As the Trump administration looks to repeal and replace the Affordable Care Act, it is uncertain what lies ahead for health care.

Some experts argue that a total repeal without replacement isn’t out of the question. Others say that the most popular provisions of the ACA, popularly known as Obamacare, will more than likely be kept. At a local level, concerns have been raised about contraceptive care, and small businesses may have to look to community groups for health insurance if a repeal goes through.

Regional impact

According to data from New York State, 25,552 people in Albany County would be at risk of losing coverage should the Affordable Care Act be repealed. A release from Governor Andrew M. Cuomo’s office, which included the data, said that a repeal would also mean a loss of $600 million in federal funding that goes to counties to lower property taxes.

According to a 2016 publication by the Healthy Capital District Initiative, the Capital Region stands out from the rest of the state because a higher rate of its  residents have health insurance and a higher percent have a regular doctor. At the same time, the Capital Region has lower rates of preventable and total hospitalizations and emergency room visits than the rest of the state.

Higher than the rest of New York was the region’s median household income of $60,722 and its poverty rate of 11.3 percent was lower than the rest of the state.

Despite this, 40 percent of Capital Region residents identified the cost of obtaining medical care a very significant obstacle, the report said.

Spokeswoman for County Executive Daniel McCoy, Mary Rozak said that the outcome for the county is uncertain, given the various potential outcomes. In a statement, McCoy expressed concern for maintaining affordable healthcare.

“We have made great progress in expanding access to care and now is not the time to propose devastating cuts to our safety net,” he said.

Impact on rural areas

One of the only primary-care practices in the rural Helderberg Hilltowns is Capital Care Family Medicine, which includes the medical director and physician, Kristin Mack, D.O., as well as nurse practitioner Jill Martin and physician’s assistant Thomas Doolin who joined the practice last month. The only other doctor in the area is a “micro-practice” solely run by Dr. Myria Emeny, M.D., in Westerlo.

“In a small practice in a rural area, patient needs are high and available resources sometimes limited,” said Mack, in an email to The Enterprise. “A full service practice is certainly affected with even small changes.”

According to Mack, the Affordable Care Act set standards in the way providers document care and set goals for their patients. This especially affected rural practices, she said, and a repeal or replacement of the ACA could not only affect patients and their health insurance, but the practices themselves.

“Changes from the national system will place new requirements on providers for care documentation on each patient and may not support the previous work done toward community-based goals,” she said, adding that she feared that the changes could take up time that could better be spent with patients.

Mack emphasized that, though she felt community care was at stake, she would stay committed to her own community practice.

“Overall, the uncertainty of what will come next cannot replace the importance of building patient relationships and delivering high level medical care as my top priority,” she said.

Individuals living in rural areas have seen an 8-percentage-point increase in coverage gains between the first enrollment period of the ACA and early 2015, according to a study by the United States Department of Health. Those who reported being unable to afford care declined by almost 6 percentage points during that time.

In a national health survey of both rural and urban nonelderly individuals conducted by the department in 2015, it was found that 56.6 percent of rural individuals had a regular doctor, compared to 47.4 percent of urban residents; 26.5 percent of rural residents and 27.2 percent of urban residents delayed or did not receive care due to cost.

Impact on birth control: the cost of contraception

At the Upper Hudson Planned Parenthood, the fear isn’t so much of losing all coverage, but rather coverage for contraception. Since Donald Trump’s election, the organization has seen a spike in requests for more permanent forms of birth control.

According to a release from Katherine Bruno, vice president of Marketing, Communications, and Public Affairs for Upper Hudson Planned Parenthood, there has been a 134-percent increase over the last year in use of long-acting reversible contraceptives (LARCs); 519 LARCs were administered in 2015, compared to 1,217 in 2016. Online appointment requests for LARCs were up by 117 percent between fall and winter; 62 requests from August to September of this year, and 135 since November 1.

“Some people are concerned about losing their access to birth control if the Affordable Care Act is repealed,” said Bruno to The Enterprise on Friday.

LARCs include intrauterine devices, injections, and under-the-skin implants. Without coverage, an IUD can range from $100 to $1,000, said Bruno. Under the Affordable Care Act, contraception that is approved by the Federal Drug Administration and is prescribed by a doctor (with the exception of abortion-inducing drugs and male birth control like condoms or vasectomies) is covered by plans in the ACA’s “marketplace” without copays or co-insurance charged. Religious employers or organizations are exempt from covering this, and some private insurance companies have not yet implemented such coverage.

“If that goes away, there is additional cost,” said Bruno.

This rush to obtain more permanent contraception has come despite the New York State Assembly passing a bill that would ensure contraception remains insured should it pass in the Senate and be signed into law by the governor. The Assembly has a Democratic majority while the State Senate is controlled by Republicans, making passage of the bill unlikely.

Last year, 55 percent of Upper Hudson Planned Parenthood patients were covered by Medicaid, 35 percent were covered by commercial insurance, and 10 percent were uninsured. The organization saw 9,441 patients and had 14,231 visits, said Bruno.

Bruno said that Upper Hudson Planned Parenthood has advised concerned women with the same advice that would be given without the current political climate: to take charge of their contraceptive plan.

“Birth control is not one-size-fits-all,” she said. “It’s never a bad time to take control of your birth control.”

Bruno said she can’t speak on what will happen to insurance for contraception.

“I guess until it happens, we’re not sure,” she said.

Impact on small businesses: a return to community aid

Businesses may return to groups like local chambers of commerce in order to keep health insurance for their employees, should health-care options for small businesses be taken away.

Currently, the ACA offers insurance plans for businesses to offer to their employees, should the businesses have 50 or fewer full-time equivalent employees (in 2016, this was expanded to 100). Businesses with 25 or fewer full-time equivalent employees may qualify for a tax credit as well. Businesses with 50 or more full-time equivalent employees may have to offer a payment to employees who purchase their own ACA insurance should their employer insurance be deemed unaffordable or not meet certain standards.

Chery Lasher, president of the Guilderland Chamber of Commerce, said that the number of businesses in the chamber decreased dramatically after the ACA was put in place. The Guilderland chamber offers insurance plans as part of its membership, but, with another option for insurance for small businesses in place, many left. Lasher said that this occurred nationwide.

“The biggest impact was on small businesses and solo entrepreneurs,” she said.

Kathy Burbank, who was executive director of the Guilderland chamber from 2007 to 2013, said it was estimated at least 75 members left the chamber in order to purchase insurance through the New York State of Health, although many used the insurance broker provided by the chamber to purchase insurance through the state’s marketplace. A majority of those who left were sole proprietors, said Burbank. Some, she said, did remain chamber members but pursued a state-offered insurance plan.

Jessica Lustig, who owns the local chain The Hot Yoga Spot, explained that, when she first opened her studio — before the implementation of the ACA — she had trouble finding health insurance as a business owner. She joined the chamber for the sole reason, she said, to have access to insurance. She is still a chamber member and uses the health insurance offered through it.

“My husband and I are each self employed so a few years ago when we were seeking insurance, this was the option available to us,” she said in an email to The Enterprise.

Because New York has its own health-care exchange, a repeal of the ACA may not affect its insurance marketplace so long as it stays within federal rules, said Burbank. But she also said that it is likely businesses would return to the chamber and its insurance plans if a repeal took place, since prices in the state marketplace have been going up.

Although Lasher said that many chamber members felt they were saving money by making the switch and not paying dues, she pointed out that the chamber does offer other benefits alongside insurance plans that are very similar to ones offered under the Affordable Care Act. Such benefits include business connections, informational programs, and opportunities to advertise themselves, she said.

She can’t say what to expect for businesses and their insurance plans now.

Lasher said that, because rates are set for this year, businesses should be unaffected in the meantime, but that they should be aware of what could happen as the next enrollment period comes around.

“My advice to businesses would be to watch very carefully and prepare for open enrollment,” she said.

What lies ahead?

In a forum held by the University of Southern California Annenberg’s Center for Health Journalism, three speakers discussed what could happen to the country’s health care under a new administration. The speakers, with differing backgrounds and political viewpoints, discussed possible outcomes for the Affordable Care Act.

Jennifer Haberkorn, a senior health-care reporter for Politico and Politico Pro who has long covered the Affordable Care Act, said at the online forum that possible outcomes include keeping popular provisions such as letting those under the age of 26 stay on their parents’ insurance policies, offering tax breaks for poor citizens, putting Medicaid into a block-grant program, or placing those with high-risk conditions into “pools.”

Joseph Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute, said that it was possible insurance companies could see more bargaining.

Despite reassurances by others that popular provisions would not be cut, Jonathan Gruber, the Ford Professor of Economics at the Massachusetts Institute of Technology, said that he wouldn’t rule out a total repeal without a replacement, noting that the health-care law implemented by the Obama administration stemmed from a conservative plan, and it wasn’t likely a better replacement could be found.

“The Affordable Care Act is not a failure,” said Gruber. “The only failure is political.”