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Conservatives have lost a presidential election and two Supreme Court rulings that could have undone the Affordable Care Act.
The law has led to large increases, more than 10 million by most estimates, in the number of Americans with health insurance. The concerns from conservatives when the ACA passed that the law would halt job growth or balloon America’s health care costs have been so far unfounded.
So will Republicans now accept Obamacare?
With Obama still in office and disliked by many conservatives, it’s unlikely many Republican officeholders will openly embrace the law. After the Court's decision, all of the party's leading White House candidates and top party officials reaffirmed GOP plans to repeal the law if a Republican is elected president in 2016.
"Today's ruling makes it clear that if we want to fix our broken healthcare system, then we will need to elect a Republican president with proven ideas and real solutions that will help American families," said Republican National Committee Chairman Reince Priebus in a statement after the ruling.
But Republicans could execute a quiet, de-facto surrender, if they choose.
The first step would be to embrace the law’s Medicaid expansion. Twenty-one states, all of which have a Republican governor or GOP-controlled state legislature, so far have declined to expand Medicaid to nearly all of their low-income residents, as the law calls for.
This opposition reflects a long-held conservative opposition to Medicaid as essentially a welfare program, but has been surprising since the federal government is paying the full cost of the coverage expansion.
The Obama administration has been browbeating these states to accept the federal funds, and Obama pressed this case in his remarks after the ruling. If more of these states take the Medicaid funds, it would illustrate the GOP has conceded to the ACA's existence, even if Republican politicians continue to criticize it.
The second step toward accepting Obamacare would be Republicans, both in Congress and on the campaign trail, creating serious plans to “replace” Obamacare if a GOP president wins. Up to now, Republicans have promised to "repeal and replace" the health care law, but the emphasis has been on repeal.
And the Republican alternatives so far offered would have provided far fewer people insurance than the ACA.
If Republicans accepted the broad outlines of Obamacare, they might shift to calling for more modest changes, such as limiting the number of people eligible for Medicaid under the law or getting rid of its employer mandate.
“I do expect that given the implausibility of any outright repeal under this president, or even a subsequent president, because of how entrenched the ACA is in the health system at this point, Republicans in Congress will move on to targeted changes, some of which could have Democratic support,” said Michael Kolber, who was an attorney in the general counsel’s office of the Department of Health and Human Services during Obama’s first term.
Republicans could take the path of seeking more comprehensive changes that seek would ensure Americans keep their health insurance, but by more conservative means. For example, some conservative health experts want to give Americans tax credits, as Obamacare does, but would not include the long list of rules and requirements for insurance plans that the ACA does.
A number of conservative health care experts have already written detailed health care proposals along those lines. But they have gained little currency in the Republican Party up to now.
Jeb Bush, one of the leading Republican presidential candidates, talked in a recent interview with the Des Moines Register about embracing the idea of health care exchanges, as set up in the ACA, but giving "broad discretion to states to create exchanges that would look more like a Republican vision of how you expand access to health care insurance."
Third, Republicans might end the flurry of lawsuits and votes in the House to block or repeal parts of the law if they concede it is unlikely to be repealed.
"We hope the right wing will graciously accept this defeat and end their attacks on everyday Americans just trying to get by," said Caroline Fredrickson, president of the American Constitution Society, a liberal legal group.
It’s not clear if Republicans will make these shifts.
"Today's ruling won't change Obamacare's spectacular flops, from humiliating website debacles to the total collapse of exchanges in states run by the law's loudest cheerleaders. Today's ruling won't change the skyrocketing costs in premiums, deductibles, and co-pays that have hit the middle class so hard over the last few years," Senate Majority Leader Mitch McConnell said on the Senate floor Thursday after the court ruling was announced.
House Speaker John Boehner, in a statement, said, "Obamacare is fundamentally broken" and "we will continue our efforts to repeal the law and replace it."
Obama administration aides have long likened the ACA to Medicare and Medicaid. Some conservatives opposed both programs at their inception in the 1960’s, but getting rid of Medicare in particular would be politically-perilous today. Republicans have already conceded that some planks of the ACA are already broadly accepted by most Americans and unlikely to be repealed by either party: barring insurance companies from charging higher rates to people with illnesses and allowing young people up to age 26 to stay on their parent’s health care plans.
But the politics of Obamacare differ from Medicare.
The ACA, unlike Medicare, is not a universal program that everyone joins at a certain age and gets an enrollment card for. While many of its benefits go to all Americans, the primary beneficiaries of the law’s health insurance reforms are people who could not previously afford insurance on their own.
These beneficiaries are disproportionately minorities, the poor and people who do not vote. Those groups all tend to vote for Democratic candidates.
And the Supreme Court ruling only illustrates that two conservatives (Justices Anthony Kennedy and John Roberts) are unwilling to gut the ACA. Others in the party still strong oppose the law, which they believe imposes too many rules on the health care system and is an overreach of federal power.
Americans for Prosperity, the conservative group backed by the Koch brothers, is likely to keep opposing Medicaid expansion and threatening primary challenges to Republicans at the state level who would seek to accept the federal funds.
The 2016 candidates vying for the support of Tea Party, such as Wisconsin Gov. Scott Walker, will be pressed to promise to gut the ACA if they are elected. Politicians tend to be bound by such promises once in office.
If Republicans keep control of both houses of Congress and win the presidency, they would be well-positioned to change the law.
"So long as Obamacare’s mandates and relentless regulations are left in place, there is no good outcome. The American people believe both subsidies and mandates are wrong, so it’s now up to Congress to use reconciliation to repeal Obamacare, and Congress should continue to do so until there is a president who is willing to sign that repeal," said David McIntosh, president of the conservative group the Club for Growth.
Reconciliation is a legislative procedure through which the Senate can adopt laws with 51 members, not the 60 required to end a filibuster. McIntosh was suggesting Republicans can repeal the health care law if they maintain majorities in the House and the Senate and a Republican wins the presidency in 2016.
In short, the battle over Obamacare may not be over.
"SCOTUS upholds ACA subsidies. Now, back to our normal partisan divisiveness over the health law," said Larry Levitt, a health care expert at the Kaiser Family Foundation, after the ruling, in a Twitter message.