Congressional Republicans are executing a strategic pivot with respect to the Affordable Care Act (ACA). In the face of successful efforts to mobilize public support for maintaining coverage, they are recognizing the political difficulty of pulling health care away from millions of people (including Republican voters) and inflicting economic damage not only on those individuals but also on providers, insurers and state governments. This shift has several components.

First, they have “slowed their roll” with respect to repeal. The original congressional action plan called for sending a repeal bill to Trump on inauguration day. Plan B called for sending him a repeal bill on President’s day. We are now on to Plan C, and we do not expect to even see a repeal plan, let alone a vote, before Congress returns from President’s Day recess. The second component involves ramping up the rhetoric on the ACA’s failures. Several congressional committees held hearings last week intended to show case failings of the law. At the same time, with help from the Trump administration, they are trying to create a self-fulfilling prophesy by undermining the operation of the ACA, creating a climate of uncertainty and confusion in order to thwart both insurer and consumer participation. Finally, in a nod to the support that most provisions of the ACA enjoy, they have made a rhetorical change from “repeal and replace” to “repair.”

While the change is a welcome testament to the success of the resistance to date, it does not reflect any change in purpose on the part of most Republicans in Congress. They remain ideologically opposed to the social welfare state and to the redistribution of wealth from the top to the bottom. They are therefore unalterably opposed to the ACA or anything like it that expands the social right to health care and pays for it mainly by taxing the wealthy and big corporations.

In addition, both Ryan and McConnell probably feel that after seven years of demanding repeal, their credibility is on the line and they absolutely have to deliver on “repeal” regardless of the consequences. In addition, the far-right, as exemplified by groups like Heritage Action, remains committed to full repeal and fear of primary challenges is still a powerful motivator within Republican Party ranks. 

That said, “repeal” is not a static concept. Although support for full repeal remains strong among congressional leadership (see Senator Hatch’s recent statement on repealing the ACA taxes), there is substantial dissension within the rank and file. The two critical wedge issues are the fate of the Medicaid expansion and whether the ACA-related tax revenue is preserved to pay for some kind of revised subsidy scheme. 

If congressional Republicans preserve both the Medicaid expansion and subsidy revenue it will open up room for bipartisan discussion on ACA amendments. If not, then any possibility of an acceptable replacement plan essentially vanishes. Although Republicans may try to come up with something, or, more likely, somethings that they call “replace,” in reality it will reflect a major erosion of health and economic security for low- and moderate-income people – especially for people with serious or chronic health conditions. If Democrats can resist pressure to bestow a patina of bipartisanship on any bill that undermines health security for the American people, then Republicans would be forced to either maintain many of the gains of the ACA or would be likely to pay a high political price for failing to do so.