Mitch McConnell” by Gage Skidmore

July 19, 2017; Newsmax

Many have spent the last few days wrapping themselves in a kind of happy blanket as the GOP repeal-and-replace bill has been facing the Great Unknown in a way we can only liken to one of those extended death scenes in a bad western. Indeed, even as we write this, President Trump has ordered everyone back to their rooms to finish the work of at least repealing, if not replacing, despite the fact that the prospect appears like it would be lucky to garner even forty votes. As they trudged obediently back, he tweeted:

Oh, yes, he did!

Some have celebrated as if this were a defeat not just of the health care bill, but of the GOP and the Trump presidency. “The stunning collapse of Obamacare on Tuesday forced Republicans to confront a sobering reality: Their party and agenda are in a deep hole, and it’s not going to be easy to get out,” Peter Sullivan of The Hill wrote. But not everyone sees such a disaster. For instance, the Kaiser Family Foundation’s Drew Altman is of a different opinion, soberly writing in Axios that the defeat of Obamacare was rated, in terms of importance to GOP voters, behind the general direction of the country, jobs and the economy, and the personal traits of Hillary Clinton.

“Republicans don’t like the ACA, and there is no doubt voting for repeal would be a real plus with the Republican base as well as with big campaign contributors,” Altman wrote. “But the assumption that Republicans will be punished if they fail to repeal the law is a different thing altogether; it has become unexamined conventional wisdom. Republican voters have other things on their minds that matter to them more than healthcare.”

The next election is not until 2018, and the agenda could switch to taxes or a foreign conflict or the Trump administration’s continuing problems. In fact, the one thing most likely to keep the ACA on the agenda now would be an effort by the administration to undermine it, and it’s far from clear who benefits and loses politically from that.

This is, in fact, is the most frightening immediate prospect—that the administration and some in the GOP would set their sights on forcing the health system into profound failure just to prove a point. While we would like to believe that this is beneath our congresspersons and certainly our president, many seem to be anticipating just that, so this may have been a relatively easy period for advocates. The next one could be expected to contain some collection of administrative and federal and state assaults.

Many such scenarios have already been contemplated. Here is one:

But how seriously should we take this threat? Very seriously, until we have proof that he doesn’t really mean it, or until Republicans take active steps to defuse it, which they can do if they choose to.

Trump can indeed do a great deal of damage. He can “let Obamacare fail” by refusing to renew the so-called cost-sharing reductions…which are paid to insurers to subsidize out-of-pocket costs to millions of lower-income people.

If he did this, insurers would probably have to hike premiums by enormous amounts, and many might exit the markets, further destabilizing them, potentially causing many millions to have no access to coverage. We know Trump sees this threat as working in his favor: Back in April, he explicitly threatened not to continue the payments for the express purpose of forcing Dems to negotiate with him. The administration didn’t go through with it, and the payments have continued, but that doesn’t mean they won’t be ended this time.

Bipartisan action would forestall the devastation that would result from a non-renewal of the CSRs, and Republicans would probably be wise to go this way even as far as their re-election prospects are concerned, since polls now indicate that the public will hold Trump and Republicans responsible for further Affordable Care Act problems on their watch. But our predictive capacities are on the fritz right now, as so many rules seem not to apply.

Let’s learn from Trump’s early feting of success in the Rose Garden after the House bill passed and not fall into the trap of thinking anything that has been won here cannot quickly be lost again.—Ruth McCambridge