With Republicans in control of the House, Senate and presidency, the Affordable Care Act faces the threat of repeal. The question is: How would repeal affect those who have purchased health insurance plans under the law, and what would replace it?

With Republicans in control of the House, Senate and presidency, the Affordable Care Act faces the threat of repeal. The question is: How would repeal affect those who have purchased health insurance plans under the law, and what would replace it?

There are no simple answers.

According to numbers provided by the Department of Health and Human Services, 20,744 North Dakotans signed up for health insurance in the marketplace the law created from Nov. 1 to Dec. 31 of last year, indicating that demand for affordable health care under the plan remains high.

CNBC cited a report showing that record numbers nationwide signed up for insurance under the law during this year’s enrollment season to the tune of 400,000 new insurance customers, for a total of 6.4 million in 2016.

North Dakota is one of the handful of red states that has chosen to expand Medicaid under the provisions of the ACA, though incoming governor Doug Burgum has not yet made clear what his plans are regarding the expansion. Andy Lankowicz, president of St. Alexius Hospital in Devils Lake, said in a November 2016 interview that he spoke to Burgum about the future of Medicaid expansion in the state.

“I asked him when he visited Devils Lake about what his position was on Medicaid expansion,” Lankowicz said. “He eventually came out and said he would consider expanding it, but that was before we knew that we’d have Donald Trump as the president-elect.”

GOP lawmakers in Washington have all but guaranteed that an Obamacare repeal is imminent, but have struggled to effectively navigate the political waters concerning a replacement of the law. Incoming president Donald Trump once supported universal health care, but has called the Affordable Care Act “terrible legislation” and says on his website that he will ask Congress to “immediately deliver a full repeal of Obamacare” on day one of his presidency.

That leaves several million newly insured customers under Obamacare in limbo as far as what their health insurance future may be.

Aviva Aron-Dine, senior advisor to HHS Secretary Sylvia Mathews Burwell, said on a conference call that repeal of the ACA would have an immediate impact on those who have benefited from the law.

“These are real people’s lives that we’re talking about,” Aron-Dine said. “We are here to talk about 11.5 million people who have signed up for the health and financial security coverage (that) the marketplace provides. We think it’s incredibly important that they can continue to have access to the health benefits of the ACA.”

An ACA repeal would likely mean losing Medicaid expansion, as the component parts of the law are designed to work in concert, meaning that scrapping the law would likely create complex questions as to how to fund state-by-state expansion of Medicaid.

That would leave the estimated 70,000 North Dakotans who were uninsured before the 2013 Medicaid expansion with immediate uncertainty about their coverage options if repeal moves forward without a sound replacement.

Though the future of the ACA and coverage for North Dakotans who have been able to afford health insurance due to the law is anything but clear, Lankowicz said in November that St. Alexius would continue to care for those in the region whose ability to afford insurance is compromised.

“My hope is to ensure that we continue to address the needs of people who don’t have coverage,” Lankowicz said last year after Trump’s election. “We’re going to do everything we can to make sure that people are still cared for in a compassionate and respectful manner.”