When a patient shows up to the emergency room needing immediate life-saving surgery, they are going to receive treatment whether they have insurance or not. With both Congress and the White House pushing for repeal of the Affordable Care Act, hospital administrators are telling lawmakers they will need to restore billions of dollars a year in federal funding to hospitals to cover the costs of treating uninsured and low-income patients.

Under the ACA, the federal government slashed “disproportionate share payments” — funds provided to certain hospitals to offset some of the cost of caring for patients who can not afford to pay. The idea is that, because the ACA requires most people to have some sort of health insurance, hospitals will be treating more paying patients.

The law has resulted in some 22 million Americans obtaining insurance they would likely not have been able to get otherwise, but a recent analysis of a Republican ACA repeal plan found that nearly that many people would go back to being uninsured within a year after repeal.

The Wall Street Journal reports that hospitals are worried that a repeal of the ACA that does not restore these and other federal funds would leave care providers on the hook.

“If you’re going to repeal the Affordable Care Act, we need to have the cuts repealed as well,” said the CEO of Tennessee-based hospital operator LifePoint at a recent conference.

In a letter [PDF] sent last week, the American Hospital Association tried to impress upon President Trump the importance of continuity of coverage.

“If the ACA is to be repealed, the potential repeal and replace should be done simultaneously, and ensure that the 22 million people receiving coverage continue to receive adequate coverage,” reads the letter. “If repeal and replace cannot be accomplished simultaneously, the reductions to
hospitals and health systems included in the ACA should be restored to ensure there are sufficient resources to provide care to the uninsured.”

Neither Congress nor the Trump administration has released any details of what an ACA replacement would look like. The 2015 repeal bill that made it all the way to President Obama’s desk before being vetoed did not have include any plan for an Obamacare substitute. The author of that legislation was Rep. Tom Price (GA), who is currently awaiting confirmation as the next Health and Human Services Secretary.

Hospital administrators say the level of uncertainty involved with ACA repeal and replacement is a big cause of concern.

“Until they have a good replacement, and all they can really do is repeal or partially repeal,” the head of one Missouri nonprofit hospital chain tells the Journal, “it makes us very worried on the coverage front and on the financial front.”

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