Last week’s debate and fire on repealing the Affordable Care Act was bookended by two narrow votes of 50 to 51 and 49 to 50 with three senators being the key actors.  In between the fewer than a dozen votes cast it became clear that a replacement plan was not possible and any reforms or modification of the ACA will likely take a bipartisan effort.

Senator John McCain (R-AZ) made a dramatic Tuesday afternoon floor entrance after his sudden cancer surgery.  In doing so he delivered a temporary reprieve for Senate Majority Leader Mitch McConnell (R-KY) but also left senators thinking about the divisive politics of the 21st century.  Three days later his comments on the current political dysfunction in the country was his rationale to help bring down this latest attempt to repeal the Affordable Care Act.

McCain’s action would not have mattered if not for the consistent opposition to what was being offered by Senator Susan Collins (R-ME) and Senator Lisa Murkowski (R-AK).  Both endured a range of opposition including Administration threats to Murkowski by the Secretary of Interior to a passing challenge to a duel to Senator Collins by Congressman Blake Farenthold (R-TX). The minority Democrats also stood united throughout the Majority Leader’s negotiations with the members of his own caucus.  McConnell attempted a repeal bill adopted by previous congresses, a proposal to repeal and replace later, the Senate Better Care Act, and then finally the slimmed down or “skinny” repeal which would have stripped out the mandate on individuals and businesses to provide or buy insurance, a provider tax, a one-year cut of funding to Planned Parenthood.

If the skinny bill had passed the Senate, the intent was to get the bill back to a House-Senate Conference.  When word spread late Thursday afternoon that Majority Leader Kevin McCarthy (R-CA) had told House members to stay available because they might attempt to pass the skinny bill, several Republican senators made clear that would not be acceptable.  They viewed the skinny bill as merely and out to continue talks.  Speaker Paul Ryan (R-WS) made public and private promises that they would not move on the bill right away but that still created unease with Republicans.  What is next and what we know:

Where Do They Go Now?

The Senate has expended the debate hours of the reconciliation and likely this reconciliation instruction.  Senator McConnell wants to move on—especially to tax cuts.  In the aftermath however, leadership of the Republican party has been forming a circular firing squad.  Some House Republicans want the Senate to still act and they are openly criticizing Senate Republicans.  The President has spent the weekend attacking Senators of his own party and some Senators such as Senator Ted Cruz (R-TX) have openly criticized his colleagues.

Can They Reform the ACA in a Bipartisan Way?

There is some support, most vocally expressed by Senator McCain that they work together on a fix.  Other Republican leaders, including Senator Lamar Alexander (R-TN) have talked across party lines.  There are some common fixes they could agree to such as assuring the President cannot refuse to provide the market stabilizing subsidies of $7 to $10 billion. These efforts could be undercut by the President.  On the other hand, this President is just as likely to sign any bill and call it victory.

Will It “Implode”?

Among the various tweets and attacks the President has called for the ACA to implode.  The Administration has contributed to the troubles of some of the exchanges by threatening to stop funding subsidizes, narrowing the sign-up period and undercutting recruitment for sign ups.  On the other hand, the ACA is working well in most parts of the country with some analysts saying the industry is stabilizing.  It is not working in dozens of counties and some states that could in fact be considered Donald Trump country.  These rural and conservative areas are most at risk and a Congress that doesn’t act may be taking a calculated risk that in the next election voters will blame the leaders of the past than the leaders of the present for anything that goes wrong.

Medicaid?

This was the biggest attempt to cut and restructure Medicaid since the Newt Gingrich Congress of the mid-1990s.  It was also the most serious effort through spending caps.  But the changes to Medicaid were also the most contentious with several Republican Senators voting against the various replacement plans because of what it would do to Medicaid.  House Republicans may try and cut it again though the next reconciliation of tax cuts.  But Medicaid may have now established itself as an important health care benefit equal to Medicare.

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