Why the Republican 'Obamacare' opposition matters

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Last November, a few days after President Obama won re-election, House Speaker John A. Boehner declared that “Obamacare is the law of the land” and signaled Republicans would stop their push to gut it.

In the few months right after the election, other Republicans also echoed this grudging acceptance of the health care law. Several GOP governors, from the more moderate Chris Christie of New Jersey to even Tea Party favorite Rick Scott of Florida, said they would expand their states’ Medicaid programs under the law, a decision the U.S. Supreme Court had left up to governors. Journalists predicted that most Republican governors, even those most opposed to the president, would eventually embrace a law that sends billions of dollars to their states to cover the uninsured.

But the anti-“Obamacare” movement never died. Republicans in Congress are waging what they acknowledge is a losing battle to delay or defund Obamacare before Oct 1., when uninsured Americans can start enrolling in new health care plans under the law. And a bloc of about two dozen Republican governors, mostly in the West and South, are not only still opposing the law, but meaningfully disrupting Obamacare in a way that Republicans in Washington simply can’t, most notably by refusing to expand their Medicaid programs as the law calls for.

For example, in Texas, the non-partisan Kaiser Family Foundation estimates a family of four with an income of $25,000 each year will be able to get health insurance that is less than $50 each month through subsidies under the law. But because subsidies only go to families over a certain income (the law anticipated the poorest would be covered by Medicaid), a family with a LOWER income, like $20,000, would get no subsidized insurance and face costs of more than $800 each month. Texas is one of the 22 states, all with Republican governors, that is declining to expand its Medicaid program.

Data from the non-partisan Urban Institute suggests that millions of Americans could affected by this coverage gap, including more than one million in Texas alone.

 This continued opposition from GOP governors has slowed the law’s implementation in other ways as well. The Obama administration has been forced to spend much more time and money on the law’s basic operations than anticipated, as states like Georgia have refused to set up the health insurance marketplaces under the law, leaving that up to the federal government instead.

This resistance by Republican governors is most significant in the South, which has many of the states with the highest rates of obesity, uninsured people and illnesses from preventable conditions. A report released earlier this month by the non-partisan Commonwealth Foundation that ranked states by “health system performance for low-income populations” found that seven of the 10 worst-performing states were in the South, with Mississippi ranked as the worst. Politicians in five of those seven Southern states are taking steps to limit the new health care law.

President Obama regularly rails against Republican governors these moves by GOP governors.

“We’ve still got a few Republican governors who are so opposed to the very idea of the law — or at least they’re doing it for politics — that they haven’t lifted a finger to help cover more people.  Some of them have actually tried to harm the law before it takes effect,” the president said in a speech in Maryland on Thursday.

But he’s only venting at those governors after the president and his advisers spent most of the year unsuccessfully trying to court them.

This Medicaid battle was one the administration did not anticipate in 2010, when the so-called Affordable Care Act initially passed, or even last year. Last March, in the midst of the presidential campaign, as well as a looming Supreme Court ruling on the health care law, Obama’s advisers decided to embrace the “Obamacare” moniker that Republicans had originally stamped on the Affordable Care Act and that the White House had long resisted.

It simplified Obama’s election strategy, but also more closely identified the health insurance program with a president strongly opposed by almost half of the country.

“You want to call it Obamacare — that’s OK, because I do care,” the president said back then.

A few months later, a group of seven justices on the Supreme Court, including two Democratic appointees (Justices Breyer and Kagan) ruled that the health care law could not require states to accept Medicaid funding, as had been originally mandated by Congress.

Those two developments created a situation in which every governor in the country would have to choose if his state participated in the Medicaid portion of the law, and that media and activists in each state would effectively cast that decision as embracing or opposing “Obamacare.”

Secretary of Health and Human Services Kathleen Sebelius has met with many of the Republican governors and argued that they should accept a program in which the federal government will be spending about 90 percent of the money to cover  new Medicaid recipients.

But unsurprisingly, the Medicaid decisions have turned into referendums on Obama in each state.

Nearly every state that has a Democratic governor is expanding Medicaid, with Democratic governors in states like Arkansas and Kentucky, where Obama is deeply unpopular, taking strong criticism for the decision. Several states where Obama won in 2012 but with Republican governors (such as New Jersey and Nevada) have also signed onto the Medicaid expansion. A few Republican governors in states where Obama lost in 2012, such as Arizona’s Jan Brewer, have also expanded Medicaid, usually while taking great fire from conservative activists.

But most Republican governors in red states are either ideologically opposed to expanding Medicaid or have figured out the obvious political challenges of doing so and ceded to them. Florida’s Scott, a Republican in a state where Obama won in 2012, said he would expand Medicaid earlier this year, but then Republicans in the state’s legislature blocked the move.

Scott got the message. He has not only stopped talking about Medicaid expansion, but is now trying to limit access of people promoting “Obamacare” to the state’s health facilities.

White House officials expect this opposition to die down over the next few years. They argue as the health care law gets more popular, low-income people in Texas or Georgia will wonder why they can’t get the same kind of insurance those in California do.

That might be true. But for now, the complicated politics of the law have created a situation in which an uninsured person in Georgia earning $9,000 a year will have much higher health care costs than one making $15,000.