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Could a Health Care Victory Emerge from the Jaws of Defeat?

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The Trump administration’s brief, ill-fated effort to repeal the Affordable Care Act came to an abrupt end Friday following the demise of the Republican replacement plan in the House. But for all the rancor that has tarred Obamacare since it became law in 2010, the path forward suggests a bipartisan opportunity for Congress and the White House to improve current law.

President Trump, for his part, didn’t sound in a forgiving mood immediately following defeat. He blamed Democrats late Friday for undermining the Republican plan, the American Health Care Act (AHCA), and over the weekend he lashed out via Twitter against the Freedom Caucus, the group of ultra-conservative House Republicans whose opposition doomed the bill.

The AHCA was never a good fit for Trump, the famously non-ideological leader who ardently opposed Obamacare as a candidate but also promised “insurance for everybody” while pledging to preserve Medicare, Medicaid and Social Security. The Obamacare replacement bill, championed by Speaker Paul Ryan, fell well short of those promises: the Congressional Budget Office estimated that it would have insured 24 million fewer people than Obamacare over 10 years, and the bill would have enabled states to convert Medicaid into a block grant program.

Then there was the almost total lack of support for the bill from major health care stakeholders including insurers, hospitals and providers – not to mention seniors and patient groups. A Kaiser Family Foundation poll fielded in the days after the bill’s unveiling found a surprising level of public concern, even before the CBO’s harsh assessment.

Even so, Trump announced his full support for the bill, imploring conservatives to support it. But Trump also suggested that rather than repeal Obamacare, Republicans should allow Obamacare to fail – and bring Democrats down with it. He reiterated those sentiments Friday, saying his administration would move on from health care and allow Obamacare to “explode.”

Obamacare is on sturdier footing than Republicans describe, according to the CBO, but Trump and the GOP could weaken the law by refusing to enforce its less popular provisions, namely the individual mandate, and starving it of federal funds. Such a gambit would have enormous political consequences if the administration’s actions make insurance harder to afford for people with serious health conditions.

The better option, as some Republicans have already pointed out, would be to work with Democrats on fixes that make the existing health insurance market more sustainable. For all of his frustration on Friday, Trump essentially forecast this outcome when he dared Democrats to come to him with their reform proposals. Republicans assert that Obamacare is beyond repair, but Democrats aren’t about to trash the law they worked so hard to pass and have gone to great lengths to protect. Any negotiation between Democrats and Trump would surely focus on improving, rather than replacing, current law.

The uncertain path forward leaves the major health care industries in a bind. None of them has an interest in watching the current system deteriorate, but efforts to mend the law may be rejected by a White House still licking its wounds from the repeal effort. Perhaps the best way to proceed is to take a page out of Trump’s book and talk directly to voters about what’s at stake for them. In health care, perhaps more than any other issue, direct communication to the public with clear, simple messaging is critical. The Obama administration, by its own admission, failed to adequately explain the benefits of the Affordable Care Act to voters. Republicans didn’t do any better selling their plan, given its unpopularity leading up to its collapse.

Trump now knows the political perils of health care reform first-hand, and that’s likely why he’s set against going down that road again without Democratic support. But he also must know that he can’t let Obamacare crash while the people benefiting from it – who are disproportionately represented by the white working-class voters who elected him – suffer.

Intra-party divisions within the GOP doomed the AHCA, but if the result is that Trump somehow forges a productive working relationship with Democrats to strengthen the current health insurance market, he will have won by losing.

Steve Weiss is a senior vice president, Health, Washington D.C.

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