So now what?
That is a hell of a question but I think the right way to start probing towards some of boundaries of the possibility space is to ask what happened.
As I see it, the winning coalition that blocked the bill was a combination of unanimous Democratic opposition plus state level Republicans who actually have to balance a state budget and deal with real issues plus Republicans in districts that make them inherently vulnerable during a mid-term swing against the incumbent party plus the reactionaries of the House Freedom Caucus. We were also aided by the ineptitude of the
wank “wonk” Paul Ryan and his coterie of enablers.
We told our stories. We mobilized. We stiffened the spine of Democrats whose spines probably did not need much stiffening. We put the fear of god into vulnerable Republicans. We scared the people who have to balance a state budget. We had on our side almost all of the interest groups that had bought into the ACA — doctors, insurers, hospitals, big drug makers and everyone else that gave a bit to get a bit. The only people who were not aghast at the AHCA were high income tax cut fanatics and policy illiterate decision makers.
We had a huge and unusual coalition pushing back against a bum’s rush. Most of this coalition was assembled in 2009 and 2010 to push the ACA through. And it was re-activated days after the election as everyone recovered from their shock, dismay and hangovers. Any time something changed, wonks were ripping through the documenation and making fast, rough and directionally right analysis with maps, figures, graphs and other hooks to allow advocates to tell personal, powerful stories that landed. And we kept on iterating powerful and emotionally connecting truth on every iteration of the bill.
We won. And our win helps our community:
Does it mean I finally can breathe again? That my health care won’t be pulled in a matter of weeks or months, on the eve of my starting biologic therapy for my Crohn’s?
This is why we fight. We’re not going to win every time. But we have to fight for conceding defeat and defeatism without making an effort means throwing ArchTeryx and others to the dogs. We’re not going to win every time, but we need to fight for both the chance to win as we did this week and to be able to look at our friends, our countrymen and ourselves with honesty as we say that we are doing everything that we can. We will need that for immigration. We will need that for global warming. We need that for our LBG and especially T allies. We might not win every time, but we can mitigate some damage, impose some delay, inflict some cost, and build effective coalitions for future action and progress every time that we hold to our values and our ideals.
So what does this mean for policy? The fear is that the ACA is here, but that the Trump Administration will sabotage it. This is a real fear, and it is one that the coalition that won this week will need to be engaged on to protect the implementation of the ACA.
There is only one completely destructive threat. The cost sharing reduction (CSR) subsidies are in limbo. They were paid for March but they could disappear at any time due to a re-interpretation of HHS legal guidance. If they go, the exchanges go as insurers are allowed to run and they will run if they are forced to pick up another 20% of actuarial value without compensation. It is a guaranteed money loser. There should be two objectives. First, a single page bill to transform CSR from discretionary to mandatory spending should be filed as the price of any Democratic support for a continuing resolution or debt ceiling increase. Secondly, every ACA-defending wonk and advocate needs to be screaming loud and clear that the CSR decision is completely a discretionary Republican decision to sabotage the Exchanges.
Essential Health Benefits and contraception coverage are vulnerable to rule making. They can be trimmed or cost-sharing free contraception may be eliminated but the lawyers can tie up decision making for quite a while.
Non-enforcement of the mandate should be priced into the premiums that insurers submit this spring. It will be pain that is borne by the non-subsidized buyers but subsidized buyers are protected. Insurers should also assume there will be no advertising campaign by Healthcare.gov and price appropriately as well as fund advertising. Ads work.
Really bad Medicaid waivers will be approved. Bad ones should be fought. But at the same time, if a Trump Administration approving an Indiana like waiver is what it takes for Florida, Georgia, North Carolina, Texas or any other hold-out state from expanding, the net good of a bad expansion easily, in my moral universe, outweighs the benefits of holding out for a no strings attached expansion in 2021 or later.
We will need to fight and be aware of sabotage but the ACA is structurally hard to knock down with the exception of the CSR risk.