Beyond ACA, GOP presidential hopefuls differ on healthcare

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 African-American 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 high-deductible, “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 passionate 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.