By failing to repeal the Affordable Care Act and then proceeding to enact a series of changes (e.g. repealing the individual mandate), Republicans have an interesting quandary: Do they help sustain the ACA to show their policy changes were wise, thereby cementing the ACA as a permanent part of the entitlement scheme? The answer is that it seems virtually inevitable — and is happening already.

Drew Altman of the Kaiser Family Foundation has an interesting take:

As they make a series of changes — through waivers and other means — to swing the programs to the right, [GOP governors] are building a broader political base for the programs in red states. That could make ACA repeal and Medicaid cuts an even tougher sell in the future than it is now. …

Idaho is one flashpoint, where the state has tried to permit insurers to offer skimpier but cheaper non-ACA compliant plans to the healthy that could push up premiums for sicker people. The federal government has stopped the state from moving ahead, while leaving the door open for it to accomplish its aims in a different way.

Kentucky has been another hot zone, as the state is being sued to block its Medicaid work requirement approved under a new waiver.

Indiana and Arkansas are two other states with controversial waiver provisions.

Waivers themselves are under fire.  They are supposed to be used for research and demonstration purposes, but administrations have long pushed the boundaries of waiver authority to pursue their own policy goals.

These changes to the ACA and Medicaid could have enormous consequences for consumers in these states. But Kentucky, Indiana, Arkansas, Idaho and Iowa have already fashioned more red-state-friendly programs, and more will follow.

Altman suggests that in touting their own fixes, Republicans will broaden the base of support for the ACA (at a new high of 54 percent). He argues, “The end result, which won’t make either side happy, could well be a broader political constituency for both the ACA and Medicaid.”

Moreover, the Trump administration, by taking the reins now, will be asked to address the downsides of the health insurance system — whether related to their ACA changes or not — just as the Obama administration had to shoulder the burden of the shortcomings of everything, from premium costs in the exchanges to increases in employer-provided insurance (which the ACA essentially left alone).

The Post reported on the train wreck awaiting Trump voters. “Insurance premiums for Affordable Care Act health plans are likely to jump by 35 to 94 percent around the country within the next three years, according to a new report concluding that recent federal decisions will have a profound effect on prices.” While states will differ, “a broad swath of the South and parts of the Midwest” — Trump country — may face “catastrophic” increases. And Republicans won’t be able to pass the buck on this one:

According to the analysis, the largest single impact will come from eliminating, starting in 2019, the ACA’s penalty for Americans who violate the law’s requirement that most people in the United States carry health coverage. That change alone, part of a massive tax bill Congress adopted in December, can be expected to increase premiums by 7 to 15 percent next year, depending on the state, and as much as 10 percent each of the following two years.

In short, while the GOP may intend to hobble the ACA, it is likely in fact to build support for it — and take the blame when its changes hit home, especially in deep-red states. Trump voters may soon find out that hollering “Repeal Obamacare!” looks a whole lot different when your own premium nearly doubles in cost. They may pine for the days when the ACA worked better.