In the early years of the AIDS epidemic, we lost patients because medicine had no effective treatment. Today, cuts to Medi-Cal threaten access to the treatment we now have. Proposition 40 would protect Medi-Cal and preserve the care Californians depend on to survive.
In the late 1980s, while practicing medicine in Los Angeles, I had a patient I will call Jim. He had been unemployed for some time, and a longtime friend had taken him in, giving him a corner in a cramped studio apartment. Jim had AIDS, and purple lesions of Kaposi’s sarcoma had spread across his face, and as they multiplied, he seldom went outside. He made an exception only for late-night movies, when there would be few people around to see him.
Jim had lost his health insurance for reasons I no longer remember, and my medical group cared for him without charge. I arranged for him to see a social worker, but she had been unable to find him a place of his own. His world contracted until it held little more than that studio apartment and our examining room. His friends repeatedly assured him that caring for him was no burden and that he could stay as long as he needed. They meant it, but Jim felt he had imposed enough. His illness and lack of means left him unable to see a tolerable way forward.
At the end of an appointment, as Jim was leaving, he thanked me and called me “Andrew.” My patients generally called me Dr. Faulk, and Jim always had. Only afterward did I hear in that unexpected intimacy a goodbye. Three days later, he died by suicide.
I could not restore Jim’s insurance, find him a less confining place to live, or erase the lesions that announced his illness whenever he stepped outside. His friends could offer him shelter and devotion, but they could not persuade him that accepting their care was different from burdening them.
In the nearly four decades since Jim died, HIV treatment has changed almost beyond recognition. But access to it remains fragile. Sustained treatment can now control the virus, often for a lifetime, and prevent its sexual transmission. Interrupt that treatment, and the virus rebounds, endangering both the patient and others.
In 2024, 143,918 Californians were living with diagnosed HIV. A 2023 analysis by the California Department of Public Health found that 67,428 adults living with HIV were enrolled in Medi-Cal, nearly 47 percent of the state’s adult HIV population.
That system is about to come under considerable strain. Beginning in 2027, many adults covered through the Affordable Care Act expansion will have to document work, school, or community service and renew their eligibility every six months rather than once a year. The nonpartisan Legislative Analyst’s Office estimates these changes could reduce Medi-Cal enrollment among childless adults by 1.6 million by 2029–30. We do not yet know how many Californians living with HIV will be among them. Anyone who has practiced medicine among people with complicated lives knows that additional paperwork can cost eligible patients their coverage when illness or unstable conditions prevent them from answering the right notice by the right date.
To a budget analyst, 67,428 is an enrollment figure. To a physician, it represents patients who need prescriptions renewed, laboratory results explained, and some assurance that the care on which their lives depend will still be there next month.
Jim had devoted friends, a social worker trying to find him housing and physicians willing to care for him without payment. Effective treatment for HIV did not yet exist in Jim’s time. Today it does, and keeping patients alive depends upon their uninterrupted access to the healthcare system that provides it. Goodwill can rescue an individual patient for a time, but California cannot build a healthcare system out of borrowed rooms, unpaid bills and private acts of generosity.
Proposition 40 would give California substantial resources to protect care as federal support recedes. The measure, the 2026 Billionaire Tax Act, would impose a one-time tax of 5 percent on the worldwide net worth of billionaires who were California residents on January 1, 2026. Despite predictions of an exodus, there is no evidence so far of a significant departure of billionaires, and the nonpartisan Legislative Analyst’s Office estimates the measure would raise tens of billions of dollars over several years.
Of those net proceeds, 90 percent would be reserved for healthcare, with the remaining 10 percent supporting public education and food assistance. That revenue could help California bridge federal funding shortfalls, preserve Medi-Cal coverage and protect community hospitals and clinics. For Californians with HIV, it could help maintain continuity of care as new eligibility requirements put their coverage at risk. We have the medical tools to keep HIV suppressed and patients healthy; what we are deciding now is whether we will fund the safety net required to sustain them.
When Californians cast their ballots on November 3, they will decide whether those who have prospered most in our state should help preserve care for those who can least afford to lose it. For a fairer tax system and healthcare that does not abandon people when they become poor or ill, I will be voting yes on Proposition 40 and no on Propositions 41 and 42.
Andrew Faulk, M.D., is a retired physician who treated people with HIV/AIDS in Los Angeles during the first decade of the AIDS epidemic. He is the author of My Epidemic, an AIDS memoir, and lives in San Francisco with his husband.
