An earlier version of this article included comments from several trade groups, as well as from the National Association of Insurance Commissioners (NAIC). The original headline may have implied that NAIC also is a trade group. Instead, it is an association of state regulators and doesn’t represent any segment of the insurance industry. This article has been updated to reflect that change.

In the opening days of 2017, associations say they are bracing for an unsure future and an unraveling of the Affordable Care Act (ACA).

The top issue for insurance brokers is the likely repeal and potential replacement of the ACA, says Charles Symington, senior vice president of external and government affairs at the Independent Insurance Agents & Brokers of America. The association, he says, will continue to push to eliminate the so-called Cadillac tax as part of any ACA repeal. As far as replacing the ACA, he says there are “significant concerns” with efforts to cap the individual tax exclusion for employer-provided health care benefits, or to limit employers’ deductibility of health care expenses.

Neil Trautwein, vice president of health care policy at the National Retail Federation, worries that the Republican majority in Congress might overreach in its attempt to replace the ACA. “Not only will most of the replacement require 60 votes in the Senate, but bipartisan compromise will be needed to assure that health care reform lasts beyond the Trump administration,” he says. “We will be working to build a bipartisan majority around protecting employer-based health coverage. No employer mandates, no taxation of benefits, no state undermining of the critical ERISA law. We won’t find a Republican overreach on health reform any more acceptable than we did the Democratic overreach on the ACA.”

Efforts to repeal and replace the ACA could destabilize insurance markets if done haphazardly, warns the National Association of Insurance Commissioners (NAIC). House leaders have reached out to governors and state insurance commissioners “because they know they have to get this right,” according to NAIC.

State regulators are already focused on 2018, according to NAIC. Their main concern is keeping carriers in the markets, or even increasing participation. They also want to expand coverage choices and stabilize rates. “Actions by Congress, the administration and the courts could all help or hurt this effort,” according to the trade group.

The uncertainty in the new administration also creates new challenges for state lawmakers, adds Trish Riley, executive director of the National Academy for State Health Policy (NASHP). Until the implementation of the ACA, health insurance had largely been a state issue. Now state legislators expect some federal oversight will revert back to the states.

Riley says there is an expectation among state legislators that they will play a role in developing and helping to implement ACA replacement legislation. “When people are uninsured, state legislators and officials from the executive branch hear from those people directly,” Riley says. “They also hear from the providers that have lost funding.”

NAIC says it will be watching the House v. Burwell case closely to see if the Trump administration continues with the appeal or if it can work out a solution on the cost-sharing reduction (CSR) program with Congress. The lawsuit, filed by House Republicans in late 2014, contends federal funding for CSR payments is illegal without an appropriation from Congress. The Obama administration appealed the suit, but following the presidential election, the House sought a stay of the appeal. The court agreed to stay the appeal until late February, according to a Dec. 29 Health Affairs blog. NAIC says eliminating the CSR could put medical care out of reach of low-income enrollees, impact participation and rates in 2018, and even destabilize the markets this year.

Hospital Groups Issue Warning

A repeal of the law would push the uninsured population to 50 million by 2016 — nearly double the number expected if the ACA remained intact, according to a December report commissioned by the American Hospital Association and the Federation of American Hospitals. If replacement legislation fails to ensure coverage similar to the ACA, the hospital associations want the new Congress to restore the Medicare hospital inflation update, as well as Medicare and Medicaid Disproportionate Share Hospital (DSH) payments, which were removed by the ACA. The report concludes that, without a replacement bill, the ACA repeal bill (H.R. 3762), which the House approved a year ago, could cost hospitals $165.8 billion. If the ACA’s Medicare reductions are maintained, hospitals also will suffer additional losses of $289.5 billion from reductions in their inflation updates, according to the report.