About 1 million people in Pennsylvania are receiving government-subsidized health insurance under Democrats' 2010 health care law that is facing an uncertain future as Republican President-elect Donald Trump takes office next month with a pledge to repeal it.
Leaders of the Republican-controlled Congress that Trump will share power with also say they are also intent on abolishing President Barack Obama's signature law.
Democratic Gov. Tom Wolf, who supports Obama's law, is watching the situation, but has had no formal conversations with state lawmakers, aides said.
"It's hypothetical and it's probably too soon to tell on a lot of this, because when people say they're going to repeal it, it's not clear what that means," said Ted Dallas, Wolf's secretary for the Department of Human Services.
No changes are expected next year for people covered through the law's insurance marketplace and its expansion of Medicaid's income eligibility guidelines, Republican lawmakers say. Congress could take months to act, and any replacement is expected to need several years to take full effect.
Republicans say they hope no one will lose coverage as a result of any forthcoming legislation. But, they say, big changes are needed to stop the cost of health care from rising so quickly, something they say Obama's law failed to do.
"This is not bringing a car in for a tuneup," said Republican U.S. Rep. Tim Murphy, of suburban Pittsburgh. "This is an overhaul."
In any case, Pennsylvania's 2015 uninsured rate was 6.4 percent, a drop of one-third after the major coverage components of Obama's law kicked in, according to U.S. Census data. That's below the national average of 9.1 percent.
About 680,000 people are now covered under the Medicaid expansion, according to the Wolf administration. That population is primarily single adults, rocketing Pennsylvania's Medicaid rolls to above 2.8 million, a record high. Its coverage of drug and alcohol treatment services has helped the fight against Pennsylvania's addiction wave, Wolf administration officials say.
The cost of keeping those 680,000 people on Medicaid is $3.6 billion a year, Wolf administration officials said, or more than 10 percent of this year's approved state budget of $31 billion.
Another 412,000 Pennsylvanians signed up for an insurance plan through HealthCare.gov in 2016, according to the Centers for Medicare and Medicaid Services. That includes 321,000 who received a tax subsidy to help pay for the coverage.
Enrollment is open for individual insurance through HealthCare.gov in 2017, although Pennsylvanians face rising premiums and shrinking options in the insurance marketplace. Jan. 31 is the deadline to enroll.
In the meantime, the Wolf administration is writing a response to a form letter from top U.S. House Republicans. The letter asks state officials for ideas on how to make health insurance easier to get, which regulations to shed and whether they would establish a "high-risk pool" if federal law allowed it.
It also said Americans deserve more "patient-oriented solutions" with fewer federal mandates and more freedom and flexibility for states to create options.
"Hopefully they'll give us some leeway in addressing the health care needs in a Pennsylvania way instead of a one-size-fits-all way," said Pennsylvania's state House Majority Whip Brian Cutler, R-Lancaster.
Republican U.S. Rep. Charles Dent, of suburban Allentown, said he expects that Congress will keep certain elements of the 2010 law — such as keeping the prohibition against denying coverage because of a pre-existing condition and a clause that allows children to stay on their parents' insurance policies until age 26. But anything that is repealed should have a replacement enacted at about the same time, Dent said.
A full repeal of the law and any replacement legislation will likely require cooperation from members of the Senate's Democratic minority.
"So here's the question: if or when Obamacare is repealed, could we put together a bipartisan coalition to replace the law?" Dent said.
Pennsylvania's Democratic U.S. Sen. Bob Casey poured cold water on any notion that he would cooperate, saying he will vigorously oppose a repeal. Republicans have done nothing but talk for years, never mind come up with something that would cover the 20-some million people covered under the law and protect everyone else that has coverage, Casey said.
Repealing the health care law would be "cataclysmic" for Pennsylvania, Casey said, "and I haven't heard a word about any kind of (Republican) proposal that would get my support."