How much more are CALIFORNIA ACA enrollees *really* paying this year due to Trump/GOP policies?

IMPORTANT: See the original post in this series for an explanation of the methodology.

Regular readers know that I've been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.

I've written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and last week it was revealed that over 3 million ACA exchange enrollees had already been priced out of the market as of April, with the number almost certain to climb further throughout the rest of 2026.

As I've repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of April have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.

In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plasn with worse networks, referral requirements to see specialists and so on.

With that in mind, that's exactly what I've decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.

Note that healthcare policy/data firm KFF published a new analysis of actual 2026 ACA enrollment and determined that average ACA Marketplace deductibles actually increased by a whopping 37% (or $1,027 per person) to a record high of $3,786 in 2026...which only serves to underscore the entire point of the very out of pocket cost analysis project you're reading right now!

I've been able to utilize KFF's data to estimate the average deductible for every state in both 2025 & 2026 as well, and have decided to start adding to those to the bar graphs.

Let's take a look at the largest state in the country: CALIFORNIA.

Here's total Open Enrollment plan selections for both 2025 & 2026 broken out by raw metal level:

On the surface, besides California seeing ~5200 fewer people sign up for coverage out of the gate, this makes it look like the average Actuarial Value (AV) only dropped slightly, from 68.8% in 2025 to 68.1% in 2026. If so, this would mean that average plan quality remained nearly the same year over year (an 0.7 percentage point drop).

HOWEVER, as I explain at length in the original post, this is misleading for two important reasons: First, because like with every other state, a huge chunk of ACA enrollees are low-income enough to be eligible for Cost Sharing Reduction (CSR) assistance, which boosts Silver plans up to Platinum levels of AV for most CSR enrollees.

When I adjust for that, the weighted average AV jumps for both years...to 76.4% in 2025 and 75.7% in 2026, a year over year drop of, once again, 0.7 points.

IMPORTANT: Unlike the first four states I've analyzed which had hard enrollment data for the various CSR categories, California is the first state-based ACA exchange I've looked at...and most of the state-based exchanges (SBEs) don't break their total CSR numbers out.

For the SBE states, I'm relying on rough estimates based on the percent of enrollees in the 100 - 150%, 150 - 200% and 200 - 250% FPL income brackets who selected Silver plans each year, which can be found in the 2025 & 2026 OEP State, Metal Level, and Enrollment Status Public Use Files (ZIP) from CMS. These percentages, when converted into raw numbers, correspond fairly closely to the actual CSR category breakouts for FFM states (+ or - 5%), so they should be close enough for my purposes. I've also come up with rough estimates for the AI/AN CSR category based on comparisons of the percent of AI/AN CSR QHPs selected in FFM states to the percent of AI/AN residents within each state. This is less than 3.3% in every SBE state except for New Mexico.

Again, these are broad estimates only but should be reasonably accurate for the purpose of estimating average Actuarial Values in the SBE states.

By combining these numbers with the average gross premiums per enrollee I'm able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 80% average Medical Loss Ratio (which, as I stated in the original post, can vary widely by carrier and year, so this should be considered a very broad average only).

HOWEVER, CALIFORNIA (along with some other SBE states) is a SPECIAL CASE because they offer SUPPLEMENTAL STATE-BASED SUBSIDIES on top of the (reduced) federal tax credits.

Furthermore, California actually had an existing state subsidy program last year as well which they completely retooled this year:

• In 2025, they eliminated the deductible completely for enrollees earning up to 250% FPL, which boosted the actual effective AV up a bit more to around 77.2% as far as I can figure. There was $165 million appropriated by the state legislature for this program, which saved an average of around $84 per enrollee in out of pocket costs last year.

• In 2026, they scrapped the deductible subsidies and instead utilized the same funding (plus another ~$25 million for $190 million total) to instead fully backfill 100% of the lost federal tax credits for the ~296,000 enrollees who earn 100 - 150% FPL instead (plus some nominal premium assistance for those earning 150 - 165% FPL). Taken literally, this should theoretically work out to reducing net premiums by around $99/year per enrollee this year.

The first table below shows what average CA premiums & OOP costs would have been both years without the state subsidy program in place.

The second shows my estimates of the actual averages of both with the state subsidy program:

It also looks like the subsidy program reduced average deductibles by around $500 compared to what they otherwise would have been in 2025.

Even with the state subsidies mitigating the damage, Covered CA enrollees are paying 36% higher net premiums on average this year, along with a 17% average increase in out of pocket costs.

Combined, on average, California enrollees are paying an additional ~$1,100 in healthcare costs this year, or roughly ~$5,300 per enrollee.

In addition, based on KFF's net data, average deductibles also jumped by 32% to over $3,700 for single coverage this year, and of course the maximum (theoretical) out of pocket cut-off for all ACA enrollees went up by over 15% this years as well, to $10,600 for single coverage.

Next up: COLORADO.

UPDATE: I forgot to note that California has also been quietly covering the $1/month "Abortion Rider" fee for all ACA exchange enrollees for years now, which means that technically their state subsidies knock another $12 off the net premiums for all enrollees every year.