Reform Update: Some Republicans suggest new Obamacare strategy, others balk

The Republican mantra on Obamacare—repeal, repeal, repeal—is coming in for questions from an unexpected quarter. Some pragmatic conservatives are concerned that continuing what has been the Republican repeal battle cry may be counterproductive in November. But they are facing fierce opposition from other Republicans, and the formerly solid opposition is showing hairline cracks.

Dean Clancy, a former senior White House health policy official in the George W. Bush administration, said Republicans are in a period where they need to appeal to those who seek repeal and move toward fixing the ACA's flaws.

“Republicans need to switch to a more nuanced approach without dispiriting their base voters,” he said, adding that the message may need to shift to emphasizing health savings accounts, pushing for more regulatory exceptions for high-deductible plans and individual-mandate penalties and basically “shrinking the Obamacare footprint.”

“They need to begin saying what they would replace it with without slipping into accepting it,” Clancy said. “If they try to win this year solely on repeal, they won't do as well as they expect.”

Clancy said “people like the sound” of not allowing the denial of coverage for pre-existing conditions, allowing young adults to stay on their parents' plan until they are 26 years old and requiring free contraceptive coverage and other mandated benefits.

Medicaid expansion has become a focal point between candidates making vague calls for “change” while seeking to repeal or “fix” Obamacare. Clancy noted how Democratic U.S. Senate candidates in Louisiana and North Carolina are making an issue of their opponents' opposition to Medicaid expansion.

Clancy testified in the Arkansas Legislature against its “private option” Medicaid program, which funneled public money into commercial plans.

Indiana's Mike Pence is the latest Republican governor attempting a conservative yet middle-ground approach to Medicaid expansion. He called for beneficiaries to contribute to the cost of their care and wants their care moved from the emergency room to the primary-care office. But even Clancy lambasted Pence and said he is hurting his state and his own presidential ambitions.

“Pence is begging for approval for reforms his masters in Washington will fundamentally reject,” Clancy said. “I think Pence is on a fool's errand and looks silly saying, 'This is conservative because I say it's conservative.' ”

Pence recently presented his case for expanding coverage to an additional 350,000 Indianans to the conservative American Enterprise Institute, but it appears his arguments fell on deaf ears.

The National Review, for example, said Pence's plan was “neither Conservative nor Federalist.”

But Grace-Marie Turner, founder and president of the Galen Institute, who called Medicaid “a terrible, terrible program,” endorsed Pence's proposal.

“I'm not in the majority,” Turner acknowledged, adding that conservative approaches to Medicaid expansion in Arkansas and Iowa are “fake efforts” at reform. “We should think of it as a pilot project,” she said of the Indiana proposal. “If we're going to transform this program, we need models.”

Doctors in Texas are watching a May 27 primary runoff to see if the Tea Party's call for full repeal will win over more nuanced calls from candidates seeking to make changes to the ACA and the state Medicaid program.

“If the Tea Party sweeps those elections, then Medicaid expansion in Texas is going to be dead for a while,” said Dr. Austin King, an otolaryngologist from Abilene who was sworn in this month as president of the Texas Medical Association, the nation's largest state physician organization. “It's going to close the door on any discussion at all for the next couple of years.”

TEXPAC, the TMA political action committee, has endorsed 12 candidates (PDF) in the May 27 election: 11 Republicans and one Democrat. King said that because the GOP is so dominant in the state, “if you want to be a player,” you have to work with the Republicans. A TEXPAC election flier, however, has unchecked boxes next to Democrat and Republican labels and instead marks the box for the “Party of Medicine.”

A blog post on the TMA website notes that TEXPAC endorsed candidates who “fight government intrusion into the patient-physician relationship, support our liability reforms, work to improve the Texas Medicaid system and help us stand guard against public health threats.”

But King said those were not the only qualities the 47,000-member TMA sought in the candidates. “We're supporting candidates who will listen to us and bring us to the table,” he said.

Medicaid expansion and reform need to occur in Texas, he said, explaining that the current program seeks to control costs by pushing people into managed-care plans that offer low reimbursement to doctors and limit patient choice through narrow network panels.

Fixing the problems requires discussions that are currently impossible in the all-for or all-against climate, he said.

“It's really kind of depressing right now,” King said. “I talk to all kinds of groups—the cattlemen, the Rotary clubs—and it's hard to have a rational discussion about what's good or bad about the ACA. You're attacked from the right or attacked from the left almost immediately. It's been an interesting experience.”

King, however, is confident the climate will improve. “I feel the political process will eventually work itself out,” he said. “But in the meantime, it's pretty uncomfortable.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks