Trump teased ACA overhaul; other Republican lawmakers have said changing the laws referred to as Obamacare can be a priority.

President-elect Donald Trump’s return to the White House could embolden Republicans who need to weaken or repeal the Affordable Care Act, but implementing such sweeping changes would still require overcoming procedural and political hurdles.

Trump, a longtime opponent of the ACA, expressed interest in changing the health law during the campaign. Additionally, some senior Republican lawmakers – who will now control each the House and Senate – have said changing the landmark 2010 laws referred to as Obamacare can be a priority. They argue that the law is simply too expensive and an overreach of the government’s powers.

The ruling trio is setting the stage for potentially seismic changes that could limit the expansion of Medicaid laws, raise uninsured rates, weaken patient protections and increase premium costs for hundreds of thousands of individuals.

“The Republicans’ plans — they don’t say they’re going to repeal the ACA, but their set of policies could amount to the same goal or worse,” said Sarah Lueck, vice chairman for health policy at the Center on Budget and Policy Priorities , a research and policy institute. “This can happen through legislation and regulation. We are ready for anything. It can take many forms.”

Over the years, Republicans in Congress have solid dozens of votes in an try and repeal the law. They didn’t accomplish that in 2017, when Trump became president, despite serving in each chambers and the White House, largely because some GOP lawmakers wouldn’t support laws they believed would cause such a marked increase in the uninsured rate .

Similar opposition to the amendment to the law may appear again, especially as polls show ACA protections are popular.

While neither Trump nor his GOP allies have detailed what they’d change, House Speaker Mike Johnson said last month that the A.C.A. needs “massive reform” and can be included in the party program if Trump wins.

Congress could theoretically amend the ACA and not using a single Democratic vote, using a process referred to as “reconciliation.” But the narrow margins by which Republicans control the House and Senate mean that only a handful of “no” votes could derail the effort.

Many of the more ambitious goals would require Congress. Some conservatives have called for changing the funding formula for Medicaid, the federal government’s medical health insurance program for low-income people and other people with disabilities. The idea could be to make use of budget reconciliation to get lawmakers to agree to cut back the share the federal government pays to the growing population. The group that will be most affected could be mostly higher-income adults and adults who do not need children, moderately than “traditional” Medicaid beneficiaries similar to pregnant women, children and other people with disabilities.

A conservative idea that will allow individuals to make use of ACA subsidies for exchange-traded plans that violate the health law would likely require Congress. This could encourage healthier people to make use of subsidies to purchase cheaper and stingier plans, raising premiums for older and sicker consumers who need more comprehensive coverage.

“This is like a plan to repeal the ACA,” said Cynthia Cox, vice chairman and director of the Affordable Care Act program at KFF, the nonprofit health information organization that owns KFF Health News. “It’s repeal by another name.”

Congress would likely be needed to pass a proposal to transfer a few of consumers’ ACA subsidies to health savings accounts to cover qualified medical expenses.

Trump could also decide to bypass Congress. He did so during his last term, when the Department of Health and Human Services invited states to use for waivers to change how they pay for Medicaid programs – limiting federal funds in exchange for greater state flexibility in running the program. Waivers are popular in each blue and red states as other changes to Medicaid are made.

“Trump will do whatever he thinks he can,” said Chris Edelson, an assistant professor of presidency at American University. “If he wants to do something, he’ll just do it.”

Republicans have an alternative choice to weaken the ACA: They simply cannot do anything. Temporary, increased subsidies that reduce the cost of premiums — and have contributed to the nation’s lowest-ever uninsured rate — will expire at the end of next 12 months without congressional motion. Then there could be contributions double or moreon average, for subsidized consumers from 12 states which have signed up for the federal ACA exchange – in accordance with KFF data.

This would mean fewer people could afford the costs of the ACA exchanges. And while the number of individuals covered by employer plans is prone to increase, it’s estimated that between 2024 and 2033 there can be a further 1.7 million uninsured people annually, in accordance with federal estimates.

Many of the states that will be hardest hit, including Texas and Florida, are represented in Congress by Republicans, which could prompt some lawmakers to think about ending the subsidies.

The Trump administration may determine to stop defending the law against lawsuits in search of to overturn parts of it. One of the most characteristic cases questions the ACA requirement for insurers to cover some preventive services totally free, similar to cancer screenings and alcohol use counseling. About 150 million people now profit from the coverage requirement.

If the Justice Department withdrew its petition after Trump took office, plaintiffs wouldn’t need to comply with the coverage requirement — which could trigger similar challenges with broader consequences. A recent Supreme Court ruling left the door open to legal challenges from other employers and insurers in search of the same relief, said Zachary Baron, director of Georgetown University’s Center for Health Policy and Law.

Meanwhile, Trump could initiate changes from his first day in the Oval Office through executive orders, i.e. directives which have the force of law.

“Early executive orders will give us an idea of ​​the policies the administration plans to pursue,” said Allison Orris, a senior fellow at the Center on Budget and Policy Priorities. “Early signaling through executive orders will send a message about what guidance, regulations and policies may follow.”

In fact, Trump relied heavily on these orders during his previous term: An October 2017 order directed federal agencies to start modifying the ACA and ultimately increased consumer access to health plans that were illegal. He could issue similar orders early in his latest term, using them to start the strategy of forcing changes in the law, similar to increased oversight of potential fraud.

The administration could take other steps early on that will conflict with the ACA, similar to limiting federal aid funding and helping people enroll in ACA plans. Both actions depressed registration during the previous Trump administration.

Trump could also use regulation to implement other conservative proposals, similar to expanding access to medical health insurance plans which can be inconsistent with ACA consumer protections.

The Biden administration has held back Trump’s efforts to expand so-called short-term health plans, disparaging the plans as “junk” insurance because they could not cover certain advantages and will refuse to cover individuals with pre-existing health problems.

The Trump administration is anticipated to make use of regulations to reverse Biden’s decision, allowing consumers to maintain and extend their plans for much longer.

But drafting the rules became rather more complicated after a Supreme Court ruling that said federal courts not needed to defer to federal agencies facing legal challenges to their authority. As a result, any Trump-era HHS rules may require greater efforts to dam them in the courts.

Some individuals with ACA plans say they’re concerned. Dylan Reed, a 43-year-old small business owner from Loveland, Colorado, remembers the pre-ACA days and doesn’t need to return to the days when insurance was difficult to get and he couldn’t afford.

In addition to attention deficit hyperactivity disorder and anxiety, he suffers from scleroderma, an autoimmune disease related to: joint pain and numbness in the limbs. Even on the ACA plan, he estimates he pays about $1,000 a month for medications alone.

He worries that without the ACA’s protections, it can be difficult to seek out coverage for his pre-existing conditions.

“It’s definitely a scary thought,” Reed said. “I probably would have survived. I would just be in so much pain.”

KFF Health News is a national newsroom dedicated to publishing in-depth journalism on health issues and is one among the predominant operating programs of KFF – an independent source of research, polls and journalism on health policy. Find out more about KFF.

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