The Three Stages of Obamacare Acceptance

Senator Ron Johnson has graduated to State Two of Obamacare Acceptance. (AP Photo/J. Scott Applewhite)

Senator Ron Johnson has graduated to Stage Two of Obamacare Acceptance. (AP Photo/J. Scott Applewhite)

Now that Obamacare is clearly moving forward, Republicans are adjusting to a new reality: it may no longer be a realistic option to simply wait until the law collapses under its own weight and vanishes entirely. GOP lawmakers are increasingly discussing a range of responses, from proposing profound changes to finally embracing a comprehensive alternative.

Which raises a question: Is it possible to envision a future in which Republicans and Democrats do enter into real negotiations over the future of the law and the health system, in which each side gets some changes it wants, in exchange for accepting some of the other’s proposed changes?

Yes, it is. But to get there, Republicans will first have to pass through what might be called the Three Stages of Obamacare Acceptance.

Right now, Republicans entertaining changes or alternatives are still proceeding from the premise that no outcome is acceptable unless it fatally cripples the law or eliminates it entirely. Republicans don’t believe the law can be fixed, since they think that even if it does work according to its own lights, it will still amount to a colossal policy failure. If Republicans want to hold that position indefinitely, there’s not much Dems can do about it.

But if Republicans do get to a point where crippling or eliminating the law is not the only acceptable outcome, there are scenarios under which they might negotiate for certain types of changes to the law, in exchange for changes Dems or liberals want.

Larry Levitt of the Kaiser Family Foundation laid out the types of incremental changes Republicans might pursue. He suggested Republicans might propose various ways of relaxing Obamacare’s regulations, in keeping with conservative policy ideas, that wouldn’t destroy the law. For instance, they could propose allowing insurance sales across state lines so competition drives down prices, something liberals might be willing to accept under certain circumstances if the law’s uniform federal minimum coverage standards are kept (which could theoretically prevent the “race to the bottom” liberals fear).

Or Republicans could propose to make tax deductions available to those over 400 percent of the poverty line who do not qualify for Obamacare subsidies, helping those who see premiums go up (which Republicans have turned into a major issue) and mitigating Obamacare’s redistributive elements a bit. Or Republicans could propose relaxing the limitations on age ratings, allowing insurance companies to charge more than the current three-to-one ratio the law mandates between older and younger people.

In exchange, liberals might ask for subsidies to be expanded to those who fall into the Medicaid gap — making too little to qualify for subsidies but too much to qualify for Medicaid in states that haven’t opted in to the expansion. Or they might ask for more in subsidies for those who currently qualify.

The point is, there are scenarios under which real negotiations over the future of the law could take place. But Republicans would have to be willing to accept something less than its complete destruction. (As Jonathan Bernstein has detailed, a general unwillingness by Republicans to try to get some of what they want on multiple issues has made the GOP into a kind of dysfunctional “post policy” opposition.)

Let’s be clear: It is certainly still possible that over the long term, Obamacare could fail, if, say, the demographic mix is bad, insurers pull out, and the exchanges collapse. If so, Republicans would theoretically be able to simply wait for the law to fall apart in a few years. But some experts are cautiously optimistic that the latest enrollment numbers suggest the law could be on track to work.

And that’s where the Three Stages of Obamacare Acceptance come in — presuming, again, that the law works at least moderately well over the long term:

* Stage One: A dim awareness that there might be some good elements in the law, and that the public might not support returning to the old system. GOP Rep. Jack Kingston, for instance, recently suggested that it might not be “responsible” to simply let the law fall apart, and that lawmakers should be open to anything in it that would help people get coverage. Kingston was immediately slapped down by his primary opponent and quickly reiterated his zeal to get rid of it entirely. Something similar happened to a GOP Senate candidate in Michigan.

* Stage Two: A genuine recognition that large numbers of people are already benefitting from the law, and that this reality needs to be reckoned with — such as by proposing alternatives or changes that purport to accomplish similar goals, even as the elimination or crippling of it remains a paramount aim. GOP Rep. Tom Price has proposed an alternative designed, in part, to cover people with preexisting conditions, but it would probably cover far fewer people, and Price continues to insist on Obamacare’s repeal, maintaining its demise is a certainty.

Meanwhile, Senator Ron Johnson has admitted that “we have to deal with the people who are currently covered under Obamacare,” and to do this, he has proposed keeping the exchanges while getting rid of the individual mandate. The latter, experts say, would fatally undermine the law, and as such this isn’t a serious proposal.

* Stage Three: Republicans accept Obamacare is likely here to stay, abandon the premise that the only acceptable outcome is crippling or eliminating the law, and negotiate to achieve incremental changes they want. This is the scenario outlined by Levitt above. It’s hard to know when this might happen in earnest – certainly not in 2014, and GOP presidential primary politics could also make this difficult next year. But you’re already seeing this a bit with GOP governors who are negotiating with the feds to create their own versions of the Medicaid expansion.

It’s always possible Republicans could win the presidency and both houses of Congress in 2016 and pass legislation repealing the law. And again, if the law fails over time, the above stages could be moot. But it’s increasingly difficult to see how repeal would work in practical terms, even with full GOP control. What’s more, as Jonathan Cohn has detailed, experts think early returns suggest the law is likely to work out. Which means you can begin to imagine Stage Three kicking in. At some point.

“If Republicans were to accept that the law is in place for the foreseeable future, then one could envision tweaks that could move it in a more conservative direction without undermining its goals, while also providing improvements to the law that liberals are looking for,” Levitt says.

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