Republicans across the country, and especially in Georgia, are united in their hope that the Supreme Court will gut a key section of the Affordable Care Act when the court rules on the health law later this month.
What they can’t agree on is the future for 413,000 Georgians who would lose their health insurance subsidies.
The plan’s critics see a ruling against the Obama administration as the next step toward the collapse of a law they fought from the start, but it would also unleash economic and political chaos.
Gov. Nathan Deal does not intend to step into what he sees as a federal matter, and he has ruled out calling for a special session of the Legislature that would bring lawmakers back to Atlanta to hash out a solution.
The bulk of Republicans in the U.S. Senate want to extend the subsidies through the 2016 elections while they come up with a consensus replacement for the wounded law known as Obamacare. But more conservative House Republicans appear less likely to restore any part of the law they loathe, and are instead looking at an Affordable Care Act “off ramp.”
The administration and Capitol Hill Democrats, meanwhile, don’t have a plan, or at least have not shared one publicly.
‘Ideology is winning out’
The case, King v. Burwell, will decide whether tax credits should be given to people in states where the federal government — not the state — runs the online insurance marketplaces established by the Affordable Care Act.
Some of the 34 states may react to a ruling against the government by creating their own state-run marketplaces, known as exchanges, but Georgia passed a law last year forbidding the creation of an exchange.
Deal said in an interview that he will not reopen the debate over allowing a state-run exchange here. And he flatly ruled out calling a special session to deal with the fallout.
“There are things that could be done, but it would require the state to make judgment calls that have already been rejected by our state and most states — like state-operated exchanges,” he said.
An Open Records Act request revealed little behind-the-scenes communications in Deal’s office on the impact of the ruling. Deal aides shared a string of articles and policy analyses about the court case, and they took part in a Republican Governors Association meeting in late May on the “various moving parts on King v. Burwell.”
And Deal, for his part, said he expects the court to phase out the subsidies if they are struck down, giving Georgia more time to react.
“Even if it significantly undoes the legislation, you’d have to think that the court itself would recognize there has to be a period of time for an adjustment,” he said. “And most of that will come from the federal government, rather than the states.”
State leaders are increasingly struggling to balance their concerns about the costs of Obamacare and the growing strains on the state's struggling rural hospitals and giant "safety net" facilities like Grady Memorial in Atlanta.
The revelation that Deal's administration is exploring a request to the federal government for more Medicaid funding for those systems prompted members of the party's right flank to question the legality of the move. Deal would likely face even greater backlash if he were to consider a state-run exchange.
The approach reflects a broader pattern of disdain toward Obama’s signature domestic policy achievement. Deal and other state GOP leaders have roundly rejected Medicaid expansion under the law as too costly in the long run.
“Ideology is winning out over good policy,” said state Sen. Vincent Fort, an Atlanta Democrat who is one of Deal’s most outspoken critics.
‘A moral obligation’
The most prominent congressional solution was authored by U.S. Sen. Ron Johnson, R-Wis. It would extend the current subsidies to August 2017 while also repealing Obamacare's health coverage mandates.
Both of Georgia’s Republican senators, Johnny Isakson and David Perdue, have signed onto the bill, as has Majority Leader Mitch McConnell, R-Ky.
“Whatever the case, you’ve got to have a transition period to go from where we are to where we need to be, and you can’t let those people (who would lose subsidies) fall through the cracks,” Isakson said. “You have a moral obligation to the 9.5 million people.”
Perdue said a two-year extension gives Congress time for “both sides of the ideological scale to come up with a solution that includes input from the industries affected” by the law.
Rep. Tom Price, a Roswell Republican, is an orthopedic surgeon and a prominent voice on health policy in his chamber. He disagrees with the Senate plan.
“It doesn’t make a whole lot of sense to me, when you have an opportunity to move in a direction of patient-centered health care and a better direction for patients, to continue a system that has clearly been destructive to both health care quality for patients as well as financial accessibility for patients,” Price said in a recent interview.
Price, the Budget Committee chairman, introduced his own King v. Burwell fix that looks like a bridge to his rewrite of the entire health law.
For those who lost subsidies, the Price bill would provide age-based tax credits that range from $900 to $3,000 per year. The replacement would be less generous than the current income-based tax credits, which average $3,264 per year.
Price’s plan has not been blessed by House GOP leadership, which created a working group earlier this year on Supreme Court responses.
The group proposed to let states opt out of Obamacare into a new plan that repeals the mandates, funds high-risk pools and expands health savings accounts, among other changes. But House Republican leaders will not put out a formal bill until the court rules, Majority Leader Kevin McCarthy, R-Calif., said recently.
The White House insists it does not have a plan of its own and deflects policy concerns to Congress.
"What our professionals have said — those who are steeped in the details of the health law and who are aware of the legal arguments that underpin this policy — that there is no simple, straightforward administrative fix that would solve a problem resulting from an adverse Supreme Court decision that would have a prompt impact in trying to correct that damage," White House press secretary Josh Earnest told reporters.
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