To avoid imminent collapse of the health care delivery infrastructure, employ the medical model and strategize accordingly:

History: The GOP wants to remove the individual/employer mandate, to ensure equal tax treatment of premiums, to invoke federalism when determining state-level Medicaid and benefit packages, and to cap federal medicaid expenditures.  The GOP cannot compromise with Democrats, as advised by those who wish to preserve Obamacare's core principles, for such "fixes" would entail  appropriation of more federal monies and establishment of a single-payer system.

Examination: Due to interim damage to free markets experiencing an insurer death spiral as private insurers withdraw from the exchanges, it is impossible merely to "repeal" Obamacare.  Regardless of whether President Trump does or doesn't cut off supplemental funding, it is vital to "replace" it with a system that will allow sufficient time for the private sector to become reactivated.

Assessment: If Republicans cannot salvage this gigantic economic sector, they could lose control of the House in 2018. If they can, the rest of the Trumpian legislative agenda will flow far more easily and The Donald will be better able to focus upon foreign affairs. Fortunately, the House emerged from having faced the morbidity/mortality of potential failure in the wake of withdrawal of the AHCA from the House floor.

Plan: To win support from the four conservative senators (Cruz, Johnson, Lee, Paul) who are reticent to endorse Trumpcare, it is necessary to ensure that the cost curve of health insurance will bend downward.  Restoring competition to the max is mandatory.

Diagnostically, a false dilemma has been fanned by the media – to wit, that it is impossible for the delicately balanced American Health Care Act to extricate America from the Affordable Care Act.  Although the focus has been trained upon the need for recipients of Medicaid expansion to switch to private plans by invoking tax credits, the necessity for the middle class to find a program that meets fundamental needs affects the bulk of the population.

Therapeutically, all that needs to be done is for the Senate to join the House in repealing the limited McCarran-Ferguson antitrust exemption for health insurers.  They can co-adopt H.R. 372, the "Competitive Health Insurance Reform Act of 2017," which was passed by by a bipartisan vote of 416-7.

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To appreciate how this one intervention will help holdouts "get there," appreciate the academic approach that will dictate a positive outcome.

Materials: Republicans heeded Walt Kelly's warning – enunciated in the comic strip Pogo during the Vietnam War era – that "we have met the enemy, and he is us" by recognizing that they cannot re-pass the Restoring Americans' Healthcare Freedom Reconciliation Act of 2015 (H.R. 3762), despite its being a scaled down version of any repeal bill.  This was a dry run that contained language that could trigger a precedent-setting adverse ruling by the Senate parliamentarian that would impede subsequent passage via reconciliation.

Methods: After these core operational questions entered mainstream debate and key players revealed their priorities, disinterested, evidence-based analysis prompted enactment of an amended bill that can transition a decimated marketplace – arguably Obama's goal – into a rejuvenated competitive environment.  Republicans have acted in good faith while bridging the gap between its poles (Freedom Caucus and Tuesday Group) – for example, while compiling what constitutes "essential" insurance benefits.

Interim Analysis: After the initial draft was withdrawn, Trump played the whirling dervish, being taken "seriously, but not literally."  He acted out his "Art of the Deal" capacity to (a) walk away and (b) direct bombast against the obstructionists of the moment.

Research Subjects: Trump launched a renewed negotiation initiative while golfing with Senator Paul on a Sunday and meeting with moderates on a Monday.  Meanwhile, Vice President Pence was meeting with the Freedom Caucus that Monday night, listening to the rationale for eliminating all three Obamacare mandates – benefits, insurability, community rating – as reiterated by Rep. Jim Jordan (listen at 8:45 a.m. EDT) – so that free-markets would be restored expeditiously and responsibly. 

Side Effects: The Freedom Caucus wanted to avoid a premium hike that would adversely impact a large number of their contituents, despite reassurances that this would be only temporary as the energized economy grows (diminishing the number of Medicaid recipients) and the health insurance industry recovers (increasing the number of competing insurers). 

Final Analysis: The contretemps over "Obamacare Lite" could be obviated by invoking Maine's successful experience when covering pre-existing conditions by creating risk pools.  Throughout, recognized was the lack of any need to hold extensive multi-committee hearings and/or to abide by updated CBO projections.

Results: These concerns prompted passage of the Upton Amendment, which accommmodated "centrist" legislators, most of whom are not vulnerable during the 2018 election cycle, who want to ensure that premiums don't skyrocket.  The key innovation was to empower states to issue opt-out waivers, particularly regarding Medicaid expansion, without engaging in a blame game.

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To place this experience into historical context, the outcome of this process merits discussion.

Background: Two prior essays detailed a pivotal method to achieve passage (overturn the Byrd Rule to overcome the Senate filibuster) and the need to collaborate ASAP (honor the essence of the Freedom Caucus message even if some ACA taxes must be retained and rehab for drug abusers must be underwritten).  Someone must have noted the first essay, for, following confirmation of Justice Neil Gorsuch, prophylactic opposition abruptly emerged against overcoming the Byrd Rule by invoking a second nuclear option, this to promote the fanciful goal of bipartisanship.

Literature Review: During the spring recess, Freedom Caucus members projected burgeoning openness, while Tuesday Group members exuded shared moderation with Speaker Ryan.  Republicans overcame the cacophony emanating from liberal media echo chambers, countering unrelenting attacks targeting Trump's "mental status" (c/o MSNBC's Joe Scarborough) and "troubled" administration (c/o CNN's Chris Cuomo) by Democrats who invoke intersectionality to demonize Republicans, regardless of their vote on the AHCA.

Future Studies: An overlooked example of secondary gain emanating from AHCA passage would be cutting D.C. paternalism, manifest, for example, by eliminating the Prevention and Public Health Fund, which, inter alia, undermines use of vaping as a tobacco risk reduction tool.  And a professional reminder of the dangers of a single-payer system emerged when it was discovered that the technical component of out-of-hospital testing of a Medicare patient cannot be billed by the hospital if he is an in-patient or less than 14 days post-discharge, thereby arbitrarily delaying acquisition of lung cancer tumor markers.

Optional Pursuit: Finally, an overlooked intervention would be to reprivatize the federal student loan program, which the ACA centralized.  This is an albatross for which Demcrats are responsible, yet they have consistently, subsequently decried it, even as they have plotted to expand it.

Conclusion: Permeating this recap is recognition that the GOP will be able to "sell" the AHCA if it demonstrably lowers premiums, and concomitant repeal of the health insurers' antitrust protection will immediately achieve this goal by maximizing insurer competition.  This is how lemonade will be squeezed out from the lemony portions of the AHCA.

Robert B. Sklaroff, M.D. is a political activist who gratefully acknowledges the clarity exhaustively provided by Bill Pascoe of Tea Party Patriots.