Why The GOP Candidates Are Tied In Knots Over Replacing Obamacare

This month, Republicans in Congress achieved what they declared to be a major victory: they sent an Obamacare repeal to the president’s desk as test-run for next year, when they say there will be a Republican president in office to sign it.

But there’s just one problem with that plan. The details have been scant as to what the GOP presidential candidates — who have uniformly railed against the Affordable Care Act — intend to enact in its place.

After five years of promises to deliver an Obamacare replacement plan — more than 20 such promises by one count –the GOP Congress still hasn’t produced. And the same mix of political perils and policy paralysis that has hamstrung the Republicans on the Hill has left the party’s presidential contenders with paltry real health care proposals that are short on details and long on vague assurances. The party that has spent years avoiding grappling with the economic, political, and policy complexities of health care reform seems no closer now that it was when Obamacare first became law.

“There have been a few proposals put up, but most of them have been pretty general and most of them have pretty much recycled, old Republican proposals that have been out there for a long time,” Timothy Jost, a health law specialist at the Washington and Lee University School of Law who supports Obamacare, told TPM. “No one seems terribly committed to coming up with an innovative proposal that could replace the Affordable Care Act and I think, in part, that’s because the Republicans really don’t know what they want. ”

There was not a single question about Obamacare alternatives at the GOP debate Thursday, nor has much time been spent on the issue in previous debates. And Hillary Clinton has signaled she plans on hitting Republicans on their lack of plan.

“Their talk of repeal is never followed by any detail about what we do to keep people having access to affordable quality health care,” Clinton said on MSNBC’s Morning Joe Friday. In contrast, the Democratic primary for the last week has been focused on health care, with Clinton attacking of Sen. Bernie Sanders’ single payer plan. Under pressure from Clinton, Sanders released Sunday the outline for how he would pay for his proposal to move to single payer. As for Clinton, she’s released multiple health care policy proposals and is deeply engaged on the subject.

The GOP candidates’ reticence on the topic may be in part due to the general dynamics of a primary race — where candidates have more to lose by going into too much policy detail — as well to the dynamics of this specific primary, where frontrunner Donald Trump has determined an agenda focused on immigration and terrorism.

But it also reflects the complexities of reforming health care with all the conditions the GOP has self-imposed. The fact of the matter is the Republicans running for the White House face the same challenges that their colleagues in Congress do in crafting a plan that achieves the same coverage goals as Obamacare without defying conservative dogma.

“They can’t achieve what Obamacare has achieved with any of things that are in the standard arsenal and they’re running on resentment of spending money on lower income and middle income people and that’s what you have to do to spread health insurance,” Theda Skocpol, a professor of government and sociology at Harvard University who has studied the health reform law, told TPM.

So far former Florida Gov. Jeb Bush (R) has released what most resembles an alternative, which includes tax credits and expanding health savings accounts. Sen. Marco Rubio (R-FL) has drawn — in broad strokes, via a Politico op-ed — a similar proposal of tax credits, deregulation and transforming Medicaid into a block grants, while what Carly Fiorina has put out amounts to state control of high risk pools — an expensive idea that has been blocked by conservative sin the past.

“There’s this sort of Republican gospel on health care reform and the first element of the gospel is Obamacare is bad — maybe evil — and must be repealed and they all swear up and down on that,” said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina-Chapel Hill. “Besides that, there’s been sort of a common set of principles that Republicans tend to have in health reform: less federal government, more state [control], less regulations, more markets, fewer mandates, more choice.”

Sen. Ted Cruz (R-TX) — who famously shut down the government over Obamacare — has so far only offered as his alternative plan the legislation he introduced in March when Congress was scrambling ahead of a Supreme Court decision that would have crippled that law. (The court ultimately upheld the ACA in King v. Burwell.)

Ben Carson, a neurosurgeon, has trumpeted an amped-up version of health savings accounts (which are already included under the ACA) and turning Medicaid into state block grants. Sen. Rand Paul (R-KY) has kept his ideas even simpler: “We could try freedom for a while.” His campaign website suggests he hasn’t elaborated much since. The other candidates have been similarly reliant on vague ideas like allowing cross-state competition among insurers and scaling back federal benefit programs by out-sourcing them to the states.

“They’re not saying many different things — generally — in terms of Republican alternatives to Obamacare,” said Tom Miller, a health care policy expert at the conservative American Enterprise Institute.

And when frontrunner Donald Trump was asked about his intentions for health care reform, his ideas sound remarkably like the Affordable Care Act.

“As soon as you put out something that would try to accomplish the same goals as the Affordable Care Act, you’re going to get attacked from some candidates proposing Obamacare-lite,” Jost said.

Part of the problem is that there is internal debate among conservatives as to the government’s role in the health care policy in the first place.

“Some of them feel like the goals, at least, of the Affordable Care Act — of extending coverage to the uninsured and improving quality and bringing down costs — are important goals, that they ought to be achieved, but in different ways,” Jost said. “Some of them, I think, frankly don’t think that coverage for lower- and moderate-income Americans is a priority. Maybe cost control, maybe cutting back on spending for Medicare and Medicaid. Achieving what the Affordable Care Act has achieved is not something they’re interested in.”

A perfect example of this tension was the debate among Republicans last spring about how to react to the King v. Burwell case had the Supreme Court decided to dismantle the subsidies offered in the federal insurance exchanges. Some argued Republicans should put out an alternative to Americans who would have lost their benefits, while others objected to anything that appeared to prop up the law.

“If you’re asking if they’re readying specific policy proposal? Well, no. And when they thought the Supreme Court was going to gut it, they didn’t,” Skocpol said. “That’s because there isn’t any. It’s far better to have it as a mobilizing issue than it is to actually having to do something about the health insurance problem.”

But if anyone in the GOP 2016 field is even thinking about the specifics of an alternative they’re holding their cards close to their chest.

“Those questions don’t even get asked. On that stage, all you have to say is Obamacare has been bad, I am going to replace it, I’m going to repeal it, and that takes you through the one minute you have to answer the question,” Miller said.