'Without the president, we can't repeal [health care law],' said Mitch McConnell. Big hole in GOP health repeal plan

For some Republicans, it’s one of the most potent attack lines this fall, prized for its simplicity.

Want to kill the new health care law? Just starve it of cash and replace it with something else.


But there’s nothing simple about it.

Experts — and even some Republicans — say a GOP-controlled Congress next year would have to struggle to erase nearly $1 trillion in health reform spending over 10 years with the flick of a pen. Key parts of the bill, like new Medicaid entitlements, would require free-standing legislation, not merely routine changes during the appropriations process.

The only way the GOP can really deal a mortal blow is by taking back the White House in 2013, these Republicans say — but, even then, the clock would be running out, with the law well into its fourth year of implementation and just a year away from when major benefits kick in.

So despite the long odds, Republicans are zeroing in on a nibble-around-the-edges strategy — a long-term, but so far loosely defined, campaign to choke off funding piece by piece and weaken the law to the point that lawmakers feel they have no other choice but walking away from it.

It’s hardly a quick fix, and it’s unlikely to fully satisfy conservative voters pushing for a speedy repeal of the president’s overhaul. Still, it’s a multipronged attack aimed at constantly putting President Barack Obama and congressional Democrats in the uncomfortable position of defending a law that has yet to win broad public support.

“Without the president, we can’t repeal it,” Senate Minority Leader Mitch McConnell (R-Ky.) said in a speech recently to a local Chamber of Commerce in Kentucky. “But we can go after portions of it aggressively.”

Sen. Tom Coburn (R-Okla.), who signed a pledge last week on DefundIt.org to withhold cash for the law, said: “There is only a certain limited amount of things you can do. You can get a vote to repeal it, and the first thing [Obama] will do is veto it. That is an exercise in futility. What you have to do is go to the specific areas where money is spent to implement it and put a limitation on the expenditures.”

Others aren’t so sure the strategy will work. “I wouldn’t dismiss it, but I would be surprised if it actually happened,” said Gail Wilensky, administrator of the Health Care Financing Administration from 1990 to 1992 under former President George H.W. Bush. “You hear this periodically when there are core groups that don’t like something. ... It is easy to talk about rhetorically; it seems to have been very hard to pull off.”

Democrats brushed back similar efforts to chip away at pieces of the bill during the debate in the Senate. And even if Republicans can take over the House, most analysts believe it’s increasingly unlikely they’ll do the same in the Senate.

Still, Republicans say they see glimmers of hope: An amendment last week by Sen. Mike Johanns (R-Neb.) to repeal a business reporting requirement, cut $11 billion from a prevention and public health fund and weaken the requirement that most Americans buy insurance got more votes than some expected. A total of 46 senators, including seven Democrats, backed the effort, a number that prevention advocate Kenneth Thorpe called “worrisome.”

The amendment embodied one prong of Republicans’ strategy — to target unpopular elements of the law for dismantling, even if they can’t succeed on the first try.

“There are many ways to attack this bill where I think you can get supermajorities,” said Sen. Lindsey Graham (R-S.C.), who plans to push for allowing states to opt out of the mandate on individuals to buy coverage.

Republicans will also try to hold back the funds needed by the Health and Human Services Department and the Internal Revenue Service to implement the law. The Congressional Budget Office estimates that each agency needs at least $5 billion to $10 billion over the next 10 years. Without that money, the biggest overhaul of the American health care system since the 1965 Medicaid program would face implementation on a shoestring.

Republicans have also discussed inserting legislative language known as a rider into an appropriations bill, prohibiting federal workers from doing anything to implement the law, such as writing the countless regulations that insurers, hospitals, physicians and state governments need to comply with it.

And they could go after more than $100 billion in discretionary spending in the law, leaving dozens of programs unfunded — but none that would be considered essential to the law’s success.

These programs include initiatives that support the longer-term goals of the overhaul — a $1.3 billion loan repayment program aimed at eliminating the shortage of public health workers, $327 million in grants to schools that assist students from disadvantaged backgrounds and $375 million to develop an interagency working group on health care quality.

Republicans “can slow down and grind Obamacare to a halt without outright repealing it,” said Michael Cannon, director of health policy studies at the Cato Institute.

Democrats believe, however, that political realities will eventually set in. Without a Republican in the White House and comfortable majorities in Congress, the GOP effort to block funding may, in the end, amount to little more than a low-level, yet persistent, annoyance for Obama.

The outcome depends largely on the will of Republicans to stick by their no-money pledge — House Minority Leader John Boehner (R-Ohio) said earlier this month that the law will “get not one dime from us” — and the determination of the president to issue vetoes.

Democrats in the White House and Congress predict that public support for the law will only rise in coming months and years as the benefits kick in, exposing Republicans to a backlash if they go too far.

The White House pushed back last week against the defunding movement, positioning the fight in familiar terms.

“Make no mistake: Defunding the Affordable Care Act is just Washington-speak for taking us back to the days when insurance companies — not you and your doctor — were in control of your care,” senior administration official Stephanie Cutter wrote on the White House blog. “If the new law was defunded, the new Patient’s Bill of Rights would be an empty promise, seniors’ costs for their prescription drugs would increase and small businesses offering health insurance would pay higher taxes.”

Alex Cortes, founder of DefundIt.org, the 501(c)4 group pushing lawmakers to sign a pledge not to fund the health care law, said he has received commitments from 125 candidates on ballots in November.

And just last week, he got a bit of high-level attention, meeting with Boehner’s staff to discuss the issue.

“This is the first necessary step to repealing” the law, Cortes said. “Repealing is going to take a while. This has to be a long-term commitment to defund it.”