HEALTH POLICY CENTER

State-by-State Estimates of the
Coverage and Funding Consequences
of Full Repeal of the ACA
Linda J. Blumberg, Matthew Buettgens, John Holahan, and Clare Pan
March 2019
In June 2018, we released a national-level analysis that estimated the coverage and
health care spending implications of eliminating the entire Affordable Care Act (ACA) in
2019 (Holahan, Blumberg, and Buettgens 2018). We did this analysis to provide
information on some of the consequences should a case then before the US District
Court for the Northern District of Texas be decided in favor of the plaintiffs.1 The
district court judge in that case did find for the plaintiffs, yet the repeal of the ACA has
been stayed pending appeal to the US Court of Appeals for the Fifth Circuit. In this
current analysis, we estimate the state-by-state implications of full ACA repeal in 2019,
updating our previous analysis to reflect 2019 Marketplace enrollment and premiums,
as well as more recent Medicaid data. We also present a new sensitivity analysis that
accounts for the uncertain circumstances for states that had Medicaid coverage
expansion waivers in place before the ACA. In addition, we provide data on Marketplace
premiums, insurer participation, and enrollment in 2018 and 2019 as indicators of the
strength of the ACA’s private nongroup insurance markets in the first year without the
individual mandate penalties in place.
The plaintiffs argue that, because the 2017 Tax Cuts and Jobs Act eliminated the ACA’s individual
mandate penalties starting with the 2019 plan year, the entire ACA cannot operate or be sustained.
Therefore, they argue that the ACA should be invalidated, or effectively repealed in its entirety.

 Because of the complexity of fully repealing the ACA, we have estimated the implications in two
ways: our main results assume that states with Medicaid 1115 coverage expansions in place before the
ACA would be able to reinstate them, and our sensitivity results assume that those states would not be
able to reinstate their waivers. How states and the federal government would respond to a full repeal of
the ACA is uncertain. The states with waivers in place in 2010 (Arizona, Delaware, Hawaii,
Massachusetts, New York, Vermont, and Wisconsin) are in different circumstances; for those that
would seek to reinstate the coverage components of their 2010 waiver, it is unclear whether and under
what conditions the current administration would renegotiate them. Thus, by estimating the
implications of repeal with and without those waivers in place, we provide a reasonable range of
possible effects.
If the entire law were eliminated and pre-ACA Medicaid expansion waivers were reinstated, our
main analysis shows the following changes in 2019:


The number of uninsured people in the US would increase by 19.9 million, or 65 percent.



Federal spending on health care would fall by $134.7 billion, a decrease of 35 percent compared
with ACA-level spending on Marketplace subsidies and Medicaid/Children’s Health Insurance
Program (CHIP) acute care for the nonelderly.
State spending on Medicaid/CHIP would fall by $9.6 billion, a decrease of 6 percent compared



with ACA-level spending on acute care for the nonelderly.
Demand for uncompensated care would increase by $50.2 billion, an increase of 82 percent



compared with ACA levels.
The effects of repeal on insurance coverage would vary considerably across the country. States



that most reduced their uninsured populations under the ACA (e.g., states that expanded
Medicaid and/or had high Marketplace participation) would experience the greatest relative
increases in their uninsured populations under repeal. For example, the number of uninsured in
Kentucky would increase by 151 percent under repeal, compared with only a 12 percent
increase in South Dakota, a state that has not expanded Medicaid and has had low enrollment in
the Marketplace.
Likewise, federal health care spending would fall most in states where coverage increased most.



Federal health care spending on Medicaid/CHIP (acute care for the nonelderly) and
Marketplace subsidies would fall by more than 40 percent in 15 states, but the relative
decreases would be much smaller in states like Mississippi (15 percent) and Texas (21 percent).
States with Medicaid 1115 waivers in place in 2010 would be able to protect more of their



coverage under repeal if they would be able to reinstate those waivers on similar terms.
However, those waivers would have to be renegotiated with the federal government, and the
results of that process are highly uncertain.
Not all seven states with pre-ACA Medicaid expansion waivers have maintained the preexpansion
coverage element of the waiver, given the opportunity to expand under the ACA. As a result, we

2

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 estimate the implications of those waivers not being reinstated under full ACA repeal as a sensitivity.
Given that Wisconsin’s waiver, for one, has been recently renewed, the most likely outcome would be
somewhere between our main results and the following results of the sensitivity analysis:


Without reinstating waivers in these seven states, up to 1.3 million more people could become
uninsured beyond the first scenario, increasing national uninsurance under repeal by 21.2
million people, or 70 percent.



Federal spending on health care could fall even further than noted above, by up to an additional
$6.4 billion in 2019, bringing the total national decrease to $141.1 billion.



Simultaneously, state spending on Medicaid/CHIP could fall further, by up to an additional $5.0
billion across the seven states, bringing the national decrease in state spending to $14.6 billion.



With higher levels of uninsurance absent reinstated waivers, the demand for uncompensated
care would be still higher. As a result, the national demand for uncompensated care could be up
to $53.3 billion higher in 2019 than under current law.

Lastly, in response to claims that the ACA’s private nongroup insurance markets could not function
effectively with guaranteed issue and modified community rating but without an individual mandate, we
analyzed Marketplace data and found that, despite elimination of the mandate penalties beginning in
the 2019 plan year


enrollment (measured as plan selections) as of the end of the open enrollment period is 97
percent of 2018 enrollment at the same point in the year;



more insurers are participating in the Marketplaces in 2019 than in 2018; and



typical benchmark (second-lowest-cost silver) premium increases in 2019 were well below
those in 2018, and many more rating regions experienced benchmark premium decreases in
2019 than in 2018.

Data and Methods
2

Our analyses use the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM). HIPSM is a
detailed microsimulation model of the health care system designed to estimate the cost and coverage
effects of proposed policy options. The model has been used extensively to estimate the cost and
coverage implications of health reforms at the national and state levels and has been widely cited,
including in the Supreme Court’s majority opinion in King v. Burwell.

3

HIPSM is based on two years of the American Community Survey. The population is aged to future
4

years using projections from the Urban Institute’s Mapping America’s Futures program. HIPSM is
designed to incorporate timely, real-world data when they are available. We regularly update the model
to reflect published Medicaid and Marketplace enrollment and costs in each state. The enrollment
experience in each state under current law affects how the model simulates policy alternatives. The
current version of HIPSM is calibrated to state-specific targets for Marketplace enrollment following

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

3

 the 2019 open enrollment period, 2019 Marketplace premiums, and late 2018 Medicaid enrollment
from the Centers for Medicare & Medicaid Services monthly enrollment snapshots. As of this
publication, no 2019 data were available on off-Marketplace nongroup or non-ACA-compliant
nongroup coverage. The simulations, account for relevant state regulations such as the banning of
short-term, limited-duration plans (Blumberg, Buettgens, and Wang 2018).
Our current-law estimates account for the federal individual mandate penalties being set to $0
beginning in plan year 2019, as well as the fact that the District of Columbia, Massachusetts, and New
Jersey have their own individual mandate penalties. Elimination of the federal individual mandate
penalties is expected to reduce insurance coverage levels compared with having the penalties in place;
however, eliminating the rest of the ACA would only exacerbate declining insurance levels.
We treat states in which the ACA Medicaid expansion has been approved by ballot initiative but not
yet implemented as nonexpansion states (Idaho, Nebraska, and Utah).
Other ACA provisions that affect Medicare, payment and delivery system reform, support for
community health centers, and preventive care initiatives would be eliminated if the ACA were fully
repealed. As with our prior analysis, we do not analyze the elimination of those provisions here.
We estimate the impact of a complete repeal of the coverage provisions of the ACA, comparing it
with insurance coverage and health care spending under current law at the national and state levels.
The current-law estimates include the repeal of the federal individual mandate penalties and other
recent policy changes, including the expanded availability of short-term, limited-duration policies; a
shortened annual open enrollment period; and reduced funds for outreach and enrollment assistance.
Our prior analysis did not account for the expansion of short-term policies under current law, because
the regulations had not yet been finalized when the report was released in June 2018.
As noted above, we present a range of estimated effects of repeal to account for the uncertainty
surrounding whether states would reinstate their pre-ACA Medicaid 1115 coverage expansion waivers.
Our main set of estimates assumes the waivers would be reinstated, whereas the second set of
estimates, presented as a sensitivity analysis, assumes they would not be reinstated. Before the ACA,
seven states received federal Section 1115 waivers to expand eligibility for Medicaid coverage; most
often, these states demonstrated that their expansion would be budget neutral for the federal
government, because savings would accrue from moving Medicaid enrollees into managed care
organizations. The seven states were Arizona, Delaware, Hawaii, Massachusetts, New York, Vermont,
and Wisconsin. Because the ACA made these waivers obsolete in ACA Medicaid expansion states, not
all waivers, or the coverage aspects of the waivers, have been renewed since 2014.
If the ACA were effectively repealed and not all state waivers were reinstated, Medicaid eligibility
in the nonrenewed states would shift back to the pre–waiver implementation eligibility levels. These
states could apply to have their waivers renegotiated with the federal government if the ACA were
invalidated, but the outcome would be uncertain. First, states would have to be willing and able to invest
the time and expenses involved with the waiver process. Second, it is unclear what terms the
administration would agree to. And third, it is unclear whether the states would be able to show that

4

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 their new waivers would be budget neutral to the federal government, given changes in circumstances
since the waivers’ original approval and intervening changes in the administration’s approach to
calculating budget neutrality. Though at least one of these seven states, Wisconsin, has a currently
active coverage waiver, we present our sensitivity results for all seven states as a sensitivity in a steadystate situation, because it is unclear how future administrations would treat new waiver requests. We
recognize that the most likely result of invalidating the ACA would fall somewhere between our main
results and the secondary results from the sensitivity analysis.
It is possible that ACA repeal would be used as a vehicle to introduce the large-scale changes to
Medicaid that the current administration now encourages through waivers, such as the imposition of
work requirements. We did not simulate any such changes to the program.

The Impact of Full ACA Repeal Assuming Reinstatement
of Pre-ACA Medicaid Coverage Expansion Waivers
National Effects on Coverage
Under current law, we estimate that 11.1 percent of the nonelderly population, or 30.4 million people,
will be uninsured in 2019 (table 1). Another 147.3 million people will have employer-sponsored
insurance, and 68.6 million people will have insurance through Medicaid or CHIP. Approximately 17.2
million people will have nongroup insurance coverage that abides by the ACA’s consumer protections,
including those receiving federal tax credits to reduce their premiums and those who buy policies with
only personal funds. Another 2.2 million people will purchase short-term, limited-duration policies on
the nongroup market. These policies, made more widely available under administrative regulations
implemented in late 2018, do not comply with ACA requirements such as guaranteed issue, modified
community rating, essential health benefits coverage, actuarial value standards, and prohibitions on
preexisting condition exclusions.
If the ACA were repealed, the number of uninsured people in the US would increase to 50.3 million,
an increase of 65.4 percent or 19.9 million people (table 1). Medicaid and CHIP enrollment would fall by
15.4 million people through the elimination of the ACA’s Medicaid expansion. Reduced Medicaid
eligibility would increase uninsurance among the low-income population.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

5

 TABLE 1

Health Insurance Coverage Distribution of the Nonelderly in 2019 under
Current Law and Full ACA Repeal with Renewed Pre-ACA Medicaid Coverage Expansion Waivers

Insured
Employer

Current Law ACA
1,000s of
people
%

Full Repeal with
Renewed Pre-ACA
Expansions
1,000s of
people
%

Change
1,000s of
people

243,939
147,314

88.9
53.7

224,062
149,685

81.7
54.6

-19,877
2,371

-8.1
1.6

19,448

7.1

12,561

4.6

-6,887

-35.4

9,233

3.4

0

0.0

-9,233

-100.0

%

Nongroup total
ACA nongroup (with
tax credits)
ACA nongroup
(without tax credits)
Noncompliant nongroup
coverage
Medicaid/CHIP
Other (including Medicare)

7,973

2.9

0

0.0

-7,973

-100.0

2,241
68,603
8,574

0.8
25.0
3.1

12,561
53,243
8,574

4.6
19.4
3.1

10,319
-15,361
0

460.4
-22.4
0.0

Uninsured

30,377

11.1

50,253

18.3

19,877

65.4

100.0

274,316

100.0

0

0.0

Total

274,316

Source: Urban Institute analysis, Health Insurance Policy Simulation Model 2019.
Notes: CHIP = Children’s Health Insurance Program. Reform simulated in 2019.

The total number of people with private nongroup insurance (ACA compliant and noncompliant)
would drop 35.4 percent (6.9 million people), compared with having the ACA in place. Though we
estimate that about 88 percent of nongroup coverage under current law is ACA compliant, postrepeal
nongroup coverage would not be required to meet ACA consumer protections unless states passed
them into law. Without the ACA’s federal tax credits to attract many healthy people into the nongroup
insurance market, those consumer protections could not be maintained because of the risk of
substantial adverse selection into the market. Therefore, those enrolling in private nongroup coverage
after repeal would likely have policies that cover significantly fewer benefits and require more out-of5

pocket spending for services, similar to nongroup coverage before ACA implementation. These policies
also would no longer be required to cover preexisting conditions. Because of the elimination of
guaranteed issue and modified community ratings, many people with current or past health problems
would be unable to purchase the plans at any price, and others would be charged very high prices for
insurance policies, further decreasing coverage and increasing financial burdens.

State-by-State Effects on the Uninsured
Table 2 shows the estimated increase in uninsurance and the percent of the nonelderly population
uninsured in each state and the District of Columbia.

6

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 TABLE 2

The Uninsured Nonelderly in 2019 under Current Law and Full ACA Repeal
with Renewed Pre-ACA Medicaid Coverage Expansion Waivers by State
CURRENT LAW

State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

1,000s of
people

%

504
75
768
206
3,421
396
171
66
35
2,327
1,594
132
202
1,297
600
149
342
252
335
51
374
137
627
331
404
639
63
182
376
66
732
207
1,488
1,168
56
704
617
304
644
57
536
101
738
4,678
383
32
670
538
92
436
74

12.3
10.5
12.8
8.1
10.0
8.4
5.8
8.4
6.1
14.4
16.9
10.4
13.8
11.6
10.6
5.7
13.7
6.8
8.7
4.9
7.1
2.5
7.7
7.0
16.2
12.5
7.5
11.4
13.8
6.0
9.7
11.3
8.9
13.3
9.6
7.4
18.2
9.1
6.2
6.6
13.3
14.0
13.2
19.2
13.6
6.5
8.9
8.8
6.4
9.0
14.8

FULL REPEAL WITH RENEWED PRE-ACA EXPANSIONS
Difference from Current law
1,000s of
1,000s of
people
%
people
%
647
143
1,064
505
7,210
796
394
94
69
3,887
2,055
143
281
1,902
1,097
336
404
630
830
134
719
239
1,347
596
504
808
175
234
658
155
1,327
434
2,095
1,672
81
1,445
763
676
1,502
124
778
114
905
6,411
484
45
1,312
1,102
254
589
85

15.8
20.1
17.7
19.9
21.0
17.0
13.2
12.0
12.1
24.1
21.8
11.2
19.3
17.0
19.3
12.9
16.1
17.1
21.5
13.0
13.6
4.3
16.6
12.6
20.2
15.8
20.9
14.7
24.1
14.3
17.6
23.7
12.6
19.1
14.0
15.2
22.5
20.3
14.4
14.3
19.3
15.7
16.3
26.3
17.2
9.1
17.4
18.1
17.6
12.2
17.1

143
68
297
299
3,789
400
223
28
34
1,560
461
11
79
605
497
187
62
379
494
83
345
102
720
265
100
169
112
52
282
89
595
226
607
503
25
741
146
372
858
67
242
12
168
1,733
102
13
642
565
162
153
12

28.4
91.4
38.6
145.1
110.7
101.2
130.0
41.8
97.2
67.0
28.9
8.1
39.4
46.6
82.7
125.7
18.0
150.5
147.4
164.8
92.2
74.0
114.8
80.0
24.9
26.4
176.8
28.7
75.1
136.0
81.3
109.0
40.8
43.1
45.6
105.3
23.7
122.2
133.2
116.3
45.0
11.9
22.7
37.0
26.5
39.9
95.7
105.0
175.6
35.2
16.0

Total
30,377
11.1
50,253
18.3
Source: Urban Institute analysis, Health Insurance Policy Simulation Model 2019.
Note: Reform simulated in 2019.

19,877

65.4

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

7

 The largest absolute increase in the number of people uninsured occurs in the largest states: 3.8
million more uninsured in California, 1.6 million more uninsured in Florida, and 1.7 million more
uninsured in Texas.
The largest percentage increases in the uninsured would occur in the states with the largest
increases in coverage under the ACA. For example, West Virginia and Kentucky have large low-income
populations and had high uninsurance rates before the ACA, and both states expanded Medicaid
eligibility in 2014. Under repeal, the number of people uninsured in Kentucky would increase by
379,000, or 150.5 percent; in West Virginia, the number of people uninsured would increase by
162,000, or 175.6 percent. The uninsured in Montana, another ACA Medicaid expansion state, would
increase by 176.8 percent, or 112,000 people.
States that did not expand Medicaid and/or do not have measures in place to encourage high
Marketplace enrollment would see much smaller changes in their number of uninsured residents under
repeal. For example, uninsurance in South Dakota would increase by 12,000 people, or 11.9 percent;
uninsurance in Kansas would increase by 62,000 people, or 18.0 percent.

Nationwide and State-by-State Effects on Federal Health Care Spending
Federal spending on acute care for nonelderly people would drop substantially with a full ACA repeal.
Federal spending on Medicaid/CHIP acute care for the nonelderly and Marketplace premium tax credits
in 2019 would fall by $134.7 billion, or 34.6 percent (table 3). The decline in federal Medicaid/CHIP
spending alone would total $82.2 billion; the elimination of tax credits and reinsurance would reduce
federal spending by $52.5 billion (not shown).
Table 3 shows how the decreases in federal spending would vary across the states and the District
of Columbia. Consistent with the findings on coverage effects, the largest percent changes in federal
health care spending from a full repeal of the ACA would occur in states with the largest coverage gains
from the ACA: states that expanded Medicaid and/or had high Marketplace enrollment. If pre-ACA
Medicaid coverage expansion waivers were renewed, the federal spending declines in waiver states
would be smaller than in the average state. However, federal health care funding would substantially
decrease in all states.
Fifteen states would see their federal health care funding decrease by 40 percent or more. These
include both large and small states, most of which expanded Medicaid eligibility under the ACA (e.g.,
California, Colorado, New Jersey, New Mexico, Virginia, Washington, and Oregon). Others, like
Wyoming and Nebraska, would experience large decreases in federal health care funding even though
they did not expand Medicaid eligibility, because their traditional Medicaid programs are relatively
small and the ACA’s premium tax credits make up a large share of their current federal health spending.
Federal health spending in Florida would drop by 40.9 percent, given the state’s very high Marketplace
participation rate.

8

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 TABLE 3

Federal Spending on Medicaid/CHIP Acute Care for the Nonelderly and Marketplace Subsidies in
2019 under Current Law and Full ACA Repeal with Renewed Pre-ACA Expansion Waivers by State
Millions of dollars, except where noted
CURRENT LAW
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Total

$

FULL REPEAL WITH RENEWED PRE-ACA EXPANSIONS
Difference from Current Law
$
$
%

5,009
1,212
10,810
5,179
48,893
5,940
4,661
1,413
1,411
22,825
10,149
1,139
1,869
9,133
8,307
3,798
2,091
8,650
7,637
1,942
6,927
7,617
13,707
6,404
4,673
8,001
2,218
1,691
3,076
951
6,687
5,254
27,920
15,097
488
14,243
4,746
5,838
15,795
1,303
5,388
826
8,196
31,271
3,179
1,146
8,631
7,949
2,929
4,970
553

3,853
672
8,691
3,401
26,491
3,128
2,810
1,111
1,130
13,483
7,830
833
1,274
6,136
5,261
2,401
1,546
4,504
4,030
1,446
3,988
5,900
8,516
4,563
3,956
6,841
1,126
917
1,906
586
3,989
3,089
17,770
10,527
309
9,829
3,510
3,286
10,743
794
3,734
626
6,609
24,815
2,188
976
3,953
3,799
1,884
3,953
310

-1,155
-540
-2,119
-1,778
-22,403
-2,812
-1,851
-302
-281
-9,342
-2,318
-305
-594
-2,997
-3,046
-1,398
-545
-4,146
-3,606
-495
-2,939
-1,718
-5,191
-1,841
-717
-1,161
-1,092
-774
-1,170
-366
-2,698
-2,165
-10,149
-4,570
-180
-4,414
-1,236
-2,552
-5,052
-509
-1,653
-200
-1,586
-6,456
-991
-169
-4,679
-4,150
-1,045
-1,017
-243

-23.1
-44.5
-19.6
-34.3
-45.8
-47.3
-39.7
-21.4
-19.9
-40.9
-22.8
-26.8
-31.8
-32.8
-36.7
-36.8
-26.1
-47.9
-47.2
-25.5
-42.4
-22.5
-37.9
-28.7
-15.3
-14.5
-49.2
-45.8
-38.1
-38.4
-40.3
-41.2
-36.4
-30.3
-36.8
-31.0
-26.0
-43.7
-32.0
-39.1
-30.7
-24.2
-19.4
-20.6
-31.2
-14.8
-54.2
-52.2
-35.7
-20.5
-43.9

389,740

255,022

-134,718

-34.6

Source: Urban Institute analysis, Health Insurance Policy Simulation Model 2019.
Note: Reform simulated in 2019.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

9

 Federal health spending in Texas, which did not expand Medicaid eligibility under the ACA and has
relatively low participation in the Marketplaces, would still fall by more than 20 percent. Tennessee
would be in a similar situation.

State-by-State Effects on State Medicaid/CHIP Spending and Reinsurance Programs
Seven states (Alaska, Maine, Maryland, Minnesota, New Jersey, Oregon, and Wisconsin) have used
Section 1332 waivers to create reinsurance programs to lower unsubsidized premiums in their private
nongroup insurance markets. These programs are partly financed by federal savings generated in
premium tax credits and additionally by state funds. These programs would be eliminated under full
repeal of the ACA. We estimate that state spending on these programs would total $327 million in 2019
under current law, a relatively small amount compared with states’ aggregate spending on Medicaid and
CHIP acute care for the nonelderly ($168.5 billion; data not shown). State spending, shown in table 4,
includes combined Medicaid/CHIP and reinsurance spending. Under full repeal, the reinsurance
program would be eliminated, as would the ACA’s Medicaid eligibility expansion. With pre-ACA waivers
reinstated, state spending in the waiver states would fall less compared with other expansion states.
Beyond eliminating reinsurance programs, full ACA repeal would also affect states’ spending on
their Medicaid and CHIP programs. Not only did Medicaid/CHIP enrollment increase in states that
expanded eligibility under the ACA, but it also increased in states that did not, though significantly less
so. The increases in Medicaid/CHIP enrollment in nonexpansion states are attributable to greater child
enrollment. With the availability of Marketplace premium tax credits, some parents applied for
subsidized Marketplace coverage and discovered that their children were already eligible for Medicaid
or CHIP and then enrolled their children in the appropriate program. Without the Marketplaces or the
associated subsidies available for that coverage because of a full ACA repeal, such parents would not
discover that their children were eligible for public insurance, and enrollment would decrease.
Decreased enrollment would therefore lead to modestly decreased state spending on these programs.
Nationwide, states’ spending on Medicaid, CHIP, and reinsurance would decrease under full repeal
by $9.6 billion in 2019, or 5.7 percent. The largest percentage decreases would occur in states that had
the lowest eligibility rates for Medicaid before the ACA and that expanded eligibility under the ACA.
These include New Mexico (16.6 percent lower spending), Kentucky (19.3 percent lower spending),
Montana (17.0 percent lower spending), and Louisiana (18.4 percent lower spending).

10

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 TABLE 4

State Spending on Medicaid/CHIP Acute Care for the Nonelderly and Reinsurance in 2019 under
Current Law and Full ACA Repeal with Renewed Pre-ACA Expansion Waivers by State
Millions of dollars, except where noted
CURRENT LAW
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Total

$

FULL REPEAL WITH RENEWED PRE-ACA EXPANSIONS
Difference from Current Law
$
$
%

1,364
446
3,030
1,327
25,538
2,904
2,958
660
484
8,324
3,493
551
529
5,369
2,698
1,400
942
1,960
2,185
826
3,946
4,644
4,666
5,037
1,129
3,246
552
737
1,111
565
3,687
1,146
13,877
4,996
275
5,848
1,647
2,128
8,468
730
1,527
395
3,267
15,051
910
740
4,067
4,032
637
2,533
275

1,307
381
3,444
1,162
22,627
2,542
2,663
740
451
7,782
3,355
650
482
5,259
2,438
1,271
888
1,582
1,783
767
3,387
5,215
4,235
4,532
1,089
3,237
458
694
983
533
3,307
955
15,952
4,567
274
5,377
1,590
1,821
8,031
643
1,410
384
3,183
13,786
876
836
3,577
3,522
554
2,419
275

-57
-65
414
-165
-2,911
-362
-296
80
-33
-541
-138
99
-47
-111
-261
-129
-54
-378
-402
-60
-559
571
-431
-505
-40
-9
-94
-43
-127
-32
-380
-190
2,075
-428
-1
-472
-58
-306
-436
-86
-117
-11
-84
-1,264
-34
96
-489
-510
-82
-114
0

-4.2
-14.6
13.6
-12.4
-11.4
-12.5
-10.0
12.1
-6.7
-6.5
-3.9
18.0
-8.8
-2.1
-9.7
-9.2
-5.7
-19.3
-18.4
-7.2
-14.2
12.3
-9.2
-10.0
-3.5
-0.3
-17.0
-5.9
-11.5
-5.7
-10.3
-16.6
15.0
-8.6
-0.4
-8.1
-3.5
-14.4
-5.2
-11.8
-7.6
-2.8
-2.6
-8.4
-3.7
13.0
-12.0
-12.6
-12.9
-4.5
0.0

168,853

159,277

-9,576

-5.7

Source: Urban Institute analysis, Health Insurance Policy Simulation Model 2019.
Note: Reform simulated in 2019.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

11

 Compared with current law, state spending under repeal would increase for states with pre-ACA
expansion waivers. This is because those earlier expansions provided federal funding at the traditional
matching rates, and these traditional rates are lower than the federal matching rate for the ACA’s
expansion population, which is at 93 percent in 2019 and would reach its low of 90 percent in 2020.
Because restoring coverage through a waiver would return the federal match to the traditional rate, full
repeal would increase state spending if those waivers were renewed. For example, repeal with the
waivers renewed would increase state spending in Arizona by 13.6 percent, or $414 million, compared
with current law.
States that did not expand Medicaid eligibility under the ACA would experience the smallest
percent changes in their spending under repeal (e.g., no net change in spending in Wyoming, a 0.3
percent decrease in Missouri, a 2.6 percent decrease in Tennessee, and a 2.8 percent decrease in South
Dakota). These states’ Medicaid enrollment changed very little under the ACA.

State-by-State Effects on the Demand for Uncompensated Care
As shown previously, repealing the ACA in 2019 would substantially increase uninsurance in the US, by
approximately 20 million more people (table 1). Consequently, repeal would also increase demand for
uncompensated care, care provided to those who cannot pay for it. Uncompensated care is financed by
federal, state, and local government programs and by health care providers (e.g., hospitals and
physicians). We estimate that, nationwide, full repeal of the ACA would increase demand for
uncompensated care by $50.2 billion in 2019, or 81.9 percent (table 5). Increases in demand for
uncompensated care would vary substantially across states, relating directly to the state’s increase in
the number of uninsured residents and their health statuses. Funding for uncompensated care is not
guaranteed to increase to meet this additional demand; consequently, a significant share of this
increased demand could translate into further unmet medical need.
ACA Medicaid expansion states with large low-income populations and narrower pre-ACA
Medicaid programs would be among the states experiencing the largest increases in demand for
uncompensated care. Demand would increase by 132.8 percent in West Virginia, 138.8 percent in
Kentucky, 116.8 percent in Pennsylvania, and 183.3 percent in Iowa, for example. Increased financial
pressure on health care providers in these and many other states could intensify if government
programs do not expand proportionate to the increase in the number of uninsured people. Smaller
increases in demand for uncompensated care would occur in states with small increases in coverage
under the ACA, like Idaho (25.2 percent increase), Alabama (20.5 percent increase), and Tennessee
(31.2 percent increase).

12

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 TABLE 5

Demand for Uncompensated Care among the Nonelderly in 2019 under Current Law and
Full ACA Repeal with Renewed Pre-ACA Medicaid Coverage Expansion Waivers by State
Millions of dollars, except where noted
CURRENT LAW
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Total

$

FULL REPEAL WITH RENEWED PRE-ACA EXPANSIONS
Difference from Current Law
$
$
%

1,093
223
1,608
609
6,052
1,019
425
104
95
4,498
2,529
213
510
2,936
1,476
373
794
673
872
222
701
353
2,010
1,187
975
1,762
239
369
641
204
1,344
417
2,816
1,838
152
1,688
1,504
642
1,555
93
954
208
1,420
6,582
784
89
1,531
1,294
316
1,080
176

1,317
379
2,431
1,446
14,103
2,069
1,204
226
151
8,461
3,687
263
638
4,640
3,060
1,057
1,107
1,608
1,950
496
1,515
784
3,958
2,253
1,232
2,341
595
552
1,394
438
2,695
908
4,519
2,984
221
3,613
2,154
1,729
3,372
215
1,465
281
1,863
9,866
1,108
174
3,243
3,116
736
1,491
289

224
156
823
837
8,051
1,049
780
122
56
3,963
1,158
50
128
1,704
1,584
684
313
935
1,078
274
814
431
1,949
1,066
257
579
356
183
753
234
1,351
490
1,704
1,145
69
1,924
650
1,087
1,817
122
511
73
442
3,284
324
86
1,712
1,823
420
412
113

20.5
69.9
51.2
137.6
133.0
103.0
183.6
116.7
58.9
88.1
45.8
23.6
25.2
58.0
107.3
183.3
39.4
138.8
123.7
123.0
116.2
122.2
97.0
89.8
26.4
32.9
149.3
49.4
117.4
114.6
100.6
117.5
60.5
62.3
45.1
114.0
43.2
169.3
116.8
130.7
53.6
34.9
31.2
49.9
41.3
96.6
111.8
140.9
132.8
38.1
64.1

61,251

111,401

50,150

81.9

Source: Urban Institute analysis, Health Insurance Policy Simulation Model 2019.
Note: Reform simulated in 2019.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

13

 Sensitivity Analysis: Effects of ACA Repeal
without Reinstating Pre-ACA Medicaid
Coverage Expansion Waivers
Tables 6 and 7 provide results when assuming pre-ACA Medicaid coverage expansion waivers are not
reinstated under ACA repeal in the seven states that had these waivers (Arizona, Delaware, Hawaii,
Massachusetts, New York, Vermont, and Wisconsin). It is likely that at least some of the seven states
will be in this situation, and therefore, the actual effect of repeal will likely fall between the main results
detailed previously and those in this sensitivity analysis. Without the 1115 waivers, repeal could lead to
21.2 million more uninsured people, a relative increase of 69.8 percent (table 6). This would result from
a larger decrease in Medicaid/CHIP coverage under repeal than shown in our main results.
States with Medicaid 1115 waivers in place before the ACA would experience especially large
percentage increases in uninsurance if those waivers were not renewed. For example, the number of
uninsured people in New York would increase by 1.2 million, or 80.7 percent (table 6), compared with
607,000, or 40.8 percent, with the waiver (table 2). The Massachusetts pre-ACA waiver was
instrumental in the state’s comprehensive reforms legislated in 2006, and coverage increased further
under the ACA. So, full repeal with their waiver renewed would still increase uninsurance in
Massachusetts by 102,000 people, but without the waiver, the number of uninsured in Massachusetts
would increase by 338,000 more people, or 245.9 percent.
If the ACA were repealed and the waivers were not renewed, federal spending on health care would
fall further than predicted in our main results. Aggregate federal health spending could drop by up to
$141.1 billion, or 36.2 percent (table 6), instead of $134.7 billion, or 34.6 percent, with renewed
waivers. Additionally, state spending on Medicaid and CHIP would fall further, decreasing by up to
$14.6 billion, or 8.6 percent (table 7), instead of $9.6 billion, or 5.7 percent, with renewed waivers (table
4).
With even more people uninsured, repeal without reinstating waivers would increase demand for
uncompensated care by up to $53.3 billion, or 87.0 percent (table 7), compared with $50.2 billion, or
81.9 percent, with the waivers reinstated.

14

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 TABLE 6

The Uninsured Nonelderly and Federal Spending on Medicaid/CHIP Acute Care for the Nonelderly, Marketplace Subsidies,
and Reinsurance in 2019 under Current Law and Full ACA Repeal without Pre-ACA Medicaid Coverage Expansion Waivers by State
THE UNINSURED
Current Law

Full Repeal without Pre-ACA Expansions
Difference
from
Difference
current law from current
N
%
(N)
law (%)

FEDERAL SPENDING ON MEDICAID/CHIP, MARKETPLACE
SUBSIDIES, AND REINSURANCE
Current
Law
Full Repeal without Pre-ACA Expansions
Federal
spending
($)

Federal
spending
($)

Difference
from current
law ($)

Difference
from current
law (%)

State

N

%

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi

504
75
768
206
3,421
396
171
66

12.3
10.5
12.8
8.1
10.0
8.4
5.8
8.4

647
143
1,392
505
7,210
796
394
122

15.8
20.1
23.2
19.9
21.0
17.0
13.2
15.6

143
68
625
299
3,789
400
223
56

28.4
91.4
81.4
145.1
110.7
101.2
130.0
84.8

5,009
1,212
10,810
5,179
48,893
5,940
4,661
1,413

3,853
672
6,674
3,401
26,491
3,128
2,810
945

-1,155
-540
-4,137
-1,778
-22,403
-2,812
-1,851
-468

-23.1
-44.5
-38.3
-34.3
-45.8
-47.3
-39.7
-33.1

35
2,327
1,594
132
202
1,297
600
149
342
252
335
51
374
137
627
331
404

6.1
14.4
16.9
10.4
13.8
11.6
10.6
5.7
13.7
6.8
8.7
4.9
7.1
2.5
7.7
7.0
16.2

69
3,887
2,055
190
281
1,902
1,097
336
404
630
830
134
719
476
1,347
596
504

12.1
24.1
21.8
14.9
19.3
17.0
19.3
12.9
16.1
17.1
21.5
13.0
13.6
8.6
16.6
12.6
20.2

34
1,560
461
58
79
605
497
187
62
379
494
83
345
338
720
265
100

97.2
67.0
28.9
43.6
39.4
46.6
82.7
125.7
18.0
150.5
147.4
164.8
92.2
245.9
114.8
80.0
24.9

1,411
22,825
10,149
1,139
1,869
9,133
8,307
3,798
2,091
8,650
7,637
1,942
6,927
7,617
13,707
6,404
4,673

1,130
13,483
7,830
671
1,274
6,136
5,261
2,401
1,546
4,504
4,030
1,446
3,988
4,947
8,516
4,563
3,956

-281
-9,342
-2,318
-468
-594
-2,997
-3,046
-1,398
-545
-4,146
-3,606
-495
-2,939
-2,671
-5,191
-1,841
-717

-19.9
-40.9
-22.8
-41.1
-31.8
-32.8
-36.7
-36.8
-26.1
-47.9
-47.2
-25.5
-42.4
-35.1
-37.9
-28.7
-15.3

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

15

 THE UNINSURED
Current Law

State
Missouri
Montana
Nebraska
Nevada
New
Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Total

N

%

Full Repeal without Pre-ACA Expansions
Difference
from
Difference
current law from current
N
%
(N)
law (%)

FEDERAL SPENDING ON MEDICAID/CHIP, MARKETPLACE
SUBSIDIES, AND REINSURANCE
Current
Law
Full Repeal without Pre-ACA Expansions
Federal
spending
($)

Federal
spending
($)

Difference
from current
law ($)

Difference
from current
law (%)

639
63
182
376

12.5
7.5
11.4
13.8

808
175
234
658

15.8
20.9
14.7
24.1

169
112
52
282

26.4
176.8
28.7
75.1

8,001
2,218
1,691
3,076

6,841
1,126
917
1,906

-1,161
-1,092
-774
-1,170

-14.5
-49.2
-45.8
-38.1

66
732
207
1,488
1,168
56
704
617
304
644
57
536
101
738
4,678
383
32
670
538
92
436
74

6.0
9.7
11.3
8.9
13.3
9.6
7.4
18.2
9.1
6.2
6.6
13.3
14.0
13.2
19.2
13.6
6.5
8.9
8.8
6.4
9.0
14.8

155
1,327
434
2,690
1,672
81
1,445
763
676
1,502
124
778
114
905
6,411
484
64
1,312
1,102
254
665
85

14.3
17.6
23.7
16.2
19.1
14.0
15.2
22.5
20.3
14.4
14.3
19.3
15.7
16.3
26.3
17.2
13.0
17.4
18.1
17.6
13.8
17.1

89
595
226
1,201
503
25
741
146
372
858
67
242
12
168
1,733
102
32
642
565
162
229
12

136.0
81.3
109.0
80.7
43.1
45.6
105.3
23.7
122.2
133.2
116.3
45.0
11.9
22.7
37.0
26.5
100.1
95.7
105.0
175.6
52.7
16.0

951
6,687
5,254
27,920
15,097
488
14,243
4,746
5,838
15,795
1,303
5,388
826
8,196
31,271
3,179
1,146
8,631
7,949
2,929
4,970
553

586
3,989
3,089
15,120
10,527
309
9,829
3,510
3,286
10,743
794
3,734
626
6,609
24,815
2,188
837
3,953
3,799
1,884
3,680
310

-366
-2,698
-2,165
-12,800
-4,570
-180
-4,414
-1,236
-2,552
-5,052
-509
-1,653
-200
-1,586
-6,456
-991
-308
-4,679
-4,150
-1,045
-1,290
-243

-38.4
-40.3
-41.2
-45.8
-30.3
-36.8
-31.0
-26.0
-43.7
-32.0
-39.1
-30.7
-24.2
-19.4
-20.6
-31.2
-26.9
-54.2
-52.2
-35.7
-25.9
-43.9

30,377

11.1

51,583

18.8

21,206

69.8

389,740

248,662

-141,078

-36.2

Source: Urban Institute analysis, Health Insurance Policy Simulation Model 2019.
Notes: Reform simulated in 2019. Bolded states had pre-ACA Medicaid 1115 coverage expansion waivers.

16

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 TABLE 7

State Spending on Medicaid/CHIP Acute Care for the Nonelderly Plus Reinsurance and Demand for Uncompensated Care Spending
in 2019 under Current Law and Full ACA Repeal without Pre-ACA Medicaid Coverage Expansion Waivers by State
Millions of dollars, except where noted
STATE SPENDING ON MEDICAID/CHIP AND REINSURANCE
Current Law
Full Repeal without Pre-ACA Expansions

State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri

State
spending

State
spending

Difference
from current
law

Difference
from current
law (%)

DEMAND FOR UNCOMPENSATED CARE
Full Repeal without Pre-ACA Expansions
Difference
Demand for
Demand for
Difference
from
uncompensated uncompensated
from
current law
care
care
current law
(%)
Current Law

1,364
446
3,030
1,327
25,538
2,904
2,958
660

1,307
381
2,617
1,162
22,627
2,542
2,663
619

-57
-65
-413
-165
-2,911
-362
-296
-41

-4.2
-14.6
-13.6
-12.4
-11.4
-12.5
-10.0
-6.1

1,093
223
1,608
609
6,052
1,019
425
104

1,317
379
3,085
1,446
14,103
2,069
1,204
275

224
156
1,477
837
8,051
1,049
780
171

20.5
69.9
91.8
137.6
133.0
103.0
183.6
163.4

484
8,324
3,493
551
529
5,369
2,698
1,400
942
1,960
2,185
826
3,946
4,644
4,666
5,037
1,129
3,246

451
7,782
3,355
509
482
5,259
2,438
1,271
888
1,582
1,783
767
3,387
4,262
4,235
4,532
1,089
3,237

-33
-541
-138
-42
-47
-111
-261
-129
-54
-378
-402
-60
-559
-382
-431
-505
-40
-9

-6.7
-6.5
-3.9
-7.6
-8.8
-2.1
-9.7
-9.2
-5.7
-19.3
-18.4
-7.2
-14.2
-8.2
-9.2
-10.0
-3.5
-0.3

95
4,498
2,529
213
510
2,936
1,476
373
794
673
872
222
701
353
2,010
1,187
975
1,762

151
8,461
3,687
337
638
4,640
3,060
1,057
1,107
1,608
1,950
496
1,515
1,603
3,958
2,253
1,232
2,341

56
3,963
1,158
124
128
1,704
1,584
684
313
935
1,078
274
814
1,250
1,949
1,066
257
579

58.9
88.1
45.8
58.2
25.2
58.0
107.3
183.3
39.4
138.8
123.7
123.0
116.2
354.0
97.0
89.8
26.4
32.9

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

17

 STATE SPENDING ON MEDICAID/CHIP AND REINSURANCE
Current Law
Full Repeal without Pre-ACA Expansions

State
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Total

State
spending

State
spending

552
737
1,111
565
3,687
1,146
13,877
4,996
275
5,848
1,647
2,128
8,468
730
1,527
395
3,267
15,051
910
740
4,067
4,032
637
2,533
275

458
694
983
533
3,307
955
13,305
4,567
274
5,377
1,590
1,821
8,031
643
1,410
384
3,183
13,786
876
717
3,577
3,522
554
2,234
275

168,853

154,284

Difference
from current
law

Difference
from current
law (%)

DEMAND FOR UNCOMPENSATED CARE
Full Repeal without Pre-ACA Expansions
Difference
Demand for
Demand for
Difference
from
uncompensated uncompensated
from
current law
care
care
current law
(%)
Current Law

-94
-43
-127
-32
-380
-190
-571
-428
-1
-472
-58
-306
-436
-86
-117
-11
-84
-1,264
-34
-23
-489
-510
-82
-299
0

-17.0
-5.9
-11.5
-5.7
-10.3
-16.6
-4.1
-8.6
-0.4
-8.1
-3.5
-14.4
-5.2
-11.8
-7.6
-2.8
-2.6
-8.4
-3.7
-3.1
-12.0
-12.6
-12.9
-11.8
0.1

239
369
641
204
1,344
417
2,816
1,838
152
1,688
1,504
642
1,555
93
954
208
1,420
6,582
784
89
1,531
1,294
316
1,080
176

595
552
1,394
438
2,695
908
5,742
2,984
221
3,613
2,154
1,729
3,372
215
1,465
281
1,863
9,866
1,108
221
3,243
3,116
736
1,777
289

356
183
753
234
1,351
490
2,926
1,145
69
1,924
650
1,087
1,817
122
511
73
442
3,284
324
132
1,712
1,823
420
697
113

149.3
49.4
117.4
114.6
100.6
117.5
103.9
62.3
45.1
114.0
43.2
169.3
116.8
130.7
53.6
34.9
31.2
49.9
41.3
148.9
111.8
140.9
132.8
64.6
64.1

-14,569

-8.6

61,251

114,550

53,299

87.0

Source: Urban Institute analysis, Health Insurance Policy Simulation Model 2019.
Note: Reform simulated in 2019. Bolded states had pre-ACA Medicaid 1115 coverage expansion waivers.

18

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 Comparison of Marketplace Competition and Enrollment
with and without the Individual Mandate, 2018 and 2019
The US Department of Justice (DOJ) filed a brief in Texas v. United States, a 20-state lawsuit against the
6

Affordable Care Act. This case will next be heard by the US Court of Appeals for the Fifth Circuit. In the
district court case, DOJ asserted that (1) the individual mandate is no longer constitutional because it is
not supported by a tax penalty, and (2) in striking down the mandate, Congress also effectively struck
down the guaranteed issue and community rating provisions, which could not operate without the
mandate. However, DOJ contended that repeal of the individual mandate penalty does not affect the
constitutionality of the rest of the ACA, including the premium tax credits and Medicaid provision.
DOJ argued that Congress did not intend to maintain the guaranteed issue and community rating
provisions without the mandate because the markets could not function with those provisions but
without the mandate. But evidence from the 2019 plan year, the first year without the penalties, proves
otherwise. In fact, the number of participating insurers in the ACA’s nongroup insurance Marketplaces
is higher and the premium increases are lower in 2019 than they were in 2018, the last year in which the
penalties were in place (table 8). In addition, though it varies by state, Marketplace enrollment remained
high in 2019, with plan selections at the end of the open enrollment period dropping by only 2.8 percent
relative to the 2018 open enrollment period (table 9).

7

More insurers chose to participate in the ACA’s Marketplaces during plan year 2019 than in 2018,
and the typical increase in premiums in 2019 was substantially smaller than in 2018. We compared the
changes in insurer participation and benchmark premiums (second-lowest-premium silver plan) in each
rating region in the country in 2018 and 2019 to compare how the private markets functioned in the
most recent year with the mandate fully in place (2018) and in the first year when insurers and
consumers fully knew that the mandate had been repealed (2019). We found that the number of
insurers in a rating region increased in 19 percent of regions in 2019, compared with only 4 percent in
2018 (table 8). The number of rating regions with declining insurer participation fell precipitously from
42 percent in 2018 to 3 percent in 2019. These indicate that insurers increased their participation in
2019 and insurer competition strengthened after a significant decrease in participation in 2018.
In addition, during the last year of the individual mandate, benchmark premiums increased by more
than 20 percent in 81 percent of rating regions; however, this situation reversed itself in 2019, the first
year without the mandate in place. In 2019, it was extremely unlikely for the benchmark premium to
increase by large amounts, and it was much more likely for benchmark premiums to decrease from the
previous year. In 2019, benchmark premiums decreased in 43 percent of rating regions, and they
increased by more than 20 percent in only 3 percent of rating regions. Again, these are distinct signs of
improvement in these markets compared with 2018. This occurred even though insurers knew at the
time they made their 2019 participation and pricing decisions that the individual mandate would no
longer be in place, and that guaranteed issue, modified community rating, and all other consumer
protection regulations in the markets would remain in place.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

19

 Thus, even without the individual mandate but with the ACA private nongroup insurance reforms in
place, the individual market continues to operate effectively when compared with 2018, when the
mandate penalties were still in place. Though several factors and sources of uncertainty may have
affected insurers’ decisions about premiums and participation in 2018, the 2019 figures indicate that a
stable market exists under current law.
TABLE 8

Changes in Insurer Marketplace Participation and Benchmark Premiums
with and without Individual Mandate Penalties
2018 was the last plan year with individual penalties; insurers made 2019
plan year decisions knowing penalties would no longer be in place.
WITH INDIVIDUAL MANDATE
PENALTIES
2017 to 2018 Rating Areas
N
%
Insurer participation
Increase in number of Marketplace
insurers
Decrease in number of Marketplace
insurers
Unchanged number of Marketplace
insurers

WITHOUT INDIVIDUAL MANDATE
PENALTIES
2018 to 2019 Rating Areas
N
%

22

4

95

19

211

42

17

3

265

53

386

78

498

100

498

100

25

5

214

43

6

1

100

20

Total rating areas
Benchmark premiums
Decrease in second-lowest-cost
silver plan
Increase of 0%–5% in benchmark
plan
Increase of 5%–10% in benchmark
plan
Increase of 10%–20% in benchmark
plan
Increase of >20% in benchmark plan

7

1

113

23

58
402

12
81

54
17

11
3

Total rating areas

498

100

498

100

Source: Urban Institute analysis of Centers for Medicare & Medicaid Services and state-based marketplace data.
Notes: This analysis includes only those rating regions that stayed consistent across each pair of years. Idaho reduced its number
of rating regions from 6 to 7 in 2018, making the 2018 national total 499 rating regions. In 2019, Washington increased its
number of rating regions from 5 to 9, making the 2019 national total 502 rating regions. The benchmark plan is the secondlowest-premium silver-level plan offered in a rating region in a given year.

20

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 TABLE 9

Marketplace Plan Enrollment in 2018 and 2019, Number of People
and Comparison between Years by State
Plan selections as of the end of the annual open enrollment period
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Totala

2018

2019

170,211
18,313
165,758
68,100
1,521,524
165,777
114,134
24,500
19,289
1,715,227
480,912
19,799
101,793
334,979
166,711
53,217
98,238
89,569
109,855
75,809
153,571
270,688
293,940
116,358
83,649
243,382
47,699
88,213
91,003
49,573
274,782
49,792
253,102
519,803
22,486
230,127
140,184
156,105
389,081
33,021
215,983
29,652
228,646
1,126,838
194,118
34,142
400,015
243,227
27,409
225,435
24,529
11,480,291

166,128
17,805
160,456
67,413
1,513,883
169,672
111,066
22,562
NA
1,783,304
458,437
20,193
103,154
312,280
148,404
49,210
89,993
84,620
92,948
70,987
156,963
NA
274,058
123,731
88,542
220,461
45,374
87,416
83,449
44,581
255,246
45,001
271,873
501,271
21,820
206,871
150,759
148,180
365,888
34,600
214,956
29,069
221,533
1,087,240
194,570
34,396
328,020
222,636
22,599
205,118
24,852
11,153,588

2019 relative to
2018 (%)
97.6
97.2
96.8
99.0
99.5
102.3
97.3
92.1
NA
104.0
95.3
102.0
101.3
93.2
89.0
92.5
91.6
94.5
84.6
93.6
102.2
NA
93.2
106.3
105.8
90.6
95.1
99.1
91.7
89.9
92.9
90.4
107.4
96.4
97.0
89.9
107.5
94.9
94.0
104.8
99.5
98.0
96.9
96.5
100.2
100.7
82.0
91.5
82.5
91.0
101.3
97.2

Sources: “Final Weekly Enrollment Snapshot for the 2019 Enrollment Period,” the Centers for Medicare & Medicaid Services,
January 3, 2019, https://www.cms.gov/newsroom/fact-sheets/final-weekly-enrollment-snapshot-2019-enrollment-period. “Final
Weekly Enrollment Snapshot for 2018 Open Enrollment Period,” the Centers for Medicare & Medicaid Services, December 28,

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

21

 2017, https://www.cms.gov/newsroom/fact-sheets/final-weekly-enrollment-snapshot-2018-open-enrollment-period. We
collected data for state-based marketplace enrollment from each state website or from local media reports in each year. Specific
sources for each of those states are available upon request.
Notes: a Total for 2018 plan selections exclude the District of Columbia and Massachusetts because plan selection totals for the
2019 plan year are not yet available for those states. Including them in the 2018 totals alone would distort the calculation of the
national 2018 to 2019 comparison.

Discussion
Despite the repeal of the individual mandate penalties and various administrative policy decisions since
early 2017 that have reduced insurance coverage and increased premiums in the private nongroup
insurance market, we estimate that 243.9 million nonelderly people will have insurance coverage
(either private or public) in 2019, and 30.4 million people will be uninsured.
Without the ACA, the number of insured people would fall to 224.1 million, if all of the pre-ACA
Medicaid coverage expansion waivers were reinstated. Medicaid enrollment would drop by 15.4 million
people, and 19.9 million more people would become uninsured. Government investments to support
health care for the nonelderly would fall markedly, with the federal government spending $134.7 billion
less and states spending $9.6 billion less in aggregate in 2019. Simultaneously, demand for
uncompensated care would balloon, potentially outstripping government and provider
ability/willingness to finance it. This would exacerbate the increase in unmet medical need that would
result regardless as a consequence of the large increase in the number of people uninsured. If the preACA Medicaid 1115 coverage expansion waivers were not all reinstated in the states that had them, the
effects on coverage, government spending, and uncompensated care would be larger still.
These shifts would decrease revenue for health care providers; increase the financial burdens
associated with uncompensated care; and increase the medical financial burdens for families,
particularly those with low and middle incomes, who are the chief beneficiaries of ACA benefits. Thus,
invalidating the entire ACA would cause considerable harm, even compared with the ACA as
restructured by recent policy changes.
Finally, using data on 2018 and 2019 Marketplace premiums, insurer participation, and
enrollment, we show that the private nongroup insurance markets continue to function effectively in
the first year without the individual mandate in place. Enrollment is down by approximately three
percent in 2019, and this may translate into a noticeable increase in the number of people uninsured
absent a mandate in some states; however, the decline appears to be modest, and some states are
experiencing enrollment increases. In addition, insurer participation has increased, and premium
increases were lower in 2019 than 2018, with many markets experiencing decreases in benchmark
Marketplace premiums. These findings clearly indicate that the ACA’s private nongroup insurance
markets remain strong, even without individual mandate penalties in place to encourage enrollment.

22

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

 Notes
1

Texas v. United States of America. 579 U.S. ___ (2016).

2

“The Health Insurance Policy Simulation Model (HIPSM),” Urban Institute, accessed March 19, 2019,
https://www.urban.org/research/data-methods/data-analysis/quantitative-dataanalysis/microsimulation/health-insurance-policy-simulation-model-hipsm.

3

King v. Burwell, 576 U.S. __ (2015).

4

Nan Marie Astone, Steven Martin, H. Elizabeth Peters, Austin Nichols, Kaitlin Franks Hildner, Allison Stolte, et al.,
“Mapping America’s Futures,” Urban Institute, accessed March 19, 2019,
http://apps.urban.org/features/mapping-americas-futures/.

5

The exception is Massachusetts, which passed its own comprehensive health care reform, including financial
assistance for low-income people, an individual mandate, and insurance market reforms in 2006.
Massachusetts’s ability to keep those reforms in place would depend on its ability to retain the federal waiver
that permitted the 2006 reforms. Even under this first scenario, we categorize nongroup coverage in
Massachusetts as ACA compliant, because the state has its own coverage requirements written into law.

6

Attorney General Jefferson B. Sessions, “Re: Texas v. United States, No. 4: I 8-cv-00167-O (N.D. Tex.),” June 7,
2018, https://www.justice.gov/file/1069806/download.

7

This estimate excludes the District of Columbia and Massachusetts, because they have not yet made their plan
selection information public for 2019.

References
Blumberg, Linda J., Matthew Buettgens, and Robin Wang. 2018. “Updated Estimates of the Potential Impact of
Short-Term, Limited Duration Policies.” Washington, DC: Urban Institute.
Holahan, John, Linda J. Blumberg, and Matthew Buettgens. 2018. “The ACA Remains Critical for Insurance
Coverage and Health Funding, Even without the Individual Mandate.” Washington, DC: Urban Institute.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

23

 About the Authors
Linda Blumberg is an Institute Fellow in the Health Policy Center at the Urban Institute. She is an expert
on private health insurance (employer and nongroup), health care financing, and health system reform.
Her recent work includes extensive research related to the Affordable Care Act (ACA); in particular,
providing technical assistance to states, tracking policy decisionmaking and implementation at the state
and federal levels, and interpreting and analyzing the implications of particular policies. Examples of her
work include analyses of the implications of congressional proposals to repeal and replace the ACA,
delineation of strategies to fix problems associated with the ACA, estimation of the cost and coverage
potential of high-risk pools, analysis of the implications of the King v. Burwell case, and several studies of
competition in ACA Marketplaces. In addition, Blumberg led the quantitative analysis supporting the
development of a “Road Map to Universal Coverage” in Massachusetts, a project with her Urban
colleagues that informed that state’s comprehensive health reforms in 2006. Blumberg frequently
testifies before Congress and is quoted in major media outlets on health reform topics. She serves on
the Cancer Policy Institute’s advisory board and has served on the Health Affairs editorial board. From
1993 through 1994, she was a health policy adviser to the Clinton administration during its health care
reform effort, and she was a 1996 Ian Axford Fellow in Public Policy. Blumberg received her PhD in
economics from the University of Michigan.
Matthew Buettgens is a senior fellow in the Health Policy Center, where he is the mathematician
leading the development of Urban’s Health Insurance Policy Simulation Model (HIPSM). The model is
currently being used to provide technical assistance for health reform implementation in
Massachusetts, Missouri, New York, Virginia, and Washington as well as to the federal government. His
recent work includes a number of research papers analyzing various aspects of national health
insurance reform, both nationally and state-by-state. Research topics have included the costs and
coverage implications of Medicaid expansion for both federal and state governments; small firm selfinsurance under the Affordable Care Act and its effect on the fully insured market; state-by-state
analysis of changes in health insurance coverage and the remaining uninsured; the effect of reform on
employers; the affordability of coverage under health insurance exchanges; and the implications of age
rating for the affordability of coverage. Buettgens was previously a major developer of the Health
Insurance Reform Simulation Model—the predecessor to HIPSM—used in the design of the 2006
Roadmap to Universal Health Insurance Coverage in Massachusetts.
John Holahan is an Institute fellow in the Health Policy Center, where he previously served as center
director for over 30 years. His recent work focuses on health reform, the uninsured, and health
expenditure growth, developing proposals for health system reform most recently in Massachusetts. He
examines the coverage, costs, and economic impact of the Affordable Care Act (ACA), including the
costs of Medicaid expansion as well as the macroeconomic effects of the law. He has also analyzed the
health status of Medicaid and exchange enrollees, and the implications for costs and exchange
premiums. Holahan has written on competition in insurer and provider markets and implications for
premiums and government subsidy costs as well as on the cost-containment provisions of the ACA.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

24

 Holahan has conducted significant work on Medicaid and Medicare reform, including analyses on the
recent growth in Medicaid expenditures, implications of block grants and swap proposals on states and
the federal government, and the effect of state decisions to expand Medicaid in the ACA on federal and
state spending. Recent work on Medicare includes a paper on reforms that could both reduce budgetary
impacts and improve the structure of the program. His work on the uninsured explores reasons for the
growth in the uninsured over time and the effects of proposals to expand health insurance coverage on
the number of uninsured and the cost to federal and state governments.
Clare Pan is a research analyst in the Health Policy Center, where she works primarily on the Health
Insurance Policy Simulation Model. Pan holds a master of public policy from the McCourt School of
Public Policy at Georgetown University.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA

25

 Acknowledgments
This brief was funded by the Robert Wood Johnson Foundation. The views expressed here do not
necessarily reflect the views of the Foundation.

The views expressed are those of the authors and should not be attributed to the Urban Institute,
its trustees, or its funders. Funders do not determine research findings or the insights and
recommendations of Urban experts. Further information on the Urban Institute’s funding principles is
available at urban.org/fundingprinciples.
The authors are grateful for comments and suggestions from Cindy Mann, Sara Rosenbaum, and
Steve Zuckerman. Erik Wengle provided the analysis of Marketplace premium and insurer participation,
and Robin Wang collected the data on state-by-state plan selections. Rachel Kenney provided editorial
assistance.

ABOUT THE URBAN INST ITUTE

500 L’Enfant Plaza SW
Washington, DC 20024
www.urban.org

26

The nonprofit Urban Institute is a leading research organization dedicated to
developing evidence-based insights that improve people’s lives and strengthen
communities. For 50 years, Urban has been the trusted source for rigorous analysis
of complex social and economic issues; strategic advice to policymakers,
philanthropists, and practitioners; and new, promising ideas that expand
opportunities for all. Our work inspires effective decisions that advance fairness and
enhance the well-being of people and places.
Copyright © March 2019. Urban Institute. Permission is granted for reproduction of
this file, with attribution to the Urban Institute.

STATE COVERAGE AND FUNDING CONSEQUENCES OF FULL REPEAL OF TH E ACA