Five ‘ObamaCare’ battles to watch

Republicans aren’t going to repeal “ObamaCare” in the next four years, but there’s still plenty of room for both political fights and policy changes.

Republicans have begun over the past two weeks to acknowledge — albeit grudgingly — that President Obama’s reelection took repeal off the table for the next four years. Conservatives have responded by stepping up the pressure on Republican governors to stand in the law’s way as much as possible at the state level, and governors do have considerable power over how the law is implemented.

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In Washington, deflated partisan rancor over the Affordable Care Act could be a blessing to industry groups with smaller, more targeted complaints about the law. Republican lawmakers and healthcare lobbyists say smaller fixes are more realistic if every minor issue doesn’t blow up into a full-scale war over ObamaCare, and the appetite for that war is finally starting to wane.

Repeal, or a different outcome at the Supreme Court, would have satisfied both groups of opponents. But for all the talk about how repeal isn’t realistic over the next four years, it also wasn’t very realistic over the past two. And if the volume of the “ObamaCare” debate dies down, Congress might be more likely to address smaller issues with a real impact on coverage and costs.

Here are five issues to watch as the new debate plays out:

Medicaid: Most Republican governors are deciding not to set up their own exchanges, forcing the federal government to step up instead. The move will make life more difficult for the Health and Human Services Department, but some form of exchange will still be operating in every state. The governors’ real weapon is in rejecting the law’s now-optional Medicaid expansion.

Before the Supreme Court made it optional, the expansion was estimated to make up about half of the law’s coverage expansion — roughly 15 million people. The success of the Affordable Care Act will be judged largely by how many people gain coverage, and GOP governors in big states like Texas and Florida can chop billions of people out of that total by refusing to expand Medicaid.

Subsidies: The push to resist state exchanges is driven in part by the hope that a long-shot lawsuit will derail federal subsidies to help people pay for private insurance. Oklahoma filed the suit, which argues that subsidies can only flow through state-based exchanges, not a federally run fallback. If that argument succeeds in the courts, only a few states will have functional exchanges and the law’s coverage expansion will be eviscerated.

Subsidies are also at risk in upcoming talks to avoid the looming “fiscal cliff.” Republicans very much want to tap into the subsidy funding to pay for a debt agreement, and Democrats might be tempted by the giant pot of money that hasn’t been spent yet.

Taxes: Several healthcare industries want desperately to get rid of newly imposed taxes, and they see the prospect of broader tax reform as an opening. Medical device manufacturers have lobbied hard for the repeal of the law’s device tax, and they have some measure of bipartisan support. Newly elected Sen. Elizabeth Warren (D-Mass.) has said the tax should be repealed, and it has never been popular with other Democrats in device-heavy states, such as Indiana and Minnesota.

Insurance rules: Big-ticket items like the policy forcing insurers to cover people with pre-existing conditions aren’t going anywhere. But insurance companies are pushing Congress and HHS to loosen up on more minor issues that they say could have a big impact on whether coverage is affordable, especially for the young and healthy people the law aims to bring into the system.

Officials at the Blue Cross Blue Shield Association said last week they think HHS can phase in new limits on age rating (charging older people a higher premium). The law only allows insurers to charge older customers three times more than younger ones, while most states let them charge five times more. Slow-walking or changing those restrictions could ease the burden on young people’s premiums, making them more likely to buy coverage and help offset the cost of covering sick patients.

IPAB: Republicans have had it in for the Independent Payment Advisory Board for a long time, and House Majority Leader Eric Cantor (R-Va.) signaled shortly after the election that the cost-cutting board will be back on the agenda this year. To a large extent, this fight is just for show — Obama would sign off on some changes to his signature domestic achievement, but he’s not going to give away its biggest cost-control tool.

Republicans’ real power comes in their ability to do nothing. The IPAB’s 15-member board has to be confirmed by the Senate. So however many hearings they hold or bills they introduce, Republicans can keep the IPAB from coming into existence just by refusing to hold votes on the nominees.