https://www.brookings.edu/research/repeal-and-replace-obamacare-what-could-it-mean/?utm_campaign=Economic+Studies&utm_source=hs_email&utm_medium=email&utm_content=38788605

Donald Trump’s pledge to “repeal and replace Obamacare” was one of his biggest crowd pleasers. It’s been noted, of course, that “repeal and replacing” is easier said than done, and indeed the President-elect has already begun to fudge. But moving forward on his broad replacement themes—expanding health savings accounts (HSAs) and state flexibility—could lead to some surprising and intriguing reforms.

Some have argued that Trump could and should strike a devastating blow to the Affordable Care Act (ACA) on his first day in office. For instance, he could decide not to appeal the lower court ruling in House v Burwell. A federal district court has ruled that that money cannot be spent on cost-sharing subsidies because Congress has not appropriated the money. So dropping the appeal would mean the end of these payments. In similar vein, he might demand repayment from insurers of billions of dollars of transitional reinsurance payments, citing a recent General Accountability Office letter declaring that the Administration lacks the legal authority to reassign to health plans some funds intended by statute for the US Treasury’s general fund.

Such first-day actions would destabilize the exchange plans, causing more insurers to withdraw and shredding the subsidy system. Even allowing a 1- or 2-year phase-out would gravely disrupt the exchange system. Yet the high cost of premiums and deductibles was the chief complaint about Obamacare among Trump supporters. In addition, the Trump surge was strongest in counties characterized by poor health. These voters would be outraged by even higher out-of-pocket costs and fewer plans.

To avoid a backlash, repeal and replace must be a measured and slower process. That’s true even if much, or all, of the restructuring could be accomplished through budget reconciliation, a budget process maneuver that would avoid a filibuster by Senate Democrats. Moreover, a replacement does not need to be nationally uniform. Republicans, long dismissive of “one-size-fits-all” solutions from Washington, should recognize that what will work in Texas and Utah may not be right for California and Massachusetts.

So, in broad terms, how might the stated themes of repeal and replace evolve?