ACA Gravestone Without the ACAand with no federal tax credits to attract healthier people intoindividual insurance markets, carriers would likely cover fewerbenefits and require higher out-of pocket-expenses. (Image:Shutterstock)

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Now that total repeal of the Affordable Care Act (ACA) isback on the menu, analysts are beginning tocrunch on the numbers on what that repeal would mean.

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And the numbers aren't pretty: an increase of 20 to 21 millionAmericans without health insurance. An 82 percent increase inuncompensated care. A sharp increase of poor, uninsured residentsin states that expanded their Medicaid programs under the ACA.

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Related: Dems aim to restore ACA as 'law of the land' withnew health care proposal

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These numbers are from the Urban Institute, released after the TrumpAdministration announced it would join a court case that argues theentire ACA should be repealed. The Urban Institute had published aprevious study outlining what the lawsuit's consequences could be,but with the new position by the Trump administration, the threatof total repeal becomes more pressing.

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Why we're still talking about this

The politics of ongoing ACA debate seems at times like a rollercoaster ride that is difficult to endure and impossible to get off.Since the Trump Administration began, the ACA has gone through arepeal and replace effort in Congress that failed by a slim margin,a tax bill change that eliminated the ACA's individual mandate, andnow this lawsuit, originally filed by 20Republican-led states.

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In the latest legal case, a Texas court recently ruled thatsince the individual mandate was repealed, the entire ACA has togo. That ruling is on appeal. Until this week, the Trumpadministration had not fully embraced the states' position; onMonday it announced the DOJ would support the case for fullrepeal.

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Winners and losers

The Urban Institute analysis looked at what the repeal wouldmean for uninsurance, Medicaid populations, andgovernmental spending. On that last front, there is at least areduction on paper in financial burden to taxpayers: federal healthcare spending would decrease by 34 percent ($135 billion) and statespending overall would fall by about $10 billion due to lessspending on Medicaid and the Children's Health InsuranceProgram.

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The downside would be substantial. The report noted thatconsumer protections built into the ACA would likely be eliminatedunless states took action. With no federal tax credits to attracthealthier people into individual insurance markets, carriers wouldlikely cover fewer benefits and require higher out-ofpocket-expenses.

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“These policies also would no longer be required to coverpreexisting conditions,” the study said. “Because of theelimination of guaranteed issue and modified community ratings,many people with current or past health problems would be unable topurchase the plans at any price, and others would be charged veryhigh prices for insurance policies, further decreasing coverage andincreasing financial burdens.”

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Life without the individual mandate

The study also looked at the impact of cancelling the individual mandate—a step that some predictedwould send the ACA markets into a death spiral of increasingpremiums.

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However the Urban Institute researchers found that the ACA hasbeen resilient, even with this change. Based on federal data, thestudy said enrollment has declined only slightly (2019 enrollmentwas at 97 percent of 2018 enrollment), more insurers joined the ACAmarketplace in the last year, and benchmark premium increases werelower than the year before, with many regions experiencing premiumdecreases.

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“Even without the individual mandate but with the ACA privatenongroup insurance reforms in place, the individual marketcontinues to operate effectively when compared with 2018,” thestudy said. “Though several factors and sources of uncertainty mayhave affected insurers' decisions about premiums and participationin 2018, the 2019 figures indicate that a stable market existsunder current law.”

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