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Editor’s Note: This article was written before the American Health Care Act was released.

For all the philosophy imbedded in the arguments and debates around the Affordable Care Act (ACA), the reality is the program isn’t perfect. While much of the law is a win for emergency medicine, financing of the program is not. The expansion of Medicaid coverage, requirements to cover preexisting conditions, coverage of children up to age 26 on a parent’s policy, and the establishment of a minimum benefit standard including the prudent layperson standard for emergency care are great for those of us who bear the biggest burden of the uninsured population when they have no other access to care. However, the mechanisms to fund these benefits for the long-term were inadequate even on the day the ACA became law. Expecting that healthy young people would opt to pay even a 50 percent discounted health care premium (let’s say $6,000 per year) versus paying 2.5 percent of their income (which is $1,000 if they are making $40,000 per year) wasn’t going to work. Without healthy people paying into the system, the existing increase in tax revenue isn’t enough to finance the whole program. Expecting that insurance companies would continue to sell policies in regions where they are losing money despite subsidies is wishful thinking at best. Given their operating losses, and the loss of additional revenue under a risk corridor program that was defunded by Congress, insurers are leaving the ACA program. As of the beginning of this year, nearly 35 percent of potential ACA enrollees have only one insurance company to choose from in the health care exchange, and another 19 percent have only two choices.

How will President Donald Trump and Congress ensure access to health care insurance—without removing the components of the ACA that everyone likes—without individual or employer mandates? That remains to be seen. Newly confirmed Secretary of Health & Human Services (HHS) Tom Price, MD, has been an ardent opponent of the ACA and will have wide latitude to change the program based upon the large number of regulatory actions that have been taken to implement and operate the program. In his first official act after his swearing in, President Trump issued the “Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal” order. This directed HHS and all departments and agencies, “to the maximum extent permitted by law,” to “delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or individual,” “provide greater flexibility to states and cooperate within them in implementing healthcare programs,” and “encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance.”