If Republicans win it all, what will they do to the ACA?

I want to make a foray into reporting and ask some healthcare wonks what they think Republicans will do to the Affordable Care Act if they win both houses of Congress and the presidency by 2016.

While Republicans gleefully anticipate the ACA's implosion, ACA supporters assure themselves that repeal is a dead dream, as the ACA has already provided insurance to millions and rewritten coverage rules (e.g., guaranteed issue) in ways that will be impossible to take away. That may be true. But it does seem to me that Republicans in control of Congress and the presidency could ruin the law without repealing it outright.  They could do so out of a combination of antipathy to a law that (colloquially) bears Obama's name and sincere belief in principles such as consumer choice and deregulation.

Will red states stonewalling the ACA pay for self-inflicted punishment?

The long-term effects of the Affordable Care Act that everyone should ardently wish for are 1) access for all Americans to affordable, adequate health insurance and 2) reduced or reversed health care inflation.

Republican governors and/or state legislatures determined to sabotage the law are causing needless suffering, by denying millions the access to Medicaid the law was designed to provide, and by refusing to run the private insurance marketplaces, forcing the federal government to operate them in 34 states, with so-far disastrous results. State-level stonewalling goes beyond refusal to build a website: it also means abjuring the responsibility both to entice insurers into the exchanges and to impose discipline on those that participate, via state adaptation of the federal coverage guidelines, and by working to prevent adverse selection in the exchanges through state regulation of the individual market outside them.

No real good can come of deliberate misgovernance. But its consequences may trigger self-correction over time. States that try to make the law work may emerge as better places to live than states that don't -- offering Medicaid to the lowest-income adults, and a competitive, well-regulated and subsidized market to those with modest incomes. That creates a range of economic freedoms -- to leave a full-time job to start a business or go to school, to go from full- to part-time to do either, or undertake the kind of de facto apprenticeships that a career change often requires, or care for a sick parent.

On the most basic level, Donald Taylor points out that the states refusing Medicaid expansion are effecting a wealth transfer to states that embrace it:

Medicare for all, or Obamacare for seniors? Or both?

Many have noted that the Medicare reform plan included in Paul Ryan's 2012 budget, though sketchy in detail, looked a lot like Obamacare for seniors plus a public option -- the public option being traditional Medicare, which would compete with private plans on an ACA-like exchange.  Throughout the presidential campaign, Ryan emphasized that his plan would not affect current seniors, only kicking in for those under 55 when the plan was enacted.

This year, to meet the GOP target of balancing the federal budget within ten years, Ryan is reportedly planning to move the migration age up.

That possibility has led Avik Roy, the most vocal spox for conservative health reform ideas, to stop worrying, love the ACA, and envision its fusion with Ryancare:

There has been an important development since last year’s House budget: the reelection of President Obama. Obama’s victory means that Obamacare will be implemented, warts and all, making it politically impossible to repeal, even if Republicans are fortunate enough to retake Washington in 2017.