community Involvement (AACI), emphasized that the consequences would fall heaviest on those already facing the steepest barriers to care.
"The concern with work requirements and twice-yearly redeterminations is that they place the heaviest burden on people who have the least—those without reliable internet or computer access, or those working multiple jobs. If someone misses a deadline or makes a small mistake, their entire coverage can collapse."
To illustrate just how precarious the system already is, she shared a personal example: "I speak English fluently. I run a healthcare organization. I've lived in this country with access to good healthcare for a long time, and yet when my daughter turned 26 and we tried to get her insured, it was a nightmare. We were transferred from number to number, waited on hold for 45 minutes, only to be told we had to call somewhere else or provide additional information."
Michael Elliott, President and CEO of Valley Health Foundation, which is tasked with supporting Northern California's largest public healthcare system, broadened the perspective to consider the impact on the entire city.
"The largest cuts ever to Medicaid will force impossible choices and erode the progress we've made over the past 15 years. There's a very real scenario where San Jose could be left with only three hospitals—far too few for a city of one million. It feels like a very precarious and dangerous moment."
Finding Opportunity in Crisis
While the tone of the conversations was urgent, the leaders also spoke about how a crisis can open the door to new approaches. Dr. Iton emphasized that local philanthropy could help create space for innovation in this moment.
"I feel like the role of philanthropy is to help catalyze opportunities like that and to broker innovation in these moments, innovation that reflects what we know about the best-designed healthcare systems in the world that actually deliver health. So it's unfortunate to have to operate in crisis mode, particularly political crisis mode, when health should really be non-partisan."
Ms.Kohli built on his point, noting that philanthropy must also recognize and support smaller organizations that have deep roots in the community.
"Different nonprofits have unique connections to specific communities. Supporting and uplifting smaller organizations is important because they have direct relationships with community members. I believe this is an opportunity to double down and do something good. While it is important to ensure our organizations continue, we should also focus on what more we can do for the community."
Measure A and Hard Choices
The Santa Clara County Board of Supervisors has placed Measure A, a sales tax increase, on the November ballot to help backfill some of the lost federal funds. If approved, it would generate approximately $330 million annually, which is far short of the $1 billion deficit.
Mr. Elliott, whose organization is going to be heavily involved in campaigning for the passage of Measure A, acknowledged both its importance and its limitations: "Measure A represents the maximum the county can legally ask for. Even if more were possible, there are political limits—voters would never approve something like a three-cent sales tax. So five-eighths is as far as we can go. Oddly, that constraint has forced us to consider what we should be doing anyway: being creative, innovative, and willing to make hard decisions. Some of those decisions will, unfortunately, mean job losses and reduced services, which bring only negative consequences. But there is also an opportunity to confront inefficiencies, traditions, and politics that have long shaped how we operate. I've seen a positive spirit emerging, a sense that this moment can push us to rethink how we deliver services—grounded in our values but also focused on sustainability."
A Shared Responsibility
The conversation eventually returned to a central theme: that the cuts will not only affect the most vulnerable, but the entire community. Sarita emphasized the interconnectedness of the system: "We are all part of the same ecosystem. When one part of the system is strained, the effects ripple across the community. Silicon Valley already struggles with deep inequities, and this may serve as a wake-up call for those with power and resources to contribute, to see things differently, and to use their influence to drive change at the state or federal level. Ultimately, this is a wake-up call for all of us."
Tony added the science to support her point: "I love that Sarita raised this point, because there is actual science behind it. The concept is called allostatic load, which refers to chronic stress. Chronic stress happens when your resources are out of balance with the challenges you face in life. The greater that gap, the higher the stress—and it shows up physiologically in elevated cortisol levels, increased risk of cardiovascular disease, and even changes in the brain. This is a reminder that we are all interconnected. We cannot assume that stress only affects low-income people or certain groups. We will all feel the consequences of the rising levels of stress in our communities."
The Role of ALF and Local Leadership
The leaders also reflected on how the ALF network could support education and collaboration during this moment. Sarita saw an opportunity: "I see this as an opportunity for ALF to use the network for education. There are people who are disconnected from the communities—yet they hold immense power, connections, and resources that influence what happens. Many individuals and organizations within the ALF network could benefit from more education about community needs and how to respond to them. There are tremendous opportunities to leverage this network for that purpose."
Tony underscored that Santa Clara County has advantages not every community can count on: "As someone relatively new to this community, I feel we're actually quite fortunate here—not just because of the wealth, which can be a double-edged sword that sometimes lulls people to sleep, but because of the leadership in this county. We have leaders who recognize healthcare as a core human right and who value investing in human dignity by building institutions that defend that right—not as an afterthought, but as a first line of defense."
Michael echoed the sentiment: "I especially appreciate what you said about the double-edged sword of wealth—because it truly is. For me, it's inspiring and also a reminder that we have to succeed. I've been saying this about Measure A: if we can't figure it out here, with the resources and institutional drive we have, then God help the folks in places without those advantages."
Dolores Alvarado's Perspective
Although unable to join the first discussion, Dolores Alvarado, CEO of Community Health Partnership, an organization that advocates for quality, affordable, accessible, and culturally competent healthcare, joined me for a one-on-one Zoom call. With over 46 years of experience in the field, she echoed many of the concerns her colleagues had raised.
"Let's be honest—there's no 'good' in this situation. For those who did qualify under the Medi-Cal expansion, if they don't stay on top of their paperwork, they risk losing coverage altogether. And when one patient loses coverage, often their entire family does too."
Though she shared many of the grim assessments of her colleagues, Dolores also offered practical ideas for collaboration as a way forward: "I think creating new partnerships between primary care and dental care would be really helpful. For example, could we work with a dental clinic at UC Berkeley or Stanford? Ideally, we like to integrate dental services with primary care, but in times like this, we may need to think differently.
Seeking out other agencies that aren't hit as hard, or finding ways to exchange services—'we'll do this for you, you do that for us'—could be part of the solution. The mental health sector is being hit just as hard, so the need for creative partnerships is urgent."
Despite the challenges, she closed on a note of hope: "I still have a lot of trust and hope in our legislators. At the county, state, and federal levels, I believe most of them are trying to do the right thing. That gives me hope. I also find hope in the way nonprofits are coming together across different areas and efforts. That collective action gives me confidence that we can push things forward."
