Republicans in Congress and President Donald Trump have their eyes trained on the Affordable Care Act, which they plan to dismantle.
How they do so, and when, may affect health coverage for millions of Americans. A dramatic shift in policy could reverberate through hospitals, insurance markets and the rest of the health-care industry. At this point, say health law experts, the only thing that's certain is more uncertainty.
But, here's a shortlist of what may be coming down the pipeline.
Turmoil on the Hill
The question is not necessarily if Congress will repeal the Affordable Care Act, but whether they will do it before a replacement is ready to go, said Wendy Netter Epstein, a health law expert at DePaul University.
“I think the biggest concern would be a repeal of the Affordable Care Act with nothing in place to backstop,” Netter Epstein said. “I think it’s quite possible.”
Senate Democrats could block a direct repeal of the health-care law with a filibuster. So Republicans have laid the groundwork to use a process called budget reconciliation, which would defund the parts of the law that rely on federal money without a single vote from the other side of the aisle.
Some of the more popular parts of the law, such as a provision that allows young people to stay on their parents' policies until the age of 26, are likely to remain. Changing this part of the law would require 60 votes in the Senate, according to the Congressional Budget Office.
House and Senate committees have an informal deadline of Jan. 27 to write legislation that would replace the ACA.
“At the end of the day, we hope that the replacement plan costs much less than Obamacare costs," said Aylene Senger, a analyst for the Heritage Foundation, a conservative think tank. "We believe that we need to help people and that we need to make sure health-care costs go down to make insurance more accessible to people; but not that we’re overly subsidizing the cost of insurance.”
As president, Barack Obama vetoed several bills passed by Congress that would have repealed the act. One of the bills was sponsored by U.S. Rep. Tom Price, a Georgia Republican who is awaiting confirmation to lead the U. S. Department of Health and Human Services.
The proposal called for a partial repeal of the health-care law, eliminating penalties to individuals who do not have health insurance, and the requirement that large employers offer coverage to full time employees. After two years, it called for stripping away funding for Medicaid expansion and subsidies that help people buy plans on health insurance marketplaces. The bill would have left in place certain market reforms, including baseline coverage requirements and the requirement that insurers cover people with pre-existing conditions.
A review this month by the nonpartisan Congressional Budget Office estimated that Price’s repeal plan would result in 18 million people losing their health insurance in the first year, a number that would increase to 27 million after Medicaid expansion and insurance subsidies are eliminated. Premiums for individuals purchasing insurance, the authors estimated, would increase at least 20 percent relative to current projections.
What changes can the new administration make on its own?
Trump can do several things to dismantle the law from his seat in the White House, even without Congress. The day of his inauguration, he issued an executive order, instructing the agency heads appointed by his administration to "minimize the unwarranted economic and regulatory burdens" of the law, and to give states more flexibility to make changes.
As president, he can also opt not to defend components of the law if they are challenged in court. The White House may drop the Obama administration’s defense for the use of cost-sharing payments for lower-income enrollees on the exchanges.
“All the public statements are that both Congress and the president are hoping to move fast,” Epstein said. “But we have eight years of the Affordable Care Act that they’re trying to undo, and the ACA is very tightly woven into aspects of health-care delivery in the U.S.”
If confirmed, Price and Seema Verma — tapped to lead the Centers for Medicare and Medicaid Services — will have the power to shape guidance and policy governing the law, as their predecessors did. The administration can also choose not to enforce laws it doesn't support.
The effect of repeal
The Affordable Care Act pushed the rate of uninsured people in the United States to historic lows. About 22 million people have gained health insurance since 2013, according to Gallup. That fell short of expectations published in 2010, which projected 32 million newly insured people by 2016.
In the St. Louis region, opinions about the renewed battle over the Affordable Care Act are mixed.
“I really hope that [Trump] repeals Obamacare. It’s not affordable for a family, to make ends meet,” said Alycia Wilson, as she visited a playground with her daughter in Edwardsville, a few days after the November election.
Wilson said her husband kept his position with the U.S. Army Reserve so the family could stay covered through Tricare, health insurance used by military families. Coverage through his civilian job, she said, was unaffordable.
“He has to do the Reserves, just so we can have insurance," Wilson said. "We shouldn’t have to make that decision.”
Randy Vines, the owner of STL Style in St. Louis, was horrified by the possibility that Congress could dismantle the Affordable Care Act.
“I started my own business and rely on the availability, the flexibility of those plans to keep my insurance,” he said. “I know a lot of people with pre-existing conditions who weren’t insured before, weren’t able to get decent insurance and now they can. That is in peril right now.”
Others hope the health insurance markets improve under Trump.
“I think this should really be fixing, dismantling — however you want to call it — the Affordable Care Act, I think that needs to be a priority for the new administration.”
Follow Durrie on Twitter: @durrieB.