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Republicans are about to learn just how much Americans hate health insurance changes

With control of the White House a month away, Republicans pledge to repeal Obamacare as one of the first acts of the next Congress. Ironically, their efforts may do more than Democrats have to entrench the Affordable Care Act. Fanciful as it sounds, the ACA’s best days may lie ahead.

Through seven years of withering Republican bombardment and 60 congressional votes for repeal, Obamacare seemed stuck in the limbo of popular indifference, rarely exceeding a 50 percent approval rating or dipping below 40 percent. The ACA has been more divisive than downright unpopular: While it consistently polls unfavorably among Republicans, with only 15 to 30 percent viewing it positively, independents split slightly negative, and Democrats generally favor the ACA, with 60 to 75 percent viewing it as a good program.

The ACA now covers more Americans, 22 million, than the vastly more popular Medicare did in its first few years. Why does the ACA remain so divisive? Among the many reasons, three stand out.

But the catch is that these same three aspects of the program also create problems for those who want to do away with it.

First, Americans are extremely suspicious about Washington tampering with their health insurance. Hence the success of the insurance industry’s infamous “Harry and Louise” ads in rousing public anxiety over the Clintons’ universal health insurance proposal in 1993. The ad featured a middle-aged, insured couple at the kitchen table, worrying about how the Clinton plan would affect their own coverage.

Second, our health insurance is complicated (to say the least). Reforms built on and around our convoluted mix of Medicare, Medicaid, Veterans services, group insurance, employer self-insurance, and individual insurance require a Rube Goldberg-like structure. The ACA is complex beyond the capacity of most voters to comprehend. That complexity leads many citizens to be suspicious of it, and also makes it susceptible to the Republican criticism du jour. Early on, critics played on economic anxieties by labelling the ACA a job-killer; then they said it would fail to cover people, and today they point to one year (2017) of premium hikes.

Third, change of any kind is hard. If 22 million previously uninsured adults are now covered, even more had to wade through an often frustrating enrollment process. Health plans, states, hospitals and their many suppliers have spent billions of dollars over the past six years implementing changes required by the ACA, and those changes are now baked in. Having changed so significantly in one direction, few of these entities are excited about a new round of changes. Indeed, none have come out recently in support of further disrupting the ACA.

The political implications of these forces are shifting

Ironically, these three factors are about to swing against those who would repeal and replace the ACA. Many specific features of the ACA poll quite well, and many Trump voters apparently do not believe that he actually means to take the features they like away. As the slogan “repeal and replace” nears reality, the fear of losing these benefits may well alter popular attitudes toward the ACA.

Already there are signs of a post-election uptick in the ACA’s popularity, and new angst about repeal. In a Pew poll taken November 30 to December 5, 47 percent approved of the program, the highest figure in months, while 48 percent disapproved, the lowest figure in months. That same group preferred expanding or leaving the ACA as is versus repealing it (54 percent to 39 percent).

Congressional Republicans have begun to worry about these trends. Rabid for repeal, they hatched a clever “repeal and delay” strategy for immediately passing a budget reconciliation bill, which Democratic Senators cannot filibuster, to defund the ACA as soon as they figure out how to replace it. But saner minds have recognized that pulling money and regulatory scaffolding from the ACA without first erecting its replacement would cause private insurers to stampede from the individual market, leaving some 30 million Americans newly uninsured. This would definitely not be the beautiful plan that Donald Trump promised.

Instead, some conservatives are calling for ways to shore up the ACA, as they try to come to a consensus on its replacement. However, for six years now, congressional Republicans have failed to coalesce around a simpler, inexpensive, market-oriented alternative. The challenge is greater than it was even a few years ago, because the ACA has set the bar at 22 million newly insured Americans. So far, the Republican replacements that have been floated fall far short of that figure.

And Republicans must be even more mindful than the Democrats of voters’ insecurity about health insurance “fixes” that come, top-down, from Washington. The incendiary rhetoric of the Tea Party and the alt-right is unlikely to reassure voters worried about yet another disruption to their coverage.

The sprawling, multifaceted American system means that small tinkers to one part can set into motion a cascading series of changes to other parts. Each of those changes energizes a new set of advocates, making the work of politicians hard.

Institutions have adapted to Obamacare, and citizens are used to its benefits

While it may be unlovable, the ACA is firmly established — written into the costly software and strategic plans of hundreds of insurers, thousands of hospitals, and the 32 states that expanded Medicaid. If Republicans upend those apple carts, they’ll make a lot of Americans very nervous.

Republicans will struggle mightily over how to replace the ACA’s budget-balanced, market-oriented reforms with something far less regulated and subsidized that doesn’t throw millions of Americans off coverage. Then they must persuade at least eight Democratic senators to support their alternative. If bipartisan reform were easy, it would have happened decades ago, when the country was far less divided, or in 2009 when Senate Democrats last tried.

So, where does that leave the ACA? Pretty darn hard to repeal and replace. But doing nothing seems equally untenable: Either the Republicans fund the ACA, leading Tea Partiers to call for their heads — and everyone else to wonder how they can support a law they revile — or they preside over an insurance crisis. If they defund it, Americans will see just how much they really had to lose. And Republicans will no longer have Obama to blame.

It sounds implausibly optimistic, but the only way out of this dead end may be for Republicans to reform the ACA, even as they claim to have done away with it. There are many ways to do this, but my favorite is to punt the issue to the states, as Sen. Bill Cassidy (R-LA) has suggested. The basic idea is to preserve most of the federal funding for the ACA, but vastly expand its state waiver provision, allowing each state to design its own replacement — or not — with its share of the federal dollars. States could enact mandates and market reforms that mirror the ACA (as Massachusetts did, before Obamacare existed), or modify them, or take entirely different approaches. Such approaches might range from Medicaid for all uninsured to high-risk insurance pools for those denied individual coverage.

“Repeal and replace” is looking harder and harder to pull off by the day. Republicans may find “reform and rename” a far more manageable goal — even if it falls short of their promise to drive a stake through the heart of the ACA, and even if it involves some pretense.

Jon Kingsdale, PhD, is associate professor of the practice at Boston University School of Public Health and a managing director of Wakely Consulting.

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