Repealing the ACA: A Close Look at What Could Happen

Leigh Page

Disclosures

February 23, 2017

In This Article

A Bumpy Road to Repeal

Now that a Republican is in the White House and the GOP maintains control of both chambers of Congress, repeal of at least some parts of the Affordable Care Act (ACA) seems almost certain.

But get ready for a bumpy ride. Republican leaders are still figuring out when the repeal will take place, how extensive it will be, and what the replacement should be. That means the overall impact of the law on doctors and the healthcare system is still unclear.

However, the impact of these changes comes into better focus when one breaks the law down into its key elements and examines each one. For example, most voters want to get rid of the mandate to buy insurance, and Senate rules make it easy to repeal. In contrast, most voters like the requirement that insurers cover people with preexisting conditions, and Senate rules make it hard to repeal.

If lawmakers follow public opinion, they will keep some provisions of the ACA. In a January survey[1] by Quinnipiac University, 51% of Americans said that only parts of the law should be repealed, vs 16% who wanted the whole law repealed.

Senate rules also make it hard to repeal the whole law. Under the rules, the GOP can use its narrow 52-vote majority to remove taxing and spending provisions in the law, but it needs 60 votes to repeal other parts of the law, such as cover people with preexisting conditions. So far, the GOP hasn't been able to win over any Democratic senators.

Then there is the problem of replacing the law with a new set of reforms, which Republican leaders are committed to carry out. For example, they want to reform Medicaid and encourage use of health savings accounts, tax-free accounts that patients can use to pay their healthcare expenses. But GOP lawmakers still don't agree on many details, such as provision of subsidies for people with low incomes and exactly how Medicaid would be restructured.

Republicans also have to decide whether the replacement measure should be passed at the same time as the repeal. One concern is that if Congress only passed a repeal, it might drag its feet on a replacement.

Also, Congress may have to act soon to avoid a meltdown of the individual insurance market. In April, health insurers have to say whether they will stay in the ACA's marketplaces, which are part of the individual market, in 2018. Some insurers have indicated they might pull out.

An immediate repeal tied to a replacement has been favored by many GOP lawmakers, including Sen Orrin Hatch (R, Utah), chair of the Senate finance committee, which will be reviewing the legislation, according to a report[2] by the Washington Post. "In my view, we need to advance replacement policies in tandem with the repeal process," he said.

Others, including President Trump, would allow a more leisurely pace. Asked by Fox News[3] when the repeal would be passed, Trump said, "I would like to say by the end of the year, at least the rudiments, but we should have something within the year and the following year."

Furthermore, even if a repeal were passed immediately, Congress might delay implementation of some key provisions. The GOP's last major repeal bill,[4] passed in December 2015 and vetoed by President Obama in January 2016, would have waited 2 years to cancel the Medicaid expansion and subsidies for insurance bought on the ACA marketplaces.

Repeal and replace is clearly in a state of flux, but it is still possible to examine each provision of the ACA and get an idea of how healthcare might change. Here is a look at 10 major provisions.

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