Donald Trump campaigned on a promise to repeal and replace the Affordable Care Act—President Barack Obama’s signature healthcare law. But it’s unclear what his plan would entail and how it would affect the 20 million people who are currently insured under the law.

We asked Wendy Parmet, Matthews Dis­tin­guished Uni­ver­sity Pro­fessor of Law and a leading expert in public health law, to explain what healthcare might look like under President Trump, who on Monday appointed outspoken “Obamacare” critic Tom Price to be his secretary of health and human services.

 

First and foremost, what’s Trump’s plan for replacing Obama’s healthcare law? What are some of the biggest hurdles facing the president-elect as he works to potentially gut—or amend—the Affordable Care Act?

The short answer is that we don’t yet know Trump’s plan for healthcare. He has repeatedly said he would “repeal and replace” the Affordable Care Act, and the person he has just selected to be secretary of health and human services, Georgia Rep. Tom Price, has been a leading congressional opponent of the ACA. On the other hand, since the election Trump has also said that he would retain some of its parts, including the requirement that insurers allow adult children to stay on their parents’ plan until they are 26 and the prohibition on denying coverage for people with pre-existing conditions.

In the past, Price has proposed limiting protections for people with pre-existing conditions to those who have had continuous coverage for 18 months. He and other congressional Republicans have also called for expanding health savings accounts and tax credits, converting Medicaid into a block grant program, and changing Medicare into a voucher program. Whether Trump will adopt these policies remains unclear.

Regardless of the specifics, Trump will face three different types of hurdles. One is procedural. Because he is unlikely to receive the 60 votes needed to overcome a filibuster in the Senate, Republicans will have to either get rid of the filibuster or rely on a procedural move known as reconciliation. Not all provisions of the ACA’s provisions can be repealed under reconciliation.

The second and more important hurdle relates to health policy. If you maintain coverage for people with pre-existing conditions while repealing the mandate to purchase insurance, healthy people will postpone buying insurance until they need it. This will result in fewer and fewer healthy people in insurance pools, and higher and higher prices. This is known as the “death spiral.”

The third hurdle is political. Taking away insurance from twenty million people will be difficult to do politically. Other Republican proposals, like converting Medicaid into a block grant program, may lead to even more people losing coverage. Many voters are unhappy with the ACA and want major changes. That doesn’t mean they will be happy if they lose their coverage altogether. Nor will healthcare workers be happy if they lose their jobs because patients lose insurance.

Some experts suggest that people would receive “less generous coverage” under Trump’s plan. How do you think Trump’s plan would affect the fortunes of hospitals, which have benefited under the Affordable Care Act, and insurance companies, which have struggled to make money selling plans under Obama’s healthcare law?

Because we don’t know what Trump’s plan is, it is hard to say how it will affect hospitals and insurance companies. But any plan that reduces coverage to millions of people, especially those with pre-existing conditions, is bound to create major difficulties for hospitals, drug companies, and others in the healthcare system. As for insurance companies, some may benefit because they will be subject to less regulation, but others have been helped by the increase in coverage and will suffer as the market for health insurance shrinks.

According to a PBS report, Obama’s healthcare law “required insurers to eliminate co-pay for a majority of birth control options, effectively making birth control free or low cost.” How might Trump’s elimination of “Obamacare” affect women’s ability to afford and access birth control?

Many women probably won’t see much of a change. It’s cheaper for insurance companies to pay for birth control than to pay for pregnancy, so many insurers will likely continue to provide robust coverage for birth control. Some employers, however, have objected to covering birth control on religious grounds. Their employees have been covered by a “workaround” that the Obama administration put in place in response to court challenges. This workaround is likely to disappear. In addition, women who lose their health insurance altogether will lose access to coverage for birth control. For them, the likely loss of federal funding for Planned Parenthood will make matters even worse.