Beyond Showmanship And Spite: Toward A Health Care “Grand Bargain”

Is a deal on health care possible? Conventional wisdom says no. “Repeal and Replace” is dead, and Republicans have moved on. So have many Democrats, toward pursuit of a single-payer plan that’s going nowhere on Capitol Hill but energizes the party’s core. Last month, President Donald Trump said he’ll “dismantle” the Affordable Care Act (ACA) on his own—and backed this up with executive orders that risk the stability of the insurance exchanges.

Democrats are angry that Trump and congressional Republicans want to repeal the ACA and roll back its expansion of health insurance coverage. Republicans are angry that Democrats pushed “Obamacare” through Congress on a party-line basis, and they see the ACA as big government running amok. Both parties are positioning themselves for primaries, and neither shows much interest in the risky work of compromise.

We’re alarmed. One of us is a Cato Institute-friendly “free-market”eer who wrote a book arguing (tongue in cheek) that Medicare is the work of the Devil. The other helped to develop President Barack Obama’s 2008 campaign health plan and believes that failure to ensure everyone’s access to health care is an assault on human decency. But we’ve come together because we believe that failure to resolve the present impasse will have hugely destructive consequences for millions of Americans’ access to health care—and for our national confidence in our political system’s capacity to function.

Designing A Deal

President Trump has cut off cost-sharing reduction subsidies to insurers and issued a directive to allow coverage options less comprehensive than the ACA requires—measures that threaten to unravel the individual and small-group markets by incentivizing younger and healthier people to exit. Meanwhile, the uncertainty that besets federal funding under the ACA for Medicaid expansion poses huge fiscal risks for states, as does Congress’s failure, so far, to renew funding for the Children’s Health Insurance Program (CHIP). And over the longer term, soaring private and public spending on medical services that deliver doubtful value erodes US productivity and well-being.

We think a bipartisan “grand bargain” to stabilize the US health care system is feasible—if key decision makers can move beyond showmanship and spite. To this end, we outline a deal that: honors but balances the competing values at stake, steadies both market and public mechanisms of medical care financing, and puts the nation on a path toward sustainability in health spending.

Our grand bargain builds on federalism. Vastly different values, priorities, and interests stand in the way of nationwide health policy uniformity. Allowing states to sort out controversial matters within broader limits than the ACA now imposes would permit creative policy alternatives to unfold and encourage local buy-in. We needn’t and shouldn’t mandate definitive answers to bitterly contested questions that can be reasonably negotiated at the state or local level. Instead, we should open political and market pathways for the emergence of answers to these questions over time.

Moving to this long game will require all sides to pass on their pursuit of a quick political win. Doing so is the key to moving from cycles of backlash and volatility to a system that builds confidence and delivers high-quality, compassionate health care to all.

The Long Game: Seven Steps Toward a Compromise that Can Work And Endure

With these basic principles in mind, we propose the following seven steps:

Moving Beyond Maximalism—Medicaid Rollback And “Medicare for All”

Republicans should end their campaign to roll back the ACA’s Medicaid expansion, and Democrats should stand down on their quest for single payer. Both pursuits inspire true believers but will go nowhere on Capitol Hill for the imaginable future.

State Flexibility

Give states more flexibility to design their Medicaid programs and to govern their insurance exchanges. One approach would be to simply allow states complete flexibility to design their own coverage rules. Alternatively, we could give states more flexibility but ensure, via federal law, that Medicaid and plans sold on the exchanges provide affordable access to effective preventive, diagnostic, and therapeutic services. States could also be allowed but not required to offer a public option through their exchanges. Instead of an all-or-none answer to the public plan question, the nation would have a framework for market-driven, state-by-state resolution. Similarly, states should be allowed to decide whether to prohibit, permit, or require enrollment of Medicaid beneficiaries in private plans. Finally, when it comes to care that serves culturally contested purposes—including, but not limited to, gender reassignment or confirmation and late termination of pregnancies for nontherapeutic reasons—states should be given autonomy to go their own ways. More federalism will achieve greater stability than would temporary nationwide imposition of one or another approach by whichever party happens to hold the electoral upper hand.

Health Savings Accounts That Appeal To Everyone

An expanded role for tax-protected health savings should have bipartisan appeal. We propose that every lawful US resident be auto-enrolled in a health savings account (HSA), funded through a refundable tax credit, scaled to income and family size. People could opt out but would lose this credit if they did. Few would do so, enabling HSAs to become a means for pursuing both market discipline and social equity.

Repeal The Individual Mandate

Sacrilege, you’re surely thinking, if you’re a Democrat who’s spent seven-plus years defending the mandate, the ACA’s most disliked element. But the mandate isn’t needed to keep healthy people in community-rated risk pools—it’s the intensity of the incentives, whether framed as penalties or subsidies, that matters. Even the mandate’s most outspoken economist-defender, Jonathan Gruber, concedes that high-enough subsidies for the purchase of insurance can substitute for it.

Such subsidies could be supplied in conservative-friendly fashion by allowing all who buy coverage on the exchanges to put HSA funds (including the tax credit we urge) toward their premiums. Sign-up for coverage could also be made more user-friendly through auto-enrollment, subject to opt-out, in “silver” plans (for tax filers who aren’t otherwise covered and aren’t Medicaid eligible). A more robust approach might condition the refundable HSA tax credit on tax filers’ purchasing insurance (or not opting out of auto-enrollment).

Congressional Authorization Of Funding For Both The ACA’s Cost-Sharing Reductions And CHIP

There is bipartisan support for restoring the ACA’s cost-sharing reduction subsidies and extending CHIP. Although annual appropriations are the norm, Congress should guarantee funding for the cost-sharing reductions for a two-year period, with automatic renewal for an additional two years if per capita subsidies rise by no more than the Consumer Price Index (CPI) during the prior two years. By so doing, Congress can reaffirm its authority over appropriations while helping to stabilize markets for individual coverage. Likewise, Congress should renew CHIP’s funding for several years—we urge three as a compromise—to both stabilize state budgets and secure health care for the millions of children who depend on this program.

The “Long Game”—Reining In Medical Spending

A long-term effort to contain spending growth is essential for US fiscal stability and consumer well-being. The ACA created a framework for doing this. The Independent Payment Advisory Board (IPAB) can limit Medicare spending, subject to congressional veto, if growth exceeds target rates. And the 40 percent “Cadillac tax” on high-cost private health plans will cover a rising share of the private market as medical costs increase. Together, these policies have the potential to contain clinical spending by capping demand. But there’s bipartisan opposition to both. The IPAB, which hasn’t yet been established, and the Cadillac tax, now delayed until 2020, are fiercely opposed by stakeholders with lots to lose, and they’re at high risk of repeal.

A grand bargain should follow through on both of these strategies, plus add similar restraints on Medicaid spending and on the amounts spent to subsidize coverage through the exchanges. Most other nations employ global budgeting to control health spending. For reasons of federalism, public philosophy, and market structure, global budgeting isn’t an option for the US. But a coordinated scheme of restraint, based on the best available behavioral and economic modeling, could apply similar braking power to our entire health economy. There’s plenty of room for argument about design details (that is, should per capita growth targets be based on the CPI? The CPI plus 1 percent?) and methods of restraint (that is, the IPAB approach? Spending caps for public programs? The Cadillac tax versus caps on tax deductibility of insurance premiums?). Continued bipartisan evasion will only make the problem worse.

Pursuing Therapeutic Value

Much more must be done to use health care resources wisely as constraints tighten. Tying financial rewards closely to clinical value via paymentpractices, market exclusivity policies, and other incentives will be critical—and will require the clearing of legal and regulatory obstacles. Voluntary action must also play a role: The grand bargain we’ve sketched here creates myriad opportunities for providers, patients, and insurers to gain by insisting on value from a sector of the economy that too often fails to deliver it.

To be sure, politics could foil all efforts to forge compromise. But there is a way forward. Our proposals achieve much that is important to both the ACA’s fiercest critics and staunchest defenders. They work in concert to address the political and market crises that immediately threaten our health care system, while laying the foundation for a long-term approach to control medical spending’s unsustainable growth.

​The ACA is the ultimate survivor


The Affordable Care Act has survived more assassination attempts than Fidel Castro — and it’s still kicking. The Kaiser Family Foundation’s Larry Levitt has a piece in the JAMA Forum laying out the argument that the ACA “continues to escape death.”

  • Levitt’s piece is mostly focused on the Senate’s repeal-and-replace efforts and the Trump administration’s implementation decisions — cutting off payments for cost-sharing subsidies and dramatically scaling back enrollment outreach.
  • “If these efforts were intended to make the marketplace implode, they may, in fact, be backfiring,” Levitt says, citing the weird abundance of plans with $0 monthly premiums and enrollment totals that are beating some experts’ expectations.

This is just the latest chapter. The ACA has been a fixture of public debate since 2009, and it has never veered far from death’s door. In that time, it has survived:

  • Any number of make-or-break moments during the legislative debate
  • Two potentially disastrous Supreme Court challenges
  • The Republican waves of 2010 and 2014, and the countless repeal votes that followed
  • A slew of self-inflicted wounds, from provisions that proved unworkable to the hot mess that was the launch.

Between the lines: The ACA has definitely taken some hits — it’s not as strong its drafters might have hoped on the day it passed. But congressional Republicans’ failure to repeal it, and President Trump backing into a massive increase in its subsidies, are just the latest signs of the law’s surprising durability.

Until Congress repeals the individual mandate, anyway…


How the elections could put the brakes on anti-ACA plans

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The most important issue in an election is sometimes, but seldom, the factor that actually determines the outcome of the election. That’s what we saw happen in Virginia this week. Health was the top issue in the Virginia race, according to exit polls, but it was only one of many factors that drove the election.

The bottom line: The election may have been more of a referendum on President Trump than health care — but the results in Virginia and in the Maine referendum on Medicaid expansion will still have a practical impact on what happens next, including the appetite for Affordable Care Act repeal and for cutting Medicaid to pay for tax cuts.

The details: Voters in Virginia named health care as far and away their top issue in the election in the network exit poll. It’s not surprising that the issue was at the top of their minds; they have been hearing all about the ACA in the news for months and about Medicaid expansion in their state.

Yes, but: Notably, the exit poll did not include the economy on the list of issues voters could choose. Fox News did ask about the economy and, as the chart shows, it and health were statistically tied in their poll.

Between the lines: When voters rank health care as a top issue in an election, it does not necessarily mean health care drove their vote. Voters’ views of the candidates themselves are generally a bigger factor. The candidates were also proxies for voters’ feelings about President Trump, and many more voters in Virginia said they were voting to express opposition to Trump than their support for him (34% vs. 17%).

Most voters who chose health care as their top issue in Virginia voted for Northam, possibly signaling that Democrats may be able to campaign on health care and the ACA in upcoming elections.

What to watch: The Maine vote on Medicaid expansion was a different story. Maine voters cast their ballots on a specific referendum to expand the Medicaid program, and it won resoundingly. The result speaks to a lesson learned in the repeal and replace debate: Medicaid and Medicaid expansion are far more popular than Republicans seem to think they are, largely because Medicaid now covers 74 million Americans and matters to a broad cross section of the American people.

The impact: The immediate political implication is that it will be much tougher to cut Medicaid to help pay for tax cuts. Another lesson is that expanding Medicaid could be a winner in other states, especially with the federal government picking up 90 percent of the costs and the Trump administration ready to let red states put a conservative stamp on their programs. Medicaid is not Social Security or Medicare yet, but politically it is a lot closer than Republicans may realize.

A lot can and probably will happen between now and 2018. But for now, the prominence of health care in the Virginia election could throw a scare into moderate Republicans about continuing to pursue ACA repeal. And the Maine referendum on Medicaid expansion could make them more cautious about cutting Medicaid.

Trump suggests repealing ObamaCare mandate in tax bill

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President Trump on Wednesday suggested using the GOP tax bill to repeal ObamaCare’s individual mandate.

“Wouldn’t it be great to Repeal the very unfair and unpopular Individual Mandate in ObamaCare and use those savings for further Tax Cuts,” Trump tweeted.

The idea is being pushed by Sen. Tom Cotton (R-Ark.) and also has the backing of House Freedom Caucus Chairman Mark Meadows (R-N.C.).

Meadows said Wednesday he supports repealing the mandate in tax reform and thinks “ultimately” it will be included because he is going to push for it. He said he has been talking to Cotton about it.

A Cotton spokeswoman told The Hill that Cotton and Trump spoke by phone about the idea over the weekend and “the President indicated his strong support.”

Senate Finance Committee Chairman Orrin Hatch (R-Utah) this week said that he wouldn’t rule out including repeal of the mandate in the tax legislation.

But other top Republicans have rejected the idea, including House Ways and Means Committee Chairman Kevin Brady (R-Texas), Senate Majority Whip John Cornyn (R-Texas) and Sen. John Thune (R-S.D.). They fear adding the ObamaCare change would jeopardize tax reform.

“Look, I want to see that individual mandate repealed,” Brady said during an interview with radio host Hugh Hewitt on Tuesday. “I just haven’t seen, no one has seen, 50 votes in the Senate to do it.”

Brady added that he would be open to adding a repeal of the mandate to the House bill if the Senate passed it first.

Asked Wednesday about the president’s tweet, Senate Majority Whip John Cornyn (R-Texas) threw cold water on the idea.

“I think tax reform is complicated enough without adding another layer of complexity,” Cornyn told The Hill.

Thune, meanwhile, said mandate repeal is “not currently a part of our deliberations.”

But Thune added that some members have expressed interest in the idea and said he was “somewhat” interested in it because of the revenue implications.

Sen. Mike Rounds (R-S.D.) on Tuesday also dismissed adding a repeal of the mandate to tax reform.

“If there was a way to do it, I’d be open to it, but I’m not going to pitch it because I want to focus on taxes in the tax reduction plan,” Rounds told reporters.

The Congressional Budget Office has estimated that repealing the mandate would save the government $416 billion over a decade.

The mandate requires people, with some exceptions, to pay a fine to the IRS if they do not have health insurance.

Experts have said repealing the mandate would result in massive premium spikes and a major increase in the number of uninsured people.

It could also send ObamaCare exchanges into a “death spiral” because it would discourage healthy younger individuals to sign up for insurance.

Asked about it on Wednesday after Trump’s tweet, Hatch again did not rule out the move, but cautioned that he wants to keep health care separate from tax reform, a point echoed by GOP aides.
“I think we ought to do tax reform. If they want to do something on health care they can do that separate,” Hatch said. It was not clear who “they” referred to.
“I’d have to really look at all sides of that. I’ve never been very excited about the individual mandate,” Hatch said.

Insurance and device taxes back on the chopping block

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It’s time once again for the insurance and medical device industries to ramp up their lobbying against the ACA’s taxes on their products. Congress has frozen both taxes, but both are set to kick in again next year.

  • A trio of Senate Democrats — Heidi Heitkamp, Jeanne Shaheen and Joe Donnelly — introduced a bill last week to delay the insurance tax for another two years. House Republicans are also hoping to find some bipartisan support for a similar measure, though they also still need to finalize the policy details.
  • Opposition to the device tax is also bipartisan, and heating up. More than 175 House members, including 43 Republicans, signed on to a letter yesterday urging Speaker Paul Ryan to bring up a bill fully repealing the device tax.

Reality check: Both industries, but especially insurers, are more likely to win another delay than see their taxes repealed.

And though there will be public pushes here and there for stand-alone bills, or for inclusion in tax reform, getting onto Congress’ massive end-of-year package is their best bet. Measures to delay the insurance or device taxes could be added to Alexander-Murray, if it comes up, as a way to win more Republican votes without losing Democrats.

Republicans go toe-to-toe, again, with competing ACA bills

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Now the Senate has two competing plans to fund the ACA’s cost-sharing subsidies — which could mean it won’t be able to pass either one. Senate Finance chair Orrin Hatch and House Ways and Means chair Kevin Brady outlined a new proposal yesterday as an alternative to the bipartisan ACA bill led by Sens. Lamar Alexander and Patty Murray.

The details: It’s hard to call these competing ACA stabilization bills. Although they’d both fund cost-sharing reduction (CSR) subsidies for two years, Hatch-Brady would also waive the law’s individual mandate for five years — effectively replacing one source of rising premiums with another.

  • Conservatives are not happy with Alexander-Murray. They’ve argued that if they’re going to keep the law’s cost-sharing payments flowing, they should be able to extract severe regulatory reforms in exchange.
  • Hatch-Brady is definitely more conservative than Alexander-Murray. The big unknown is whether its presence will stop more Republicans from accepting Alexander-Murray as “The Bill” — especially in the House, where its standing is weaker than in the Senate.
  • What they’re saying: “Sad attempt at relevancy by health care staff on Finance who are upset that their boss is entirely focused on tax reform, as he should be,” a senior GOP aide told my colleague Caitlin Owens.

The odds: 100% of the available evidence, from the entire Trump administration to date, suggests very strongly that Republicans are not capable of passing a health care bill on their own. They couldn’t do it with 50 votes in the Senate, and either one of these bills would need 60.

  • Alexander-Murray has 60 votes in the Senate.
  • Hatch-Brady would have an extremely hard time getting there. Waiving the individual mandate will be too much to ask from most, if not all, Democrats.
  • Leadership will likely face a choice between passing Alexander-Murray, with only minor modifications; or not passing anything at all.
  • All of this still probably comes down to December, when lawmakers have to deal with a host of thorny must-pass bills.

ACA Repeal Votes Defy Preferences Of Constituents

Despite repeatedly failing to advance legislation through the Senate, Republicans in Congress have not abandoned their goal of repealing and replacing the Affordable Care Act (ACA). The latest attempt at repeal in the form of the Graham-Cassidy bill would have established a per capita cap on federal Medicaid financing, eliminated the individual mandate, and undermined protections for older adults and people with preexisting conditions, by allowing states to opt out of key ACA insurance regulations. It would also have eliminated funding for the ACA’s Marketplace premium and cost-sharing subsidies and Medicaid expansion, and redirected some of that funding toward block grants to states.

One puzzling aspect of this and previous repeal efforts is that they nearly succeeded in spite of widespread public support for the core elements of the ACA that would have been overturned. Although almost 80 percent of nonelderly adults favor keeping the Medicaid expansion and nearly 70 percent favor keeping the premium subsidies, previous legislation eliminating or weakening these provisions passed the House by a vote of 217–213 (with House votes by district shown in Exhibit 1) and fell just a few votes short of passing the Senate. ACA protections for people with preexisting conditions—including guaranteed issue, community rating, and essential health benefits—are even more popular, eliciting support of 80 percent to 90 percent of nonelderly adults, and age rating limits are supported by three-quarters of adults.

A possible explanation for the perseverance toward repeal despite its unpopularity is that residents in districts and states where members of Congress voted for repeal may exhibit less support for key ACA provisions compared to those living in districts and states where members voted against repeal. If favorability toward these provisions varies widely across politically polarized Congressional districts and states, voting patterns in Congress may simply reflect legislators’ responsiveness to the preferences of their constituents. In contrast, if favorability toward ACA provisions is high across districts and states, it would indicate that the push for repeal is motivated by factors beyond constituent demands.

Most Nonelderly Adults Support Keeping Core ACA Provisions In Districts Where Members Of The House Voted For Repeal

To understand the link between congressional votes and public opinion on ACA repeal, we used data from the Urban Institute’s March 2017 Health Reform Monitoring Survey to examine public support for keeping or repealing core ACA provisions among a sample of more than 9,500 nonelderly adults—and the potential impact of repeal on coverage—based on how their member of the US House of Representatives voted for the American Health Care Act (AHCA) last May and how their senators voted for the Better Care Reconciliation Act (BCRA) and Obamacare Repeal and Reconciliation Act (ORRA) last July. Senators voted on a third repeal bill, the Health Care Freedom Act, that would have eliminated the individual mandate without directly targeting other core coverage provisions described in the survey.

We found that although support was somewhat lower in House districts where representatives voted for the AHCA, 75.2 percent of adults in these districts supported keeping the Medicaid expansion and 64.3 percent of them supported keeping the premium subsidies (Exhibit 2). In districts where representatives voted against AHCA, support was 81.0 percent for Medicaid expansion and 72.6 percent for the premium subsidies. There were no differences by districts’ House votes in support for the ACA’s guaranteed issue and community rating provisions, and only slightly higher support for essential health benefit requirements and age rating limits in districts where representatives voted against the AHCA.

Little Or No Variation Across States In Support For Core ACA Provisions

Support for Medicaid expansion did not vary across states. In states where at least one senator voted for either the BCRA or the ORRA, 77.5 percent of adults supported keeping the Medicaid expansion, which is not significantly different from the 79.1 percent supporting Medicaid expansion in states where both senators voted against both repeal bills (Exhibit 3). Support for keeping premium subsidies was somewhat lower in states where a senator voted for repeal (65.7 percent versus 71.9 percent). In states where both senators voted against both repeal bills, adults were only 2.2 percentage points more likely to support guaranteed issue, 2.0 percentage points more likely to support community rating, and 4.3 percentage points more likely to support age rating limits relative to adults in states where at least one senator voted for repeal. Support for essential health benefits was similar in each state group.

It is possible that members of Congress are more responsive to certain segments of their districts and states, including those individuals who are most likely to vote or those who participate in primary elections. However, we found that in districts where representatives voted for the AHCA, support for most core ACA provisions was high among those who either self-identify as Republicans or lean toward the Republican Party platform, including those who refer to themselves as “strong” Republicans (Exhibit 4). Majorities of both groups supported keeping the Medicaid expansion and consumer protections. About half of those who identify as Republican or lean Republican and 41 percent of strong Republicans supported keeping the premium subsidies. Similar patterns were found among Republicans in states where at least one senator voted for repeal. We also found widespread support across all districts and states among groups with high voter participation rates, including those ages 50–64 and those with high levels of education and income (data not shown).

Repeal Would Jeopardize Coverage And Benefits Of Adults Across House Districts

Adults with Marketplace coverage or Medicaid—including the Medicaid expansion population and those enrolled in Medicaid under pre-ACA eligibility rules—could be affected by repeal of Medicaid expansion, benefit cuts resulting from the establishment of per capita caps on Medicaid funding, elimination of premium subsidies, and/or loss of consumer protections. The share of adults with these types of coverage is larger in House districts where representatives voted against the AHCA. However, these changes would still affect many adults in districts where representatives voted for the AHCA. About 1 in 5 adults (19.5 percent) in House districts where members voted against repeal were enrolled in Medicaid or Marketplace coverage, compared to about 1 in 6 adults (16.3 percent) in House districts where members voted for repeal (Exhibit 5). These differences were driven by the higher Medicaid enrollment in states expanding Medicaid, where representatives were more likely to vote against the AHCA; there were no significant differences in Marketplace enrollment. An additional 3 percent of adults were enrolled in non-Marketplace nongroup coverage both in districts where representatives voted for the AHCA and in districts where they did not. These adults are not eligible for premium subsidies but could lose protections against discrimination by age or health status. Nearly two-thirds (63.3 percent) of adults with Marketplace plans with a premium reported that their premium was subsidized (data not shown). Another 18.5 percent of Marketplace enrollees with a premium did not know whether they received a subsidy, indicating that the 63.3 percent reporting a subsidy represents a lower bound on the share with subsidized coverage.

In States Where Senators Voted For Repeal, A Larger Share Of The Population Would Be At Risk Of Losing Marketplace Coverage

Although adults were more likely to be enrolled in Medicaid in states where both senators voted against both repeal bills (which were generally Medicaid expansion states) than in states where at least one senator voted for repeal (14.8 percent versus 10.7 percent), Marketplace coverage was slightly higher in states where a senator voted for repeal (6.0 percent versus 4.6 percent) (Exhibit 5). The difference in Marketplace enrollment is likely due in part to eligibility for Marketplace subsidies for adults with incomes between 100 percent and 138 percent of the federal poverty level in states that did not expand Medicaid.

Limitations To The Analysis

One limitation to this analysis is that our sample is only adults ages 18–64, and there may be more variation in public opinion toward the ACA across districts and states among the elderly population. However, we found similar patterns across states and districts when we limited our sample to adults ages 60–64, suggesting levels of support across districts and states may be consistent for older age groups as well. In addition, public opinion toward the ACA has changed since March 2017, although most polls have shown a rise in support for the ACA, and growing opposition to repeal legislation would suggest an even larger gap between congressional efforts and constituent preferences.

Without A Strategy For Protecting Coverage, Repealing Core ACA Provisions Threatens Recent Gains In Health Care Access

These findings suggest that congressional votes to repeal the ACA’s core financial assistance provisions and consumer protections are not aligned with the preferences of constituents. Moreover, the potential loss of coverage and benefits from repealing these provisions and transforming Medicaid financing is high in both areas where members of Congress are pursuing repeal and areas where members have opposed repeal. Public opinion and concern for those who would be harmed may have helped derail repeal efforts thus far, but Republicans have come close to securing a legislative majority that is not deterred by these factors. If legislation modeled on Graham-Cassidy or previous repeal bills succeeds without a clear strategy for sustaining coverage, it is likely to reverse the recent gains in health care access and affordability in districts and states across the country.