A health care lawyer who has advised the Clinton Foundation on legal issues says many factors could affect just how much Republicans really change the U.S. health care system in the next few years, and how quickly any changes made actually occur.

Richard Zall, chair of the health care practice at New York City-based Proskauer Rose LLP, talked about some of the forces that could moderate the winds of health care system change in a recent interview.

Zall once ran a company that helped hospitals and medical group practices share health risk with health plans. He now focuses mainly on offering clients regulatory compliance advice, and on representing health care companies and investors in corporate transactions, such as joint ventures.

Since 2003, he has been helping the Clinton Foundation with the legal work needed to do things like make low-cost prescription drugs available in poor countries.

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Zall said he thinks one force that could shape U.S. health policy discussions over the next few years is leading Republicans’ realization that Democrats’ lack of support from Republicans for the Affordable Care Act caused problems.

The message to Republicans is, if Republicans simply repeal the ACA without providing an adequate replacement, and without some Democratic support, “you’re going to own this thing,” Zall said. “You own all the consequences.”

Many Republicans seem to want to find a solution that will keep poor people and sick people from falling through coverage holes, Zall said.

For a look at three other forces of policy friction that Zall sees affecting efforts to repeal and replace the ACA, read on:

Some elected officials leading the charge to repeal 'Obamacare' may not fully recognize all the legislative steps involved, Zall said.

Some elected officials leadng the charge to repeal “Obamacare” may not fully recognize all the legislative steps involved, health care lawyer Richard Zall said.

1. Non-Obamacare ACA provisions

Most Republicans who have talked about repealing the health law have talked about ”repealing Obamacare,” and not about repealing “the Affordable Care Act,” or repealing the ”Patient Protection and Affordable Care Act of 2010″ and the “Health Care Education and Reconciliation Act of 2010,” the two acts that make up the ACA statutory package.

Many large parts of the ACA have nothing to do with the health insurance exchange system, the employer coverage mandate, the individual mandate, or restrictions on health insurance underwriting, product design or other matters typically associated with the term “Obamacare.”

Zall said that he has heard few complaints about many major sections of the ACA, such as the provisions that expanded support for medical professional training programs, and that he has heard little talk about some other, insurance-related sections of the law, such as the sections that set standards for programs that resolve disputes between patients and health plans.

Once Republicans are in a position to get some kind of ACA-shaping legislation through Congress, they may end up passing legislation that revamps the ACA, rather than repealing and replacing the entire law, to avoid disrupting the provisions that have been well-accepted, Zall said.

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Vice President-elect Mike Pence comes from a state that accepted ACA expansion funds. (Photo: AP Images)

Vice President-elect Mike Pence comes from a state that accepted ACA expansion funds. (AP Photo)

2. Medicaid expansion

Zall noted that Mike Pence, the president-elect, has been the governor of Indiana, a state that negotiated a ”waiver program,” or adjustment to the standard Medicaid rules, and accepted Affordable Care Act Medicaid expansion money.

Some other states led by Republicans also took Medicaid expansion money, and most hospitals like the Medicaid expansion program, Zall said.

Hospitals may persuade Republicans to make the Medicaid expansion program more flexible, and more open to letting states use mechanisms such as co-payment requirements to hold down spending, rather than simply returning Medicaid to where it was in 2010, Zall said.

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Health care policy attorney Richard Zall said he's getting many questions about what will change as a result of the Nov. 8 election.

Health care policy attorney Richard Zall said he’s getting many questions about what will change as a result of the Nov. 8 election. Vice President-elect Mike Pence has already promised a “tsunami of legislation” in the new administration’s first 100 days. (Photo: iStock)

3. The high cost of care

Zall said the most important force for stability is that the underlying forces driving up health care costs, and system players’ focus on controlling costs.

The forces pushing the players to consider strategies such as population health management techniques “are as strong today as they were the day Barack Obama was inaugurated,” Zall said. ”The beat marches on.”

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