Is the fight to repeal and replace the Affordable Care Act dead?

The White House is delivering mixed messages on whether it will keep trying to repeal and replace the Affordable Care Act, while other Republicans say they are committed to that plan.

In their first attempt since President Donald Trump took office, House Republicans failed to pass their bill to repeal and replace former President Barack Obama’s health care law, after seven years of promising to do so. On March 24, the day Republicans killed their American Health Care Act, Trump said he would now turn his attention to tax reform and wait for Democrats to approach him about making changes to the Affordable Care Act.

"I think we have to let Obamacare go its way for a little while, and we'll see how things go," he said.

White House Budget Director Mick Mulvaney echoed Trump’s sentiment on NBC’s Meet the Press March 26.

"My guess is what will happen now is we're going to move on," Mulvaney said, when asked by host Chuck Todd if they would repeal and replace Obamacare by the end of 2017.

Yet Trump, speaking of a possible health care deal, told lawmakers on March 28, "I have no doubt that that's going to happen very quickly."

And other Republicans, including House Speaker Paul Ryan, R-Wis., say they still want to pass a bill by the end of the year.

"We’re not going to just all of a sudden abandon health care and move on to the rest," he said March 27.

So is the fight to dismantle the Affordable Care Act over? We reached out to health policy and political science experts, who were skeptical that a complete overhaul of the law will happen. But there are significant problems with the law, and the health care system generally, that both parties will have to eventually address.

"The AHCA may be dead but that doesn't mean that changes to our health care system are off the agenda entirely," said Sarah Gollust, a professor of health policy at the University of Minnesota.

Hard to see a path through Congress

Given Democrats’ united opposition to repealing the Affordable Care Act in full, and fundamental disagreement among Republicans about what the replacement should be, it’s hard to imagine a legislative path forward. There are just 52 Republicans in the Senate, so nearly all of them would have to agree on the replacement or get a few Democrats on board.

Last week, Republicans tried to use a maneuver called budget reconciliation to pass their bill, the American Health Care Act, because it would have allowed them to get the bill through the Senate by avoiding a filibuster. But Republican leaders couldn’t get enough "yes" votes among their own party, because conservative Republicans thought the law didn’t do enough to scale back government involvement in health care. Moderates were concerned it would make insurance less affordable for poor senior citizens.

Robert Field, a professor of law and health policy at Drexel University, said he’s not convinced that lawmakers will be able to craft a bill that satisfies both factions and doesn’t take benefits away from people who got used to them under the Affordable Care Act.

"We’ve been struggling with these issues for 100 years," he said.

Republicans could make changes to the law and try budget reconciliation again, but because of the complex rules attached to budget reconciliation, that window of opportunity has nearly closed for this year, said Sarah Binder, a political science professor at George Washington University. Republicans could try budget reconciliation again with next year’s budget bill, but they appear to want to use that opportunity for tax reform, instead.

Instead of repealing the Affordable Care Act in full, a bipartisan group of moderate Democrats and Republicans could come together to address some of the issues with the law, like the lack of competition in some regions’ individual insurance marketplaces or better enforcing the mandate that everyone has insurance.

Some Democrats and Republicans show openness to this concept — such as Sen. Susan Collins, R-Maine, and Rep. Jim Cooper, D-Tenn. — but it’s far from certain that enough lawmakers, including Trump, would be on board.

"It's certainly possible that small tweaks could be enacted with Democratic support to shore up the health care exchanges in the states, but I see little evidence at this point that the administration intends to do so," Binder said.

If Republicans could get their Affordable Care Act replacement bill to Trump’s desk without any Democratic votes, the law might still be unsustainable in the long term, said economist Gail Wilensky, who headed Medicare and Medicaid under President George H.W. Bush. The Affordable Care Act has been so politically toxic in part because it passed with just Democratic support.

"(The Republican bill) was going to repeat the same mistake that occurred with the Affordable Care Act," Wilensky said. "Have you learned nothing? That is the recipe for unstable social legislation."

History doesn’t bode well

While there is no procedural obstacle that would stop Republicans from making a new run at repealing and replacing Obamacare, recent congressional history provides few examples of rebound bills that have been tried, failed, and then attempted again successfully.

For instance, no serious second attempts were made after President George W. Bush tried to partially privatize Social Security in 2005 or when President Barack Obama attempted to pass gun control or immigration reform in 2013.

A rare example of a failure followed by a success was the legislative battle over welfare reform in 1995 and 1996, said Gregory Koger, a University of Miami political scientist. At the time, Bill Clinton was president and the GOP controlled both chambers of Congress.

"The Republicans passed it as part of a budget reconciliation bill, and it was vetoed," Koger said. "Then Congress passed welfare reform as a separate bill, and it was vetoed. Then the Republicans tried a third time, and it became law."

Another example of a success after a failure was the passage of the Emergency Economic Stabilization Act of 2008, which created the Troubled Asset Relief Program, sometimes known as the Wall Street bailout. The House initially voted down the bill, but after the Senate passed an amended bill, the House followed suit two days later.

For health care, the most directly comparable example is the effort by President Bill Clinton to pass his version of health care reform. Work started at the beginning of the Clinton presidency in January 1993, and legislation was officially sent to Congress on Sept. 22 of that year.

There was never a formal vote "since it was clear they had nowhere near the votes for it to pass," Wilensky said. Legislative momentum petered out midway through 1994, she said — leaving too little time to mount a new effort before the midterm elections.

The current situation is "somewhat different," she said. There is more time left before the 2018 midterm elections to make a second attempt, and both Republicans and Democrats "know that the law needs some modifications," Wilensky said.

What if Trump does nothing?

If Congress doesn’t do anything, the Trump administration could just stop enforcing the law — by refusing to allocate funding or enact regulations, for example — or let the status quo continue. Trump believes this will cause the health system’s problems to compound exponentially until lawmakers have no choice but to make changes.

"The best thing we can do politically speaking is let Obamacare explode," he said March 24. "It is exploding right now."

Trump’s talking about the individual insurance marketplace, which faces rising premiums and insurance provider departures in some regions of the country. If problems continue without fixes or additional subsidies to offset premium costs, more people would likely drop out of the market, causing premiums to go up even further, and forcing more people out.

However, the vast majority of Americans get their health insurance through their employers or the public programs of Medicare and Medicaid. Just 7 percent of the U.S. population in 2015 had insurance they purchased individually on the open market, according to the Kaiser Family Foundation.

So if no one tries to fix the problems with the individual insurance marketplace, "there would be ripple effects" on the health care system overall, but "not tidal waves," Field said.

Wilensky said she believes the problems with the Affordable Care Act will eventually become so acute that a bipartisan solution might become necessary.

"At some point there’s going to need to be a modification of legislation," she said.

Dr. Kevin Schulman, a professor of medicine and business at Duke University, said that he believes the public wants a reprieve from the skyrocketing costs of health care. He added that Obama is often blamed for this problem even though it long preceded the Affordable Care Act and affects everyone, not just those who have insurance through the law. Yet Schulman doesn’t see any serious attempts to address that core issue among the health care policy proposals floating around Washington.

"It doesn’t seem like a lot of people on the Hill have agreement about what the problems are," he said. "Coming to a consensus on a solution is even more challenging. I’m not optimistic that they can get there."