How Trump can still sabotage ObamaCare

After the House Republican plan to replace the Affordable Care Act collapsed under the weight of GOP infighting and the bill's own stunning unpopularity on Friday, President Trump spent the weekend blaming various people and factions for the embarrassing self-defeat: Democrats, the House Freedom Caucus, conservative groups that lined up against the American Health Care Act, and, in private and maybe cryptically on Twitter, House Speaker Paul Ryan (R-Wis.).

Trump also spelled out his Plan B on Twitter Saturday morning:

The idea that ObamaCare will "explode" or "collapse" in a "death spiral" is a popular talking point for Trump and fellow Republicans. "The worst is yet to come with ObamaCare," Ryan said on Friday, in the press conference where he admitted that Republicans didn't have the votes to topple it. "Do we try to prop it up? It is so fundamentally flawed, I don't know if that is possible." In the moments after the GOP bill failed, Trump said that "bad things are going to happen to ObamaCare" and Democrats, not him, "100 percent own it."

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The strategy — or maybe more accurately, threat — seems pretty clear: Wait for the Affordable Care Act to die, then blame Democrats. That's a risky proposition for a governing party, as The Wall Street Journal notes, and Senate Minority Leader Chuck Schumer (D-N.Y.) argued on Sunday that such a plan would "backfire" spectacularly:

But political calculus aside, ObamaCare just doesn't appear to be "collapsing" or "imploding" or "exploding." So far, despite a 22 percent average premium increase for ACA marketplace plans this year and GOP pledges to kill the law, enrollment in state and federal marketplaces was 12.2 million as of Jan. 31, a 4 percent drop from the same point in 2016. (The vast majority of marketplace customers don't feel the premium increase because of federal subsidies.)

The Congressional Budget Office, headed by a conservative economist, predicted this month that the individual health-insurance market will remain stable under current law, and other economists generally agree. The ACA is certainly not in a "death spiral," writes Matthew Fiedler, a fellow with the Center for Health Policy at the Brookings Institution, and in fact it "remains likely that insurers' individual market business will return to a roughly break-even or slightly profitable position in 2017, absent other policy changes."

In case you missed that last part about possible policy changes, Brooks Jackson at the the Annenberg Public Policy Center's fact-check site is more explicit. "Republicans repeatedly claim that ObamaCare is in a 'death spiral,' collapsing of its own weight. This is wishful thinking on their part, with little evidence to support it," he writes. "If they want it dead, they'll probably have to kill it themselves."

Even before the failure of the AHCA, Trump and Republicans had a strong motivation to want ObamaCare to collapse and die. The GOP has been predicting its inevitable demise — and actively trying to smother it — for seven years, and saving America from the "disaster" of ObamaCare was one of Trump's big campaign promises. Now, killing off ObamaCare administratively may be the only way to get rid of it, and Trump already appears to be taking that route.

Last Thursday, for example, Health and Human Services Department Inspector General Daniel Levinson informed Congress that he is investigating the Trump administration's decision to pull advertising and outreach for ObamaCare registration in the crucial final week of enrollment. And the Trump administration is now planning "to ramp up its efforts to alter the Affordable Care Act in one of the few ways it has left — by making changes to the law through waivers and rule changes," The Wall Street Journal reports. HHS Secretary Tom Price, a strident ACA critic, can take steps that "could have sweeping repercussions, accomplishing some of the same types of changes Republicans were unable to push through Congress."

"The Trump administration has a spectrum of options, ranging from actively undermining the ACA marketplaces to administrative actions that start to reshape the insurance market in a more conservative mold," Larry Levitt, a senior vice president at the Kaiser Family Foundation, tells The Wall Street Journal.

Price does face some constraints — rewriting the rules governing the ACA will require time, public comment periods, and overcoming probable lawsuits — but he has already started making changes to Medicaid, and he could eventually prune the array of essential health benefits that have to be covered under ObamaCare plans, significantly weaken the individual mandate that Americans have health insurance or pay a fine, make it harder for people to get Medicaid access, and, The Journal says, "allow an end to certain subsidies that insurers get, which could quickly cause the individual markets to crater."

The Affordable Care Act needs some changes, as everyone acknowledges, with maybe the biggest problem being dwindling competition in certain parts of certain states. Some parts of Tennessee could have no eligible insurance plans by next year. It would be better for people in the states with few choices — most of which voted for Trump — if Trump and Congress focused on solving those fixable problems.

There should be no ideological obstacle for Republicans, E.J. Dionne argues in The Washington Post, since "the Affordable Care Act is rooted in the principles and policies of RomneyCare," the free-market health-care solution enacted by 2012 Republican presidential nominee Mitt Romney. In fact, "it was an alternative to liberal calls for a government-run single-payer system," he says. Democrats can't just bask in the afterglow of TrumpCare's collapse, Dionne adds. "They will have to expose and fight any efforts by the Trump administration to sabotage the Affordable Care Act through regulation. They should propose a package of improvements to make the ACA work better and dare Trump — and the dozen or so non-right-wing Republicans who helped block the Trump-Ryan bill — to join them."

The idea that Paul Ryan would go along with Democratic proposals to fix ObamaCare is pretty far-fetched. But if Democrats could somehow convince Trump that saving the Affordable Care Act would be a big political victory, well, stranger deals have happened.