Be­yond ACA, GOP pres­i­den­tial hope­fuls dif­fer on health­care

Modern Healthcare - - NEWS - By Paul Demko

The bur­geon­ing group of of­fi­cial and unof­fi­cial Repub­li­can pres­i­den­tial con­tenders all agree on one thing when it comes to health­care pol­icy: They re­ally, re­ally hate Oba­macare.

For­mer Florida Gov. Jeb Bush called the law that has re­duced the num­ber of unin­sured Amer­i­cans by nearly 17 mil­lion a “mon­stros­ity.” Dr. Ben Car­son, the re­tired AfricanAmer­i­can pe­di­atric neu­ro­sur­geon, said the Af­ford­able Care Act is “the worst thing that has hap­pened in this na­tion since slav­ery.”

But dif­fer­ences are emerg­ing on the can­di­dates’ ap­proaches to strength­en­ing the long-term fi­nances of Medi­care, with for­mer Arkansas Gov. Mike Huck­abee buck­ing Repub­li­can or­tho­doxy. That could be­come an im­por­tant fis­sure in the GOP pres­i­den­tial pri­mary cam­paign.

The dis­cus­sion about the ACA is un­likely to gain more nu­ance dur­ing the GOP pri­maries. That’s be­cause there’s no po­lit­i­cal pay­off to say­ing any­thing but hor­ri­ble things about Pres­i­dent Barack Obama’s sig­na­ture health­care re­form law, which re­mains deeply un­pop­u­lar among Repub­li­can ac­tivists. “The only way a Repub­li­can gets in trou­ble is if they say they want to some­how make the ACA work bet­ter,” said Robert Blen­don, an ex­pert on health­care pol­i­tics at Har­vard Uni­ver­sity. “There’s just no con­stituency in Repub­li­can pri­maries for that po­si­tion.”

Some can­di­dates, while pro­vid­ing few de­tails, have of­fered clues on their vi­sion for re­peal­ing and re­plac­ing the ACA. Sen. Marco Ru­bio (R-Fla.) has pro­posed a three-part plan in­clud­ing pre­mium tax cred­its for in­di­vid­u­als that he says would be com­pa­ra­ble to the tax breaks for em­ployer-based health plans.

He also backs a menu of long-stand­ing con­ser­va­tive pol­icy nos­trums, in­clud­ing al­low­ing in­sur­ers to sell plans across state lines and ex­pand­ing health sav­ings ac­counts.

Bush said in March that the gov­ern­ment’s pri­mary role in health­care should be to pro­vide ac­cess to high­d­e­ductible, “cat­a­strophic” cov­er­age. He ad­vo­cates re­plac­ing the ACA “with a model that is con­sumer-di­rected, where con­sumers, where pa­tients, have more choices … where the sub­si­dies, if there were to be sub­si­dies, are state-ad­min­is­tered … where peo­ple have more cus­tom­ized types of in­sur­ance based on their needs.”

But Bush’s ten­ure as a well-paid board mem­ber for Tenet Health­care Corp.—which has strongly sup­ported cov­er­age ex­pan­sion ef­forts un­der the ACA—has prompted skep­ti­cism among some con­ser­va­tives about his anti-Oba­macare bona fides. Bush stepped down from the board in De­cem­ber, when he be­gan ac­tively ex­plor­ing a pres­i­den­tial cam­paign.

The GOP field, with two ma­jor ex­cep­tions, is also uni­fied in re­ject­ing the ACA’s Med­i­caid ex­pan­sion. Louisiana Gov. Bobby Jin­dal and Wis­con­sin Gov. Scott Walker have boasted about their re­fusal to take the fed­eral dol­lars, which hasn’t been broadly popular in their own states. In con­trast, New Jer­sey Gov. Chris Christie and Ohio Gov. John Ka­sich sup­ported Med­i­caid ex­pan­sion in their states.

Ka­sich, who has strongly sig­naled his in­ter­est in run­ning, has been a pas- sion­ate evan­ge­list for Med­i­caid ex­pan­sion, which has an­gered many in the GOP. “Put your­self in the shoes of a mother and a fa­ther of an adult child that is strug­gling,” he told a Repub­li­can leg­is­la­tor dur­ing his state’s de­bate over ex­pan­sion in 2013. “Walk in some­body else’s moc­casins. Un­der­stand that poverty is real.”

Dif­fer­ences also are emerg­ing over Medi­care. Christie has made ma­jor Medi­care and So­cial Se­cu­rity re­struc­tur­ing the cen­ter­piece of his agenda, propos­ing to grad­u­ally raise the Medi­care el­i­gi­bil­ity age to 69 and hike pre­mi­ums for se­niors with in­comes above $85,000. His pro­posal is seen as an ef­fort to re­vive his scan­dal-marred pres­i­den­tial prospects, but it could alien­ate the GOP base of older vot­ers.

Last month, Bush and Ru­bio also came out in fa­vor of rais­ing the re­tire­ment age for fu­ture Medi­care ben­e­fi­cia­ries. “The math is un­mis­tak­able,” Ru­bio said. Two other de­clared can­di­dates, Sens. Rand Paul (R-Ky.) and Ted Cruz (R-Texas), have long backed grad­u­ally rais­ing the Medi­care age. None of them have ad­dressed the Con­gres­sional Bud­get Of­fice’s 2013 find­ing that rais­ing the Medi­care age to 67 would have only a mod­est ef­fect on the fed­eral deficit be­cause it would lead to higher spend­ing on Med­i­caid and ACA pre­mium sub­si­dies.

But Huck­abee has staked out a sharply dif­fer­ent, pop­ulist stance on Medi­care, vow­ing to pro­tect the pro­gram from cuts. “I’ll never rob se­niors of what our gov­ern­ment promised them and even forced them to pay for,” he said last week.

That could cause headaches for other Repub­li­can can­di­dates be­cause most have em­braced the am­bi­tious en­ti­tle­ment re­struc­tur­ing agenda laid out by Rep. Paul Ryan (R-Wis.). Medi­care is highly popular with vot­ers, es­pe­cially se­niors, and Democrats ef­fec­tively pum­meled the GOP ticket of Mitt Rom­ney and Paul Ryan on the Medi­care is­sue dur­ing the 2012 pres­i­dent cam­paign.

“I’ll never rob se­niors of what our gov­ern­ment promised them and even forced them to pay for.”

For­mer Arkansas Gov. Mike Huck­abee

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