As the debate over the repeal of the Affordable Care Act (ACA) evolves, CHCF will maintain a list of data resources and emerging analyses, from CHCF and other organizations, on the potential impact on California. Resources are organized reverse-chronologically and cover the following topics:

• Implications of Senate Tax Bill
• Graham-Cassidy Plan
• Analysis of the US Senate’s Better Care Reconciliation Act
• Analysis of the US House’s American Health Care Act
• Impact of Potential Elimination of the ACA’s Cost-Sharing Reductions
• Gains in Health Care Coverage Under the ACA — and Potential Impact of Repeal
• Impact of ACA Repeal on Economic Indicators and Health Care Spending
• Insurance Market Regulation Before Health Reform
• High-Risk Pools
• General Resources

This page will be updated regularly. If you have suggested additions, please email Anne Sunderland.

Implications of Senate Tax Bill

Estimates of the Increase in Uninsured by Congressional District Under the Senate GOP Tax Bill
The version of the Tax Cuts and Jobs Act passed by the US Senate on December 2, 2017, includes a repeal of the ACA’s individual mandate. Using estimates from the Congressional Budget Office, this analysis projects how many people in each of the country’s congressional districts would be uninsured in 2025 as a result of repealing the individual mandate. The California estimates are pulled out in this spreadsheet. (Center for American Progress, December 5, 2017)

Graham-Cassidy Plan

Key components of this proposal to repeal and replace the ACA include (1) replacing the ACA’s marketplace subsidies and funding for the Medicaid expansion with a block grant whose funding would be below ACA levels and shrink dramatically over time (compared to current law) and disappear after 2026, (2) converting Medicaid’s current federal-state financial partnership to a per capita cap, and (3) allowing states to waive ACA consumer protections. Certain states, including those that expanded Medicaid under the ACA, would be more adversely affected than others due to the distribution formula for block grant funds, with California losing the most funding. The proposal was revised on September 13, 2017.

550,000 Fewer California Jobs Projected Under Last-Ditch GOP Health Bill in 2027
Projects that in 2027 California would have 550,000 fewer jobs, $60.4 billion less in state GDP, and $4.4 billion less in state and local tax revenue under Graham-Cassidy compared to current law. The job losses would be much more severe than those projected under previous ACA repeal proposals considered by Senate Republicans this year. Job losses are broken down by California’s medium and large counties and all congressional districts under Graham-Cassidy in 2027. (UC Berkeley Center for Labor Research and Education, September 26, 2017)

Potential Impacts of Graham-Cassidy-Heller-Johnson on Californians and the Individual Health Insurance Market (PDF)
Models the coverage impact of two scenarios for how California might respond to a nearly $139 billion cut in federal funding between 2020 and 2027 under Graham-Cassidy. In the first scenario, California uses its greatly reduced funding to maintain coverage for Californians with low incomes in Medi-Cal; in the second, California prioritizes protecting the individual market at the expense of spending on Medi-Cal. Finds that, in both cases, the consequences of the cuts would start taking effect in 2020 and quickly lead to millions losing their coverage. Both scenarios would result in 7.5 million Californians becoming uninsured by 2027 — a higher number than before the implementation of the Affordable Care Act. (Covered California, September 25, 2017)

New Graham-Cassidy Draft: States with Hold-Out GOP Senators Favored, Potential Higher Costs Remain for Those with Preexisting Conditions
Describes the non-Medicaid provisions of the new version of Graham-Cassidy released late Sunday, September 25. Concludes that much of the bill is the same as the earlier draft, although there are significant changes including substantial funding increases for states represented by some GOP senators who have expressed concerns about the bill. Also concludes that consumer protections for people with preexisting conditions remain “very tenuous.” (Timothy Jost, Health Affairs Blog, September 25, 2017)

Summary and Preliminary Fiscal Analysis of the Combined Medicaid and Health Benefit Exchange Provisions in the Graham-Cassidy-Heller-Johnson Amendment (PDF)
Finds that Graham-Cassidy would result in the loss of $4.4 billion in federal funds in 2020, rising to $53.1 billion in 2027. The cumulative impact from 2020 to 2027 would be $138.8 billion lost in federal funding. Includes impacts due to reductions in federal funding for Covered California subsidies as well as Medicaid. Notes that the negative financial impact on California outstrips that of previous repeal proposals including AHCA and BCRA. (California Department of Health Care Services, September 22, 2017)

The Graham-Cassidy-Heller-Johnson Proposal (HR 1628, Revised) ACA Repeal and Replace Worst Case for California (PDF)
Provides a detailed look at various components of the Graham-Cassidy proposal revised on September 25 and what they might mean for California. (Insure the Uninsured Project, September 25, 2017)

How Many People in Your County Could Lose Coverage Under the Graham-Cassidy Bill?
Based on estimates from the UC Berkeley Center for Labor Research and Education, calculates projected coverage losses by county in 2027 under Graham-Cassidy as a percentage of total county population as well as a percentage of total Medi-Cal enrollment. Total coverage losses as a percentage of county population range from 9% in Placer County to 24% in Mendocino County. (California Health Care Foundation, September 21, 2017)

What Are the Potential Effects of the Graham-Cassidy ACA Repeal-and-Replace Bill? Past Estimates Provide Some Clues
Uses previous CBO scores of ACA repeal bills that closely resemble Graham-Cassidy to estimate the impact of the bill. Based on those estimates, Graham-Cassidy would result in 32 million people losing coverage after 2026. Fifteen to eighteen million could become uninsured in 2019. Half of all Americans live in states that are likely to waive the ACA’s protections of people with preexisting conditions and required essential health benefits. (Commonwealth Fund, September 20, 2017)

5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage at Risk
Describes how the Graham-Cassidy proposal revamps and cuts Medicaid, redistributes federal funds across states, and eliminates coverage for millions of poor Americans. (Kaiser Family Foundation, September 19, 2017)

The GOP’s Last-Ditch Effort to Repeal the Affordable Care Act Is the Worst One Yet for California
Estimates that under the Graham-Cassidy bill, 6.7 million Californians would lose coverage in 2027 when compared to projections under current law. Breaks down estimated coverage losses by population type (Medi-Cal expansion adult, Medi-Cal child, Medi-Cal senior, Medi-Cal disabled, and Covered California subsidized enrollee) and by California congressional district and county. Also provides points of comparison for federal funding losses to California (e.g., the estimated $57.5 billion federal funding loss is equivalent to more than one-third of all General Fund spending in California’s budget. (UC Berkeley Center for Labor Research and Education, September 18, 2017)

Like Other ACA Repeal Bills, Graham-Cassidy Plan Would Add Millions to Uninsured, Destabilize Individual Market
Updated analysis of the revised version of Graham-Cassidy. Based on previous Congressional Budget Office scores of similar ACA repeal proposals, projects that more than 32 million would lose coverage after 2026. Finds that in 2026, federal funding for coverage programs would be reduced by $80 billion compared to current law. California, specifically, would receive $28 billion less that year. In 2027, national federal funding would decline by $299 billion compared to current law. (Center for Budget Policy and Priorities, September 18, 2017)

Cassidy-Graham Plan’s Damaging Cuts to Health Care Funding Would Grow Dramatically in 2027
Summarizes the impact of the Cassidy-Graham bill to repeal and replace the ACA, with particular focus on 2027 when the bill’s temporary block grant (which would replace, at reduced funding level, the ACA’s Medicaid expansion and marketplace subsidies) would expire and its Medicaid per capita cap cuts would become increasingly severe. Estimates that in 2027 alone the bill would cut federal health care funding by a total of $299 billion and by $57.5 billion in California relative to current law. (Center for Budget Policy and Priorities, September 16, 2017)

Cassidy-Graham’s Waiver Authority Would Gut Protections for People with Pre-Existing Conditions
Explains how latest version of Cassidy-Graham would give states broad waiver authority to eliminate the ACA’s core protections for people with preexisting health conditions. (Center for Budget Policy and Priorities, September 15, 2017)

Graham-Cassidy: A Closer Look At The Medicaid Provisions
Explores the Medicaid provisions of Graham-Cassidy in further detail, including new options for states to eliminate benefits and services, and adopt more restrictive enrollment questions, restrictions on the use of states’ short-term assistance funds, and errors in math underlying the funding allocation formula. (Sara Rosenbaum, Health Affairs, September 14, 2017)

Summary of Graham-Cassidy-Heller-Johnson Amendment
Summarizes key components of the latest version of the Graham-Cassidy proposal, in table format and by specific categories such as premium subsidies, individual health insurance market rules, women’s health, Medicaid, and more. (Kaiser Family Foundation, September 13, 2017)

New Graham-Cassidy Bill: A Last GOP Shot at ACA Repeal and Replace Through Reconciliation
Summarizes latest version of Graham-Cassidy with extra focus on explaining the block grant provision. After 2019 a temporary block grant would be used in lieu of the money the ACA provides for premium tax credits, cost-sharing reductions, the Medicaid expansions, and the Basic Health Plan Program. Money would be distributed through a complex formula that would change over the 2020 to 2026 time period. (Tim Jost, Health Affairs, September 13, 2017)

Cassidy-Graham: the Obamacare Repeal Plan McCain Just Endorsed, Explained
Summarizes the Cassidy-Graham bill and explains the implications, including how it limits options for California to maintain coverage expansion. (Sarah Kliff, Vox, September 6, 2017)

Analysis of the US Senate’s Better Care Reconciliation Act

Summary of the Better Care Reconciliation Act, Discussion Draft Revised by the US Senate July 13, 2017 (PDF)
Provides overview of BCRA, including provisions added or amended in the July 13 revision (Insure the Uninsured, July 2017)

How ACA and Revised BCRA Premiums and Deductibles Differ Within and Among States
Interactive map and state fact sheets on projected net premiums and deductibles in 2020, by rating region, under the ACA and the revised BCRA introduced on July 20. Projections for a 60-year-old consumer, at 100%, 200%, 300%, and 400% FPL. In Orange County, California, at 100% FPL, total net premium and deducible would be $0 under the ACA versus $8,020 (65% of income) under the BCRA. At 200% FPL, net premium and deductible would be $2,390 (10% of income) under ACA versus $9,830 under BCRA (40% of income). (Urban Institute, July 2017)

State-by-State Coverage and Government Spending Implications of the Better Care Reconciliation Act (updated)
Provides state-by-state estimates of the impact of the July 13 version of the BCRA on health care coverage and costs by 2022 compared to current law. Finds that California’s uninsured rate would rise 139%. Does not include analysis of the proposed “Cruz amendment.” (Urban Institute, July 2017)

Updated: Who Gains and Who Loses Under the Better Care Reconciliation Act
Updated analysis of the changes in taxes and federal health benefits across families grouped by income under the July 13 version of the BCRA (excluding the proposed “Cruz amendment”). Finds the revised BCRA’s effects “very regressive.” Families with income below 400% FPL would experience net tax and benefit losses. Families with income above 400% FPL would experience net gains under the revised BCRA. Greatest net gains would go to families with income above 600% FPL. (Urban Institute, July 2017)

Compare Proposals to Replace The Affordable Care Act (updated)
An interactive table comparing repeal-and-replace proposals to current law along multiple parameters (overall approach, individual mandate, premium subsidies, insurance market rules, women’s health, Medicaid, exchanges, etc.). Now includes BCRA discussion drafts of July 13 (with Cruz amendments) and July 20, as well as the Obamacare Repeal Reconciliation Act of 2017. (Kaiser Family Foundation, July 2017)

Stability Lost: Implications for Consumers and the Individual Insurance Market Under the Senate Proposal (PDF)
Assesses the impact of the July 20 version of the BCRA on stability of the individual insurance market, based on Covered California’s experience. Predicts that the bill will lead to collapse of individual markets in all states. Also finds that (1) proposed changes in the benchmark formula for tax subsidies would result in low-value insurance policies with deductibles as high as $26,000 for a family, (2) proposed stabilization funding is too low to account for market upheaval and would result in multibillion-dollar shortfalls between 2022 and 2026, and (3) individual market collapse is especially likely with adoption of the proposed “Cruz amendment,” allowing insurers to offer “bare bones” plans. (Covered California, July 2017)

Congressional Budget Office Report on HR 1628, the Better Care Reconciliation Act of 2017, as Posted by the Senate Budget Committee on July 20, 2017 (PDF)
The current draft of the bill would reduce federal deficits by $420 billion over the 2017–2026 period, compared to a reduction of $321 billion estimated on June 26 for a previous version of the legislation. Estimated effects on health insurance coverage and premiums are similar in both versions, with an increase in the number of uninsured by 22 million in 2026, relative to current law. (Congressional Budget Office, July 2017)

How Big are the Projected Medi-Cal Cuts Under the Senate Bill in Context of the State Budget?
Under the BCRA, California stands to lose over $30 billion in Medicaid funding in 2027 alone. This blog converts the projected lost 2027 federal dollars to 2017 dollars and looks at what that amount covers in the 2016/2017 state budget. (UC Berkeley Center for Labor Research and Education, July 2017)

Establishing a Per Capita Cap in Medicaid: Implications for California
Estimates the fiscal impact of a per capita cap on Medi-Cal, California’s Medicaid program, based on the Senate’s June 22 version of the BCRA. Also describes the cap in detail, outlines operational issues and challenges created by the cap, and reviews the choices available to California if the cap is established. (Manatt Health, July 2017)

What Are the Implications for Medicare of the American Health Care Act and the Better Care Reconciliation Act?
Provides an overview of provisions in the AHCA and BCRA that will affect Medicare financing and spending. Finds that under these proposed laws, the Medicare Part A trust fund will become insolvent in 9 years, rather than in the 11 years projected under current law. (Kaiser Family Foundation, July 2017)

The Better Care Reconciliation Act: Economic and Employment Consequences for States
Provides estimates, nationally and by state, of the impact of the BCRA on employment and gross state product. By 2026, there would be 1.45 million fewer jobs nationally, and gross state products would be $162 billion lower, compared to levels under current law. In California (see appendix [PDF]), there would be 117,000 fewer jobs, and the gross state product would be $13.5 billion lower by 2026. (Commonwealth Fund, July 2017)

Year-by-Year Impacts of the Senate Better Care Reconciliation Act
Based on the CBO analysis of the BCRA, this fact sheet shows the year-by-year policy changes that would eventually lead to 22 million more Americans becoming uninsured. (Insure the Uninsured Project, June 2017)

Congressional Budget Office Report: HR 1628, Better Care Reconciliation Act of 2017
The Congressional Budget Office and the Joint Committee on Taxation estimate that enactment of the Senate’s Better Care Reconciliation Act would increase the number of people who are uninsured by 22 million in 2026 relative to current law. It would also reduce the cumulative federal deficit over the 2017–2026 period by $321 billion. (Congressional Budget Office, June 2017)

Data Graphic: Cost and Coverage Impacts of the Better Care Reconciliation Act of 2017
Infographic based on the Congressional Budget Office analysis of the BCRA showing the law’s impact, compared to the American Health Care Act (AHCA), on federal spending and the number of uninsured. (NEJM Catalyst, June 2017)

Premiums and Tax Credits Under the Affordable Care Act vs. the Senate Better Care Reconciliation Act: Interactive Maps
Provides interactive, county-by-county national map showing predicted premium and tax credit changes after BCRA enactment for current ACA marketplace enrollees at age 27, 40, or 60 with an annual income of $20,000, $30,000, $40,000, $50,000, $60,000, $75,000, $100,000, or 351% of the federal poverty level. (Kaiser Family Foundation, June 2017)

Premiums Under the Senate Better Care Reconciliation Act
Provides estimates, by state, of predicted premium changes under BCRA (after taking into account tax credits) for people currently enrolled in the federal and state marketplaces. Finds that marketplace enrollees would pay on average 74% more toward the premium for a benchmark silver plan in 2020 under the BCRA than under current law. For California (see appendix), monthly average premiums for a benchmark silver plan (after tax credits) would increase by 104%. (Kaiser Family Foundation, June 2017)

Unpacking the Senate’s Take on ACA Repeal and Replace
Overview of the BCRA’s major provisions, including a detailed look at Medicaid-related changes. (Health Affairs Blog, June 2017)

Better Care Reconciliation Act (BCRA) Analysis
Finds that the long-term impacts of the BCRA on the Medi-Cal program go beyond the devastating impacts in the AHCA, as the cost shift from the federal government to states substantially increases over time under the BCRA. The BCRA would shift nearly $3 billion in costs to California in 2020, growing to over $30 billion by 2027. (California Department of Health Care Services, June 2017)

Barely Covered: Initial Analysis of Coverage and Affordability Impacts to Consumers Under the Proposed Better Care Reconciliation Act (PDF)
Provides an initial assessment of individual market coverage and affordability under the BCRA and shows significant reductions in benchmark benefits and tax credit support particularly for lower income and older individuals. The stability funds included in the BCRA may mitigate the negative premium effects of policy changes in in 2018 and 2019 but require significant state revenues to match federal contributions in the out years. (National Academy for State Health Policy, June 2017)

Analysis of the US House’s American Health Care Act

In March 2017, House Republicans introduced the American Health Care Act (AHCA) to repeal and replace major components of the ACA. On March 24, Republican leaders decided to not bring the AHCA to a vote in the House of Representatives. An amended version of the bill was approved in the House on May 4.

How the American Health Care Act’s Changes to Medicaid Will Affect Hospital Finances in Every State
Models the impact of lost Medicaid funding under the AHCA on US hospitals. Over the next 10 years, hospitals in all states, but especially hospitals in Medicaid expansion states, will see an increase in uncompensated care — a treatment or service not paid for by an insurer or patient. California’s uncompensated care costs are expected to rise 171%. (Commonwealth Fund, June 2017)

The Impact of the American Health Care Act on Employment
Computes changes in federal spending and revenue from 2018 to 2026 for each state and projects the effects on states’ employment and economies. Finds that the AHCA would raise employment and economic activity at first, but lower them in the long run. States that expanded Medicaid would experience faster and deeper economic losses. Projects that California would lose over 32,000 jobs by 2026. Read the California results (PDF). (Commonwealth Fund, June 2017)

Consequences for States of AHCA
Projects the effects of the proposed law on states’ employment and economies. States that expanded Medicaid would suffer the most. (Commonwealth Fund, June 2017)

How Might Premium Costs Differ Within States Under the ACA and AHCA?
Compares 2020 consumer spending based on predicted differences between the tax credit structures of the ACA and the AHCA. Explore the map, brief, and state fact sheets. (National Academy for State Health Policy, June 2017)

Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? (PDF)
Examines 30 factors that could be high risk factors affecting states’ ability to respond to proposed federal Medicaid cuts and financial restructuring under the American Health Care Act and proposed presidential budget. All states would face challenges adapting to federal Medicaid cuts and caps but states with specific characteristics would be at higher risk. (Kaiser Family Foundation, June 2017)

How Repealing and Replacing the ACA Could Reduce Access to Mental Health and Substance Use Disorder Treatment and Parity Protections (PDF)
Explains how the ACA expanded coverage for mental health (MH) and substance use disorders (SUD), and finds that repealing and replacing the ACA could reverse the decades-long effort to reduce historical disparities in MH and SUD treatment. (Robert Wood Johnson Foundation and Urban Institute, June 2017)

Republican Plans to End Medicaid as We Know It Would Threaten Medi-Cal Coverage and Benefits for Millions of Californians
Offers updated and in-depth data on Medi-Cal coverage in every California county, and describes how the AHCA could affect this coverage. (California Budget and Policy Center, June 2017)

The ACA and Medi-Cal: What’s at Stake? (PDF)
Provides a detailed analysis of the changes to Medi-Cal under the ACA, and the potential impact the AHCA would have on the program. (Insure the Uninsured Project, May 2017)

Gaps in Coverage Among People with Pre-Existing Conditions
Estimates that 6.3 million people — 23% of the 27.4 million nonelderly adults with a gap of several months in insurance coverage in 2015 — could potentially face higher premiums under the House’s AHCA, due to pre-existing health conditions. (Kaiser Family Foundation, May 2017)

Medicaid Cuts in House ACA Repeal Bill Would Limit Availability of Home- and Community-Based Services (PDF)
Discusses the potential impact of the AHCA on Medicaid-funded home- and community-based services (HCBS). Includes state-specific figures on number of Medicaid enrollees using HCBS and spending on seniors and children and adults with disabilities. (Center for Budget and Policy Priorities, May 2017)

House Health Care Bill Ends Medicaid as We Know It (PDF)
Discusses AHCA’s Medicaid provisions. (Center for Budget and Policy Priorities, May 2017)

Summary of The American Health Care Act (PDF)
This fact sheet outlines the major components of the AHCA as passed by the House of Representatives on May 4, 2017, including a summary of all final amendments. (Insure the Uninsured Project, May 2017)

Compare Proposals to Replace the Affordable Care Act
Compares the AHCA, including amendments, to current law. (Kaiser Family Foundation, May 2017)

House GOP Health Plan Cuts Tax Credits, Raises Costs by Thousands of Dollars for Californians
Finds that in more than half of California’s counties, cost increases for Covered California enrollees would average more than $4,000. Includes a California county-by-county analysis. (Center on Budget and Policy Priorities, April 2017)

House Narrowly Passes ACA Repeal-and-Replace Bill That Would Leave Millions Uninsured
Analyzes how the MacArthur amendment, introduced on April 26, would alter the potential impact of the AHCA. (Commonwealth Fund, April 2017)

Congressional Budget Office Scores the American Health Care Act (PDF)
Summary of the Congressional Budget Office’s score of the AHCA (Insure the Uninsured Project, March 2017)

The American Health Care Act: What Will It Cost Californians?
This joint information hearing of the California Assembly Committee on Health and Assembly Budget Subcommittee No. 1 was held on March 22, 2017, in Fresno. Below are the materials presented at the meeting:

• What the Patient Protection and Affordable Care Act (ACA) Means for California (PDF)
  Summarizes the major provisions and enhanced federal funding under the ACA and describes the impact of both in California. (Legislative Analyst’s Office, March 2017)
• AHCA: Medicaid as a Per Capita Capped Allotment and the CBO’s Analysis (PDF)
  Summarizes the AHCA’s provisions around Medicaid financing and how they differ from current practice. (Legislative Analyst’s Office, March 2017)
• The American Health Care Act: What Will It Cost Californians? (PDF)
  Analyzes insurance market regulations and tax credits under ACA versus AHCA. Also provides background on the CBO’s analysis of the AHCA and what it might mean for California. (Insure the Uninsured Project, March 2017)
• Medi-Cal Expansion Under AHCA: Severe Coverage and Funding Loss Unless State Backfills Billions in Federal Cuts
  Projects the impact that the proposed cuts for the Medicaid expansion eligibility group under the AHCA would have over a 10-year period on Medi-Cal enrollment, the state’s budget, and the Medi-Cal funding that supports the state’s health care system. The report finds that 3.7 million fewer Californians would be enrolled in Medi-Cal by 2027. (UC Berkeley Center for Labor Research and Education, March 2017)
• Summary and Preliminary Fiscal Analysis of the Medicaid Provisions in the Federal American Health Care Act (PDF)
  Estimates the costs to California to maintain the Medi-Cal program under the Medicaid financing provisions of the AHCA. The analysis finds that the AHCA would shift nearly $6 billion in costs to California in 2020, growing to $24.3 billion by 2027. (California Department of Health Care Services, March 2017)

Covered California Releases Regional Analysis of Support Provided to Consumers Under the Affordable Care Act Compared to Changes Proposed in the American Health Care Act
Compares the financial help that Covered California consumers would receive in 2020 based on the current ACA subsidies to the proposed subsidies of the AHCA. Provides side-by-side comparisons (PDF) for consumers age 27, 40, and 62 who earn $17,000, $30,000, or $75,000 per year in each of California’s 19 rating regions. (Covered California, March 2017)

The Impact of the House ACA Repeal Bill on Enrollees’ Costs
Analyzes the “net financial impact” (changes in premiums after the application of tax credits, plus cost-sharing) of the American Health Care Act on enrollees in the individual market by 2020 and 2026. National analysis with California-specific figures. According to the analysis, net costs would go up by $9,203 for California families with low incomes by 2020 and by $13,801 by 2026. (Center for American Progress, March 2017)

Coverage Losses by Congressional District Under the House ACA Repeal Bill
Calculates, for each congressional district in the country, the number of people who would be uninsured under the American Health Care Act for several categories of coverage types. National analysis with California-specific figures. Explore the data in this interactive map. (Center for American Progress, March 2017)

Tax Credits Under the Affordable Care Act vs. the American Health Care Act: An Interactive Map
Estimates, by county, premium tax credits consumers would receive under the ACA in 2020 with what they’d receive under the American Health Care Act as unveiled March 6 by Republican leaders in Congress. National analysis with California-specific estimates. (Kaiser Family Foundation, March 2017)

Preliminary Analysis of Impacts to Consumers from Changes in Premium Subsidies and Cost-Sharing Reductions Available Under the Proposed American Health Care Act (PDF)
Shows the financial assistance provided under the ACA to a variety of hypothetical Covered California enrollees (individuals or a family) in Los Angeles and San Francisco, with various ages and incomes compared to the financial assistance that would be provided under the AHCA. Estimates are based on 2017 premiums and costs. (Covered California, March 2017)

Impact of Potential Elimination of the ACA’s Cost-Sharing Reductions

The Effects of Terminating Payments for Cost-Sharing Reductions
Finds that if the Trump Administration stops funding CSRs, premiums for silver plans on the ACA health insurance exchanges would rise 25% by 2020. It would also increase the federal deficit by $195 billion over 10 years. (Congressional Budget Office, August 2017)

How Cost-Sharing Reductions Work and the Critical Role They Play in the Individual Market (PDF)
Summarizes how cost-sharing reductions work, who benefits from them, and why they are so important to keeping individual health insurance markets stable. (Covered California, July 2017)

The Effects of Ending the Affordable Care Act’s Cost-Sharing Reduction Payments
Finds that ceasing payments for the ACA’s cost-sharing reductions could save $10 billion but cost an additional $12.3 billion in premium tax credits — an estimated net increase of $2.3 billion, or 23%, in federal spending on marketplace subsidies — in 2018, if insurers continue to participate in ACA marketplaces. (Kaiser Family Foundation, April 2017)

Potential Impact to the Federal Budget of Not Directly Funding Cost-Sharing Reduction Subsidies (PDF)
Finds that if the Trump administration doesn’t continue to fund the ACA cost-sharing reductions (CSRs), it will cost the federal government $47 billion over the next decade. Analysis projects that as a result of defunding CSRs, health plans would implement rate increases to pay for the CSR subsidies, which would increase federal spending for Advanced Premium Tax Credits far more than the cost of funding CSRs directly. (Covered California, April 2017)

Evaluating the Potential Consequences of Terminating Direct Federal Cost-Sharing Reduction (CSR) Funding (PDF)
Models the effects of an increase in premiums for Covered California silver plans that would result if the federal CSR subsidy were defunded and health plans had the opportunity to build the costs of such subsidies into their rates. A more detailed appendix (PDF) modeled the market impact of loading the CSR premium adjustment onto all plans, not just silver plans. (Covered California, January 2017)

Gains in Health Care Coverage Under the ACA — and Potential Impact of Repeal

Impacts of the ACA on Insurance Coverage by Congressional District, 2013–2015
Provides data about changes in the uninsured between 2013 and 2015 by every congressional district in the country across a range of demographic characteristics (race, age, income, citizenship, etc.). Includes data tables and an infographic for each district. See California districts. (State Health Access Data Assistance Center, June 2017)

Medicaid Coverage of Effective Treatment for Opioid Use Disorder (PDF)
Finds drastically larger utilization of buprenorphine in states that expanded Medicaid under the ACA compared to those that did not. Per the report, increased utilization of buprenorphine treatment for opioid use disorder (OUD) under Medicaid could improve outcomes for expansion state residents for relapse, retention in OUD treatment, involvement in the justice system, health, and mortality. (Urban Institute, June 2017)

Medicaid in Small Towns and Rural America: A Lifeline for Children, Families, and Communities (PDF)
Examines the changing levels of Medicaid coverage and uninsured rates at the county level by age between 2008/2009 and 2014/2015, with a focus on rural areas and small towns. National analysis with California-specific data. For example, in California, the percentage of children in rural areas and small towns covered by Medi-Cal rose to 54% from 43% as the uninsured rate among that group fell from 10% to 4%. (Georgetown University Center for Children & Families and UNC NC Rural Health Research Program, June 2017)

California’s Self-Employed and Small Business Employees Experienced Large Health Coverage Gains Under ACA
Finds that, before the ACA, nearly one in three self-employed Californians and those working for small businesses was uninsured. This dropped to one in five by 2015. More than 1.5 million self-employed Californians and those working for small businesses now have ACA coverage. (UC Berkeley Center for Labor Research and Education, May 2017)

Potential Impact of ACA Repeal on California: Premium Tax Credits
Interactive data map by SIS shows what it might cost Covered California consumers — by county, age, and income — if the ACA premium tax credits were eliminated. For example, in Alameda County premiums for some consumers could jump 467%, or nearly a quarter of annual earnings. (Social Interest Solutions, February 2017)

Fact Sheets: Medi-Cal Enrollment by District
Summarizes Medi-Cal enrollment data for August 2016 by US congressional district, California senate district, and California assembly district. (UC Berkeley Center for Labor Research and Education, February 2017)

Five Million Californians Could Lose Coverage Under ACA Repeal: Data by Congressional District (PDF)
The number of Californians covered under the Medi-Cal expansion and receiving financial assistance to purchase a plan via Covered California, organized by California congressional district. (Health Access, January 2017)

ACA Repeal in California: Who Stands to Lose?
Includes demographic breakdowns of those covered under the Medi-Cal expansion as well as subsidy-eligible Covered California consumers. The appendix details, per county, the number of people (and percentage of the overall population) represented by both groups — along with each county’s uninsured rate 2013–15. (UC Berkeley Center for Labor Research and Education, December 2016)

How Would Repeal of the ACA Affect Californians’ Health Coverage?
Includes interactive map that shows, per county, the percentage of residents that are covered by either the Medi-Cal expansion or Covered California. (Pauline Bartolone and Lydia Zuraw, California Healthline, December 2016)

Covered California Enrollment by Zip Code, March 2016
This interactive map shows how many Covered California enrollees live in a given geographic area. (California Health Care Foundation, December 2016)

Medi-Cal Reaches Millions of People Across California, but Faces an Uncertain Future
Details, per county, the number of people (and percentage of the overall population) enrolled in Medi-Cal (both expansion and nonexpansion populations). (California Budget and Policy Center, December 2016)

Facts and Figures on the ACA in California: What We’ve Gained and What We Stand to Lose
Highlights the impact of the ACA in California with a focus on coverage gains. (California Health Care Foundation, November 2016)

Obamacare Has Increased Insurance Coverage Everywhere
Includes a table of American Community Survey data that shows the change in the uninsured rate, and the drop in number of uninsured people, between 2013 and 2015 in each congressional district in the country. The four congressional districts with the biggest improvements are all in California. (FiveThirtyEight, September 2016)

Impact of ACA Repeal on Economic Indicators and Health Care Spending

Which California Industries Would Be Most Affected by ACA Repeal and Cuts to Medi-Cal?
Identifies which industries in California have the highest proportion of workers enrolled in either the Medi-Cal expansion under the ACA or Covered California with subsidies. Discusses how ACA repeal could impact these workers and the firms that employ them. (UC Berkeley Center for Labor Research and Education, February 2017)

Impact of Medi-Cal Expansion on California’s Public Health Care Systems
Fact sheets on the impact of Medi-Cal expansion on public health systems and hospitals estimate potential revenue losses if Medi-Cal expansion is repealed and describe improvements in care delivery that are at risk. Includes estimates of potential job and GDP losses as well as increases in the uninsured rate in the county where the system or hospital is located. (California Association of Public Hospitals and Health Systems, February 2017)

How Would Repealing the Affordable Care Act Affect Health Care and Jobs in Your State?
Estimates losses in coverage and jobs due to ACA repeal. National analysis with California-specific estimates. (Economic Policy Institute, January 2017)

Fact Sheets: What Do California Counties Stand to Lose Under ACA Repeal? (PDF)
Summarizes potential coverage and economic losses in selected California counties: Fresno, Kern, Kings, Los Angeles, Madera, Merced, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare. (UC Berkeley Center for Labor Research and Education, January 2017)

Repealing Federal Health Reform: Economic and Employment Consequences for States
Includes national and California-specific estimates of job losses as well as declines in state and local taxes, gross state product, and other economic indicators in the event of an ACA repeal with no replacement plan. Also see the CHCF infographic on the California-specific figures. (The Commonwealth Fund, January 2017)

The Impact on Health Care Providers of Partial ACA Repeal Through Reconciliation
Estimates the reduction in spending on health care services by insurers (public and private) and households and the increase in uncompensated care that the uninsured would seek as a result of partial repeal of the ACA. National analysis with California-specific estimates. (Urban Institute, January 2017)

Implications of Partial Repeal of the ACA Through Reconciliation
Compares future health care coverage and government health care spending under the ACA and under passage of a reconciliation bill similar to one vetoed in January 2016. National analysis with California-specific estimates. Also see the follow-up brief, Partial Repeal of the ACA Through Reconciliation: Coverage Implications for California Residents. (Urban Institute, December 2016)

California’s Projected Economic Losses Under ACA Repeal
Estimates losses in employment, gross domestic product, and state and local tax revenue in California under a partial repeal of the ACA. Also estimates losses for select counties with more than 10% of their population enrolled in the Medi-Cal expansion: Fresno, Kern, Los Angeles, San Bernardino, San Joaquin, Stanislaus, and Tulare Counties. (UC Berkeley Center for Labor Research and Education, December 2016)

What Coverage and Financing Is at Risk Under a Repeal of the ACA Medicaid Expansion?
Examines the changes in coverage and financing that have occurred under the Medicaid expansion to provide insight into the potential scope of coverage and funding that may be at risk under a repeal. National analysis with California-specific estimates. (Kaiser Family Foundation, December 2016)

Insurance Market Regulation Before Health Reform

Challenges of Partial Reform — Lessons from State Efforts to Reform the Individual and Small Group Market Before the ACA
Highlights the experiences of four states that unsuccessfully attempted to reform their individual and small group markets before the ACA — and how their failures should inform the current debate on repealing the ACA. Read the CHCF blog post on the paper. (PricewaterhouseCoopers, February 2017)

ACA Repeal Resource: California’s Individual Market Before Health Reform
Provides an overview of California’s individual market before the ACA, links to resources to learn more, and identifies potential concerns if the ACA is repealed. (California Health Care Foundation, February 2017)

How Accessible and Affordable Were Individual Market Health Plans Before the Affordable Care Act? Depends on Where You Lived (PDF)
Summarizes the laws of 50 states and the District of Columbia regarding guaranteed issue, preexisting condition exclusions, and health status rating in the individual market before the ACA. (Georgetown University Health Policy Institute, January 2017)

Pre-Existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA
Reviews medical underwriting practices in the individual health insurance market prior to 2014, and estimates how many American adults could face difficulty obtaining private individual market insurance if the ACA were repealed or amended and such practices resumed. National analysis with California-specific estimates. (Kaiser Family Foundation, December 2016)

High-Risk Pools

House Health Care Plan Is Not Enough to Keep High-Risk Pools Afloat
Analyzes the April 26 version of the AHCA and finds that the bill’s funding for high-risk pools would result in a shortfall of $2.5 billion in California — and almost $20 billion nationwide. A follow-up analysis, The Upton Amendment to the ACA Repeal Bill Will Have Almost No Effect (released May 3), includes the additional $8 billion added to the AHCA to further support high-risk pools over five years. It finds that the California shortfall remained $2.3 billion — and approximately $18 billion nationwide. (Center for American Progress, April/May 2017)

The False Equivalency of High-Risk Pools to Replace the ACA
Analyzes California’s high-risk pool before the ACA, the Major Risk Medical Insurance Program, and finds that it was plagued by long waiting lists, exorbitant premiums, low annual and lifetime benefit caps, coverage exclusions for pre-existing conditions, and limited participation by health insurers. (Insure the Uninsured Project, April 2017)

High-Risk Pools for People with Preexisting Conditions: A Refresher Course
A national analysis of state-based high-risk pools before the ACA and the challenges they encountered. (Commonwealth Fund, March 2017)

General Resources

ACA Watch
As the federal repeal-and-replace debate unfolds, ITUP’s ACA Watch will periodically highlight emerging federal proposals, Congressional and administrative actions, and potential impacts for health care and health reform in California. (Insure the Uninsured Project, updated regularly)

Coverage, Access, and Affordability in California: Key Data 2013–2016
Collection of data and resources used to maintain ACA 411, an interactive data analysis tool that helped users explore the ACA’s impact on California until January 2018.

Covered California Data and Research
Includes a range of data on Covered California enrollment, membership, products, and prices. (California Health Benefit Exchange, updated regularly)

Research and Analytic Studies Division
Official statistics and analytical studies related to Medi-Cal that inform policy and assist DHCS in achieving its mission and goals. (California Department of Health Care Services, updated regularly)