As the Republicans are learning, balancing health care affordability with access and cost control is like a game of Jenga® played with razor blades. (Photo: iStock)

You may not know the name Rufus E. Miles, Jr., after whom “Miles’ Law” is named, but his eponymous dictum is in full evidence as the Republicans make their Sisyphean effort to “repeal and replace” all things ACA.

In 1948, Miles was serving the Truman administration as Chief of the Labor and Welfare branch at the Bureau of the Budget. One of his examiners took a higher paying position at another agency of which the examiner had been highly critical. Miles predicted that the examiner would stop being critical of his new agency and would instead become an outspoken critic of the Bureau of the Budget. Asked why he believed this, Miles said, “Where you stand depends on where you sit.” That became known as “Miles’ Law.”

What may or may not be resolved between the time I write this column and the time you read it is uncertain. What is absolutely certain is that Republican factionalism coupled with the GOP’s seemingly genetic inability to effectively message is creating significant challenges for President Donald Trump’s “Repeal and Replace” campaign promise.

Related: Review and revision are key to ACA reform

From the start, the Republicans stumbled in their messaging. The House proudly announced their bill. Mere minutes later, more conservative Republicans were arguing that not only was it nothing close to “repeal,” but it failed the “replace” test as well. It took the House leadership several days and a really lame PowerPoint presentation to explain that this was just the first of a multi-part strategy, and that the initial salvo was moving forward under reconciliation because that process carries a lower burden for passing in the Senate.

Yet even that attempt at procedural explanation could not quiet the intra-party factions. Miles’ Law applied equally to the House’s Freedom Caucus and Republican Study Committee, which felt the proposal retained too many ACA policies and principles, and slammed the creation of a seemingly new entitlement program in the form of tax credits. Outside groups such as Heritage Action and the Club for Growth also piled on the refundable tax credit opposition bandwagon.

Related: Pence gives ACA attack update

And still other traditional conservatives criticized the bill, worrying that it would increase the number of uninsured. Under the ACA, the whole “number of uninsured” argument is at best something of a red herring. Having an insurance card in your wallet is not the same as being able to afford the deductibles, co-pays and other out-of-pocket costs that often come before treatment. Regardless, initial reports of the proposed tax credit amounts may leave many with much higher premium costs, thus reducing the number of insured.

Meanwhile, back on The Hill, pretty much everyone other than the Speaker’s core group in the House is foaming at the mouth over the non-repeal repeal. Most, if not all of these folks knew full well that despite the overheated campaign rhetoric, it would be a legislative and regulatory impossibility to blow up the ACA with one shaped charge. Yet the dissention from all quarters — real and perceived — is making the Republicans seem inept at best.

As the Republicans are learning, health care is complex. Balancing affordability with access and cost control is a game of Jenga® played with razor blades. The affordability and the access illusions were completed in 2010 and are now coming home to roost. The cost control component, arguably the linchpin to transparency and the hope of achieving any real reform, has become the third rail of the problem. The courage to deal with cost and its twin sister, transparency, seems nowhere to be found.

Republicans should be wary of how perilously close they are to co-opting Will Rogers’ famous bon mot, “I am not a member of any organized political party. I am a Democrat.” If some are not willing to compromise and change where they sit so they can change where they stand, they will be just one more historical example of another traditionally Democrat practice: the circular firing squad.

Related:

Where’s the Democrats’ ACA repair plan? 

5 agent jabs at a draft ACA date change

Former GOP House speaker thinks ACA system will stay