I have been telling anyone and everyone, for years, that the Republicans have no alternative to the ACA because there is no good, conservative alternative to the ACA. Republicans are smart enough (some of them at least, Paul Ryan is) to know that once you extend a social support to the middle-class it is extremely difficult to take that benefit away and doing so will result in political suicide. So they can't, and won't, go back to the pre-ACA system, but they also know there is no workable alternative to the ACA that doesn't drastically expand the government's role in health care.
In a sense, they've been in a good situation these past six years, because they've been able to successfully claim the ACA is horrible without having to really do
anything about it, or propose any viable alternative. They, like everyone else, assumed Hillary would win and that they would be able to continue to avoid having to substantively deal with the issue. Now here we are, with Trump unexpectedly as president, and the public looking at them anxiously to hear their plan to improve on something they've been screaming is an absolute disaster for years.
They're screwed, and they know it. Will Americans pick up on it? Hard to say. Right now, Republicans are scrambling for time so they can figure out a strategy for how to politic and message their way out of this. If they can do that soon, they might be okay, but the longer they delay the greater the likelihood is that this will be politically terrible for them.
David Frum, who I think of as a pretty principled conservative, wrote this article over a year and a half ago
, before Republicans found themselves in their current predicament, but I think it remains a good, pragmatic summation of the conundrum they now find themselves in. It offers some suggestions for how to tweak the ACA to be more in line with conservative thinking, while acknowledging that, yes, these are just tweaks rather than a major overhaul. The question is: will tweaks be enough, after all of the hyperbole about the horribleness of the ACA? I think most Republicans think no, they won't.