If Congress can't pass a bill, with or without Democrat support, they'll face similar pressure in two years, perhaps in the midst of a "horrendous fiscal situation."
Despite a high-profile effort and public failure, Republicans aren't finished with healthcare. Or, it might be said, healthcare isn't quite finished with Republicans.
Despite earlier signals that they would move on from healthcare legislation, the Trump administration seems like it wants to try again.
The odds that its next attempt will also fail have to be at least even, so whether that's smart politics are not is arguable.
But Obamacare does need some changes to avoid longer-term ills that include exploding federal deficits, in an economic recession that is sure to come at some point, says Jeff Goldsmith, a national adviser to Navigant's healthcare practice.
Goldsmith, a self-described healthcare futurist and associate professor of Health Sciences at the University of Virginia, says the hundred billion-dollar-plus annual outlays for the as yet unrepealed and unreplaced Affordable Care Act pales by comparison to the trillion dollars a year currently spent on Medicare and Medicaid, which represent an existential threat to the U.S. economy.
"If this process fails, we're right back at it in two years in midst of a horrendous fiscal situation," he says.
'A Morass'
That situation would get notably worse should interest rates and recession risks rise, as is expected.
"This is such a morass. Unless that is contained we've got a terrible fiscal problem," he says, noting that he is a fan neither of the ACA or the recently failed Republican alternative.
Goldsmith says the core purpose of the failed bill was not to fix the problem of runaway healthcare costs, but simply to "undo the redistribution of income at the heart of the ACA, which itself was taking money from wealthy and giving to the working poor in clumsy way."
A Quagmire
Goldsmith says legislation surrounding healthcare in recent years proves the wry saying attributed to Lewis Carrol's Alice in Wonderland: "If you don't know where you're going, any road will take you there."
"The ACA was a good deed done badly, is the way I've put it to my students," he says. "But the difference in getting it passed was that there was strong and consistent political guidance from the White House."
That guidance included rough agreements reached at various White House summits with interest groups. Each group agreed to broad ideas of what they would give up in return for gaining insurance coverage for millions more Americans through their support, or at least their indifference, to the ACA.
And still, the ACA passed with no Republican support.
"They did it with full connivance and support of the industry," Goldsmith says. "That's a very large group of actors who have played almost no role in this process—something else that ought to give the Republicans pause."
That kind of prior agreement among factions wasn't present in the recent failed bill.
But Goldsmith says the ACA needs tough changes, if not the long promised repeal-and-replacement, because of its contribution to future deficits, especially in (forecast) times of economic malaise.
"That 72 million who are on Medicaid goes to 80 million in a recession and the federal deficit already grew 40% from 2015 to 2016," he says.
"We're nearing the end of an expansion. What happens when state and federal revenues fall and people lose their jobs and the rolls grow?"
Head Down, Manage Prudently
In some ways, managing a healthcare organization remains relatively simple amid the uncertainty. At least the road map is pretty well laid out.
Providers will see diminished cash flow, which means they must continue to focus on efficiency and try to move payers toward putting them in charge of managing healthcare for a regularly paid flat fee per member—that is, taking on risk.
"If I'm a health system CEO, I'm looking at my community care strategy. I'm looking at the strength and comprehensiveness of my network and how I can contract meaningfully with health plans," Goldsmith says.
"You don't need a bill to pass to do these things, it's just prudent management."
Regardless, he says, hospitals will get hurt no matter what happens in the form of reduced payment, increased bad debt, or both.
Hospitals had been exerting a lot of energy in learning how to practice population health in self-defense.
Apparently, given the lack of vision and cooperation that should exist if people of good will really want to try to fix healthcare in a fair and fiscally sustainable way, they should continue to do so.
Philip Betbeze is the senior leadership editor at HealthLeaders.