President-elect Trump and Congress have a couple of options in deciding how to best repeal the Affordable Care Act, each with dramatically different impacts. NPR sorts through the options and looks at how existing Obamacare insurance plans will be affected.

KELLY MCEVERS, HOST:

Trump has said one of his top priorities as president is to repeal and replace Obamacare, but Senate Democrats could make an outright repeal tough. Trump says he’ll consider keeping two popular provisions, a requirement that insurers cover people with existing conditions and another that lets children stay on their parents’ policies until age 26.

As NPR’s Alison Kodjak reports, there are several ways to get rid of the rest of the health care law but not without creating major disruptions in the insurance market.

ALISON KODJAK, BYLINE: Democrats who supported the Affordable Care Act could use their filibuster power to block Trump and congressional Republicans from directly repealing the law. But there is a workaround. For bills related to the budget or taxes, the filibuster doesn’t apply. And Republicans in Congress gave it a test drawn earlier this year.

JOHN MCDONOUGH: Last fall and January of this year, they demonstrated quite convincingly that they could frame a budget reconciliation bill, get it through the House, get it through the Senate, get it to the president’s desk, which they did. President Obama vetoed it. President Trump would sign that bill.

KODJAK: That’s John McDonough, a professor at Harvard who is a Senate staffer who worked on Obamacare. He says if a similar bill passes next year without a replacement…

MCDONOUGH: Then we are looking at a national holy mess in the insurance market like we’ve never seen before.

KODJAK: That’s because the parts of the law that can be repealed in a budget bill are the ones that make the health insurance market function, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

KAREN POLLITZ: The mandate to have health insurance or pay a penalty, the mandate on employers to provide health benefits and the tax credits and cost-sharing subsidies that make it affordable for people to get health insurance would be repealed.

KODJAK: What can’t be reversed that easily – the parts of the law that prevent insurers from discriminating against sick people.

POLLITZ: You can’t be turned down based on your health status. You can’t charge customers more based on their health status.

KODJAK: All of which make health insurance more expensive. Pollitz says this combination would lead healthy people who think insurance is too expensive to drop their policies and sick people to buy. Insurance companies will then raise prices to account for their sicker customer base, leaving more people to drop insurance.

POLLITZ: And that’s what sometimes is referred to as the death spiral.

KODJAK: As in killing the insurance market. An even faster way for a President Trump to deal a blow to Obamacare would be to drop an Obama administration appeal of a court ruling against the law.

Earlier this year, a federal judge ruled that subsidies designed to cut the costs in some policies are illegal. That’s because Congress didn’t appropriate money for the payments which go to health insurers. Dropping the appeal would leave the court ruling in place.

POLLITZ: That would either force them to jack up premiums or to just face tremendous losses.

KODJAK: Under either scenario, these experts say, the changes could lead to the end of the individual health insurance market. Alison Kodjak, NPR News, Washington.

Copyright © 2016 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.