The new administration and Congress have set down a path to repeal the Affordable Care Act (ACA) through a reconciliation bill with a delayed effective date, and then to subsequently replace it with yet-to-be-determined policies at a future date. A similar “repeal and delay” bill was vetoed by President Obama last year. The Congressional Budget Office (CBO) recently estimated the impact such legislation would have on premiums and access to plans in the Health Insurance Marketplaces (Marketplaces). In a previous Century Foundation post, we translated CBO’s projected premium increases into dollar amounts and found that repeal-and-delay could add roughly $725 to $900 to the 2018 average annual premiums for young adults.

Today, we analyzed another one of CBO’s conclusions on the legislation: that “roughly 10 percent of the population would be living in an area that had no insurer participating” in the first year after enactment, which could be 2018. In 2017, zero percent of Americans had no insurer participating in their Marketplaces.

While the decision by insurers whether or not to offer coverage in a particular county is multi-facted, the map below lays out—in our view—one of the more likely scenarios under repeal and delay for 2018. The map identifies the counties that are most at risk of a complete loss of competition—those counties where only one insurer currently participates. The cumulative population of these at-risk counties represents slightly less than 20 percent of the total U.S. population. The High Risk counties, which have the lowest number of potential customers among all at-risk counties, correspond to the 10 percent of the population projected by CBO to lose total access to Marketplace coverage. The Vulnerable counties also only have one insurer, but have a larger customer base, making them less likely to lose all insurer participation in the first year, all else equal.

While this analysis depicts only one possible scenario under either “repeal and delay” or administrative actions to undermine the same policies, it is clear that, no matter how you distribute the effects, a loss of access to Marketplace coverage for 10 percent of Americans cannot be written off. And with these access to coverage loss numbers projected by CBO to grow to 50 or even 75 percent of the population with the repeal of financial assistance, the “repeal and delay” approach ultimately fails to meet the promise of more coverage by the president and members of Congress.

Cover photo: Matthew Perkins, Old Bourke Hospital Bed, February 11, 2016.