With some Congressional Republicans suggesting that a repeal of the ACA is still front and center it will not likely happen when the Congress returns after the spring break. With the CR funding due for resolution within days of reconvening, a full FY 2018 budget release in Mid-May, and a desire to do a tax package, health care could get pushed to the end of this year or even next year.

The President has denounced the ACA and argues it will fail.  That is something the Administration could assist on but that might not be the best political strategy if they are tied to any significant decline in coverage. In addition, at its core, the ACA is based on some core Republican ideas that had been part of a 1993-94 Republican Senate proposal that was a counter to the Clinton plan: it keeps private insurance as the main partners, mandates individuals to buy insurance and provides tax credits.  In addition, it is working well in several states.

Two main features could go a long way toward strengthening the ACA’s future, the expansion of Medicaid and the funding of some subsidies within the exchanges.

Some states, most of all Kansas, are reconsidering whether they should now opt into the Medicaid expansion. Nineteen states have refused the Medicaid expansion despite the fact that the expansion includes the federal government providing more than 90 percent of funding.  Kansas state is in a political dispute with an overwhelming number of legislators voting to expand Medicaid under the ACA but Governor Sam Brownback is threatening a veto such a move.  If that happens a few more Republican votes would be needed to override that veto.  In Virginia, Democratic Governor Terry McAuliffe has resubmitted an expansion to his Republican legislature.  While the leaders are still opposed, that could become an issue this November’s as the legislature is up for reelection.  Others among the 19 states are also vaguely reconsidering.  Approximately 6 million more people could get coverage under a Medicaid opt in by the last states.  Some of those states could get added pressure with the rising numbers of opioids addicts and the fact that expanded Medicaid has resulted in increased substance use treatment.

Meanwhile, HHS must once again consider what its position will be with the on-going House of Representatives lawsuit filed against the Obama administration and HHS Secretary Burwell.  The case attempts to cut out the Administration’s ability to provide some subsidies within the ACA state exchanges to reduce co-pays and deductibles for lower income customers.  The Trump Administration and Republican House leadership have successfully delayed any court decisions based on the belief they would repeal the law.  That has allowed continued funding.  There were some suggestions last week that the House may go along with continued subsidies.  If not, it could knock some people off the exchanges.

There are other items that HHS could pursue but some could have an opposite effect on the exchanges.  For example, if the Administration attempted to shave some of the reach of the ten-essential benefits package by making them less generous that could put downward pressure on premiums and that could increase enrollment.  All such actions, if they increase the number of insured, would only make it more difficult for the Congress and the President to repeal the law.  Increasing in the number of insured may also push some of the low performing states to seek greater support or fixes from Washington instead of pressure to eliminate it.

It all remains to be seen but before that Congressional Republicans would have to agree to giving up on a repeal.