Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, and read previous columns here.
The Republican plan to defund Obamacare is running into some roadblocks on Capitol Hill. Some Republicans don't like it. Some really, really don't like it. President Obama near certainly wouldn't sign off on it and, even if the government did shut down, it wouldn't stop the law's implementation.
So, in other words, there are obstacles to the defunding strategy. And, in general, it's pretty difficult to stop Obamacare at this point. The law survived a Supreme Court decision and a presidential election, the two events that – had they turned out differently – could have lead to Obamacare's full-scale repeal.
This isn't to say that Republicans are completely out of options; there are ways to dismantle or at least disassemble a few pieces of the Affordable Care Act. While they're certainly not surefire, here are some possibilities currently on the table.
1. Lobby hard against the Medicaid expansion.
Six states, by the Kaiser Family Foundation's count, have not decided yet whether to move forward with expanding Medicaid under the Affordable Care Act. The Medicaid expansion is a hugely important part of the health-care law, responsible for about half of Obamacare insurance expansion. Without it, the law's reach dwindles.
Stopping the Medicaid expansion would reduce Obamacare's reach and create a messaging problem for health law supporters. “How do you explain this in a way that seems fair and reasonable, that the higher-income people get help but you don’t?” said Mike Perry, a founding partner at polling firm PerryUndem Research, told me recently. “Advocates on the ground are really struggling with that group. They want to have a positive message but don’t know what to say.”
2. Convince young, healthy people not to sign up for the law's subsidies. Or do an enrollment drive with the old and sick.
The White House has made no secret of the crucial role that young adults play in the Affordable Care Act's success. Their low medical bills, if young adults sign up, would be expected to keep premiums down for everyone else. On the flip side, a marketplace filled with sick and elderly people would have really high health insurance costs.
There's already some chatter about campaigns to dissuade people from enrolling in the health law's program, including one that focuses on burning Obamacare draft cards. Some Republican offices say they won't help constituents connect with the health law's programs. The pitch to young adults, Obamacare opponents I talk to, would go something like this: Why spend hundreds, maybe thousands, on health insurance coverage when you could simply pay a $95 fine instead?
3. Chip away at the law piece by piece.
Congress has had surprising success chipping away at small health law provisions. It has passed seven laws that have tweaked or repealed Affordable Care Act requirements. One killed the CO-OP program, which was meant to increase the number of health plans available on the insurance marketplaces. Another ended a long-term insurance program that the Obama administration had given up on implementing.
Are these changes that will kill the Affordable Care Act altogether? No. Do they chip away at its funding sources? Yes, and the Obama administration has already said it's strapped for cash in the Affordable Care Act's implementation. Some further repeal proposals, especially efforts to eliminate the medical device tax, have already gotten relatively strong bipartisan support. It's not the whole law, but it's something.
4. Elect a new president in 2016. Preferably, one who opposes Obamacare.
"Our view is that if you want to change the policies in Washington, you've got to change the players," says Sal Russo, chief strategist for the Tea Party Express. "As long as you have a President Obama, you can't really complain about the Republican House not getting things done. Obviously Obama is not going to get to a point where he decides this was a mistake."
Russo says he now sees the best repeal strategy as one that rests on campaigns: namely, ones that lead to a Republican-controlled White House and Senate. One concern about this strategy, in Republican circles, is that it will be too little, too late. The health law's subsidies will have rolled out, and Americans won't want to give them up. Russo disagrees, saying, "My guess is they have more bad news than good news coming on implementation."
5. Set expectations high for Obamacare's rollout. Like really, really high.
A risky strategy, definitely, but an idea that Sen. Tom Coburn (R-Okla.) raised with me in a recent interview.
"What I do know is if you do say it's going to be terrible, terrible, terrible as Republicans have been saying, and it’s only one terrible, it’s going to look good," Coburn says. "We shouldn’t overhype things. We should just watch."
State officials working on the health-care law are worried about expectations being set to high. They speculate that having such a low bar to clear – Obamacare not being a complete and total disaster – actually helps them have a successful rollout.
KLIFF NOTES: Top health policy reads from around the Web.
Medicare Part D premiums are really stable. "Medicare Part D premiums will average about $31 in 2014 — up from $30 for the past three years. The Part D deductible will fall from $325 to $310 in 2014. 'There is continued very strong competition within the Part D plan," said Jonathan Blum, deputy administrator and director for the Center of Medicare. When the coverage gap program began, 'there was lots of concern that filling in the doughnut hole would cause Part D costs to go up.'" Kelly Kennedy in USA Today.
Ted Cruz is battling Republican colleagues over Obamacare defunding. "The Texas freshman senator and his senior aides are unleashing a barrage of attacks on their fellow Republicans for refusing to support their plan to choke off Obamacare as a condition for funding the government. Cruz’s chief of staff is lambasting fellow conservatives like Oklahoma’s Tom Coburn for serving in the “surrender caucus.” His top political strategist has compared Mitch McConnell to Barack Obama. And the senator himself has said many Republicans are “scared” to wage this fight." Manu Raju and Burgess Everett in Politico.
Boehner is planning more Obamacare votes. "Over the next few months, the House will vote to require verification for health care subsidies, stop the Independent Payment Advisory Board and eliminate funding streams, according to a source in the closed House Republican Conference meeting where he announced the strategy." Jake Sherman in Politico.