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Congress is back in session on Tuesday, and leaders of both houses say their first order of business will be to repeal Obamacare.

If they do that, it will be a slap in the face to President Barack Obama just three weeks before he leaves the White House. The Affordable Care is the outgoing president’s signature achievement, marked by an elaborate signing ceremony in March 2010 at the White House, with lofty speeches from the vice president and Obama himself.

“Today, after almost a century of trying, today after over a year of debate, today, after all the votes have been tallied, health insurance reform becomes law in the United States of America,” Obama said that day, to long applause from the assembled crowd.

And Joe Biden famously leaned over to remind the president that it was “a big ***ing deal.”

But Republicans have been vowing to repeal the law since the day it passed, and they’ll soon have a sympathetic president in the White House to sign whatever bill they send him.

“We will repeal the disaster known as Obamacare and create new health care, all sorts of reforms that work for you and your family,” President-elect Donald Trump vowed last month in Orlando.

That new health care plan hasn’t been fleshed out yet by Trump or his allies in Congress. So they say they’ll vote to get rid of Obamacare, but delay its demise until they come up with a replacement that will cover the millions of people who have insurance thanks to the law.

But insurance companies and health care analysts are worried.

“I don’t see how you talk to any [insurance] carrier and give them any desire to hang around to see what they replace it with,” says Dr. Kavita Patel, an internist at Johns Hopkins University Hospital and senior fellow at the Brookings Institution. “Why would you stick around for that?”

Patel worked in the White House and helped create the Affordable Care Act. But she’s not alone in her concern.

Last month the health insurance trade group America’s Health Insurance Plans sent a letter to lawmakers asking them to keep in place many of the financial incentives that are central to the law — including subsidies for patients to help them buy insurance and cover copayments, and a provision that eliminates some taxes on insurers.

The American Academy of Actuaries also warned in its own letter that a repeal of the ACA without replacing it would be dangerous to the long-term health of the insurance market.

Still, Republicans appear determined to move ahead with the vote as soon as this week.

Some history:

Democrats rammed the Affordable Care Act through Congress in 2010 with no Republican support.

It was a huge, complicated law and, like most legislation, it was flawed. Over the subsequent six years, Republicans, who were angry at the way the Affordable Care Act was passed, refused to cooperate in any actions that would be seen as helping it succeed. Instead, they promised in speeches and television interviews to repeal it entirely. In fact, the House has voted more than 60 times over the years to do just that.

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Then-Speaker of the House John Boehner stands next to a printed version of the Affordable Care Act during a Capitol Hill news conference on May 16, 2013. Chip Somodevilla/Getty Images hide caption

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Chip Somodevilla/Getty Images

“There’s no getting around the fact that lots of Republicans campaigned hard against the ACA and a lot of them won, including the person at the top of the ticket,” says James Capretta, a scholar at the conservative American Enterprise Institute.

But even with control of both chambers of Congress and with Trump in the White House, Republicans can’t simply repeal Obamacare. They would need the help of at least a handful of Democrats to overcome a filibuster.

Democrats can’t, however, filibuster budget bills. So Republican leaders have decided to defund Obamacare, eliminating the tax penalties for those who don’t buy insurance and the subsidies to help people pay their premiums. Essentially, that guts the law’s main elements.

The problem for Republicans is that today, an estimated 20 million people get their insurance through Obamacare. About 10 million buy policies through the exchanges set up by state and federal governments, and most of those patients get subsidies to help pay the premiums.

And millions more are covered because the law allows states to expand the number of people who are eligible for Medicaid, the health insurance program for the poor.

So people who had pre-existing conditions that shut them out of the insurance market before the ACA passed, or people who had reached insurer-imposed lifetime benefit limits, generally like the law.

But, then there are people like Will Denecke, who is mad because his insurance costs have gone up since Obamacare passed. Before the law was enacted, he spent about $340 a month on health insurance.

“Incredibly, we got a notice from my health care company, Moda, which has been having financial problems, that my premium was going up to $930,” he said last October.

He’s a self-employed urban planning consultant in Portland, Ore., and, unlike most people in Obamacare, he makes too much money to qualify for government subsidies.

“I’ve had health insurance my whole life, but it’s just offensive in principle to think of spending $1,000 a month on health care insurance when there is a good chance I won’t need it,” he said.

He was considering just letting his coverage lapse.

And, on the other side, you’ve got people like Leigh Kvetko of Dallas. She takes 10 medications every day because she’s had two organ transplant procedures, and the drugs are part of her daily regimen to survive. After Obamacare passed, she was able quit her job at a big company and start a business with her husband, because she could finally get individual insurance.

“This particular plan, the fact that they cannot discriminate against me because of how I was born, was a lifesaver, literally,” she says.

House Ways and Means Committee Chairman Kevin Brady told the Washington Times last month that consumers needn’t worry. “We can assure the American public that the plan they’re in right now, the Obamacare plans, will not end on Jan. 20, that we’re going to be prepared and ready with new options tailored for them,” he said.

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Emil Girardi moved to San Francisco on New Year’s Eve in 1960. He loved everything about the city: the energy, the people and the hills. And, of course, the bars, where Girardi mixed drinks for most of his adult life.

About 10 years ago, the 83-year-old New York native had a stroke and collapsed on the sidewalk near his Nob Hill home. Everything changed.

“I didn’t want to go out of the house,” Girardi recalled, adding he only felt comfortable “going from the bedroom to the dining room.”

He’d started to fear the city’s streets — and growing older.

An out-of-state friend worried about his isolation and called a San Francisco-based nonprofit called Little Brothers, Friends of the Elderly. The organization works to relieve isolation and loneliness among the city’s seniors by pairing them with volunteers.

Little Brothers matched him with Shipra Narruhn, a computer software trainer who has volunteered with various organizations over the years, and became involved with Little Brothers after her mother’s death. The organization started in France after World War II and now operates in several U.S. cities, including Chicago, Philadelphia and San Francisco.

Cathy Michalec, the executive director of the local nonprofit, said older adults often become less mobile as they age. Cities like San Francisco, because of hills, crowded streets or old housing stock, are difficult for many seniors. That can lead to isolation and loneliness, Michalec said.

“Those 50 stairs you used to be able to go up and down all the time, you can’t go up and down all the time,” she said. “The streets are crowded and sometimes unsafe. … Sometimes, our elders say, it’s easier to stay in the house.”

Across the nation, geriatricians and other health and social service providers are growing increasingly worried about loneliness among seniors like Girardi. Their concerns are fueled by studies showing the emotional isolation is linked to serious health problems. Research shows older adults who feel lonely are at greater risk of memory loss, strokes, heart disease and high blood pressure. The health threat is similar to that of smoking 15 cigarettes a day, according to AARP. Researchers say that loneliness and isolation are linked to physical inactivity and poor sleep, as well as high blood pressure and poor immune functioning.

A 2012 study showed that people who felt lonely – whether or not they lived with others or suffered from depression – were at heightened risk of death. It also showed that 43 percent of people over 60 felt lonely.

“If someone reports feeling lonely, they are more likely to lose their independence and they are at greater risk of dying solely from being lonely,” said Dr. Carla Perissinotto, a geriatrician and researcher at the University of California, San Francisco who authored the study.

There can be many causes of loneliness, Perissinotto said, including illness, hearing loss or life changes such as retirement or the loss of a spouse. “The usual social connections we have in younger life end up changing as we get older,” she said.

Narruhn recalled that she and Girardi would just visit at his apartment, in the beginning. She’d tell him about her travels and her adult daughter. He’d tell her about his adventures in San Francisco. He described what the city was like as a young gay man, and told her about the friends he had lost to AIDS. They talked about music, books and cooking.

“I could tell from talking to him that he had a lot of interests,” she said. “At one time, he was very sociable.”

Gradually, Narruhn started bringing him music from Italy, India and Mexico. Girardi liked the songs he could snap his fingers to. Finally, Shipra convinced him to go out to lunch – and to visit a hidden, tile-covered staircase in San Francisco with her.

“Shipra came to see me, and came to see me and came to see me,” he said. “Finally, she said, ‘You have to get out of the house.'”

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Girardi (right) and Narruhn head to one of their favorite San Francisco restaurants for lunch. Because of their friendship, Girardi says, he no longer fears leaving his apartment or getting older. Research shows loneliness can hurt seniors’ health. Anna Gorman/KHN hide caption

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Anna Gorman/KHN

Soon, they were going to jazz shows, on walks and to the park. Narruhn said she invited Girardi to do eclectic things with her – chakra cleansings, Reiki healing sessions – and he was always game. Over time, his fear subsided. So did his loneliness.

“After she took me out of the house, then I didn’t want to stop,” Girardi said.

There isn’t much research about the effectiveness of programs such as Little Brothers. But Perissinotto said they can help seniors build new social connections. Other efforts to address loneliness include roommate matching services in various states and, in the United Kingdom, a call-in hotline.

“Maintaining connections, that touchy-feely thing, is actually really important,” Perissinotto said. “It’s hard to measure, it’s hard to quantify, but there is something real. Even though we don’t have the exact research, we have tons of stories where we know it’s [had] an effect in people’s lives.”

AARP Foundation also recently launched a nationwide online network to raise awareness about social isolation and loneliness among older adults. The network, Connect2Affect, allows people to do a self-assessment test and reach out to others feeling disconnected.

AARP, the Gerontological Society of America and other organizations are hoping to help create more understanding of isolation and loneliness and to help lonely seniors build more social connections.

“Loneliness is a huge issue we don’t talk enough about,” said Dr. Charlotte Yeh, chief medical officer of AARP Services. “There is a huge stigma.”

One afternoon in November, Narruhn came by to take Girardi out to one of their favorite restaurants on Polk Street. The waiter greeted them by name. Over Italian food, they planned several more visits together.

Girardi said he doesn’t fear growing older anymore. He’s surrounded by his new family. And by good music, he said, and “snapping fingers.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. You can follow Anna Gorman on Twitter: @annagorman.

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