For Republican leaders, one loaded phrase represents the difference between the party they are and the party they wish to be: “repeal and replace.”
Since 2010, Republicans have pledged to repeal and replace President Obama’s Affordable Care Act — promising a legislative backflip that would please conservatives who despise the law’s every word and moderates who want to keep some of its benefits.
They haven’t been able to do it — although not for lack of trying. The GOP-led House has voted 56 times to repeal or undermine the law, but zero times on a plan to replace it.
On Tuesday, the party’s unsolved dilemma made its first big appearance in the 2016 Republican presidential race. First, Wisconsin Gov. Scott Walker released a plan that would replace the health-care law with a mix of tax benefits and deregulation, designed to make insurance more affordable but less government-controlled.
Then, almost immediately, he was attacked by a fellow Republican candidate, Louisiana Gov. Bobby Jindal, who said that Walker’s supposedly conservative plan is actually terribly liberal.
In fact, Jindal said, Walker’s plan is so bad that it might signal the death of conservatism itself. And also dishonor the Fourth of July.
“When did conservatism die?” Jindal said in a written statement. He said that Walker’s plan would make Americans more dependent on government spending, giving the lie to Walker’s past praise for Independence Day. “With this Obamacare lite health care proposal, he’s going to have to drop those lines from his speech.”
The Affordable Care Act, signed into law in 2010, created a series of benefits to make obtaining insurance easier. It offers subsidies to help low-income people pay for coverage. New rules allow children to stay on their parents’ plans until age 26 and prohibit insurers from denying coverage to people with expensive preexisting conditions.
This is one half of the GOP’s dilemma: Those benefits, like most government benefits, would be difficult to take away. An estimated 19 million people could lose health insurance if the measure were repealed.
“It’s almost motherhood and apple pie now, that any plan should protect people with preexisting conditions and help people without health insurance to buy it,” said Larry Levitt, senior vice president at the Kaiser Family Foundation. “It’s hard for any candidate to walk away from those ideas.”
But this is the other half of the dilemma: The Affordable Care Act remains unpopular among the primary voters Republicans care about. They particularly resent its regulations and bureaucracy, and the “individual mandate,” which requires most people to obtain insurance or pay a fine.
All of the 17 major Republicans running for president have promised they would repeal the law. But most of them have said relatively little about what they’d put in its place.
Front-runner Donald Trump, for instance, has said that his replacement would be “something terrific” and that it would involve making an unspecified deal with hospitals to treat the poor and uninsured.
“How do you do that, though?” CNN’s Dana Bash asked him.
Trump did not seem to know.
“We are going to have to work out some kind of a very, very smart deal with hospitals,” he said.
The three GOP candidates who have released the most detailed plans are Jindal, Sen. Marco Rubio (Fla.) and — on Tuesday — Walker.
Walker’s plan is 15 pages, but five of those pages contain only logos and three more pages are devoted to tearing apart the health-care law. The other material, the “replace” part of Walker’s proposal, includes elements common to other Republican plans.
It would, for instance, allow people to buy health coverage from insurers outside their states. That is intended to allow greater competition, but critics say it could lead to a “race to the bottom,” with insurers clustered in the state that regulates them the least.
“Imagine if you could follow any state’s gun-control regulations,” said Katherine Hempstead, director of the coverage team at the Robert Wood Johnson Foundation.
Walker also would punt some key issues to state governments.
The states could decide whether to require insurers to cover children on their parents’ plans up to age 26. States could set up “high-risk pools,” which are insurers of last resort, to cover those who can’t get private insurance because of preexisting conditions.
And the plan would offer tax credits to people who buy health insurance on their own, instead of through an employer. These credits — worth up to $3,000 per person per year, depending on age — would be a new way to accomplish one of the Affordable Care Act’s old goals. Which is making insurance more affordable for consumers.
Walker, speaking at Cass Screw Machine Products in Brooklyn Center, Minn., said he thinks that, if elected, he could get this done quickly.
“We make sure this happens right away. Because, look, we’ve got to repeal Obamacare entirely — lock, stock and barrel. And we’ve got to repeal every part of it,” Walker said.
Even for a Republican president, however, “replace” would not come that easily. It might take months of haggling and compromise and bitterness to produce a solution, just as it did for Democrats when they had all the power.
Tuesday offered a preview: Jindal’s fiery attack on Walker was based on a fairly wonky disagreement. Walker’s sin was that his tax credits would be . . . refundable.
Meaning that, under Walker’s plan, someone who received a $3,000 tax credit — but owed only $2,000 in taxes — would get a $1,000 check from the government. Jindal prefers offering insurance-buyers a tax deduction, which would lower tax bills but not promise anybody a check.
“His plan is fundamentally accepting the premise of Obamacare — that we need a new federal entitlement program,” Jindal said. “Surely we as Republicans have more courage than this.”
That’s the distinction that killed conservatism and besmirched Independence Day. If Walker, or Jindal, becomes president, that’s the fire that lies ahead.