During his campaign, President-elect Donald Trump promised quick repeal and replacement of the Affordable Care Act.

But how would repeal work? One way would be for the Trump transition team to work with Congress to develop a replacement law, says Bruce Merlin Fried, managing partner at the Denton’s law firm in Washington and a former long-time official at the Centers for Medicare and Medicaid Services.

While an act of Congress then could repeal ACA, Senate Democrats still have sufficient numbers to filibuster attempts at repeal, delaying action temporarily.

However, Trump also could decree, possibly via an executive order, that he will no longer enforce the Affordable Care Act and that no federal employees may be involved in administering it.

If ACA is repealed, state insurance exchanges may be able to decide if they’ll continue to operate, Fried speculates. ACA replacement programs could include health savings accounts or Medicaid block grant programs to states, which would enable insurers to more easily market across state lines.

If ACA is repealed and replaced, it would be good opportunity to revisit privacy and security rules, Fried says. Privacy and security are part and parcel of the data-driven healthcare strategies that have governed insurance exchanges, care coordination, data analytics and other initiatives fostered by the ACA.

But a question needs to be asked, according to Fried. “Have too many privacy requirements become an impediment to using data? This is an issue that could be examined.”

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Fried cautions, a conservative Congress also could revisit the question of whether it’s proper for the government to continue economic support to providers for implementing health information technology, or if that is more a function for the private sector to fill.

Much of the GOP resistance to the ACA stemmed from a conservative view of the proper role of the federal government, Fried notes. However, repealing the ACA would mean taking away insurance coverage for more than 20 million Americans whose lives would be significantly affected, at least for a period of time until a replacement program is up and running. Fried said he doubts lawmakers will risk the resulting wrath of those individuals.

So far, many lawmakers haven’t taken the ripple effects of repeal into account, he adds. “It’s easy to make promises in a campaign; the execution will be much more complicated than currently recognized.”

For instance, if ACA falls, hospitals would have a significant portion of their financial support removed, Fried warns. And in many towns across the nation, hospitals already are the largest employer, and revenue reduction would cause them to trim jobs. “Immediate repeal would be enormously destructive to the healthcare industry,” he contends.

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