Guaranteeing everyone coverage, regardless of their health, without requiring everyone to participate will only guarantee one thing — the collapse of the insurance market. The healthy will leave and the sick will stay.

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MORE than six years ago, Washington state fully embraced the Affordable Care Act (ACA) and the benefits have been profound. The number of people without health insurance has dropped from nearly a million to under 500,000. Before the ACA, people buying their own plans couldn’t get maternity or prescription-drug coverage. Now they can.

More than 600,000 people also gained coverage through an expansion of Medicaid — more than double the amount predicted. The money spent on uncompensated care in our state has plummeted from $2.3 billion to $1.2 billion. And our friends and neighbors struggling with an illness can no longer be denied health insurance.

Since its passage, Congress has voted more than 60 times to repeal the entire law. It has never voted to amend or repair it nor proposed a replacement.

For years, we’ve heard the Republican mantra “repeal and replace.” Now, with the recent election, they get their chance.

President-elect Donald Trump has said he likes popular parts of the ACA, such as children up to age 26 being allowed to stay on their parents’ health insurance and preventing people from being denied coverage if they have a pre-existing condition. He also supports allowing health insurers to sell across state lines and abandoning the mandate to buy insurance.

If there’s one thing insurers hate, it’s uncertainty. Insurance is the business of predicting risk. You need to know whom you’re covering to predict how much you’ll pay out in claims.

Guaranteeing everyone coverage, regardless of their health, without requiring everyone to participate would guarantee only one thing — the collapse of the insurance market. The healthy would leave and the sick would stay.

We should know. Washington state tried this back in the 1990s, and it failed. We passed the Health Services Act of 1993, which included a mandate and guaranteed coverage. Two years later, the Republican-controlled Legislature repealed the mandate. By 1999, there were no insurers left, and you could not buy an individual health plan in our state.

The basic principal of health insurance is this: It works best when everyone participates — the young and the old, the healthy and the sick.

This is not politics; it is how insurance works.

So why not allow insurers to sell their plans in any state they like? The ACA already allows this, but only when reasonable conditions are met. It requires uniform consumer-protection standards and states must actually agree to participate. The Republican proposal allows any state to sell its plans anywhere, without permission, and the consumer’s home-state protections would no longer apply. Insurers would be drawn to the state with the least regulation and consumer protections.

Also, it’s highly unlikely that insurers’ interest in this concept would grow for one reason: They cannot build provider networks. Out-of-state insurers do not have the bargaining power they need to build a cost-effective network, and without this they simply cannot compete.

I’ve spent most of my career working to reform health care and improve the lives of the consumers I serve. The ACA was just the first step to fixing what’s wrong with our system. No major policy change is ever perfect right away. It takes revisions and compromise to get it right. So far, the proposals being considered are recycled ideas of the past. They are not a panacea or even a fair promise of relief.

If the new administration is serious about addressing the rising costs of health care, it should start by looking at what Kaiser Health found in its recent research on what the public thinks the top health-care priorities for the next president and Congress should be — only 37 percent of people support repealing the ACA. Instead, 72 percent want high-cost prescription drugs to be available to people who need them and 63 percent support government action to lower drug costs.

We’ll know over the next several weeks what other options the new administration is considering. But it is already clear what’s at stake. Repealing the ACA without a viable, meaningful replacement is not just a disaster, it’s a death sentence for many.

Depending on the direction taken, I promise to do what we can at the state level to retain the reforms we know have made our communities and our lives better.