President-elect Donald Trump has promised over and over in recent months that he will repeal and replace the Affordable Care Act, also called Obamacare, when he reaches the White House.
"Obamacare is a disaster. You know it. We all know it," Trump said at a debate last month. "We have to repeal it and replace it with something absolutely much less expensive."
Now that Trump will move into the Oval Office in January, the question is whether he'll be able to completely repeal the six-year-old law that has had an impact on every aspect of the U.S. health care system.
"It's a challenge for a Trump presidency," says Jack Hoadley, a research professor at Georgetown University's Health Policy Institute. "To get a true repeal and replace through, he needs 60 votes in the Senate." That's the minimum number of votes needed to overcome a filibuster in the Senate.
"Repeal of the law is absolutely going to come up, and the only potential defense against that would be a Democratic filibuster — if Republicans even allow a filibuster," says Austin Frakt, a health economist who runs the blog The Incidental Economist.
But even if Trump can't repeal the Affordable Care Act in its entirety, there's a lot he can do through rule-making and smaller legislative changes to weaken the law and mold it more to his liking.
"They are probably, practically speaking, talking about leaving the ACA, as is, in place," Hoadley says. "Then he can change the ACA to have it showcase the kinds of plans he wants to see in place."
During his campaign, Trump proposed a series of measures that he said will allow people to buy affordable health insurance policies outside of the Obamacare exchanges.
Those measures include promoting tax-free health savings accounts that might help individuals save money to pay for health care costs and allowing people to deduct the cost of their premiums on their personal income tax returns. Trump has said he also wants to allow insurers to sell policies across state lines to boost competition.
Trump could alter the Obamacare exchanges to promote high-deductible health plans and health savings accounts to get a result similar to what he's looking for.
"He could change the details of how the marketplaces work," Hoadley says. "It's all worked out through regulation. You could just suspend the regulations."
Alternatively, Trump could embrace the health care plan promoted by House Speaker Paul Ryan, which starts with repealing the Affordable Care Act. It includes many of the same principles as Trump's plan, but has more details.
One of the biggest challenges Trump faces is that about about 20 million people today have health coverage because of the Affordable Care Act, according to the Department of Health and Human Services. The uninsured rate hit an all-time low of 8.9 percent this year, according to the Centers for Disease Control and Prevention.
An analysis of Trump's plan by The Commonwealth Fund estimates it would increase the number of people who lack health insurance by as many as 25 million, and increase the federal budget by as much as $41 billion. That's because much of Trump's plan involves giving tax breaks to encourage people to buy insurance while taking away the requirement to buy insurance — a mandate embedded in Obamacare.
Even if Trump fails to repeal the law, Frakt says, he could easily destroy it from within by refusing to fund it through the budget process.
"The only thing stopping that is, it's a big deal to throw millions of people off insurance without offering something in return," Frakt says.
If Trump is right that his health savings accounts are a good enough replacement, then he'll be able to get rid of Obamacare through a vote or through neglect.
ROBERT SIEGEL, HOST:
Now that Donald Trump is headed to the White House, what happens to Obamacare? The president-elect has vowed to repeal and replace the 6-year-old health care law. Less clear is what would take its place.
Well, joining us now is NPR health policy correspondent Alison Kodjak to look ahead to health care under a Trump administration. And, Alison, first of all, can Donald Trump repeal the Affordable Care Act?
ALISON KODJAK, BYLINE: Well, with the support of the House and Senate which are remaining Republican, he could potentially just repeal the law as he has promised, but a straight repeal might encounter a Democratic filibuster - actually would likely encounter one. So he has some other ways that he could undermine the law or partly repeal it.
One is just changing the regulations that detail how the law is implemented to make them more compatible with his vision. Another is just not enforcing some of the policies, including the individual mandate.
And then lastly there is this court ruling that stands that takes away the subsidies - about half the subsidies - that people get under the law. It was a lawsuit filed by the House of Representatives a few years ago. And he could effectively just let that ruling stand rather than appeal it, which the Obama administration has done, and that would also destroy the Obamacare exchanges.
SIEGEL: Well, let's say that he does manage to either repeal or somehow kill Obamacare. What does he say he'll put in its place?
KODJAK: The proposals he's made during his campaign include replacing it with what's called health savings accounts, which are essentially tax-advantaged savings accounts to allow people to pay for their own health insurance, and to make health insurance premiums tax deductible, which he says will make everything more affordable.
In addition, he wants to allow insurance companies to sell insurance across state lines. That would make more competition and therefore, he says, lower premiums. Paul Ryan has also made a proposal. It's a little more detailed but has pretty much the same outlines. But above all, they would get rid of the mandate requiring people to buy health insurance.
SIEGEL: A lot of people have insurance because of the Affordable Care Act. What would happen to them? How does a President Trump move from one system to a post-Affordable Care Act system?
KODJAK: Yeah, well, that's a really good question, and it's left pretty unclear at this point. There are about 20 million people who have insurance directly because of the Affordable Care Act. About half of them have bought it through the exchanges, and about 10 million of them have it through Medicaid expansion. He hasn't really said what would happen with Medicaid if he were to repeal the law, whether states that have expanded Medicaid would have to reverse that expansion. So it's left unclear what will happen to those people.
In terms of what would happen to the people who have bought insurance through the exchanges, Mike Pence, his running mate and now vice president-elect, has said that they would phase out the subsidies over time to smooth the transition and allow people to find other ways to buy health insurance through these health savings accounts and other things. The only real comprehensive review of Donald Trump's proposals, however, says it will still leave millions of people uninsured.
SIEGEL: Alison Kodjak is NPR's health policy correspondent. Alison, thanks.
KODJAK: Thank you, Robert. Transcript provided by NPR, Copyright NPR.