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If the Obamacare law is repealed, could California keep it anyway?

Millions of Californians have gained health insurance under the Affordable Care Act.  Now the future of that federal law – and medical coverage for those people  -- is in doubt. President-elect Donald Trump said repeatedly during his campaign that one of his first acts would be to “repeal and replace” the law known as Obamacare.

The Times spoke to experts about whether it would be possible for the state to keep operating its Obamacare exchange called Covered California, where consumers shop for subsidized health insurance, if the law was repealed.

Could the state keep its Obamacare exchange?

“The simple answer is that it would be extremely costly,” said Gerald Kominski, director of the UCLA Center for Health Policy Research.

Kominski’s research team estimates that California is receiving more than $20 billion annually in federal assistance to subsidize consumers who buy policies from Covered California and pay for others who became eligible for free or low-cost care under Medi-Cal, which covers the poor.

Walter Zelman, chair of the public health department at Cal State L.A., said the infrastructure for the Covered California online marketplace has already been built. He said the state could pass a law similar to Obamacare requiring everyone to have health insurance and banning insurers from discriminating against those with pre-existing conditions.  

“The only problem would be the money,” Zelman said. It would require a substantial rise in state taxes, he said. “It’s probably out of the realm of possibility.”

So what happens if the law is repealed?

In the worst-case scenario, millions of Californians would lose coverage. California’s uninsured rate has fallen from 17% at the end of 2013, just before the law was enacted, to 8.1% at the end of last year, according to the federal Centers for Disease Control and Prevention.

One group at risk of being uninsured are poor adults without children who became eligible for Medi-Cal under an expansion of the program included in the law. And about 90% of those with higher incomes who have purchased insurance through Covered California now get subsidies financed by federal taxpayers.

The Urban Institute estimates that there will be 7.5 million uninsured in California in 2021 if the law is repealed. That would be more than twice the number without insurance if the law had stayed in place, the group said.

How likely is a full repeal?

Even Trump said during his campaign that he supports the mandate for all Americans to have insurance as well as the requirement that insurers cover those with pre-existing conditions.

“Well, I like the mandate,” Trump said in February at a GOP town hall in South Carolina. “I don't want people dying on the streets. The Republican people, they don't want people dying on the streets.”

On Friday, Trump told the Wall Street Journal that he was willing to preserve at least two provisions of the law: the ban against denying coverage for existing conditions and a provision that allows children to stay on their parents’ policy until they reach the age of 26. 

“It will be much harder for them to repeal and replace than they think,” Zelman of Cal State L.A. said. “You can’t just step in and change the rules on which people have been relying for years.”

melody.petersen@latimes.com

Follow @melodypetersen on Twitter

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