With the results of the 2016 election now in the record books,Congress and the president are set to engage, for the second timein less than a decade, in a debate over the future of the health care system of the UnitedStates.

Donald Trump will be the fourth president in a row to enteroffice with his political party in at least nominal control of bothhouses of Congress. For the first time since Dwight Eisenhower waselected in 1952, an incoming Republican president saw his party winan absolute majority in both the U.S. Senate and the U.S. House ofRepresentatives. And one of the first items on President-electTrump's agenda will be the future the Patient Protection andAffordable Care Act.

The Affordable Care Act (ACA) is the result of more than a yearof intense legislative debate that produced a bill that ran morethan 1,000 pages and has spawned tens of thousands of regulations,rulings and releases over the seven years since it was signed intolaw.

It constitutes an intricate web of inter-related andinterdependent laws, regulations, mandates and subsidies that haveaffected health care stakeholders such as employers, providers,insurers, drug manufacturers, government programs and privateinsurance, to name just a few. Although President-elect Trumpcampaigned on a promise to “repeal and replace” the ACA, achievingconsensus again on how to reform the health care system will not bean easy task.

The Trump administration will have to consider the impact ofrepeal on the federal budget, as well as the level of congressionalsupport for repeal and replace. Will there be congressionalconsensus on all aspects of repeal and replace? Or will someprovisions remain in place, such as the ban on pre-existingcondition exclusions and coverage of adult children in employerplans to age 26? President-elect Trump recently said he's open toleaving both provisions in place, suggesting that “repeal and replace” might become “amend andmodify.”

The Senate's Democrats, who are supporters of the ACA, mightattempt to filibuster any attempts to dismantle it. In that event,the Republican majority might attempt to enact changes via thereconciliation process, a complex parliamentary maneuver thatlimits the kinds of changes that can be made. In addition topolitical support, the support of health care industrystakeholders, such as employers, providers, insurers, manufacturersof drugs and medical devices and consumer advocates, will becrucial to any significant health care legislation.

The full outline of the Trump administration's plans for healthcare reform will become clear over the coming weeks and months.Congressional Republicans have already issued a 37-page outlineregarding what they view as a possible replacement for the ACA.Changes could include:

• Repeal of the individual and employer mandates. Although theseare likely to be the first of the ACA provisions to be targeted,employers should realize that the mandates—and the ACA reportingobligations and penalties—remain on the books.

• Portability of health insurance. Financial support for portablehealth care coverage, including a universal refundable tax creditfor individuals and families to purchase a health care policy;

• Repeal of the Cadillac Tax. Preserving employer-provided healthinsurance, including a repeal of the Cadillac Tax and enactment ofa refundable tax credit coupled with a cap on the employer healthcare exclusion;

• Medicaid reform. Converting federal Medicaid funding to blockgrants and ending the expansion of Medicaid under the AffordableCare Act;

• Association health plans. Expanding opportunities for smallbusinesses in voluntary organizations to band together to offersmall business health plans;

• Wellness programs. Preserving employee wellness programs andopposing EEOC regulations that hinder and obstruct theirimplementation;

• Stop loss insurance. Preserving the current definition of stoploss insurance; and

• Liability reform. Medical liability reform including caps onnon-economic damages and adoption of the loser pays rule.

Other possible health care reforms

Congress may also consider the following proposals from theTrump campaign in the coming year:

• Allowing all individuals to deduct health insurance premiumspaid on a post- tax basis;

• Negotiating Medicare prescription drug prices;

• Removing barriers to entry into free markets for drug providersthat offer safe, reliable and cheaper products; and

• Revising and possibly withdrawing the contraceptive regulationsfor religious organizations.

How quickly all of this — or any of it — can be accomplishedwill be one of the first tests of the new president'sadministration.

For now, the status quo remains. The employer mandate to offeraffordable, minimum value health insurance to full-time employeesstays in effect with all its compliance and reporting obligationsfor the 2016 year, including the requirement to file Forms 1094 and1095 in early 2017.

The individual mandate to carry health insurance or pay apenalty also remains in effect. The public exchanges, which coveralmost 13 million people and subsidize coverage for 85 percent ofthose enrollees, are conducting open enrollment for 2017 and haveseen a surge of enrollment immediately following the election.Employers are likely to continue staying the course as things shakeout in Washington.

Will he or won't he?

In his first televised statements since winning the presidentialelection on Nov. 8th, President-elect Donald Trump stepped backfrom his pledge to completely repeal and replace the AffordableCare Act. During a 60 Minutes interview with CBS News' LesleyStahl, Trump expanded on his health care plans, noting hedefinitely wants “to focus on health care” once he takesoffice.

Stahl: Let me ask you about Obamacare, which you say you'regoing to repeal and replace. When you replace it, are you going tomake sure that people with pre-existing conditions are stillcovered?

Trump: Yes. Because it happens to be one of the strongestassets.

Stahl: So you're going to keep that?

Trump: Also, with children living with their parents for anextended period, we're gonna—

Stahl: You're gonna keep that—

Trump: Very much try and keep that. Adds cost, but it's verymuch something we're going to try and keep.

Coverage for those with preexisting health conditions andallowing children to remain on their parents health insurance plansuntil the age of 26 are two of the ACA's most popularmandates.

Stahl: And there's going to be a period if you repeal it andbefore you replace it when millions of people could lose – no?

Trump: No, we're going to do it simultaneously. It'll be justfine. We're not going to have, like, a two-day period and we're notgoing to have a two-year period where there's nothing. It will berepealed and replaced. And we'll know. And it'll be great healthcare for much less money. So it'll be better health care, muchbetter, for less money. Not a bad combination.

Experts have estimated Trump's health care plan would leaveanywhere from 18 million to 25 million Americansuninsured.