What can statewide Republican candidates do to ‘dismantle Obamacare?’

‘Dismantling Obamacare’ has become a major plank in the campaigns of several republican candidates for statewide office in Montana.

Gubernatorial Candidate Rick Hill firmly opposes the Affordable Care Act.And go to the websites of State Auditor Candidate Derek Skees and Attorney General Candidate Tim Fox—Fighting Obamacare is listed as a top priority. A regular mention of gutting Obamacare seems almost required this election season if you’re a republican candidate.

Well, Executive Director of the Montana Republican Party, Bowen Greenwood says elections are supposed to be about issues.

“We bring those things up in every opportunity because that is the point of an election. When the government has gone wrong, it needs to be changed,” Greenwood said.

And he says the Affordable Care Act is a major issue for voters. A recent poll by Lee Newspapers shows 53 percent of Montanans don’t support the law, while 40 percent do.

Dr. Michael Sparer is the Health Policy and Management Department Chair at the Columbia University school of Public Health. He focuses on the politics of healthcare, ,primarily in the United States.

He says the nation is seeing this kind of focus on the Affordable Care act in states across the country. He says it’s a debate not only about the specifics of the healthcare law, but also more broadly about the wider role of government in the U.S.

“I think there’s no doubt that the healthcare issue and the politics of the affordable Care Act are far more intense and are a far more significant part of this campagin than we typically see,” Sparer said.

So what could state Republican Candidates do to fight this federal law if elected?

Sparer says states do have a series of decisions to make, and he points mainly to two. The first is the reform’s health insurance exchange provision.

“Each state under the affordable care act is encouraged but not required but is encouraged to create what’s known as a health insurance exchange,” Sparer said.

It’s basically a government-facilitated insurance pool to get better prices for the uninsured. If the state decides not to create the health insurance exchange, the federal government will create one for the state and run it.

“Unless Governor Romney becomes President and unless the Affordable Care Act is repealed, the state of Montana is going to have a health insurance. the only question is going to be who’s running it, the state or the federal government,” he said.

Republican majorities in the 2011 Legislature turned down proposals by current state auditor Democrat Monica Lindeen to create a Montana exchange. Montana GOP executive Director Bowen Greenwood says whether or not the exchange is made at the state or federal level, some things remain the same.

“We don’t get a real say in the exchanges,” Greenwood said, “about what kinds of insurance companies are going to be allowed to compete or what kinds of insurance our people are going to have. The law does not allow us to have any real say in the fate of our people and that’s why we oppose it.”

Columbia University’s Michael Sparer says that statement is not true, states would have a significant amount of discretion over the form and substance of their exchange.

“Are these Republican Candidates in an effort to sound as if they are refuting the federal government, are they giving the federal government more control?” I asked Sparer.

“I think clearly one thing they’ll argue, those who say they are not going to set up the exchange, one thing they’ll argue is by refusing to do so will save the state money even though most of the cost of setting up an exchange will be set up by the federal government has said they will bear. But state’s will say hey listen we’re not going to use our state employees, we’re not going to use directly state tax dollars. We’re not going to be involved so we’re going to try to save some money here,” he said.

The other major part of the Affordable Care Act up to state leaders that Sparer mentions is the optional Medicaid expansion provision.

Republican candidates are saying they would not expand Medicaid to cover more uninsured, even though the Federal government would pick up most of the tab. Sparer says there’s no doubt that means a state that does not expand Medicaid will have more people that are uninsured.

Some charge that will put some of the poor out of reach of the individual mandate in place in the Affordable Care Act.

But Sparer says the ACA has some exceptions.

“If you don’t have access to affordable insurance in your community, the mandate doesn’t apply to you. Someone who is uninsured who would be eligible for medicaid but the state chooses not to expand the program. Odds are the mandate won’t apply to them and they will simply remain uninsured,” Sparer said.