Now that total repeal of the Affordable Care Act (ACA) is back on the menu, analysts are beginning to crunch on the numbers on what that repeal would mean.

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

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released after the Trump Administration announced it would join a court case that argues the entire ACA should be repealed.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

Why we're still talking about this

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

In the latest legal case, a Texas court recently ruled that since the individual mandate was repealed, the entire ACA has to go. That ruling is on appeal. Until this week, the Trump administration had not fully embraced the states' position; on Monday it announced the DOJ would support the case for full repeal.

Winners and losers

The Urban Institute analysis looked at what the repeal would mean for uninsurance, Medicaid populations, and governmental spending. On that last front, there is at least a reduction on paper in financial burden to taxpayers: federal health care spending would decrease by 34 percent ($135 billion) and state spending overall would fall by about $10 billion due to less spending on Medicaid and the Children's Health Insurance Program.

The downside would be substantial. The report noted that consumer protections built into the ACA would likely be eliminated unless states took action. With no federal tax credits to attract healthier people into individual insurance markets, carriers would likely cover fewer benefits and require higher out-of pocket-expenses.

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

Life without the individual mandate

The study also looked at the impact of cancelling the individual mandate—a step that some predicted would send the ACA markets into a death spiral of increasing premiums.

However the Urban Institute researchers found that the ACA has been resilient, even with this change. Based on federal data, the study said enrollment has declined only slightly (2019 enrollment was at 97 percent of 2018 enrollment), more insurers joined the ACA marketplace in the last year, and benchmark premium increases were lower than the year before, with many regions experiencing premium decreases.

“Even without the individual mandate but with the ACA private nongroup insurance reforms in place, the individual market continues to operate effectively when compared with 2018,” the study said. “Though several factors and sources of uncertainty may have affected insurers' decisions about premiums and participation in 2018, the 2019 figures indicate that a stable market exists under current law.”

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