The announcement of the death of the AHAC and the president’s prediction of the “explosion” of the ACA broke in an unusual way. Robert Costa of the Washington Post got the word directly from the president and then tweeted that the AHAC was being withdrawn before Paul Ryan had a chance to meet with Republican House members to tell them of the big decision. Costa published an article about the surprising call he received. Costa wrote:


President Trump called me on my cellphone Friday afternoon at 3:31 p.m. At first I thought it was a reader with a complaint since it was a blocked number.

Instead, it was the president calling from the Oval Office. His voice was even, his tone muted. He did not bury the lead.

“Hello, Bob,” Trump began. “So, we just pulled it.”….

Before I could ask a question, Trump plunged into his explanation of the politics of deciding to call off a vote on a bill he had been touting.

The Democrats, he said, were to blame.

“We couldn’t get one Democratic vote, and we were a little bit shy, very little, but it was still a little bit shy, so we pulled it,” Trump said.

Trump said he would not put the bill on the floor in the coming weeks. He is willing to wait and watch the current law continue and, in his view, encounter problems. And he believes that Democrats will eventually want to work with him on some kind of legislative fix to Obamacare, although he did not say when that would be.

“As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal. And they will come to us; we won’t have to come to them,” he said. “After Obamacare explodes.”

“The beauty,” Trump continued, “is that they own Obamacare. So when it explodes, they come to us, and we make one beautiful deal for the people.”

An hour later flanked by Vice President Pence and Secretary Price of HHS, the president made the same statement before cameras in the Oval Office.


Costa reports more of their conversation:

As he waits for Democrats, I asked, what’s next on health care, if anything, policy-wise?

“Time will tell. Obamacare is in for some rough days. You understand that. It’s in for some rough, rough days,” Trump said.

“I’ll fix it as it explodes,” he said. “They’re going to come to ask for help. They’re going to have to. Here’s the good news: Health care is now totally the property of the Democrats.”

Speaking of premium increases, Trump said: “When people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”

He returned again to a partisan line on the turn of events.

“To be honest, the biggest losers today are Nancy Pelosi and Chuck Schumer,” Trump said of the House minority leader and the Senate minority leader. “Because now they own the disaster known as Obamacare.”

After predicting disaster, the president tweeted reassurance to all Americans.


Donald J. TrumpVerified account @realDonaldTrump  Mar 25


ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!

Over the weekend the president expanded his criticism of those who were blamed for the failure of the AHCA to make it out of the House:


Donald J. TrumpVerified account @realDonaldTrump  Mar 26


Democrats are smiling in D.C. that the Freedom Caucus, with the help of Club For Growth and Heritage, have saved Planned Parenthood & Ocare!


The mantra of the president and the speaker is that the ACA is both the law of the land and it will remain a disaster.  Neither of them, nor Dr. Tom Price, the Secretary of HHS, seem to recognize that they have taken an oath to enforce our laws and have a moral and constitutional obligation to support the ACA as long as it remains the law of the land if they can not repeal it and are unwilling to improve it.


We should take the president’s prediction very seriously because his administration does have the ability to blow up the ACA or kill it by a combination of benign neglect and active assaults. The bill has been wounded by actions that most people do not recognize. Marco Rubio tried to use his successful attack on the ACA as a reason that he should have been the Republican nominee for president. Robert Pear’s article in the New York Times in December 2015 was a prediction of the disruptions and difficulties experienced in the exchanges this year that Rubio enabled.  Rubio’s work allows the president and speaker to speak so ominously about the ACA’s future:


A little-noticed health care provision slipped into a giant spending law last year has tangled up the Obama administration, sent tremors through health insurance markets and rattled confidence in the durability of President Obama’s signature health law.

The attack stems from two years of effort by Senator Marco Rubio and others in Congress to undermine a key financing mechanism in the law. So for all the Republican talk about dismantling the Affordable Care Act, one Republican presidential hopeful has actually done something toward achieving that goal.

Mr. Rubio’s efforts against the so-called risk corridor provision of the health law have hardly risen to the forefront of the race for the Republican presidential nomination, but his plan limiting how much the government can spend to protect insurance companies against financial losses has shown the effectiveness of quiet legislative sabotage.


President Trump began his attack on the ACA shortly after his inauguration as many of us noted with horror and  as Noam Levey documented in the LA Times in late January.


The Trump administration’s decision to pull television ads urging Americans to sign up for coverage under the Affordable Care Act is stoking fears that the White House is trying to sabotage the nation’s insurance markets in an effort to hobble the program, jeopardizing coverage for millions.

The move, which comes just days ahead of a critical enrollment deadline for Obamacare health plans, follows Trump’s executive order last weekend in which he suggested his administration wouldn’t implement rules crucial to sustaining viable markets.

And it coincides with a concerted effort by Trump and Republican congressional leaders to portray the law as collapsing, despite evidence to the contrary from independent analysts.

Senior Republicans have been pressuring health insurers to publicly declare that Obamacare is failing, according to industry officials. A number of health plan leaders told congressional Republicans that they would not say that, said the officials, who asked not be identified for fear of antagonizing the GOP.

It is easy to be clairvoyant and be certain of the failure of a program when there are so many acts of omission and commission that are available to you as the chief executive. It is a lot easier to undermine the ACA than it is to defend it, improve it, and to dedicate yourself and your administration to making it work because it is the law. What will happen? My guess is that Trump and Company will continue to work toward his prediction. The president knows that the explosion he predicts will occur because he knows who will light the fuse. We live with the ACA in  a metastable moment.

What else do we know? We know that the AHCA was not a legitimate path toward


…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.


Nothing was a clearer demonstration of the fact that Paul Ryan’s AHAC was a thinly veiled attack on Medicaid and an attempt at tax relief than were his attempts to gain the support of the “Freedom Caucus.” The president and the speaker were caught between their promise to their base to make the repeal of Obamacare job #1 and the reality that despite all of its imperfections the ACA is a remarkable initial piece of social legislation that more and more people were finally recognizing for the lives it was saving and improving everyday that it survived.


The AHAC as it was proposed took deep whacks at Medicaid. As its passage seemed less and less likely Ryan and Trump were willing to sacrifice the Essential Health Benefits for all Americans that the ACA required in every policy. What those last minute attempts to get the AHAC through the House revealed was that access, quality and lowering the cost of care were  not the objectives of the president despite all of his words about being able to give us care better than we had ever had for less money. Lower taxes were the objective and the big winners would have been those who get their care from their employer along with a six or seven figure income. More Americans came to realize finally as the debate occurred that the losers would be the underserved and the safety net institutions like the Boston Medical Center and the other practices and institutions who are challenged daily to solve enormous problems with limited and shrinking resources. Many respected economists believed that in time the bill would have increased the cost of care for all Americans compared to what they could expect from the flawed ACA.


The withdrawal of the AHCA was a retreat but not a defeat for those who do not believe healthcare is an entitlement worth the best efforts of the nation but rather a consumer choice to be purchased by those who have the means. That mindset persists and it controls HHS. The ACA is the law of the land, but its guardians don’t care for it, or for the ideas upon which it is constructed.


Former President Obama laid out plausible paths for improvement of the ACA in articles published earlier this year in the New England Journal of Medicine and JAMA. If President Trump was inclined to learn more to enable him to deliver on his campaign promise to the American people that he would guarantee them fabulous healthcare, I would suggest that he consult a recent article in the Harvard Business Review about ways to improve the ACA written by David Blumenthal and Sarah Collins.


The AHCA produced many nervous healthcare executives and governors who were wondering how the gains of the last seven years would survive after having the rug of Medicaid pulled out from under them. My advise is to hold on to those worries and any plans and ideas they were working on before the bill was pulled.


I recently attended a retreat of the combined boards of the Boston Medical Center that was a proactive response to the challenges that the BMC faces in an era of financial transition and uncertainty. Hundreds of thousands, if not millions of patients who had no resources have received the care they needed through this wonderful institution since its founding one hundred and sixty two years ago. We live in strange times when such a valuable and venerable asset is at risk.


As the presentations and conversations proceeded at the retreat, I was impressed with the strategic thinking that was presented. BMC leaders understand the challenge, and they correctly understand that their response must be a universal process of dramatic transformation. As I listened, I was hoping that responsible institutions and providers around the country were going through the same process. I believe that whatever is the law of the land, the most effective thing that healthcare can do to insure care for the largest number of citizens is to lower the cost of care through waste elimination, process improvement and innovation. I believe through our deep commitment to better care for our patients, we will overcome the current uncertainties that persist around the ACA, and beyond the continuing attack on the concepts upon which the ACA stands, a better world does lie ahead.