Don’t just dump ACA; reform it

America is stuck in an uncomfortable limbo ahead of any formal action by Congress to pursue an unwinding of the Affordable Care Act — “unwinding” being a term descriptive of a best-case scenario.

The worst case? That would be an abrupt repeal with no replacement plan at the ready, something that, most experts believe, would cause instability in the health-care market.

One consolation of this moment in limbo is that it means nothing terrible has happened yet. There is still an opportunity here, one that Congress should seize, to do this unwinding more carefully.

Even with its own bedrock health law in place and a history of quality coverage for working families, Hawaii also stands to suffer if the Affordable Care Act is pushed off the congressional cliff with nothing in place to break its fall.

Ever since the 2010 enactment of the ACA, better known as “Obamacare,” there’s been upheaval in the moribund U.S. health care system. Much of the federal law represents a drastic improvement in access to health insurance.

The expansion of Medicaid eligibility, as well as the subsidized plans offered in online “exchanges,” have provided a new onramp to health coverage for some 20 million people nationwide.

And sensing this was a “last chance” to sign up, even Hawaii, with its low uninsured rate, this year has some 17,000 new enrollees.

There’s been an extension of parental coverage to young adults up to age 26. There is the “guaranteed issue,” meaning that one can’t be turned away from a health plan because of pre-existing conditions.

The ACA has pressed for reimbursement based on quality measures rather than payment by procedure. It’s encouraged more collaboration among medical providers, breaking down silos, aided by a push for electronic data sharing. The health-care sector already was trending this way, but the law certainly helped put modernization on the front burner.

There’s the negative critique, of course.

For a range of reasons, the ACA rollout over six years has taken the country through some rough turf. A rush of sicker patients with deferred health issues into doctors’ offices raised costs and premiums, not always sufficiently offset by federal subsidies and tax credits. Insurance pools for individuals were sometimes too small, making rates too high.

Minimum standards of what a health plan covered, coupled with complex regulatory requirements, has prodded some providers to leave the marketplace, leaving patients with a narrower choice of plans and accepted doctors.

In Hawaii especially, the list of health plans businesses could offer employees with the promised discount began to drop, as the Hawaii Medical Service Association withdrew from the exchange. That online marketplace, the Hawaii Health Connector, had proven a colossally expensive mess, and enrollment transitioned to the federal exchange when the Connector was shut down.

Now Hawaii has gained some relief through a waiver from the requirement for businesses to buy plans from the exchange, with some federal funding in place to offset premiums.

But there is some worry being expressed that an abrupt repeal of the ACA will endanger that fallback plan and leave Hawaii businesses, and their employees, high and dry.

Republican leaders on Capitol Hill have said they will not pull the rug out from under the millions worried about losing coverage, but so far there have been no backstop plan presented to reassure anyone.

The tragedy here is that so much political capital has been invested in the repeal — the GOP has made a show of voting for it dozens of times — that now the unified Republican leadership feels compelled to deliver on the promise promptly.

The hope is that the less idealogically driven president-elect, Donald Trump, once again might be the wild card here, and in a good way.

Trump himself has promised to “repeal and replace” the law throughout the campaign, but he has been opposed to the notion of having nothing at the ready the moment it is struck down. He dislikes any symbolic immediate repeal that goes into effect at some much later date.

Like any businessman, he undoubtedly realizes the financial world hates uncertainty. And in this vein, he also has said the law could be allowed to fall under its own weight so that Republicans don’t take the blame for any fallout. Meanwhile, leaders could build their version of health reform, even finding common ground with Democrats to enact changes rationally.

There are various elements of the law where there could be agreement. The ACA’s “Cadillac tax” on deluxe health plans is hated by both sides. There could be a way to incentivize enrollment without the individual mandate. Some regulatory changes could make the reforms more business-friendly.

Republicans should be pressed to adopt this businesslike strategy. Dealmaking seems to be in Trump’s DNA, and his GOP partners really should get on board.