The Trump administration, working with governors and state legislatures, could make dramatic state by state changes to Medicaid and the ACA marketplaces using two types of state innovation waivers. Section 1332 of the ACA, which went into effect on Jan. 1, 2017, lets states waive several key provisions of the ACA, including the individual mandate, the employer mandate, the premium tax credit, cost-sharing subsidies, and essential health benefits for ACA marketplace plans. In short, Section 1332 (ACA) waivers let states operate their health care systems as if major parts of the ACA do not exist. Additionally, Section 1115 (Medicaid) waivers give states the opportunity to waive federal Medicaid law. The changes made possible by Section 1115 waivers aren’t as dramatic as those contained in the AHCA—for example, states can’t use these waivers to fully restructure Medicaid under block grants or per capita caps, nor can the federal government use them to take away federal reimbursements for Medicaid expansion—but they are still significant.

. . .

The seeds of Friday’s failure to pass a health care bill were sown long ago, back when the Republicans used “repeal and replace” as a rallying cry in their successful campaign to regain control of the U.S. House of Representatives. Return to the status quo ante is not nor has ever been possible and the insurance markets have been changed too much by Obamacare for that to happen. However, the various actors inside the Republican’s House majority could not agree on what “repeal and replace” meant.  Whether it was to be done all at once or in stages was never decided, never agreed upon except by congressional leadership who essentially sprung their approach on everyone else.

. . .

President Donald Trump blamed Democrats for the defeat of his bid to overturn the 2010 Affordable Care Act and enact Republican policy in its place. In some ways he may have been right.

Supporters of the health law popularly known as Obamacare launched an all-out campaign for its survival, keeping Democrats unified in opposition to its repeal, and identifying and exploiting Republican divisions that ultimately forced GOP leaders to pull the bill at the eleventh hour Friday.

In every corner were top officials from former President Barack Obama’s administration, reeling from an election that put their party out of government and left them with plenty of free time on their hands.

. . .

With the collapse of Republicans’ health plan in the House on Friday, the Trump administration is set to ramp up its efforts to alter the Affordable Care Act in one of the few ways it has left—by making changes to the law through waivers and rule changes.

The initiative now rests with Health and Human Services Secretary Tom Price, who has vowed to review every page of regulation and guidance related to the ACA. The steps he and the administration take next could have sweeping repercussions, accomplishing some of the same types of changes Republicans were unable to push through Congress.

. . .

Last night Phil Klein had a report that is much more significant than I think a lot of people have realized:

Sen. Mike Lee, R-Utah, said on Wednesday that the Senate parliamentarian has told him that it may be possible for Republicans to push harder on repealing Obamacare’s regulations than the current House bill, which contradicts the assertion by House leadership that the legislation goes after Obamacare as aggressively as possible under Senate rules. . . . Lee also said that the parliamentarian told him it wasn’t until very recently, after the unveiling of the House bill, that any Republican even asked her about the possibility of repealing regulations with a simple majority.

. . .

Business groups were hoping a quick repeal of the Affordable Care Act would give employers more flexibility on health care and create momentum for priorities like a tax overhaul.

Friday’s decision by House GOP leaders and President Donald Trump to abandon a vote on the Republican health plan left them less certain on both fronts.

“This is a dismal failure,” said Juanita Duggan, chief executive of the National Federation of Independent Business, a group representing small businesses. “NFIB is officially unamused, and we’re not going to let them off the hook.”

. . .

There is no precise headcount of how many people have gained coverage because of the Affordable Care Act. And it is downright impossible to reliably estimate the number of people who might lose coverage if Congress repeals and replaces it. The “20 million” figure appears to have originated in a March 2016 report by the U.S. Department of Health and Human Services. That report declared that “the provisions of the ACA have resulted in gains in health insurance coverage for 20.0 million adults through early 2016.”

Estimates by the Heritage Foundation find that 14 million people (including children) gained public or private coverage in 2014 and 2015. Unlike government surveys, Heritage examined data from insurance company regulatory filings and from the government’s own headcount of Medicaid enrollment.

They found that 84% of the newly insured gained coverage through Medicaid and a related government program for low-income children.

. . .

Speaker Paul Ryan and House leaders had been toiling behind closed doors for weeks assembling their Obamacare repeal bill as suspicion on the far-right simmered to a boil.

So on March 7, just hours after Ryan unveiled a plan that confirmed its worst fears, the House Freedom Caucus rushed to devise a counterstrategy.

In a conference room in the Rayburn House Office Building, the group met that evening and made a secret pact. No member would commit his vote before consulting with the entire group — not even if Trump himself called to ask for an on-the-spot commitment.

Twenty-eight of the group’s roughly three dozen members took the plunge.

. . .

What politicians, those hardy folk, don’t understand about health care is how anxious it makes their constituents. Not suspicious, not obstinate, but anxious. Because unlike such policy questions as tax reform, health care can be an immediate life-or-death issue for you. It has to do with whether, when, and where you can get the chemo if you’re sick, and how long they’ll let you stay in the hospital when you have nobody, or nobody reliable and nearby, to care for you. To make it worse, the issue is all hopelessly complicated and complex and pits you as an individual against huge institutions—the insurance company that doesn’t answer the phone, the hospital that says “I’m afraid that’s not covered”—and you have to make the right decisions.

. . .

House Republicans pulled their health-care bill shortly before a vote on Friday, and for once the media dirge is right about a GOP defeat. This is a major blow to the Trump Presidency, the GOP majority in Congress, and especially to the cause of reforming and limiting government.

The damage is all the more acute because it was self-inflicted. President Trump was right to say on Friday that Democrats provided no help, but Democrats were never going to vote to repeal President Obama’s most important legislation. And that’s no excuse. Republicans have campaigned for more than seven years on repealing and replacing ObamaCare, and they finally have a President ready to sign it. In the clutch they choked.

. . .