What could a repeal of the ACA look like?
Previous repeal proposals offer clues as to what future efforts to walk back the ACA could look like. Some proposals aimed to fully repeal the law. Others involved a partial repeal, which could be more easily enacted through a budget reconciliation act requiring only a simple majority of votes in the Senate.
Full repeal would eliminate all the ACA’s insurance market reforms, its coverage expansions, its premium subsidies (tax credits) for people with low to moderate income, and its revenue-raising provisions (including a tax on medical devices).
Under partial repeal through budget reconciliation rules, only pieces of the law that have budgetary effects can be considered. This means that ACA provisions related to coverage and affordability could be repealed. All insurance market reforms would remain in place, however.
How would repeal of the ACA affect health insurance coverage?
Under partial repeal, significantly more people would lack health coverage than under full repeal, as counterintuitive as that might seem. That’s because partial repeal would almost certainly trigger a “death spiral” in the nongroup insurance market.
It would happen like this. Without the ACA’s premium subsidies and requirement that people have health insurance — but with market rules still in place that restrict insurers’ ability to adjust pricing for risk, deny coverage, and modify benefits — premiums would rise sharply. Only people who are sicker than average, and thus use more health care services, would enroll in marketplace plans, which would have increasingly greater proportions of sicker, higher-cost enrollees. As premiums grow larger and coverage becomes less affordable, more and more healthy people would stop purchasing insurance, triggering additional premium increases. Eventually the nongroup insurance market would be virtually wiped out.
Studies suggest a full repeal would lead to between 21 million and 24 million more uninsured people than there are currently, with Medicaid enrollment falling by 14 million to 15 million and coverage through the nongroup market falling by 6 million to 9 million. But partial repeal would result in 30 million to 32 million more people without insurance, with 13 million people losing Medicaid and 18 million losing nongroup coverage.
