The AHCA is supposed to come up for a vote this week. The House Republicans want a vote on Thursday as that would be seven years to the day that the ACA was signed. As of now, it looks like the GOP does not have the votes to pass it through the House. They definitely don’t have the votes to pass it through the Senate. The votes in the House might be found if the Medicaid provisions are made harsher and
shorter. And for every screw tightened on Medicaid to get a House Freedom Caucus vote, the further the bill moves away from 51 votes in the Senate.
If the AHCA is to be defeated, it will be defeated by a coalition of unanimous Democratic opposition and Republicans who face state wide electorates and know that there is value in what the ACA does. So what does a win look like if and after the AHCA is defeated?
Right now, a repeat of the Social Security strategy of 2005 of Hell NO is the Democratic Alternative makes a lot of sense. The goals of the two parties are diametrically opposed and clear partisan and policy responsibility align incentives nicely.
The Social Security strategy of 2005 of offering nothing and listening to nothing is a tempting strategy but I think it is a flawed strategy for one critical differentiation if the AHCA is defeated. In 2005 the Bush Administration did not have the legal nor administrative tools to wreck Social Security on their own. The checks were still going to be processed on time, the electronic fund transfers would still go out and the money would still be collected by the IRS. The program was on auto-pilot and immune from administrative wrecking.
The ACA is not like that. It can be administratively wrecked. The easiest way to wreck the Exchanges is for CMS to declare that they will not pay the Cost Sharing Reduction subsidies. If the CSRs are not paid, the market is empty as soon as state law allows insurers to terminate policies. No carrier would offer. The only downside to that approach to a Repeal but not Replace Republican is that there are too many bloody fingerprints on the knife. More subtle attacks include a quiet campaign of telling insurers that the mandate will not be enforced, decreased maintenance or improvements to Healthcare.gov, active advertising against enrollment and other ways of making the risk pool horrendous while highlighting the high rates that non-subsidized individuals pay to compensate for the increased variance and sicker risk pool.
The Medicaid expansion is vulnerable as well given the recent guidance that CMS will allow non-health related conditions to tie to 1115 waivers. An actively opposed CMS can significantly decrease Medicaid enrollment by encouraging work requirements, frequent re-determination, and more complex enrollment procedures.
The ACA is administratively vulnerable. It can not be killed administratively, but it can be lamed.
So the way to protect the fundamental goal of the ACA is to get the Republicans who would have voted against the AHCA onboard with modifications that make those Republicans key stakeholders and defenders of health care reform against their own party.