The attempt to dismantle the Affordable Care Act (ACA) has officially begun. On January 4, 2017, the Senate voted 51 to 48 to begin the debate on a budget resolution that would allow for legislation to repeal major provisions of the ACA. Debate in the Senate on the budget resolution is expected to continue for days. Once the Senate approves it, the resolution will move on to the House.1

As this budget resolution is likely to move forward, the concern now is what the government plans to replace the ACA with — and when that will happen.  

Republicans do acknowledge that any replacement will take time. Even if only parts of the ACA are repealed, changes may not be seen for several years. What Republicans are not doing is giving any clear indication as to what the changes in health policy will be.

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The most likely legislation to be repealed includes: The elimination of tax penalties for individuals who refuse to buy health insurance and for larger employers who do not offer health insurance to employees; elimination of Medicaid funds provided to states that have expanded Medicaid eligibility; and the elimination of private health insurance subsidies for coverage purchased through the health exchanges.2

It is unclear how insurance companies will respond. But there will be little incentive to continue to support the health insurance plans set up by the ACA marketplace — especially if subsidies are eliminated and employers stop paying for health insurance for their employees. 

What is at stake? It has been conservatively estimated that ACA repeal will cause over 20 million people to lose their health insurance. Those affected are mostly individuals with lower incomes who qualified for Medicaid under the Medicaid expansion. The Urban Institute estimates that 4 million children will lose coverage, the uninsured will increase by 29.8 million, 12.9 million will lose Medicaid or CHIP, and state and local governments could be faced with $1.1 trillion more in uncompensated care costs between 2019 and 2028.3