Trump threatens ACA marketplace collapse and nuclear blame war

In one sense, it may have been the worst-timed op-ed of all time. I argued in a piece published in the online NYT yesterday (submitted back on March 13!) that Senate Democrats should engage with sponsors of the Cassidy-Collins ACA reform bill to shore up Republican moderates who I thought likely to ultimately pass some lightly sanded version of the AHCA, or otherwise act to eviscerate Medicaid in particular.

While there was obviously a good chance the AHCA would not pass the House this week, I never dreamed the Republicans would simply give up for the present. For me the truly astonishing moment was when I saw Ryan quoted on Twitter saying "“We’re going to be living with Obamacare for the foreseeable future,”

That's the Trump factor. Just as he swung wildly and obliviously into the Freedom Caucus camp to allow them to pull any fig leaves of rationality from the AHCA, when thwarted he swung wildly back to call off the whole thing.

But it's that very swing that leaves my core point relevant: Democrats still need to find a way to win a measure of Republican buy-in to the ACA, because the Trump administration can kill it administratively -- swiftly or slowly, subtly or obviously. That goes in part for Medicaid, via a rush of work requirements and administrative harassment, as well as for the marketplace, which can be destroyed at a stroke by stopping CSR payments or by a host of more gradual means, already begun, nicely chronicled by Dan Diamond.

That's where Trump's at just now.  Check out last night's insanity:

“... Obamacare is in for some rough days. You understand that. It’s in for some rough, rough days,” Trump said.

“I’ll fix it as it explodes,” he said. “They’re going to come to ask for help. They’re going to have to. Here’s the good news: Health care is now totally the property of the Democrats.”

Speaking of premium increases, Trump said: “When people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”

He returned again to a partisan line on the turn of events.

“To be honest, the biggest losers today are Nancy Pelosi and Chuck Schumer,” Trump said of the House minority leader and the Senate minority leader. “Because now they own the disaster known as Obamacare.”

Trump may lose the nuclear blame war he's threatening here. But it's wholly within his power to trigger it.  Democrats don't need to engage with the Cassidy-Collins bill just now, because there's no worse legislative alternative to stave off. But they do need to find a way to buy some Republican willingness to make the ACA marketplace function-- something to trade for, say, the stability fund that was in the AHCA -- or at a minimum, enforcement of the individual mandate and a measure of good-faith outreach to prospective enrollees. Loosening up the ACA innovation waiver process may be a good way to do it.

An out-take from my NYT piece elaborates on the part that I think remains valid, leaving aside for the time being the endnote on Cassidy Collins. Signing off with this:
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While an enacted compromise may seem an impossible dream at this point, ultimately Democrats need a healthcare truce as much as Republicans do. Last April, some months before he withdrew Aetna from most of the ACA marketplaces in which had participated in 2016, CEO Mark Bertolini said this about the marketplace:

we see this as a good investment, hoping that we have an administration and a Congress that will allow us to change the product like we change Medicare every year, and we change Medicaid every year.

But we haven't been able to touch this product because of the politics. But if we can get to that point, we believe we are in a very good place to make this a sustainable program.

No federal benefits program -- not Medicare, not Medicaid, not the marketplace -- can thrive without constant adjustment, from administrators and legislators. Since inception, the ACA marketplace has been denied such essential adjustment, and has in fact had to withstand outright sabotage from Republicans -- who threw up hurdles to the training of enrollment counselors, undercut funding for a crucial risk adjustment program, and refused to fix obvious flaws, such as the so-called "family glitch" that renders many whose employers offer family coverage they find unaffordable ineligible for marketplace subsidies.

So both sides need a deal.  The PFA, with its bifurcated program choice masking essentially unlimited program design options, could be the basis of one. Democrats should treat it as such..