What comes next for Iowans covered by the Affordable Care Act?

More than 8.8 million people - including 52,000 Iowans - have signed up for insurance through the federal marketplace, which offers subsidies to pay for coverage, the Centers for Medicare and Medicaid announced Friday.

That's days after both President Barack Obama and Vice President-elect Mike Pence met with their respective parties to discuss strategy in preserving or repealing the Affordable Care Act.

Obama told Democrats to preserve his legacy, while Pence called repealing the law the 'first order of business.”

The Senate took the first step last week, debating a budget resolution that essentially allows the legislature to move forward on budget reconciliation. This permits them to repeal portions of the law with only a simple majority that cannot be filibustered by Senate Democrats.

Since the law was enacted, Republicans in Congress have voted more than 50 times to try to repeal all or part of the ACA. However, so far they have offered few details on what a replacement for Obamacare would look like.

A poll released Friday by the Kaiser Family Foundation reported that 75 percent of Americans either don't want Congress to repeal the ACA or to wait until a replacement plan has been announced.

Edwin Park, vice president for health policy at the nonpartisan research institute Center on Budget and Policy Priorities, said when Congress took similar action last year the bill would have eliminated Medicaid expansion and subsidies, but those benefits were unwound over a period of two years.

'There's some talk of more than two years in this package,” he added, on a Thursday conference call with reporters.

The penalties for those who did not have health insurance also would be eliminated immediately.

'But there is no replacement plan, which is the most critical aspect,” Park said. 'Replacement would happen at some subsequent point, assuming there is one at all.”

Washington, D.C.-based Urban institute has modeled the impact of what could happen, detailing two stages of the impact. Coverage would be affected immediately, Park said, 'because the mandate is critical to encourage people to enroll and to ensure balanced risk pool.”

The Urban Institute estimates that nationally:

l The number of uninsured people would rise from 28.9 million to 58.7 million in 2019, an increase of 29.8 million people (103 percent)

l Of the 29.8 million newly uninsured, 22.5 million people become uninsured as a result of eliminating the premium tax credits, the Medicaid expansion and the individual mandate.

l The additional 7.3 million people become uninsured because of the near-collapse of the nongroup insurance market.

In Iowa, that means an additional 230,000 people would become uninsured, according to the Urban Institute's analysis, rising from 153,000 uninsured to 383,000. That's an increase of 150 percent.

In addition, Park said, because there will be such a large increase in the uninsured, hospitals and other providers will see a greater demand for uncompensated care. In 2019, those 29.8 million newly uninsured people would seek an additional $88 billion in uncompensated care - but that would balloon to $1.1 trillion between 2019 to 2028.

Phase two

The second phase of a repeal is whatever might happen to the Medicaid program if further cuts take place, either through block grants or other methods.

ACA Repeal puts coverage of 11 million Americans - including 140,000 in Iowa - who are now enrolled in Medicaid and another 4 million who could enroll if states expanded Medicaid, said Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

'It's really important to take note of what we're seeing now, she said. 'Louisiana only expanded six months ago, and the state has a dashboard tracking things, including 2,000 adults diagnosed with hypertension now treated, 4,000 adults screened for colon cancer and 1,000 polyps removed and 45 diagnosed.”

On average, the federal government pays for about 57 percent of Medicaid costs and the states pick up the balance.

Under a block grant program, as suggested by President-elect Donald Trump and House Speaker Paul Ryan, the federal government instead would give states an annual lump sum of money and states would decide how best to use the money. A move to a block grant program would save the federal government money, by shifting costs to the states and in many cases, forcing states to decide what to cut, Solomon said.

'It's based on what the population looks like today,” she said. 'But 10 or 20 years from now, when (baby boomers) are in their 80s or 90s, the needs will be very different.”

Reuters contributed to this story.

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