5 takeaways from the demise of the AHCA

President Donald Trump's decision last Friday to scrap the American Health Care Act ahead of a House vote sent some Republican lawmakers reeling, while Democrats celebrated the survival of the ACA. Though only a few days have passed, key lessons from the failure of the AHCA have already emerged, according to a recent Health Affairs blog by Billy Wynne, managing partner of TRP Health Policy.

Here are five takeaways from the fall of the AHCA.

1. There's no such thing as a sure thing. President Trump's vow to take down the ACA was a cornerstone of his campaign, and upon his election he promised to repeal the law "right out of the gate."

"Decisions have been made by the President-elect that he wants to focus out of the gate on repealing Obamacare and beginning the process of replacing Obamacare with the kind of free market solutions that he campaigned on," Vice President Mike Pence said on Fox News Nov. 20.

However, there is a difference between making a political statement and actually changing policy. Republican lawmakers sought to take down the ACA with haste, but creating new healthcare reform that would protect Americans' coverage gains and stabilize the markets "is invariably complex and time-consuming, creating vulnerabilities and pitfalls both known and unknown at the outset," Mr. Wynne wrote.

2. Don't underestimate the power of stakeholders. Nearly every hospital and hospital group, physician association and patient advocacy group opposed the AHCA. Republican governors of states that expanded Medicaid also opposed the bill, saying a Medicaid expansion freeze would harm residents and shift significant costs to states.

While lawmakers worked to repeal the ACA anyway, stakeholders took to town halls, made phone calls and wrote letters and tweets to voice their opposition. On the day the AHCA was originally supposed to be voted on in the House, a Quinnipiac University poll found only 17 percent of the public supported the bill and 56 percent opposed it. By the time Congressional Republicans began to take stock of stakeholders' concerns, it was too late, according to Mr. Wynne.

3. The ACA is more conservative than its critics believe. "While it was lambasted by Republicans as the manifestation of a Marxist dystopia, the truth of the ACA is that it is a very moderate law," Mr. Wynne wrote. Before he was even elected, former President Barack Obama in 2008 negotiated with Republican counterparts and convened bipartisan summits to query experts and debate ideas on healthcare reform, according to Mr. Wynne.

Although Republicans "eventually defected from the cause," the resulting legislation included a number of traditionally conservative strategies, such as tax credits for the purchase of commercial — not government — health plans, with the individual mandate ensuring enough people would buy in. This had been central to many other Republican healthcare reform proposals in the past.  

Other key conservative ideas in the ACA include price and value transparency to guide consumers' choice when selecting a health plan; greater emphasis on prevention and community health centers; and the ability for states to run their own exchanges and determine their own essential health benefits, among others.

4. Tom Price may be the most powerful man in healthcare. The Trump administration has promised that the ACA will "explode" or collapse under its own weight. By the forces of sabotage or neglect, that could happen, according to Mr. Wynne. HHS Secretary Tom Price, MD, is in control of that power.

Dr. Price has enacted several simple maneuvers that have already created measurable effects. For example, reduced publicity for HealthCare.gov and creating an aura of uncertainty about the future of the ACA can lead to lower enrollment rates. Value-based payment systems that are intended to improve quality and lower costs have been suspended, and governors have been informed that they have the right to impose cost-sharing and premiums on Medicaid beneficiaries.

While these changes can have broad effects, they are minimal to "some of the more nuclear options" Dr. Price has at his disposal, such as the option to cease from defending the cost-sharing subsidies under the ACA, according to Mr. Wynne.

5. Bipartisanship remains a possibility. "There really is a better way, and it's for both parties to come together to forge durable improvements to our health care system," Mr. Wynne wrote. "While not as expedient or gratifying to the inner ideologue inside us all, the long, frustrating work of compromise is the only viable path forward."

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