In The Arena Why the GOP Won't Touch Obamacare

Richard Kirsch is a senior fellow at the Roosevelt Institute and a senior advisor to USAction, a grassroots organization that advocates for affordable health care, among other things.

By now, most of us are expecting widespread GOP victories in the midterm elections that will give Republicans complete control of Capitol Hill come January. But Tuesday will also deliver an inconvenient truth: The single item at the top of the Republican legislative agenda, the signature talking point of the last four years, is likely to go nowhere.

Even Mitch McConnell admits it. After six years of railing against Obamacare, here’s the sum total of what Republicans are likely to do if they win control of the Senate: Little, if anything.


Obamacare has been Republicans’ favorite whipping boy even before it became law in 2010. They’ve used it time and again on the campaign trail to fire up voters against the White House and Democrats in Congress. But now that they seem poised to begin doing something about it, they will have to face a new reality: The Affordable Care Act is here to stay and Republicans will be political losers if they mess with it too much.

But you wouldn’t know that from listening to the talking points. In a Wall Street Journal column, Karl Rove wrote that “Obamacare is re-emerging as a major liability for the Democratic Senate that passed it.” (Never mind that he distorted the results of a Gallup poll, inaccurately claiming that 54 percent of respondents said the Affordable Care Act has hurt their families when what they said, in fact, was that the ACA thus far has had no effect on their families. In New Hampshire, as in other states, GOP senate candidates like Scott Brown continue to use votes for Obamacare to link Democratic senators like Jeanne Shaheen to the president and his low approval ratings.

This week McConnell admitted that repealing Obamacare is impossible, in the face of a likely Democratic filibuster and a certain presidential veto. But McConnell didn’t tell the whole story. That was left to Ohio’s Republican Governor John Kasich, when he pointed out last week that the “political and ideological opposition” to the ACA won’t hold water “against real flesh and blood and real improvements in people’s lives.”

Kasich insists that he was just talking about Medicaid expansion, but the same political logic applies to the ACA as a whole. With millions of people newly covered, and with major industries including insurance and hospitals benefitting, the ACA will not be repealed, dismantled, defunded or defanged. Any changes will be around the margins and even these will be complicated to pull off.

Senate Republicans will have to face the consequences if they take votes to do what is now politically unpopular: repeal the ACA or defund its provisions that provide health coverage. Most Americans now hold the correct position on the Affordable Care Act: keep and improve it, rather than repeal it. In the latest monthly Kaiser health tracking poll, two-out-of three (64%) of all those surveyed and of independents (65%), want to “improve the law” rather than “repeal and replace it.” The anti-repeal numbers keep getting stronger, up from 58% six months ago.

Repealing the ACA would create a lot of losers. The “flesh and blood” Kasich refers to represent millions of newly insured people and their families, now covered for the first time through the health exchanges or Medicaid.

Remember all those folks who Republican sought to champion when Obama broke his promise that you can keep your insurance if you like it? It turns out most of them are now paying less for the better coverage they got in the ACA exchange. Are Republicans willing to take away their new, improved health insurance?

Even a chunk of the Republican base, which is older and more reliant on Medicare, might become worried if they understood that they might have to pay more for preventive services and prescription drugs if the law is repealed.

Two major industries would also be big losers. Private health insurance companies have added millions of members since the ACA’s passage: in the exchanges, in Medicaid and—less noticed—as more people have chosen employer-based coverage. Hospitals will see the cost of covering people without coverage drop almost $6 billion this year, particularly in states that have expanded Medicaid. Hospitals have been the leading lobbying force in getting Republican states to expand Medicaid and would vociferously oppose federal repeal.

All of which means that Republicans in the Senate, facing a 2016 terrain that is widely-seen as favoring Democrats, will have to think several times before using their majority’s soapbox to advocate repealing or eviscerating the ACA.

Caught between the new emerging political reality and the promises made to their base, what would a Republican Senate majority do? The odds are they will push for a straight repeal vote to satisfy their core supporters, knowing that they are likely to face a Democratic filibuster. But Democrats would be wiser to allow the vote and subsequent presidential veto, in order to get Republicans on the record, squeezing Republicans who face tough elections in 2016.

The real dance will be around what Republicans can pass without worrying about a filibuster, through the budget reconciliation process. Although any action could still be vetoed by President Obama, this process—which is how the final amendments to the ACA were enacted in March 2010—would allow a Republican majority to make changes to how the ACA raises and spends money.

In looking at their list of options, Republicans may remember that while “Obamacare” may not be popular overall, almost every one of its major individual provisions is. Will Republicans go after the heart of the law, subsidies for coverage under the exchanges and Medicaid expansion?

The most tempting target is likely to be the financial penalties behind the unpopular individual mandate, which requires individuals to obtain insurance. However, the mandate is key to making a wildly popular part of the ACA work—the ban on insurers denying coverage for pre-existing conditions. Without the mandate, young and healthy individuals—those who often forego insurance until later in life or use medical services less often—could stay out of the insurance pool, leaving insurers with an older and more expensive client base. But this connection between the mandate and making the ACA attractive enough so that insurers don’t preclude coverage of those with pre-existing conditions is not obvious to everyone. Democrats will work aggressively to make the connection clear and the president would undoubtedly veto any move to eliminate the mandate, but this could nevertheless be an attractive Republican target.

Republicans may wrestle most intently with the penalties tied to the employer mandate, an issue that McConnell has singled out. Eliminating the penalties, which have been delayed by the Obama administration, would appeal to large parts of the business sector. Short of that, Republicans could increase the weekly hours an employee must work—from 30 to 40—before the employer is required to provide coverage—a change that would appeal to low-wage employers.

However, moves to reduce or eliminate the employer mandate would result in more people receiving subsidies in the exchanges, which along with the reduced revenues from no employer penalties, would result in an increase in federal spending. The budget will be impacted by ending some of the other Affordable Care Act taxes, like the tax on medical devices—the other provision McConnell has spotlighted.

Any of these changes would create a new dilemma for Republicans—how to pay for them, assuming Republicans continue to insist on paying for new expenses or making up for forgone revenues. At this point, changing the ACA could become caught up in a larger battle about the budget, with all the enormous complications that entails.

Governor Kasich’s comment underscores the new truth about the ACA: As long as Republicans can rail against Obamacare without actually taking any responsibility, they can have their cake and eat it too. But if they control both houses of Congress, Republicans will have to face tough choices. Politics and ideology will come face-to-face with the new politics created by “flesh and blood and real improvements in people’s lives.”