Obamacare Jujitsu

Instead of working to repeal or resist Obamacare, Republicans might better serve the conservative cause by saving it.  

The SCOTUS decision on the Affordable Care Act (Obamacare) was, on the surface, a victory for the President – it didn’t vitiate the law.  But the ruling also created a huge problem for the Administration by preventing the federal government from compelling states to expand their Medicaid rolls, which was to account for at least half of the newly-insured under the program. 

Even before the High Court decision, the ACA allowed states to abdicate responsibility for instituting the law’s “state health insurance exchanges” – which were conceived to connect the uninsured with individual health insurance policies that met ACA specifications.  People unable to afford premiums for policies offered through the exchanges were supposed to receive government subsidies.

 

However, the ACA, as written, doesn’t appear to allow these federally-funded insurance premium subsidies in states which don’t set up their own exchanges. 

So, should Texas governor Rick Perry, Indiana Governor Mike Pence and several other Republican governors – who represent a large swath of the U.S. population – follow through with their plans to spurn both the Medicare expansion and the exchanges, it will imperil Obamacare. 

Ironically, this predicament creates a viable pathway for Republicans to achieve an aim that seemed impossible after Obama’s reelection – overhaul of Obamacare. Not the "repeal and replace" Republican candidates campaigned  on, but "repair and replace."

As of yet, there is no model – or even a detailed outline – of how the state health insurance exchanges will work.  It’s vaporware.  And the ACA grants tremendous discretion to the Secretary of HHS.  This has already created "government by waiver" on steroids, with thousands of ACA exemptions granted to favored unions and employers.   

Republican Governors can flip these problematic aspects of Obamacare into positives.

Collaborating amongst themselves and with leading conservative health care thought leaders, businesses and private organizations, their states should leverage the federal funding from ACA to build a patient-centered, market-based, primarily state-administered health care paradigm. 

They, not Washington bureaucrats, should fill-in the blank slate that is the health insurance exchange concept.  These Republican governors should band-together to maximize scale and outsource the exchanges to Amazon Web Services, Orbitz, Expedia or another private contractor with proven expertise in this field.  The ACA health exchanges dwarf online travel exchanges in complexity - it would be imprudent, if not insane, for governments to attempt such a daunting undertaking without world-class private sector resources.

If the governors can demonstrate that their homegrown versions of the ACA will improve health care, increase the percentage insured, enhance efficiency and contain costs, the HHS Secretary has the power to "waive them into being." Perhaps Congress will have to enact legislative patches in some cases (which would be greatly facilitated with support from Republican governors), but much can be achieved simply by pushing the HHS waiver envelope. 

For example, Rick Perry, his friend and former health care entrepreneur Rick Scott and health care policy genius, Louisiana governor Bobby Jindal, could pool resources and ideas – and even band together to create a TX/FL/LA plan. 

John Kasich of Ohio and Rick Snyder of Michigan – two Republican governors who've announced they will opt-into the ACA’s exchanges and Medicaid expansion – could link up with their Republican cohorts Mike Pence in Indiana, Terry Branstad in Iowa and Scott Walker in Wisconsin to create a “Midwest Care” plan. 
 

Given his national profile and branding as a bipartisan problem-solver, Chris Christie in New Jersey is particularly well-positioned to play a leading role, as well. 

Republican governors caving on the ACA without dramatic concessions from the Obama Administration would be a betrayal of Republican philosophy, their states' constituents and abject political malpractice.

In his superb January 17 National Journal piece, “Why Obama Needs a Better Understanding of Republicans,” Major Garrett wrote: 

The art of a deal in politics is not to win so much that you remain popular, but to win enough so that you remain popular while your opponent wins enough so that he or she remains popular, too. 

Garrett concluded that President Obama has failed to grasp this fundamental political truth. 

But, given the corrosive impact the ACA is already having on the economy and the ability of Republican governors to stymie the program, the Obama Administration has a huge incentive to put ideology aside.  Allying with Republican governors could rescue what the President sees as his signature achievement.  And enable him to spread the blame for any of its ill-effects. 

It’s the “Force Obama to Take Yes for an Answer” strategy. A way for Republican governors to “put partisan politics aside” – while taking the “Obama” out of Obamacare by stealth. 

If these Governors craft conservative iterations of ACA that work, the fact that their approach diverged sharply from Obamacare as originally designed won’t matter.  An initially pernicious program will be healed; both Democrats and Republicans can declare victory.