I am going to be frank here. This issue is very close to my heart, due to harsh and difficult to overcome life experiences.

The ACA is what was possible at the time it was enacted. One party holding a blanket "no" position very seriously diluted what was actually possible. Most notably, the opposition wasn't over a better way. It was all about simply not beginning the process to improve. Today, that opposition is pointing to tepid results, and they are right about those results, while completely ignoring their reasoned and deliberate efforts to insure the results are tepid at best.

They desire failure in the hopes that we can return to ignoring this problem, not that they have a better vision, or can contribute in some other meaningful way.

Understanding that is important.

Really, the most meaningful aspect of the ACA is that it represents us getting started on health care reform long overdue. Popular support for the idea of improving health care runs consistently high. Our costs are roughly 2X above the second most expensive system in the world and are not sustainable. Most of us feel this impact, and the need to improve is obvious.

A handful of votes would have transformed the ACA from the tepid legislation is is today. One notable omission is public, "cost plus" insurance access, potentially a Medicare buy in plan. This would have done a lot to improve on price control and foster competition as well as experimentation with public, "cost plus" type delivery systems too. We could take care of a lot of people for a lot less money given just a little innovation in this space. Some nations get by on tech from the 70's and 80's and have overall outcomes comparable and, in some cases, better than our aggregate outcomes now.

Regardless of where you stand on all of that, the reality is we finally got started. 40 years overdue. And it's all a little bit better now in aggregate, and life changing for some 20 million plus Americans today.

Now that we have started, it's time to improve on the ACA, and the more we do and the sooner we do it, the better off we all will be. That's the real message.

Don't like the ACA? Great! Neither do I. We had to get started somewhere, and the ACA was that possible start, diluted only by people unwilling to actually start to do the work to improve this for everyone.

The question really isn't repeal or not. The question is how to continue to improve. Given the costs, we need to very seriously improve.

There is no death spiral. The ACA is working as intended and it's doing a lot of people real good in terms of access to health care and debt / bankruptcy related to health care. Had the ACA been law a few years before, I would have been able to avoid the choice between losing everything, or losing somebody I love.

Of course, she is still here, and that is good, but my financial life will never be the same. Just imagine all your gains, home, etc... gone at 40 something. That is what happens to people. And it still does, but the ACA puts some real options out there that really do help a lot of people avoid that scenario and doing that is really worth it. I know my life would be very different today had the ACA been law.

It's easy for people of means, or who have good insurance through their employer, etc... to rage on about the "injustice" of the ACA. Whatever. No joke there. I really am being dismissive, because the value of getting started on this problem in the USA really is as big of a deal as proponents make it out to be.

It's much harder to talk about fact based, data driven rational policy intended to improve the deplorable state of health care policy in the USA today. Quite frankly, it's not enough to repeal. The end game on that is unacceptable to the vast majority of Americans.

No, the real denial is over the great need to continue the journey we started with the ACA. A "replace" type proposal is plausible. An "improve" type proposal is likely possible and practical.

Repeal is a dead end with no meaningful end game for anyone really.