The ACA has significantly reduced the number of uninsured, cutting the national uninsured rate from more than 13% to around 8.8%, according to Moody's Investors Services.
Rolling back the law could strip coverage from millions of people, which would translate to more emergency and acute care and less preventive measures. It would also eliminate subsidies on health exchanges, which could make insurance unaffordable for the 8 million to 9 million people who currently receive them.
Providers' balance sheets would suffer as those that currently receive insurance under expanded Medicaid programs would likely become bad debt or charity, analysts said. This could limit their ability to expand access and provide financial assistance and community outreach.
"The ACA is something to work with and something we can improve upon. To throw the whole thing out hard would make it hard for us to pivot the Titanic on a dime," said Dr. Allison Suttle, Sanford Health's chief medical officer. "It is frustrating when we have invested a lot to move down this track."
When people don't have insurance coverage, it's harder to keep people healthy, Suttle said.
Suttle's boss went into the office to get a flu shot recently and saw her dad sitting there. He wasn't sick, but a Sanford health coach reached out to him and reminded him to have his A1C levels checked.
"We are not paid to do that—there is no CPT code for that," Suttle said. "We are finding gaps in care so we can keep patient healthy so they don't have to come into the ER with high blood sugar. It's that type of preventive care we can do when people are covered. It changes the paradigm of how we care for patients."
Sanford health coaches work in tandem with behavioral healthcare workers who screen for depression and other mental health issues. Identifying those issues allows Sanford to better manage chronic diseases, Suttle said.
Insurance coverage facilitates colonoscopy and mammography screenings that can detect early stages of cancer.
"Coverage is key," she said. "To throw the whole thing out just because one part of it was removed could be devastating. It could have huge implications to a complex large health system that has already been making these moves."
Providers have also invested in the infrastructure, technology and staff to facilitate new payment models like accountable care organizations, bundled payments and Medicare shared savings.
"To just throw that out seems very unlikely," said Fred Geilfuss, a partner with the law firm Foley & Lardner. "There would be a lot of people who are motivated to figure out a way to continue that momentum."
AMGA, a trade association that represents physician groups, doesn't expect its members to cease its work on value-based payment if the ACA were repealed, especially in regards to ACOs. Chet Speed, the AMGA's vice president for public policy, said physician practices have invested millions of dollars to get their ACOs up and running.
"They won't have the financial incentives but once you have created these programs internally, you have invested so much money and time and change management, to unwind it would make no sense," Speed said.
Although he said ACOs would have a hard time continuing their relationships with physicians and hospitals if the ACA were repealed. Waivers have been applied to the Stark Law so physicians and hospitals can have financial relationships. Those protections would go away if the ACA went away.
However, commercial payers have also begun their own ACOs, which will likely continue even without the ACA, said Don Crane, CEO of America's Physician Groups, which represents more than 300 medical groups and independent practice associations.
"Their customers, purchasers and employers want to see value in the commercial marketplace, they want to see ACOs, they want measures that bring value. That is what's driving health plans, meeting the demands of their customers," he said.
Clare Pierce-Wrobel, senior director of the Health Care Transformation Task Force, said that ACA repeal may invigorate the commercial payers to lead the charge on the value-based movement.
"Commercial payers aren't dependent on the provisions of the ACA and continue to move forward with ACOs and bundled contracts," she said. "I don't see the momentum fading for the private sector at this point."