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Lessons for the next act on health care

Rebecca Zisser / Axios

When Congress comes back next week, it's going to start the next chapter on the Affordable Care Act — and it probably will set its sights a lot lower for changing the law, now that the repeal effort has collapsed. There are a lot of lessons Republicans can learn from the failure that effort — and a few that Democrats can learn too, if they're honest about their own experiences since the ACA became law.

Here are the main lessons for the next round.

Do it step by step. That's how Senate HELP Committee chairman Lamar Alexander says he wants to handle it, starting with a limited bill to stabilize the ACA markets.

Republicans have to decide what they want. Stanford's Lanhee Chen said it became clear during the repeal debate just how deeply divided conservatives are on health care policy, to the point where they couldn't rally around any alternative to the ACA. “Those differences will outlive the debate we just went through and go on to impact discussions about health reform going forward," he said.

The details matter. It wasn't just John McCain who said a big health care bill should go through hearings. Lisa Murkowski said her “no" vote was meant as a warning that "We're not ready to go to the floor to wrap this up." Now Alexander and Democratic Sen. Patty Murray will have hearings on their bill — a chance to grapple with the details even if the bill is smaller.

If one party owns it, it doesn't last. This is a lesson for both parties. When Democrats passed the ACA on their own, it was only safe as long as a Democrat was in the White House. Under a Republican president, there's no guarantee it will get the minimum support to survive. If Republicans rewrote the health care system by themselves, they would have been taking the same risk. (So, Democrats — single payer? Really?)

Ditch the talking points. Rodney Whitlock, a former Senate Republican aide when the ACA was passed, said the Alexander-Murray hearings could help by forcing Republicans to face the need for the risk sharing protections — and by forcing Democrats to figure out what they're actually willing to do to improve the ACA, not just talk in single-payer applause lines.

Don't overpromise. Funny thing about both the repeal debate and the original ACA debate — they both promised lots of winners and no losers. That doesn't happen in health care. Greater benefits force healthy people to pay more than they want to pay, skimpier benefits are cheaper but hurt vulnerable people. As Whitlock put it: “In health care, there's no such thing as a free lunch."

You can change the ACA, but you're not going to get rid of it. Unless Senate Republicans find that 50th vote — and there's no sign that they're anywhere close — the next chapter is going to be about putting a more conservative stamp on it. Turns out John Boehner was right.

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