We're in Cassidy-Collinsville, Chapter 2

Last March, Peter Suderman wrote a clever column claiming that Republican changes to the ACA -- repeal of the individual mandate, creation of a parallel ACA-noncompliant individual market -- were achieving the goals of the ACA repeal/replace bills. I noted the missing piece there: defunding the ACA, in particular the Medicaid expansion and Medicaid more generally. That was the "hot-beating heart" of the failed Republican repeal bills. Instead of AHCA- light, I suggested:

In the aftermath of the 2017 assault, the ACA resembles not so much a system established by a mainstream Republican repeal-and-replace bill as it does the kind of compromise that might have emerged from a negotiation over the Cassidy-Collins bill introduced in January 2017, if negotiation over such a plan had been possible (it wasn't, because no more than a handful of Republicans were interested in the bill).

We're not in ACA Repeal-and-Replaceville. We're in Cassidy-Collinstown

Peter Suderman argues that The GOP Accidentally Replaced Obamacare:

Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it.

There's a good degree of truth in this. Suderman runs through the panoply of Republican legislative and administrative whacks at the ACA's structure and benefits on the federal and state level: individual mandate repeal; creation of a parallel market of non-ACA-compliant plans; regulatory hurdles to Medicaid enrollment aimed particularly at the ACA Medicaid expansion population; repeal of the Independent Payment Advisory Board for Medicare. And Suderman adds a creative future-cast twist: If Democrats take power and pursue a fully or quasi-single payer system, Republicans may end up defending the relatively moderate -- and Republican-moderated (or adulterated) -- status quo, i.e. the ACA.

Suderman's neat conceit leaves a core factor out of the equation, though: funding.

Also undead: Cassidy-Collins

Rising out of the grave with the monstrous AHCA, or at least wriggling its toes a little, is the more moderate Cassidy-Collins ACA remake bill, dubbed the Patient Freedom Act. That bill, introduced in January, preserves the ACA's funding base and allows states to maintain the Medicaid expansion and, if they wish, their ACA marketplaces in their current form.  

Back in March, in the New York Times online, I urged Senate Democrats to engage on the Cassidy-Collins, if only to shore up Republican Senate moderates in their efforts to stave off roughly matching trillion-dollar cuts to benefits and revenue. I submitted the piece on March 13, and it appeared on March 24, hours before House Republicans pulled the AHCA without a vote. When Paul Ryan declared that "Obamacare will be with us for the foreseeable future," the op-ed seemed insta-obsolete. No more.

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:

Psst, Democrats: Help Republicans out of the repeal box via Cassidy-Collins

I don't want to be prematurely optimistic, but the House ACA repeal bill, the so-called American Health Care Act, seems despised from all sides -- so much so that both Jonathan Chait and Jonathan Bernstein speculate that it's designed to fail. It's being denounced by Tea Partiers as Obamacare Lite and by progressives -- and conservatives with any commitment to extending insurance access -- as certain to un-insure millions to tens of millions of low income ACA beneficiaries.

More to the point, its release was immediately preceded by a letter to Mitch McConnell from four Republican senators in states that have expanded Medicaid -- Portman, Capito, Gardner and Murkowski -- warning that the repeal bill should provide "stability" for beneficiaries of the expansion.

Still, perceptions of the way things are likely to fall out change quickly. Leadership in both the House and Senate have declared they want to move quickly -- McConnell indicating he'd give the House bill a quick floor vote in the Senate, though later half-walking that back. Underlying the process is the enormous pressure Republicans have built under themselves over seven years to rip the ACA apart. If the bluster from the far right about faux repeal blows over, the moderates defending Medicaid could go wobbly. In fact, they've left themselves space to. Look at the language with which they've "defended" the expansion (my emphasis):

Triage, Sister Simone, triage

In a q-and-a session at Health Action 2017 last week, I suggested that Democrats might be savvy to engage with the Cassidy-Collins ACE "replacement" bill, which merely breaks the ACA's fingers rather than disemboweling it. When incoming Families USA exec director Frederick Isasi implied that this could potentially make sense, Sister Simone Campbell, a heroine of ACA passage and defense, rebuked him (and so, by proxy, me):

I have to confess, Frederick, after that great presentation I wanted to … say don’t you dare engage Collins-Cassidy because it’s based on Health Savings Accounts, and only 30 percent of our nation’s families have any savings. So let’s be real.

I don't like HSAs any more than Sister Simone does, but... I have a response up on healthinsurance.org