Under President-elect Donald Trump, a Republican majority in Congress says it's determined to quickly repeal and replace the Affordable Care Act, President Barack Obama's far-reaching health care overhaul. Or, perhaps not.

House Majority Leader Kevin McCarthy has gone on record saying the Congress will pass repeal and replacement by the end of February. But some Republicans have said they prefer to take more time - perhaps three years or longer - to phase in changes more gradually.

Trump himself has said he'd keep some of the more popular aspects of Obamacare, although neither he nor congressional

Republicans have yet outlined a detailed replacement strategy. And in an interview on Sunday, the president elect seemed to suggest, without giving specifics, that even more people would be able to get insurance after he takes office.

Ideas broached by Republicans have not tended to be as generous, including cutting Medicaid spending but allowing health insurers to sell policies across state lines to save costs.

The details have immense consequences for an estimated 20 million Americans now covered under Obamacare who previously did not have health insurance.

But despite votes in both the House and Senate last week smoothing the way for repeal, nothing appears more certain about Trump's health care plans than uncertainty.

"It's hard to read what he's going to do," said Joseph Casey, chief financial officer at Sturdy Memorial Hospital in Attleboro. "It's difficult to forecast."

The Affordable Care Act came into existence in 2013 with the promise of making health insurance available to millions more Americans and requiring insurers to cover pre-existing conditions. But over the past several years the system has become the subject of controversy as costs have increased and insurers have pulled out of several states.

But there seems little doubt among local health care executives and political leaders that sweeping changes being considered by the incoming administration and many in Congress are likely to have a major impact on how health care is delivered and paid for.

That includes everything from benefits and health insurance subsidies to how hospitals and other providers are paid for services they provide to the poor.

A major shift in health care policy, such as outright repeal of the ACA, could present hospitals with certain financial repercussions, for instance.

For one thing, Casey said, payments to hospitals were reduced with the introduction of Obamacare to partially offset the cost of expanding health coverage to more people. For another, the federal government significantly reduced reimbursements to hospitals for patients who could not pay as more people signed up for subsidized health insurance.

Casey says he doesn't think payments to hospitals will be raised if Obamacare is repealed, while it's more likely that additional patients unable to pay will begin showing up at emergency rooms. That means hospitals could lose additional money.

Those are just two of the complexities raised by repeal. A far bigger one is whether Massachusetts will be able to continue to deliver health coverage for virtually all residents and how it will pay for it if the federal government drastically reduces its commitment.

Massachusetts pioneered the concept of universal health care by adopting its own Commonwealth Care plan in 2006, a development that eventually served as the model for Obamacare. A number of changes were required when the national Affordable Care Act was adopted in 2013, and the state continues to operate its program under a waiver.

But Massachusetts' Medicaid-funded program, like those of all other states, is dependent on funding both from the state and federal governments under a partnership arrangement. About $9 billion of the $15 million cost of Massachusetts' Medicaid comes from federal coffers.

A reduction in federal Medicaid funds as advocated by congressional Republicans theoretically would force states to come up with more money or cut back on their programs.

U.S. Rep. Joseph Kennedy III said any move to repeal Obamacare without a workable replacement is "beyond irresponsible" and could potentially bankrupt hospitals and health care systems.

"To have people who are struggling to get access to health care and, on the strength of an empty political promise to take that away without any idea about how we're going to replace it is beyond irresponsible, it's just mean," he said.

Kennedy said some estimates indicate as many as 20 million to 30 million Americans could lose health insurance under repeal.

In the Bay State, health care advocates and politicians, including Republican Gov. Charlie Baker, have re-stated their commitment to continuing expanded health care coverage, regardless of what the federal government does.

"We need to do what ever we can to ensure that those already enrolled can continue to have coverage and to avoid confusion," said Eric Linzer of the Massachusetts Association of Health Plans.

He also said major changes such as a replacement of Obamacare should come with a reasonable phase-in period to ensure an orderly transition and avoid destabilizing health care markets.

The state's doctors have also been vocal on the repeal issue.

The Massachusetts Medical Society has joined 20 other groups representing health care providers, insurers and advocates to form a coalition to preserve as much as possible the near-universal health care model in Massachusetts.

"It's taken us 10 years to get where we are," said medical society President Dr. James Gessner, who noted Massachusetts has the lowest percentage of uninsured residents in the country. "I don't think anyone wants to backslide on that."

According to a recent report, only 2.8 percent of Massachusetts residents are without health insurance, compared with 9.8 percent nationwide.

Gessner said certain aspects of the current health care system, such as ballooning premiums for certain users, are in need of attention. But he said the system has been effective at covering the greatest number of people and that on the whole costs, while increasing, have been proportional to the increase in the number of subscribers.

Gessner said he has his doubts about a quick repeal and replacement of Obamacare, noting that many states that have expanded health care coverage under the Affordable Care Act are represented by Republican congressmen who will have to answer to the voters.

"A lot of people who will be losing their coverage (under repeal) aren't going to be happy about that," he said.

The Massachusetts Health and Hospitals Association, which represents hospitals and health care providers, also says it is "strongly opposed" to repeal of the Affordable Care Act, said President and CEO Lynn Nicholas.

"The ACA has changed the way we deliver health care and, either directly or indirectly, has led to improvements in access and quality for everyone," she said in a statement.

Despite the specter of replacement and repeal, Obamacare remains highly popular in Massachusetts where the number of applicants continues to climb. As of November, membership in subsidized health care plans stood at 233,000, according to the website healthinsurance.org, which also said that the 23,000 people who selected coverage for 2017 was more than double the number of early enrollments in 2016.

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