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Can the GOP Still Stop Obamacare? Let’s Count the Ways

“Obamacare is the law of the land,” House Speaker John Boehner (R-Ohio) told ABC News last week … before reversing course within minutes and affirming that his goal remains to repeal the “job-killing” legislation.

Boehner’s quick turnaround — a “whip-flop,” to borrow Micah Weinberg’s popular neologism — reflects Republicans’ general reaction in the week since President Obama’s re-election. Lacking executive authority and controlling only one house of Congress, the GOP’s options to slow the Affordable Care Act’s implementation have dramatically dwindled.

As a result, some of Obamacare’s most ardent critics are accepting that the law will stand, despite issuing Cassandra-like pronouncements about our nation’s long-term fate.

“Obamacare is here to stay … [although it’s] destined to be the last major entitlement,” Avik Roy, a former health adviser to the Romney campaign, wrote in Forbes last week.

But Republicans can still work to derail Obamacare. Here’s how.

Refuse To Opt Into Exchanges, Medicaid

Republican governors will lead 30 states next year, which gives the party tremendous influence over the next stage of ACA implementation — essentially, whether states will create a state health insurance exchange or opt into the law’s Medicaid expansion.

“Now is not the time to go wobbly,” the Cato Institute’s Michael Cannon exhorts conservatives in National Review.

“Obamacare is still harmful and unpopular … if enough states [refuse to implement its provisions], Congress will have no choice but to reopen” the law, and the GOP’s control of the House should allow the party to win concessions, according to Cannon.

As of Wednesday morning, about six states remained strongly opposed to the ACA’s Medicaid expansion, and nearly a dozen states were balking at implementing a health exchange, ahead of a looming end-of-the-week deadline to declare intentions.

But that number of Obamacare holdouts may have just shrunk by one.

Florida Gov. Rick Scott (R) — one of the earliest and most outspoken opponents of the ACA — on Tuesday night said he’s begun working toward implementation of the law.

Push for Scaled-Back Reforms

The GOP may not be able to win outright repeal of Obamacare, but the party is beginning to maneuver in an attempt to roll back some of its key provisions.

One starting point is likely to be the Independent Payment Advisory Board — which continues to be controversial given its role in cutting Medicare spending — House Majority Leader Eric Cantor (R-Va.) wrote in a letter to his colleagues last week.

“If we successfully make the case” to repeal IPAB and other measures, according to Cantor, “there are some issues that I suspect Senator Reid will have a difficult time compelling his members to oppose outright.”

Meanwhile, various taxes in the ACA — which were intended to help pay for the law — are coming under scrutiny, especially with deficit talks looming. As part of early negotiations, Republicans are currently targeting an excise tax on medical device manufacturers, which is expected to take effect in 2013, as well as a separate tax on high-income earners.

Let the Law Fail

The ACA will need to be fixed.

This isn’t a political pronouncement as much as a policy certainty; over the years, Congress has come together to repeatedly tweak Medicare and Social Security.

And some cracks in the new law are already apparent. Experts are calling for changes to how Obamacare cuts provider reimbursement. The law’s Pre-Existing Conditions Insurance Plan is well below enrollment estimates but well above its planned costs.

Meanwhile, the Supreme Court’s decision to let states choose whether they’ll participate in the ACA’s Medicaid expansion has opened a new loophole: There’s a chance that many poor Americans will make more than the federal poverty level, but too much to qualify for Medicaid.

In theory, Congress could work to come up with bipartisan patches to the law — but continued, willful resistance from the GOP will make the necessary fixes hard.

Moving Forward

Taken together, Republicans’ options to stop Obamacare are relatively limited in scope. Barring a major change in the political climate, the GOP will mostly rely on tactics to impede and slow the law, a far cry from the party’s stated goal of repeal-and-replace.

And the broader energy, and urgency, to repeal Obamacare outright seems to be dying down. A Kaiser Family Foundation poll released on Tuesday found that only one-third of Americans support repealing the law, the lowest level since the poll began tracking the issue.

But with full implementation of the law still months and years away, we’re not done talking about Obamacare.

“The reality of the economic and political situation means the core elements of the ACA remain very much in play,” the Heritage Foundation’s Stuart Butler wrote last week in the JAMA Forum.

“The Obama administration is arguing that the election means the ACA is a settled issue,” Butler adds. “It is far from that.”

Here’s what else is happening around the nation.

Administration Actions

  • President Obama‘s health policy team likely will remain intact during his second term, some health policy experts and former federal health officials say. They believe the makeup of team might reshuffle only slightly, primarily because the Affordable Care Act has weathered the judicial and election challenges, positioning it for full implementation within the next two years (Reichard, CQ HealthBeat, 11/8).

Challenges to Reform

  • On Thursday, House Speaker John Boehner (R-Ohio) took to Twitter to reiterate the House GOP’s goal to fully repeal the ACA, shortly after he suggested in a television interview that repealing the law no longer is on the GOP’s agenda (Viebeck, “Healthwatch,” The Hill, 11/8). Boehner said House Republicans had no firm plans to conduct another round of votes to repeal the ACA and that “Obamacare is the law of the land” (Mascaro, “Politics Now,” Los Angeles Times, 11/8).
  • Some Republicans are planning a series of initiatives aimed at dismantling parts of the law or slowing its progress. For example, House Majority Leader Rep. Eric Cantor (R-Va.) has said the GOP could successfully repeal the law’s Independent Payment Advisory Board (Baker, “Healthwatch,” The Hill, 11/7).

Effects on Employers

  • As they prepare for key provisions of the ACA to take effect, employers are increasingly turning to high-deductible health plans with incentives that encourage workers to play a larger role in managing their own health. Some employers say workers’ health and the overall health care system would benefit from workers being more proactive about their health care, such as researching the best hospitals and physicians and shopping for deals on services (Wilde Mathews, Wall Street Journal, 11/11).

Eye on the Exchanges

  • HHS has given states
    until Dec. 14 to submit detailed plans for establishing the health insurance exchanges under the ACA (Kliff, “Wonkblog,” Washington Post, 11/9). The extended deadline aims to help states obtain the technical support necessary to pursue their own exchanges (Pear, New York Times, 11/9). States that plan to partner with the federal government will have until Feb. 15 to submit a blueprint and declaration letter. The deadline extension will not affect the anticipated January 2014 launch of the exchanges, and states still must inform HHS by Nov. 16 whether they intend to set up their own exchanges (Zigmond, Modern Healthcare, 11/9).
  • At least 20 states will set up their own health insurance exchanges in 2014 under the ACA, according to Avalere Health. Avalere also estimates that more than one-third of states likely will have the federal government operate an exchange for them and 13 states likely will adopt a “partnership” model, in which the government would assist states in establishing the exchanges (Viebeck, “Healthwatch,” The Hill, 11/7).
  • There is little available information about how federally run health insurance exchanges would work, observers say. Although HHS has extended the deadline for states to submit their exchange blueprints, the Obama administration has yet to release details on how many plans will be included in the exchanges, what those plans will be, what will be covered and at what rates (Pittman, MedPage Today, 11/12).

Inside the Industry

  • On Wednesday, following President Obama‘s re-election, hospital shares spiked and insurer shares dipped, as the two industries braced for the full implementation of the ACA (Humer, Reuters, 11/7). Altogether, the Dow Jones Industrial Index and the Standard & Poor’s 500 traded down about 2.4% amid questions about how Obama would address looming deficit negotiations. Health care stocks overall traded down about 1.4%, but most of those losses were in insurers’ share prices (Kutscher, Modern Healthcare, 11/7). Meanwhile, the Bloomberg Industries hospitals stock index rose by 6.1% on Wednesday (Armour/Nussbaum, Bloomberg, 11/7).

In the States

  • Political shifts in state legislatures as a result of the 2012 election could affect how the health reform law is carried out. In the election, Democrats took control of five additional state legislatures, while Republicans added a governorship and took control of three state legislatures. Overall, the GOP will have 30 governors and control 24 state legislatures in 2013, while Democrats will have 19 governors and control of 18 state legislatures (Galewitz, “Capsules,” Kaiser Health News, 11/7).
  • Last week, voters in three states — Alabama, Montana and Wyoming approved ballot initiatives that block the implementation of the ACA’s individual mandate, while Florida residents voted against a measure that would have blocked the implementation of the mandate in the state (Radnofsky, Wall Street Journal, 11/7). Meanwhile, voters in Missouri approved Proposition E, which prevents newly re-elected Gov. Jay Nixon (D) from creating a state-run health care exchange under the ACA (KOLR10, 11/6).

Spotlight on ACOs

  • Accountable care organizations created by the ACA should focus on specific patient populations, and lawmakers should periodically re-assess the model’s goals to avoid the problems that have caused integrated delivery networks to fail in the past, according to an analysis published in Health Affairs (Zigmond, Modern Healthcare, 11/5). The analysis explained the similarities between ACOs and integrated delivery networks created by the Clinton administration (Gold, “Capsules,” Kaiser Health News, 11/5).

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