Andy Slavitt

President Trump is in a big rush for House Republicans to repeal the Affordable Care Act by the time he reaches the 100-day mark on Saturday. This revives what for many Americans has been an agonizing process of watching their access to health care become a political football in the worst tradition of Washington dealmaking — secretive drafting, rushed votes, multiple closed-door sessions and minimal debate.

But as many lawmakers found out over this month’s two-week congressional recess, there is a real debate going on in the real world. The public is increasingly knowledgeable about health care and increasingly united on the role the government should play.

The senators and House members who chose to talk directly to voters heard firsthand stories about what their constituents expect from the health care system. I was at a town hall where a woman tearfully described her fear that she wouldn’t be able to afford the medicine that helps her treat her mental illness if the ACA is repealed. Even at a conservative Chamber of Commerce event I attended, all the health care questions revolved around the increased premiums and the reduction in coverage under the Republican bill.

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The town halls seem to coincide with recent public surveys indicating that the decades-long debate over whether all Americans should have guaranteed access to health care is becoming settled. As Sen. Bill Cassidy, R-La., a physician, summed it up recently, “There’s a widespread recognition that the federal government, Congress, has created the right for every American to have health care.”

The majority also want the government to require insurance companies to cover them whatever their health status and outlaw policies with caps, gaps or hidden “gotchas.”

Americans are proving to be not only engaged, but also surprisingly well-informed — even about complex health care policies. Sen. Dean Heller, R-Nev., found this out when he faced a woman at a town hall who insisted that he state his position on high-risk pools, which she opposed and which are a prominent feature of the newest Trumpcare bill. Very likely, most in the room hadn’t even heard of a high-risk pool two months before, let alone understood how punitive and unworkable they can be for people who need care the most.

It’s clear from the town halls that Americans are no longer satisfied with simple platitudes and talking points that might have worked during campaign season. They have come to recognize that when a buzzword such as “freedom” is applied to the health care debate, it often means the freedom for insurance companies not to cover things most Americans find essential.

Pat Roberts, a conservative senator from Kansas, learned this the hard way. When asked whether he supported getting rid of the guarantee of essential benefits, he joked, “I sure don’t want my mammogram benefits taken away.” He was barraged with stories from the pre-ACA days when plans didn’t cover basic services and lives were lost. He soon apologized.

Roberts is not alone in finding himself out of step with a more informed and activated public. The latest House Trumpcare proposal would let insurers charge sick people significantly more and effectively eliminate access for people with pre-existing conditions.

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Republicans are facing not just one but two immediate votes that for many will pit the interests of their constituents directly against their party leaders. The first involves the government’s commitment to insurers to reduce the cost of deductibles for low-income individuals. Lawmakers could put money for this in a bill they need to pass to keep the government running past Friday. If they don’t, they will reduce access to insurance for millions and could risk a government shutdown in the process. They will also be at odds not only with the public but also with doctors, hospitals, states and bipartisan experts who are united in calling on Congress to keep its commitment.

Republican leaders are also planning a floor vote this week on their latest version of Trumpcare. Given the changes, it could be even more unpopular than the original and force many members to decide whether to vote against their districts or their party bosses. The latter have often come out ahead. Like all bosses, they carry a lot of day-to-day influence. They hand out committee assignments, set the legislative agenda, and help members raise funds for re-election.

After the recess, however, there are signs that voters might be in a stronger position. Rep. Jeff Denham, R-Calif., who had very recently been calling for repealing the ACA, told a town hall that "there are things in the Affordable Care Act we expect to stay." He pledged to make sure any changes are “responsive to my community.”

For many House members who live in districts with much to lose, these votes present a tough choice. More than ever, the folks back home seem ready to hold their representatives accountable if they make the wrong one.

Andy Slavitt, a member of USA TODAY's Board of Contributors and a former health care industry executive, was acting administrator for the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter @ASlavitt

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