Where Does Jeb Bush Really Stand On Obamacare?

Former Florida Gov. Jeb Bush (R) has projected an anti-Obamacare line like the rest of his likely competitors in the 2016 field. But unlike the rest of them, Bush has been largely absent from the roiling national debate on heath care since he left office eight years ago.

To be sure, Bush has condemned Obamacare like essentially every other proud Republican, saying it’s “flawed to the core” and “doesn’t work.” But when it comes to getting wonky, Bush has been more eager to talk about immigration reform or education, his signature policy areas.

Despite more than 20 years in public life, including two terms as governor of Florida, there is precious little in the public record about Bush’s fundamental positions on the key health care policy issues. That leaves some major questions about Bush’s views on health care, particularly Obamacare.

Does Bush advocate full repeal of the law? What is his preferred alternative? Does he support bringing back Obamacare’s crucial subsidies if the Supreme Court invalidates them in over 30 states this summer?

Health care wasn’t Bush’s primary focus area as governor, Matthew Corrigan, a professor at the University of North Florida who wrote a book on Bush’s time in the statehouse, told TPM.

“He has talked about entitlements in general being way out of control. He’s brought it up a couple of times, and so I think a legitimate question should be asked, ‘Well, what are you going to do about Medicare and Medicaid if you’re elected president?'” Corrigan said.

Bush’s recent public comments on Obamacare have focused mostly on the political tactics of Republicans fighting the law. He has cast a skeptical eye toward the utility of the more-than-50 votes in Congress to repeal President Obama’s signature legislation.

“We don’t have to make a point any more as Republicans,” Bush told The Wall Street Journal in December. “We have to actually show that we can, in an adult-like way, we can govern, lead.”

Bush wasn’t totally on board with Sen. Ted Cruz’s (R-TX) push to threaten a government shutdown over full repeal of Obamacare. In October of 2013, Bush said that there was “some ground lost from a political point of view.”

“Republicans just need to take a step back and show self-restraint and let this happen a little more organically,” Bush said at the time. In an interview with ABC he said, “Tactically, it was a mistake to focus on something that couldn’t be achieved and that’s what that was, it was tactics.”

Still, on the bigger questions of strategy and policy, Bush’s views are far from clear. In his nationally-televised speech to the Detroit Economic Club this week, Bush did not mention health care policy, even though the speech’s theme was poverty and income inequality. Right now, the website of Bush’s new PAC, Right to Rise, doesn’t contain any issue-specific positions, including on health care. His nascent campaign did not respond to TPM’s questions regarding his positions on Obamacare.

Through a coincidence of timing, Bush has not been engaged in the wrenching political debate over Obamacare of the past seven years. He served as governor from 1999-2007, when health care reform was not a major topic in the national discourse. Bush was out of office and back in the private sector before health care reform became a major issue in the 2008 presidential election and well before the polarizing congressional debate over the passage of Obamacare in 2009-10. Bush has not been involved in the subsequent legal battle waged by conservatives to dismantle the law.

Since Bush left office in 2007, he has sat on boards, delivered speeches, and written a book. Much of that didn’t involve directly weighing in on Obamacare, but there were a few exceptions. While serving as a member of the board of directors of hospital giant Tenet Healthcare Corp., Bush was asked to discuss his views on expanding Medicaid. He refused, saying “I just don’t want to get in trouble back home.”

One of Bush’s first public steps toward running for president was actually to cut ties with Tenet. It’s easy to see why. Like most hospitals, Tenet benefited from Obamacare, which reduced the number of uninsured who couldn’t pay their hospital bills. Tenet CEO, Trevor Fetter, noted that Obamacare has been good for the company.

“As we look at the past four months, we can see a steep ramp of people who are newly insured and are seeking care in our hospitals,” Fetter told the Dallas Business Journal in May 2014. “February was double January, and March was double February. It’s a steep ramp of people who are now accessing the health care system.”

Bush was against expanding Medicaid after Florida Gov. Rick Scott (R) announced that he would accept funds through Obamacare.

“I have doubts because I think if three years from now, as I understand it, three or four years from now, the deal is that the fed match goes from 95 [percent] back to what it is now, which is about 55 in Florida,” Bush told CNN (it should be noted that Bush goofed the cost of expansion in that interview).

A year earlier, Bush and Clint Bolick co-authored The Immigration Wars: Forging An American Solution, which as title suggests, is mostly about immigration. The most Bush and Bolick get into Obamacare is when they argue how it’s inflamed “anti-immigration sentiment.”

“This is why the Obama administration’s attempt to coerce states to adopt a major Medicaid expansion as part of its national health-care program had the effect of inflaming anti-immigration sentiment,” they wrote. “Although the administration assured the states that illegal immigrants would not be eligible for Medicaid benefits, their children who are born in the United States are eligible because they are citizens.”

Bush at a town hall meeting after signing the Affordable Health Care for Floridians Act in 2004.

Bush’s two terms as governor of Florida offer limited insights into his positions on health care policy. In 2005, Bush tried to enact a major change to the state’s Medicaid program by moving Medicaid recipients to a managed care type of health care plan. At the time the New York Times described, the pilot program, as “far reaching” and said if enacted it would “make Florida the first state to allow companies, not the state, decide the scope and extent of services to the elderly, the disabled and the poor, half of them children.” Bush wanted to test the changes statewide, but the Republican-controlled legislature limited the pilot program to just two counties, Broward and Duval.

Other states have moved Medicaid beneficiaries into managed care plans, but some of Bush’s proposed changes were “unprecedented at the time,” according to Joan Alker, a research associate professor at Georgetown University’s Health Policy Institute.

Bush’s plan also featured a program to encourage healthy behavior but that had huge administrative costs and was eventually dropped, Alker said. It also included what was essentially a voucher program as an alternative to Medicaid. The problem, Alker said, was that the people choosing the alternative weren’t getting the full benefits that they would have had under Medicaid.

The Obama administration eventually renegotiated aspects of Bush’s pilot program.

“Today, the primary legacy of Gov. Bush’s reform is Florida has the vast majority of its Medicaid beneficiaries enrolled in managed care companies. That is also true in many other states, and Florida’s managed care appears to be mediocre at best,” Joan Alker told TPM.

Bush did implement some cherished smaller-scale conservative health care policies, expanding health saving accounts and high-risk insurance pools, in The Affordable Healthcare for Floridians Act, which he signed in 2004. But by 2013, before Obamacare fully took effect, Florida still had the second highest uninsured rate in the country, at about 25 percent of state residents.

As healthcare, and Obamacare in particular, will remain one of the primary litmus tests for key Republican voting blocs, Bush’s lack of experience in dealing with thorny healthcare issues could be a stumbling block on his way to the primary.