For now, the ACA lives on.  But destruction of the program — even without legislation — can still be inflicted. Here’s how the Trump administration can mortally wound health care reform.

• Kill Cost Sharing Subsidies: In 2014, House Republicans challenged the legality of the cost-sharing subsidies. These subsidies are critical to help people who make less than 250 percent of the federal poverty level purchase insurance in the marketplace. People at this income level are usually working but not making enough to afford insurance premiums. A lower court sided with Republicans and the Obama administration appealed. If the new administration drops the appeal and subsidies end, many people — especially the healthiest people — would drop out. That could be a death knell for the marketplace. Remember, most of the people on the marketplace are eligible for these subsidies.

• End the Individual Mandate: If, as promised, the Trump administration does not collect information about whether people purchase insurance, as the individual mandate requires, expect real problems. The mandate is essential to creating a wide-range of people in the insurance pool — young, old, sick, healthy. That’s how insurance works. But without enforcement of the mandate, the people with the highest health care needs are the ones most likely to purchase insurance. Younger and healthier people may choose to “go bare.” The result? Spiraling premiums that would make insurance through the ACA unaffordable.

• Reduce Predictability and Clarity: Insurance is the business of predicting risks and charging premiums to cover that risk. Insurers need predictability and clarity —both now in short supply.  Conflicting statements from the Administration about its intentions with the ACA means insurers will hedge their bets, and hike premiums to cover the costs of this uncertainty. Who will remain in the marketplace as premiums rise and mandates aren’t enforced? Only those with the highest health care needs.

I believe there’s a reason all of the Democrats and four out of five of the Republicans in the New Jersey delegation were ready to vote against the Trump administration’s American Health Care Act (AHCA). That plan would have allowed the sale of plans that cherry pick the younger and healthier — a back door way to allow insurers to price insurance based on gender and pre-existing conditions.

In New Jersey, we did not allow this kind of coverage even before the ACA. We all lose if only younger people or men or the healthiest among us can obtain affordable insurance.  We all lose if people skip screenings for curable cancers or don’t receive the prenatal care crucial to healthier pregnancies and babies. We all lose if women fail to refill birth control prescriptions that reduce unplanned pregnancies, or if people avoid treatment for substance abuse. Luckily the AHCA, which proposed nothing to improve health care delivery or reduce costs of care, was pulled from consideration. But the move to repeal the ACA is continuing.

Most people in NJ do not want to see the 750,000 newly insured folks in our state suddenly lose their coverage. What would happen to the breast cancer patient halfway through her chemotherapy? Or the teenager with Type 1 diabetes who needs insulin shots to survive?

In New Jersey, we have a history of protecting consumers with preexisting conditions and limiting the ability of insurers to insure only the healthiest people. We found a way to expand coverage and use funds to help more people obtain health insurance.

As we follow the changes in Washington we also must begin, now, to work on state solutions. I do not suggest the answers are easy. But already the Quality Institute, along with political leaders on both sides of the aisle, is working to find sensible solutions. We have no time to waste.