Donald Trump ran for president on promises to repeal and replace Obamacare, but that hasn't stopped millions of Americans from signing up for healthcare insurance through the ACA marketplaces. So far, enrollment is already north of 4 million for 2017. Will more Americans sign up for coverage this year than ever before? And, what could health insurance reform mean for these individuals beyond 2017?

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Deadline deals

Last Wednesday, Dec. 14, was originally the deadline to file for health insurance through the marketplaces if you wanted coverage to begin on Jan. 1. However, a late rush prompted the Department of Health and Human Services to extend the deadline to Dec. 19.

In a tweet storm earlier this week, HHS Secretary Sylvia Burwell reported that 1 million Americans had already signed up for coverage through Obamacare between Dec. 12 and Dec. 14.

Those new enrollments will be added to the 4 million Americans who already had enrolled in Obamacare through Dec. 10. For comparison, in the same period last year, 3.75 million people had enrolled.

As of Dec. 15, nearly 1 million people were still in the process of signing up.

Targeting 10 million?

Last year, 10 million Americans signed up and paid for health insurance through Obamacare, and this year's totals suggest a similar number of people will sign up this year, in spite of insurance premium increases and promises of repeal.

The pace of enrollment suggests that the majority of Americans getting their coverage aren't being frightened away by premium increases, which reach into the double digits in some areas of the country.

Last year, about 9 million people received tax credits that subsidize their insurance premiums. On average, these tax credits totaled $300 and reduced a person's monthly premium to less than $100 per month.

These tax credits are adjusted to reflect premium price changes, so most Americans aren't feeling the sting of spiking premiums this year.

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IMAGE SOURCE: GETTY IMAGES.

What's next for Obamacare

In the past, Republicans have suggested private market solutions to replace the Affordable Care Act, and on the campaign trail, Donald Trump frequently said his plan is to repeal the ACA and replace it with something else.

Trump hasn't offered up too much insight into what his replacement might look like, but he's indicated in the past that competition across state lines will be part of the solution. He's also said he plans to target sky-high drug prices, which he may do by decreasing regulation and allowing drug reimportation from countries where medicine is sold for less, such as Canada.

If Trump repeals Obamacare outright, its impact could be greatest on patients, hospitals, and insurers.

Congress has said it wants to avoid a repeal that leaves currently employed people high and dry. That could mean a gradual phase-out of Obamacare, or forbidding insurers from canceling plans for a period of time.

If Trump eliminates subsidies to individuals and families, it's hospitals that could take a hit to their profitability. Currently, subsidies are linked to income, so their disappearance would probably lead to a decline in coverage for cash-strapped Americans, and a corresponding increase in hospital bad-debt expense and charity care.

Alternatively, it's insurers that could benefit most from reform. A decline in enrollment would have the biggest impact on low-income enrollees, who have, historically, been more costly to insure because of their lack of access to primary care, and their reliance on emergency rooms.

Assuming insurers gain more underwriting flexibility to craft insurance pools that are more profitable, then insurer profits could climb even as the total number of people with insurance falls.

In selecting Tom Price as Secretary of HHS, Trump appears to be a fan of Price's repeal-and-replace plan. In 2015, Price's Empowering Patients First Act offered up a blueprint for replacing Obamacare with a solution that includes "individual health pools and expanded health savings accounts, tax credits for the purchase of coverage, and lawsuit abuse reforms to reduce the costly practice of defensive medicine."

Specifically, Price's plan provides states with block grants to establish high-risk insurance pools, and it offers taxpayers tax credits linked to age, rather than income. Previously, Price's plan called for a maximum credit of $3,000 per year for individuals age 50 and up.

Looking ahead

Millions of Americans continue to enroll in Obamacare despite uncertainty, and that suggests there remains an important need for accessible insurance. It's anyone's guess what Trump's repeal-and-replace plan will ultimately look like, but it appears that it could include tax credits, risk pools, health savings accounts, and competition across state lines. Whether such a policy will be a net win or loss for patients, care providers, and healthcare companies will depend on the details. With millions of people still relying on Obamacare, the stakes are high. 

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