How Democrats might lose the ACA insta-repeal battle and win the war

In the interview I posted last week with Chris Condeluci, who was counsel to Republicans on the Senate Finance Committee when the ACA was being drafted,  I foregrounded the most urgent point at present: ACA proponents have a very short window to deter lightning passage of a repeal-and-delay bill, and at least a handful of Republican senators may be responsive to pressure and balk at repeal with no replacement. Three defections would kill insta-repeal, if Democrats hold together.

I think this possibility has been underplayed. 21 Republican senators are in states that have enacted the Medicaid expansion, and many of those states have slashed their uninsurance rates by 40% or more.

Still, odds are probably that Republicans will go through with a repeal-and-delay, in which they preserve the ACA Medicaid expansion and marketplace subsidies for at least 2-3 years while they allegedly craft a replacement plan.

If that's the case, there's still a high-stakes battle to be fought. Its outline can be discerned in the detailed options menu Condeluci laid out for Republicans (or their aides) racing to draft a repeal bill. Since that interesting material was buried rather deep in the prior post, I've reposted it below.

The sticking point (to my mind) is whether repeal of the taxes that largely fund ACA benefits is delayed along with repeal of the benefits. If not, the Medicaid expansion is probably dead, along with marketplace subsidies that make coverage affordable for lower-income buyers. The negotiations with Democrats over a replacement bill that Condeluci envisions are really only possible if substantial tax revenue is still coming in.

#NoRepealWithoutReplace: Tweet to save the ACA

A quick review of the cliff's edge the ACA is up against -- and (perhaps) how to back off it:

1. Republicans are vowing to use budget reconciliation to repeal the core elements of the ACA by February, delaying the defunding of some or all benefits for 2-3 years while they allegedly craft and enact a replacement..

2. As Republicans will have a 52-48 majority in the 115th Congress, insta-repeal can be stopped if three or more Republican senators balk at repeal-and-delay, calling instead for simultaneous repeal-and-replace (none of them will take a stand outright for preserving and amending the ACA).

3. Eighteen Republican senators represent states that have enacted the ACA's Medicaid expansion, which has by itself cut the ranks of the uninsured by about 20% nationwide -- and by more than that in many expansion states.

The ACA's fate may be determined this week

While Republicans have made amply clear their intention to swiftly pass an ACA repeal-and-delay bill in early 2017, it seems to me that a few facts about this looming prospect have not fully sunk in.

The first is that success is not a foregone conclusion. If three Republican senators balk at ripping up the ACA without a replacement in hand -- or at least, without a clear blueprint of how to get to replacement without throwing the individual market for health insurance into turmoil -- then the process slows, and the damage may be mitigated or avoided entirely.

Second, Republicans will never pass "repeal" and "replace" together -- unless perhaps they win 60 senate seats in 2018. Repeal-and-delay is their only option for delivering on their promises.

Third,  the time to stop the train is now -- in the coming week, between Christmas and New Year's, when senators and members of Congress will be home. The ACA had its long hot summer of rabid town halls, demonstration and counter-demonstration. ACA repeal gets a cold short week. And a lot of action is in planning.

These rather basic points were confirmed to me by Christopher Condeluci, a healthcare consultant who was tax and benefits counsel to Republicans on the Senate Finance Committee in 2009, when the ACA was being drafted.

Hmmmm...Team Trump queasy about ACA insta-repeal?

I credit nothing said by Team Trump...but this does not sound like ACA repeal:

“The enrollment numbers announced today show just how important health care coverage is to millions of Americans,” said Phillip J. Blando, a spokesman for the Trump transition team. “The Trump administration will work closely with Congress, governors, patients, doctors and other stakeholders to fix the Affordable Care Act’s well-documented flaws and provide consumers with stable and predictable health plan choices.”