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After years and years of railing against the Affordable Care Act and threatening constantly to have it repealed, the GOP is finally in a position to do so, and seem to be at something of a loss. After trying and failing to pass bills that would repeal the ACA during Obama’s time in office, the House, Senate and presidency are all about to be Republican-controlled, which makes this a cinch. It’s becoming very clear, however, that during the last two presidential terms, Republicans haven’t worked on coming up with what they think should be in place instead of the ACA. Was this because they never had any interest in doing the work of overhauling a healthcare system in the first place, and instead just wanted to make life as difficult as possible for Dems while whipping the GOP voter base into a frenzy over a system that many of those same voters actually rely on for coverage? Who can say! It may forever remain a mystery. At this point, Republicans have held firm to their promises to repeal “Obamacare — but without providing any plans or proposals for what they think should replace it, only repeating vaguely that some sort of replacement will come. Nevertheless, they’re still going to go ahead with working to repeal it ”by the end of the week,” according to Republican Senate Majority Leader Mitch McConnell!

How would this work? Right now Republicans are pushing what they call “repeal and delay” — a bill that would repeal the ACA immediately, but with a two-year “transition period for putting in place an alternative,” during which elements of the ACA would in some way remain active. The specifics of how this would work are another thing that Republicans haven’t full articulated, except for Mitch McConnell saying on Face the Nation, “There ought not to be a great gap” between repealing the act and replacing it and that Republicans would be “replacing it rapidly after repealing it.”

US Secretary of Health and Human Services Sylvia Mathews Burwell has written an op-ed for the Boston Globe explaining why she doesn’t think “figuring it out later” is a great plan in this area:

Congress plans to take steps toward repealing the Affordable Care Act without any replacement. Opponents of the ACA have had six years to coalesce around a replacement plan, and they have not. Now they’re asking us to trust that they will in a few more years. But the stakes are too high to move forward on repeal without knowing what comes next. Under a “repeal and delay” scenario, health insurers would pull out of the market or dramatically raise prices. Hospitals and states would pull back on new investments as they prepare for an onslaught of uncompensated care. And if we ultimately went over the cliff, our national uninsured rate would jump from the lowest in history to higher than it was before the Affordable Care Act, according to independent experts. In every state in New England, the rate of the uninsured would more than double.

It’s not clear what the eventual proposed replacement for the ACA would be, especially since, as many profiles of Trump voters have since revealed, significant numbers of GOP voters actually rely on it, and many have pre-existing conditions that would bar them from accessing affordable health coverage if they had to return to the system of coverage that preceded the ACA. It’s not out of the question that Republicans will re-introduce a slightly modified and rebranded version of the ACA, gambling that what voters really objected to was Obama’s name being associated with the plan. For his part, Obama has said that ”If in fact the Republicans make some modifications… and re-label it as Trumpcare, I’m fine with that.”

Even if elements of the ACA are able to remain, the healthcare market would at the least still experience major turmoil in the transition period, and Medicaid would be deeply impacted. The current proposal from Paul Ryan would “reduce the federal contribution for the expansion population to each state’s standard federal Medicaid matching rate, which would be closer to 60% on average. Many states likely would end their expansions if they had to come up with the billions of dollars to replace the lost federal funding.” Losing the Medicaid expansion that was part of the ACA, which many Republicans have opposed, would result in millions of uninsured — Politifact estimates “the number of additional Americans who would lose coverage or be unable to get it for the first time would start at 19 million in the first year and increase incrementally before leveling off to 24 million within a couple of years.” (Politifact also warns that “keeping coverage for people with pre-existing conditions while repealing much of the rest of the law is not so easy.”)

And since Republicans are dedicated to trying to defund Planned Parenthood as part of their repeal effort, which would prevent the citizens who rely on using Medicaid to obtain healthcare through Planned Parenthood — primarily low-income women and women of color accessing lifesaving routine care and preventative services — from receiving affordable care. (As Planned Parenthood itself explains, there isn’t a line item in a federal budget for PP — what “defunding Planned Parenthood” means is blocking reimbursement for services provided at PP. And thanks to the Hyde Amendment, those services that can be reimbursed already don’t include abortion.) When organizers tried to deliver petition signatures asking the government not to defund Planned Parenthood to Paul Ryan’s office, they weren’t allowed to.

.@SpeakerRyan's office sent 6 security guards to block delivery of 87K #IStandWithPP petitions telling Ryan not to defund Planned Parenthood pic.twitter.com/56QHwhjR2q

— Planned Parenthood Action (@PPact) January 6, 2017

At least a few Republicans aren’t wholly on board with the repeal as it’s currently being pushed; John Kasich of Ohio and Rick Snyder of Michigan have protested that many of their citizens rely on the Medicaid expansion, and that repeal without a concrete replacement plan would leave them out in the cold. There isn’t necessarily a lot of optimism around this movement; Modern Healthcare says Republican experts think this push is “unlikely to influence congressional Republicans, but there’s always some hope that more Republicans could join them — especially if their constituents call and make it clear that they rely on the ACA and Planned Parenthood, and will only vote for legislators who support them.

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