GOP cant give up Obamacare repeal talkPolitico October 14, 2014Deep down, Republicans who know health care know the truth: Obamacare isnt about to be repealed.But you wont hear that in this election and maybe not in 2016, either.Republicans may be split on many issues, but they remain fiercely united in their loathing for the Affordable Care Act; they still see it as a terrible law, and they want it to go away. But GOP staffers and health care wonks also know that, even if they win the Senate, theyre not going to accomplish that in the next two years while President Barack Obama is still in office.And after that? Well, think of the last time a major social program was repealed after three enrollment seasons, with millions of people getting benefits. Thats right it hasnt happened.Just dont expect a reckoning with the voters, where Republicans tell voters they cant get rid of it not as long as vows to repeal rile up campaign crowds and serve as fundraising catnip. Instead, the talk will slowly turn to what pieces of the law Republicans might be able to knock out in the next two years, followed by a full airing of plans in the 2016 presidential race that will shift the conversation to replacing as much of the law as possible, according to interviews with a dozen GOP strategists, staffers and health care analysts.Republican candidates will keep shining the spotlight on the laws problems, and theyll have to compete with the likes of Ted Cruz, who still gets thunderous applause with his promise to repeal every word of Obamacare. But soon, theyre going to have to turn the conversation away from what theyd like to do and start talking about what they can actually do this late in the game.Even the most strident opponents of the ACA are coming around to the realization that, I want to repeal every word, but I dont think that is feasible, said Chris Condeluci, a consultant whos a rarity in health policy circles: a former Republican Senate staffer who worked on the Affordable Care Act.(Also on POLITICO: New strategy: Underselling Obamacare for Year 2)Gail Wilensky, a longtime health care expert who ran the Medicare agency under the first President George Bush, concluded that even though the law is still unpopular even after the benefits have kicked in I think we are at the point where people have to realize this isnt going away.A big turning point, according to Senate Republican health aides, was when health insurers not only didnt abandon the Affordable Care Act after the bumpy first enrollment season but also signed up in greater numbers for the second enrollment season, which starts in November. Thats seen as a sign that health insurance companies have accepted the law and dont believe its going anywhere.Besides, Wilensky said, I think a lot of Republicans, in quiet conversations, understand that there is no precedent for repealing a program after the benefits have already started.What they cant do at least not yet is break that news to the voters. They havent forgotten the uproar when House Speaker John Boehner tried to do that in 2012, after Mitt Romney lost the presidential election and Boehner conceded that Obamacare is the law of the land. No one wants to be the second Republican to say that.If you listen to Republican candidates, you wont hear anyone conceding that the ship has sailed. Instead, you hear what works best on the campaign trail: Obamacare is a disaster, its bankrupting the country, and its making everyone lose their health plans and doctors. Even if they dont say repeal, voters who hear that list of horribles will get the message and the Republican faithful arent likely to settle for anything less.In the Arkansas Senate race, Rep. Tom Cotton says his goal is to repeal Obamacare, start over, and get it right. In Louisiana, Rep. Bill Cassidy, running against Sen. Mary Landrieu, said in a TV ad that his goal is to replace Obamacare with a plan that gives the power to you, not to politicians and bureaucrats. And dont forget Iowa Senate candidate Joni Ernst, who ran an ad showing her firing a gun at the law.The voters who hear those messages, however, are in for a big disappointment over the next two years when Republicans wont be able to get 60 votes in the Senate for a full repeal, even with a GOP Senate.Theyll get excited again in 2016, when Republican presidential candidates will try to outdo each other in Obamacare bashing. But by the time they get to vote, millions more people could be enrolled in the program and it will be that much more entrenched in the health care landscape.Thats why some conservative health care experts are disappointed that Republicans arent farther along after all this time in deciding what they want instead.If you dont have a larger destination in mind that you want to get to, then you just let the concrete harden a little more, said Tom Miller, a health care expert at the American Enterprise Institute.Its not that alternatives dont exist. A replacement plan by Sens. Orrin Hatch and Tom Coburn, a similar one by the 2017 Project and a more recent version by Avik Roy of the Manhattan Institute have all gotten serious attention in GOP circles. They all target what conservatives genuinely believe are the worst features of the health care law higher coverage costs and fewer choices although they differ in how much of the law theyd wipe away. Roys version would keep a deregulated version of Obamacares health insurance exchanges and use them to cover some Medicare and Medicaid beneficiaries, while the others would get rid of more of the laws central features.But Republicans and conservative activists havent gotten on board with one plan, and arent likely to anytime soon. They cant even agree on whether it should be one big alternative or a bunch of smaller ones.Im a strong advocate of rifle-shot stuff, said Grover Norquist of Americans for Tax Reform, citing ideas like tort reform and letting people buy insurance across state lines two proposals Republicans have been circulating for years. With narrower changes, Norquist said, you can see what each of them does, and you can argue each one on the merits.The best that anti-Obamacare voters can hope for over the next two years, if Republicans win the Senate, is that Congress would send Obama a budget reconciliation bill with popular changes that would be hard for him to veto like repealing the laws employer mandate and its tax on medical devices. They might also get rid of the laws unpopular rule that defines full-time work as 30 hours a week. All of those changes could win at least some Democratic support.But the exact package hasnt been decided yet, and there are are limits to what can actually be done through budget reconciliation especially since the Republican leadership would have to find a package that could unite everyone from Mitch McConnell to ideological firebrands like Cruz to purple-state Republicans like Rob Portman of Ohio and Pat Toomey of Pennsylvania, according to top Senate Republican aides. They know the smart strategy is to make it a tough choice for Obama, which means sending him only the most popular fixes, not try to gut the whole law and make it easier for him to veto the bill.They also know that Republican voters and grass-roots conservative activists wont have any patience for going soft on repeal.There is a disconnect between the private dialogue and the public dialogue, said one Republican health policy expert who has been talking to Hill staffers about Obamacare options. I think there is a practical recognition among some Republicans that they should try to do some constructive stuff that is not repeal. But theres also a reluctance to look like theyre abandoning the goal of repeal.Take Portman the Ohio senator whos contemplating a run for president in 2016 but could also just run for reelection instead. Either way, hed have to appeal to Democratic voters, not just Republican ones. Portman still talks about repeal as a goal, as well as the need to replace the whole law. But in a telling choice of words, he noted at a Christian Science Monitor briefing last month that there are more specific areas where Congress could act and the president would actually sign legislation like the elimination of the medical device tax.Republicans know the conversation is going to have to shift over the next two years. They still want a more market-oriented health care system with more choices for consumers, without all the required benefits in Obamacare plans and with fewer expensive subsidies. But they disagree about whether that requires throwing out all of the health care law or whether it could be built on the existing foundation.Political operatives still think full repeal is possible, and that even popular features of the law, like coverage of pre-existing conditions and allowing young adults to stay on their parents plans, could just be re-created in some form in a conservative alternative. You have to start with a new foundation, said political strategist Rory Cooper, who was communications director for former House Majority Leader Eric Cantor. If your house is built on a cliff thats eroding, you cant just change the drapes.But conservative health care analysts are warning that, with 7.3 million people already enrolled in Obamacare and more on the way in the next enrollment season, Republicans cant disrupt their health coverage by just erasing the law not without undermining their own criticisms of the law for leading to the cancellation of peoples health plans. They say any replacement plan has to include a transition for those people, like letting people keep their Obamacare plans and Medicaid coverage if theyve already signed up.The more realistic folks always understood that moving ahead on repeal would require some kind of replacement plan, said James Capretta of the Ethics and Public Policy Center, who co-wrote an article in the Weekly Standard about the most likely elements of an alternative. You cant easily disrupt whats already in place without offering a transition.Right now, Republican Senate candidates can campaign easily against Obamacare without spelling out an alternative. But in 2016, Republican presidential candidates will have to have fully developed alternatives and not just run against Obamacare one more time, according to pollster Kellyanne Conway.A philosophy is not a plan, Conway said. They dont have to accept the law as a permanent fixture of American health care, she said, but it will fall to them to be much more clear on what the form of replacement will be.Theyll get different reactions from grass-roots activists, depending on the audience. Roy of the Manhattan Institute, who says his plan is designed to work without requiring a full repeal, says he has gotten a good reception from conservative activists once he explains that the high cost of health coverage is a long-term problem that didnt start with Obamacare.I think the perception of the grass roots is that we had a free-market system before, and then Obamacare replaced it with a government takeover, Roy said. The real question is, will politicians be able to walk people through that?Even among tea party activists who are committed to fighting the law, its not clear that repeal every word is still their goal.It is for Sharon Calvert of the Tampa Tea Party in Florida. Her solution, she said, is still to get rid of the whole law, she said, and then replace it with incremental changes that can be tested and adapted. Its kind of like when you have a totaled car. You cant fix the car. Just throw it out and get a new one, she said.For Michael Openshaw of the North Texas Tea Party, however, its not necessary to repeal every word of the law. It would be enough, he said, to let people stay in Obamacare plans but also let insurance companies start offering health insurance with fewer benefits again including catastrophic health plans to compete for their business.I can get by on that, and its less of a shock to the system. Im enough of a realist to know that, Openshaw said. But he also says that kind of a change serves as a repeal because the new system wouldnt be able to compete with the old one: Obamacare will evaporate on its own if we let insurance companies go back to doing what they used to do.The activists may still want to destroy the law, one way or another, but most conservative health care experts say theres no point in wishing for a return to the old health care system. Republicans can still use the coming debates to advance the market-based health care reforms theyve wanted for years, they say, but they cant pretend that Obamacares reforms particularly its new insurance rules and its coverage of pre-existing conditions can just be wiped off the books as if they were never there.Even Medicare has changed significantly over the years, and it is now a very different program than it was when it started, Miller said. But Medicare also teaches a lesson the public will have to learn about the Affordable Care Act: You never get back to a blank slate.