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.