As a result of federal and state policy decisions made in 2025, authors project that 4.6 million Californians under age 65 will be uninsured by 2030 — an increase of 2.2 million — and the uninsured rate will nearly double to 14.7%. This will erode much of the progress California has made since the Affordable Care Act and subsequent state actions to move closer to universal coverage. It will also widen disparities in health care coverage, particularly for low-income, Latino, and undocumented Californians, who already face higher-than-average uninsured rates.

This report, which uses estimates from the California Simulation of Insurance Markets (CalSIM), features Srikanth Kadiyala, a senior economist at the UCLA Center for Health Policy Research, and Dylan H. Roby, an affiliate at the UCLA Center for Health Policy Research.

The report developed by the Health Economics and Evaluation Research (HEER) Program through a contract with the California Health and Human Services Agency (CalHHS) examines various aspects of health care financing, such as the role of health plans, provider payments, and benefits; their respective impact on access, quality, and equity; and key considerations if California opted to implement a unified health care financing system. 

The key design considerations for unified financing in California discussed in the report include: 

• Models of unified financing 
• Eligibility and enrollment rules 
• Benefits options 
• Approaches to premiums and cost sharing 
• Provider payment methods 
• Approaches to promoting effectiveness, efficiency, and equity

Authors provide county-level projections of how many fewer Californians will be enrolled in full-scope Medi-Cal by 2028 as a result of policy changes in federal H.R.1 and the enacted 2025–26 state budget. These projections assume the state implements H.R.1 as proposed in the 2026–27 January state budget.

Findings: There is considerable uncertainty about the enrollment impact of these policy changes. Estimates represent the high end of potential Medi-Cal coverage losses. Authors project that 2.98 million fewer Californians will be enrolled in Medi-Cal by 2028 based on and as a result of the following policy changes:

• H.R.1 work requirements, applied to both federally-funded and state-funded ACA expansion adults (1.87 million)
• H.R.1 six-month eligibility redeterminations, applied to both federally-funded and state-funded ACA expansion adults (270,000)
• Asylees, refugees, and other humanitarian immigrants who lose eligibility for federally-funded full-scope Medi-Cal because of H.R.1 and are subsequently moved to partial-scope Medi-Cal (200,000)
• Enacted 2025–26 State Budget enrollment freeze for undocumented adults (550,000)
• Enacted 2025–26 State Budget $30 monthly premiums for state-funded adult enrollees with “unsatisfactory immigration status” (95,000)

This analysis uses administrative data, not survey data, as its basis. Authors estimate the number losing full-scope Medi-Cal coverage, not the number projected to become uninsured. Individuals who lose Medi-Cal may choose to enroll in job-based health insurance coverage (if they have that option) or obtain unsubsidized coverage in the individual market. 

Off-label prescribing — when medications are used for indications not approved by the FDA — is widespread in the U.S. healthcare system. This study uses trazodone, a drug approved in 1981 for depression, as a case study to examine broader issues surrounding off-label utilization and spending.

Findings: Although only approved to treat depression, trazodone is frequently prescribed off-label for indications of uncertain clinical value (insomnia, anxiety). Using nationally representative data from the Medical Expenditure Panel Survey, authors estimate that approximately 24 million trazodone prescriptions were filled in 2019, with healthcare spending of $294 million. At least 85% of prescriptions (∼20 million) and 84% of spending ($247 million) were for off-label indications, primarily insomnia. Health plan reimbursement per prescription was nearly identical for on-label and off-label use, despite the significant evidence gap.

These findings illustrate the scale and inefficiency of off-label prescribing and highlight challenges facing clinicians, patients, and payers. Authors propose a set of policy solutions — including public and private investment in evidence generation, pricing drugs to account for off-label use, and value-based reimbursement — to advance a more efficient system of off-label use. Trazodone presents a revealing case of the broader systemic problem of off-label prescribing for indications of uncertain clinical value.