Alexander Hamilton liked legislative checks and balances, but he's dead. Donald Trump is the president. (Image: Library of Congress)

I think many reporters and analysts who are watching the Affordable Care Act attack efforts in Washington are making the same mistake I made a few weeks ago.

I worked hard to figure out how the Senate rules for considering budget measures and ordinary bills work. I got in so deep that, for a few hours, I could remember the name of the Senate parliamentarian.

I thought that President Donald Trump might have a hard time getting the 60 votes needed to change or replace the ACA under traditional Senate rules, as opposed to simply de-funding it under traditional Senate rules. Or, that he might have a hard time getting major, quick changes to the ACA through the courts.

Then I watched Senate Republicans get Trump cabinet secretaries through the committee review process without the committee member quorums normally required.

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I also saw how Trump changed border control rules with a simple executive order that, as far as I could tell, wasn’t even up on the White House website when it took effect.

Homeland Security John Kelly said Sunday that his department will comply with court orders regarding the executive order. But there have been press reports of U.S. Customs and Border Protection personnel at some airports ignoring the court orders. It’s not clear how easy it is to get the court orders enforced when violations occur.

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After I thought about all of this, I realized that Trump has learned something important from the Obama administration: How to  aside checks and balances, such as Senate procedural rules and court rulings.

For all sorts of high-minded reasons, Obama administration officials blew off many, many House Republican requests for information about ACA programs, such as the Consumer Operated and Oriented Plan program, the ACA cost-sharing reduction subsidy program, and even the ACA Small Business Health Options Program small-group exchange program.

The U.S. Department of Health and Human Services would send official after official to congressional hearings to, in effect, say nothing, in an effort to defend the ACA programs against the Republican meanies in Congress.

HHS officials defied the Republicans in Congress because House Republicans were always trying to strangle the ACA.

HHS officials wanted to defend their ability to offer flawed but potentially life-saving health coverage for the moderate-income sick people who, in many states, had no access to major medical coverage of any kind before the ACA came along.

But the result of HHS people wiggling procedural rules hard to defend the ACA is that they showed Trump and congressional Republicans how to use new and improved versions of that strategy to attack the ACA.

Trump may not have the 60 votes needed to get an ordinary bill through the Senate under traditional Senate procedural rules. But, think about it: Why would Trump pay attention to traditional Senate rules?

So, you say, the federal courts will rule against him and tell him to comply with the rules.

Trump has people on the ground. Judges sit in courtrooms far away. Trump’s people on the ground may not worry all that much about distant judges’ frowny faces.

If that analysis is correct, Trump might have what amounts to a magic wand to do whatever he wants about federal health care rules.

If Trump really does have a magic health policy wand, it seems as if he might use the wand to make the kinds of changes he and other Republicans often made when they were campaigning. Those were the kinds of changes popular with the Tucson, Arizona-based Association of American Physicians and Surgeons.

If TrumpCare will be a version of AAPS Care, then the post-ACA system might involve heavy use of health savings accounts, or the introduction of a flat tax combined with advice that Americans should set aside cash for health care expenses.

In Trump-AAPS Care World:

        • Provider networks might go away.

        • Health plan utilization management efforts might go away.

        • Patients would pay for routine care with their own cash.

        • Major medical insurers would focus mainly on reimbursing consumers for large claims directly.

        • Major medical insurers might offer ”free” preventive care in an effort to get some idea about what the patients were like before they filed large claims.

Another consideration is that insurers’ underwriting margins might depend heavily on insurers’ conversations with Trump and his top aides.

If insurers did a good job of making their case to Trump and his top aides, maybe the administration would be generous, as Trump reportedly was when he met earlier this week with executives from pharmaceutical companies.

If insurers did a poor job of making their case, then Trump and his aides might decide that insurers were the villains and use their policymaking magic wand to punish them.

Allison Bell is a senior editor at LifeHealthPro.com.

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