In March of last year, Senate Minority Leader Mitch McConnell (R-Ky.) stood on stage at the Conservative Political Action Conference and declared that "Obamacare should be repealed root and branch." But in May, when he was asked about whether Kentucky's health insurance exchange, Kynect—the local face of Obamacare—should be dismantled, he insisted that the two weren't related. "I think that's unconnected to my comments about the overall questions here," he said. More recently, when McConnell was questioned by The New York Times about what to do with people in his home state who now receive coverage through the law's Medicaid expansion, he responded, "I don't know that it will be taken away from them." Root and branch repeal is starting to look more like twig and leaf.
McConnell is, of course, still broadly opposed to Obamacare, as are most residents of Kentucky. His opponent, Democrat Alison Grimes, has been delicate in her support of the law, and clearly believes that, overall, Obamacare is a political liability. But there is a shift happening. It's not that Republicans are abandoning opposition to the law. But they appear increasingly uncertain about how to deal with it now that it has arrived.
McConnell is only the most prominent example. Rep. Tom Cotton, who is challenging Democratic Senator Mark Pryor in Arkansas, continues to state his opposition to Obamacare. But he has also avoided directly answering questions about the state's participation in the Medicaid expansion, even in the state's modified Medicaid "private option." Asked last month about people who are already covered through the health law, Cotton said, "We'll see what we can do about reforming it, and potentially protecting people who have already received some of the benefits." Is that support for repeal? Or reform?
There are more examples. Pennsylvania GOP Gov. Tom Corbett recently agreed to a modified Medicaid expansion. And as TPM's Dylan Scott recently noted, Republicans legislators in Indiana, Wyoming, and Tennessee are looking at ways to participate too.
Part of what's happening here is that, in some sense, Obamacare's Medicaid expansion has become a separate issue from the rest of the law, thanks to the Supreme Court's decision to allow states to opt out without jeopardizing all of their existing federal Medicaid funding. Obviously, the Medicaid expansion is a significant component of the law, one of its two main vehicles for coverage expansion, along with subsidized private insurance in exchanges. But at least for now, the choice for a state to build an exchange is a choice of who runs the exchange—the state or the federal government. With the Medicaid expansion, the choice is whether or not to expand coverage, which makes it different in kind. Add to that the fact that hospitals are major employers in many districts, and Republican legislators often have close ties to local doctors and the hospital industry, which generally supports the expansion, and that makes it a fraught issue for at least some GOP politicians.
But the bigger issue is that Republicans never really had a post-Obamacare battle plan. Late last summer, at a small private event, I asked a senior Hill Republican what would happen after January 1, 2014, when the health law's coverage expansion went live. The response I got was that something would have to change, and that Republicans would finally, after years of promising to propose and promote a replacement health law, have to figure out how to describe what they wanted to do next. There would be a reckoning. There would have to be.
Then October arrived, the exchanges crashed out of the gate, insurers started canceling plans that people liked, and the GOP decided they didn't need to figure out what to do next. Obamacare's crash saved them from having to decide.
At the end of the month, with the exchange still in disarray, and hopes for a quick fix fading, I asked a House GOP aide what the party would do next when, inevitably, the mess cleared up. Here's what I was told:
"There's just no appetite to lay out an entirely new agenda of ideas," a House GOP staffer told me in October. Instead, the focus is on "expanding existing criticism" and "continuing to bludgeon the administration" over problems with the current law. "If Republicans were interested in fixing health care, they would have been talking about it much earlier," the staffer said. "They weren't."
The party's current confusion about how to respond to the coming of Obamacare coverage expansion is, in large part, the consequence of this years-long refusal to develop any alternative policy preference. Republicans have long known that they are against Obamacare, but that's all they knew. There have been other plans and proposals that have popped up and sparked some conversation, but none have gained traction with leadership, or become fixtures in GOP agendas or talking points.
But this isn't the whole story. There are other factors in play as well. And it's not just the GOP that is uncertain about how to proceed.
There has been a sort of settling of opinion on Obamacare in recent months; it's clear that it's unpopular, and that the repeated attempts to message into success aren't working. But with the follies of open enrollment behind us, and the most obvious website problems mitigated, it's also less of a priority than it once was. As The Washington Post's Greg Sargent, who has catalogued emerging Republican slipperiness on Obamacare, pointed out yesterday, the polls are consistent in revealing public opposition to the law—and yet it's not the most pressing issue.
That settling has left both parties in a transition period, unsure of exactly how to talk about a law that remains unpopular and yet also difficult to fully repeal. Republicans continue to state opposition to it, especially when talking to the base, and yet are loath to support wiping out all of its benefits, especially for home-state constituents. Democrats, in turn, voice support for the law, especially when talking to activists and donors, but publicly advocate fixing the system—though usually without providing much detail about specific fixes. You can see this dynamic in the McConnell race. "It is not exactly a mutual nonaggression pact," writes Jonathan Martin in The New York Times, "but neither McConnell nor Grimes has an interest in focusing on the Affordable Care Act."
The result is a convergence of sorts, and also a kind of wary standoff, in which both parties are grappling with the fact that Obamacare is unpopular, but also that millions of people are now receiving its benefits. Neither side knows quite how to respond. It's like watching two boxers circle each other in the ring, holding in defensive positions.
I'm not sure where this goes, or how this ends. Republicans have repeatedly promised, in public, to move beyond repeal to replace, and privately many will even say that reform is more likely, but so far, work on plans that would do so has occurred largely at the margins. At least for now, we're likely to see the holding pattern continue; the GOP is almost openly running a no-agenda strategy in the mid-terms this fall. Much will depend on how the second and third open-enrollment seasons go, the results of the 2014 election, the messaging and policy choices made by the party's next presidential nominee, and the outcome of the race for the White House in 2016.
But it's at least possible to imagine that the current convergence continues, and eventually results in a melding of the two party's stances, leaving much of Obamacare's basic infrastructure, including the exchanges, in place but altering them substantially and using them, in a kind of ju-jitsu move, as a vehicle to reform the rest of the entitlement system, which is ultimately a much bigger fiscal problem. That's essentially what the Manhattan Institute's Avik Roy has proposed in his recent health entitlement overhaul plan, which would deregulate the exchanges, end the individual mandate, transition Medicaid and Medicare to the exchanges, and, according to one estimate, could expand coverage even more than Obamacare.
The danger with that sort of plan is that no one will like it—that Republicans will see it as a concession to Obamacare, and Democrats as a fundamental attack on entitlements. Certainly it's not something that the base on either side is willing to accept right now. But it's also the sort of clever compromise that could eventually find backers on both sides of the aisle, especially as Obamacare settles in further.
It wouldn't be root and branch repeal, and Republicans and their allies would need to accept that. But, to extend the metaphor a bit, it might be something more ambitious and arguably more important—a plan that, yes, leaves Obamacare's roots in place, but instead replants the rest of the garden around it.