Despite campaign promises, complete repeal of Affordable Care Act could be difficult

Linda Slobodnik, a private contractor, was diagnosed with breast cancer in 2012.

She underwent a double mastectomy and has been cancer-free for four years. But her insurance plan cost nearly tripled - rising from about $450 a month to more than $1,200. She couldn't afford it, she said.

But thanks to the Medicaid expansion, made possible due to the Affordable Care Act - one of President Barack Obama's signature pieces of legislation - the 53-year-old Manchester woman is insured.

But Slobodnik said since Tuesday's election, she's been extremely worried for herself and other breast cancer survivors she knows.

'This whole situation terrifies me,” she admitted.

That's because Republican President-elect Donald Trump vowed on the campaign trail to repeal the ACA - more commonly called Obamacare. However, making good on that promise may be easier said than done.

President Barack Obama's 2010 National Health Care Reform law extended medical insurance to 25 million people - including about 180,000 in Iowa - by expanding Medicaid in 31 states and creating subsidized coverage for individuals through exchanges.

The ACA has run into challenges over its lifetime. Parts of the law have been weakened through legal challenges.

In addition, several of the largest U.S. health insurers, including UnitedHealthcare, have pulled out of the exchanges for individual coverage after losing money on a sicker-than-expected group of patients. Meanwhile, consumers not eligible for government subsidies have seen premiums rise sharply, including a projected average increase of 25 percent for 2017.

Now Republican lawmakers, who have voted more than 50 times to repeal all or part of the law, have begun pressing Trump to deliver. Senate Majority Leader Mitch McConnell said on Wednesday - in the midst of the fourth open enrollment period - that repealing Obamacare is a 'pretty high item on our agenda” for the new Congress.

But a complete repeal of Obama's ACA may not be immediately in the cards, as Republican lawmakers will hold 51 seats in the U.S. Senate at latest count, well short of the 60 seats required to overturn it.

In addition, Trump said on Friday he is open to keeping to key parts of the law - a provision that allows children to stay on their parents' health plans until age 26 and a provision that prohibits insurers from denying coverage due to a patient's pre-existing conditions.

Instead, health policy experts said, Trump could try to dismantle key elements through a process called budget reconciliation. That would allow him to eliminate funding for the income-based subsidies that make the new insurance plans affordable, or cut the money providing expanded Medicaid benefits.

'Some of the policy experts on the Republican side would say tearing it up and starting over would be very disruptive,” said Paul Howard, director of health policy at the conservative Manhattan Institute.

‘The big problem'

'The big problem is there is no real, clear plan for replacement,” said Pete Damiano, director of the University of Iowa's Public Policy Center. 'It makes it difficult to really speak on specifics.”

Days after the election, Trump's transition team released some details on his website similar to those discussed during the campaign, including re-establishing high-risk pools and allowing people to purchase insurance across state lines.

The state's version of Medicaid expansion, the Iowa Health and Wellness plan - which began Jan. 1, 2014 - provides insurance for more than 130,000 people while there are another 50,000 people in Iowa buying plans on the exchange. But Damiano added that Iowa has a fairly low participation rate on the exchange - only about one in five Iowans eligible to buy the subsidized plans does so, he said - meaning there is a potentially larger impact of Iowans affected by a repeal.

While the federal government provided 100 percent of funding to states that expanded Medicaid programs for the first two years, it was scheduled to step down to 90 percent in 2017. Iowa could continue to fund the expansion, Damiano said, but there are competing budget interests, from education to water quality, and he was unsure of the legislature's willingness to fund a large-scale health care policy plan.

However, some elements could not be eliminated by depriving the law of funds. For example, the ACA prevents insurers from denying coverage to people based on their health or pricing insurance based on gender. Mandatory coverage of preventive benefits also would be unaffected - short of a complete repeal.

It also is not clear if Trump would try to reverse the individual mandate, which requires people to purchase health insurance or pay a penalty. The goal of the requirement was to broaden the pool of policyholders to include more healthy Americans, which in turn would stabilize costs.

Trump also would face a tight deadline were he to try to dismantle the insurance exchanges by 2018; many state-based health insurance regulators require insurers to submit plans for the upcoming year by April or May - only a few months into a new administration.

Enrollment opened on Nov. 1 for 2017 coverage, and once those plans are purchased, it would be legally difficult for Trump to cancel them before the one-year contracts run out, said Molina (Calif.) Healthcare Chief Executive Officer Dr. Mario Molina.

Even still, there is a good deal of confusion surrounding the future of the exchanges. Karen Wielert, a marketplace navigator in Eastern Iowa, said since the Nov. 8 election she has fielded several calls from people asking about 2017 coverage.

She took part in a conference call with U.S. Department of Health and Human Services officials on Thursday, she said, and navigators were told they can continue to enroll individuals and help them apply for subsidies.

'There still is a lot up in the air leading up to the Jan. 20 inauguration,” she said. 'We'll wait until that time to see what he (Trump) wants to do.”

The federal government, for its part, still is putting out a positive message, saying in a Thursday statement that it's 'all in for this Open Enrollment” time period.

'This is coverage that is vital to millions of Americans, and that is being proven yet again as more people sign up, including (Wednesday), when more than 100,000 people signed up for coverage, the highest single-day total so far during this Open Enrollment,” Health and Human Services Press Secretary Marjorie Connolly said.

Changes to the health care delivery system also were part of the ACA - from moving to a more value-based payment system through Accountable Care Organizations to more coordinated care.

Sabra Rosener, vice president of government and external relations for UnityPoint Health, said regardless of the ACA's future, the hospital system will continue to focuses on delivering high quality, patient-centered care. The drop in the uninsured rate did mean the health care organization saw a drop in the amount of charity care it provided, she said, but it will continue to care for individuals if that number ticks back up under a new plan.

'We're a nonprofit, statewide system,” she said. 'We think about patients first and will continue to be that safety net, it's part of our mission.

'Obviously we are now getting reimbursed for those patients who were not covered before, so if that coverage stops the payments stop.”

UnityPoint Health is keeping an eye on the transition plan, she said, and believes the new administration will address the health care issue quickly.

'The ACA started conversations,” Rosener said - conversations 'that wouldn't have had the attention of the whole Congress without the ACA. ... There are good things in the ACA, and I think we need to think carefully of how we want to preserve those and move on.”

Reuters contributed to this report.