Supporters of the Affordable Care Act have been emboldened recently by several developments that suggest repealing the health care law could inspire a tremendous backlash and spook Republicans in Washington, who are badly at odds with one another, into full retreat.

President-elect Donald Trump, who previously undermined congressional repeal efforts by insisting that Republicans replace and repeal the law simultaneously, pledged on Saturday the replacement would provide “insurance for everybody.” That same day, Representative Mike Coffman of Colorado became a symbol of GOP jitters when he sneaked away from a regular constituent meeting that was overrun with people alarmed by the repeal effort. And on Tuesday morning, a Congressional Budget Office analysis found that the GOP’s repeal legislation would strip insurance from 18 million people in one year, and deny insurance to millions more over the ensuing decade.

The repeal push is uniting liberals and dividing conservatives, leaving supporters hopeful that their efforts to save the law might ultimately prevail. Stopping repeal requires only three GOP defections, and even if Republicans pass legislation that sunsets the Affordable Care Act in the coming years, the law’s supporters will still have time to rescue key elements of it, if not the whole thing.

These encouraging signs are fueling liberal activism; it’s possible to imagine a Tea Party–like resistance forming on the left and making Republicans pay a political price for threatening their constituents’ health care. But as they rack up near-term victories, Obamacare supporters should think ahead to what the fight will look like in the coming weeks and months. The moral of the Tea Party story is that Democrats knew they’d pay a price for passing Obamacare—but they passed it nevertheless. The momentum of the past several days could easily dissipate or reverse itself, and liberals should be prepared to act if and when it does.


Republicans are clearly scared of the political risks of defunding Obamacare. Try as they might to blame Democrats, they even seem to realize that once they change the law in any significant way, they will own the consequences. This is why, for instance, Republicans have agreed to throw money at insurance companies during an Obamacare phaseout period to keep them from fleeing the market. It’s why Senators Susan Collins of Maine and Bill Cassidy of Louisiana want to punt the question of Obamacare repeal to individual states.

But Republicans have also hinted at another approach, which would essentially flip the order of events so that the consequences come before the votes.

“[T]he easiest thing would be to let it implode in ’17 and believe me, we’d get pretty much whatever we wanted,” Trump insisted in his first and only transition press conference, “and believe me, we’d get pretty much whatever we wanted, but it would take a long time.”

That teed it up for House Speaker Paul Ryan, who used the same false claim about the law’s self-implosion to mislead a cancer patient during a CNN town hall last week. “I think the president-elect said this yesterday, ‘We could just sit back and watch it all happen and say, “Oh, look at what the Democrats did.”’ That would be irresponsible for us to do that.”

Contra Republicans, Obamacare is not in a death spiral. A record number of Americans enrolled in Obamacare policies for 2017. After a significant-but-predicted correction that drove up premiums this past year, experts believe the continued demand for marketplace health plans mean prices will stabilize.

That is, unless something else drives them up.

If the Trump administration and Republicans in Congress were to administer the law this year in an above-board way, they would debunk their own death spiral talking point. On the other hand, if they repealed the law without replacing it simultaneously, any market disruptions that ensued would be attributed to them.

Liberals have thus dismissed Trump and Ryan’s comments as so much idle talk. But Republicans could feasibly engineer a scenario in which their own official statements and intentional mismanagement destabilize the law before they take any concrete legislative or administrative steps.

Republicans’ simply saying the law will sunset has alarmed insurers, who might decide to pull out of the marketplaces before the next enrollment period. Why stick around in a voluntary program that is likely to disappear? More will follow if the Trump Department of Health and Human Services takes steps to let the program wither. As outgoing HHS Secretary Sylvia Mathews-Burwell told a roundtable of reporters on Tuesday, administrators determined to neglect Obamacare could make it inhospitable to carriers and consumers alike, under the cloak of darkness, through poor “execution.” Make it harder for people to sign up, for instance, and the upward trend in enrollment could reverse.

This is not to mention administrative and regulatory steps the Trump administration could take that would be slightly more transparent, but still complex, and unlinked to any vote in Congress.

Insurance companies are well attuned to what’s happening in the government, and—crucially—they will set their 2018 rates this spring. If premiums spike again, it will likely be because Republicans, now fully in power, have sown doubt in the market with their hostility to the law. But the Trump administration will only be a few weeks old by then, and Republicans will disclaim any responsibility, citing higher premiums as evidence Obamacare was already collapsing. “We haven’t even touched it yet!” they might say.

That line will be false; but it will also seem plausible to the uninformed. A whole genre of mediocre journalism, which sustains itself on the insight that perception matters more than substantive truth in politics, will portray this as “bad news for Democrats,” and recriminations will begin. The nightmare is that liberals are unprepared for this contingency, and Democrats in Congress begin to peel off as they and their constituents see premiums spike.

Obamacare supporters might be able to get ahead of this scenario if, before spring arrives, they can credibly establish that Republicans are undermining the market through dithering and sabotage. The worst thing they could do is celebrate near-term victories and assume that the humanitarian stakes of repeal will take care of the political problem for them.