‘Repeal and replace’ is dead. Republicans can’t figure out what comes next.

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Former President Donald Trump is gone and so are his promises to throw out Obamacare. Now the Republican Party is left with figuring out what comes after “repeal and replace.”

GOP lawmakers rarely mention Obamacare, and a GOP-backed challenge to the law at the Supreme Court doesn’t appear to be a major threat. Republican attacks on Democrats pursuing a “government takeover” of health care through a single-payer system don’t quite sizzle when President Joe Biden has made clear he wants nothing to do with it. And long-favored Republican designs on shrinking the health care safety net isn’t great policy or politics in the middle of a pandemic and economic crisis.

Which leaves a big fat question mark about what vision of health care Republicans will offer to voters as the country emerges from the pandemic, after a decade in which implacable opposition to the Affordable Care Act was part of the GOP’s core identity.

“Republicans don’t run on health. If they do, it’s always negative danger warning, not positive improvement optimism. It’s in their DNA,” said Tom Miller, a health policy expert at the conservative-leaning American Enterprise Institute who has advised candidates on health care over the years.

“If the Republicans have a health care agenda, they haven’t shown their cards,” said Drew Altman, who runs the Kaiser Family Foundation. Some ideas they do tout — about drug prices, for instance — are “pinpricks” that wouldn’t lead to fundamental change, he said. Other ideas they’ve pushed in recent years, like Medicaid work requirements, would shrink rather than expand the number of people covered and government dollars spent.

Nowhere has the post-repeal Republican vacuum been more evident than in two days of Senate confirmation hearings this week for the likely next Health secretary, Xavier Becerra. Republicans seldom mentioned the landmark health care law, let alone critiqued it, across five-plus hours of testimony. They spent almost as much time quizzing Becerra, a longtime House member who is now California attorney general, about an obscure federal drug discount program called 340B that pharmaceutical companies and hospitals are feuding over than they did about the health care wars of the past decade.

At one point, when Becerra promised to use the top perch at the Department of Health and Human Services to improve the Affordable Care Act rather than push for the “Medicare for All”-style system that he has championed in the past, the top Republican on the Senate Finance Committee, Mike Crapo (R-Idaho), replied: “I appreciate hearing that.”

Obamacare has played a huge role in every election since Barack Obama himself won the presidency promising health reform in 2008. His health law was one reason Democrats lost control of the House immediately after its passage — and why they won back the chamber a few years later after Trump’s failed, unpopular repeal drive. Health care again could play a pivotal role in determining control of Congress in the 2022 midterms.

But now Obamacare is firmly implanted in the U.S. health care system and viewed more favorably. It’s still not embraced by large numbers of conservative voters, but public attitudes have softened toward many of its key components. Keeping young adults on their parents’ health plans until age 26 and protecting the tens of millions of people with pre-existing conditions is now the American way.

“The ACA has become sort of embedded in popular consciousness, whether people realize it or not,” said Nicole Huberfeld, an expert on health law at Boston University. Given that Republicans couldn’t repeal the law when they ran the government, she added, “Maybe they’ve learned to move on.”

Republicans no doubt will figure out some kind of health care message between now and the 2022 elections. But it’s TBD. And it may not center on the ACA.

Miller expects Republicans will return to arguing about the deficit, and that could bring back battles over Medicare and Medicaid. But the shaky finances of the Medicare trust fund didn’t feature prominently in the Becerra hearings either. Becerra was able to answer plain vanilla questions about Medicare with pledges to work with Republicans to protect the elderly.

Republicans could also try to shape some health care spending and small print that’s crucial to the industry, Miller said, though that’s not likely to be an election changer. Some of the Republican populism that’s now channeling anger toward tech giants and social media companies could also target “Health Care Inc.,” he said.

But it may be time for something completely different — and possibly less partisan, said David Winston, president of the Winston Group, a strategic planning and survey firm. Winston, who has advised congressional Republicans for a decade and used to work for Newt Gingrich, noted that amid the pandemic, people are thinking differently about their health — not just their health insurance.

“It’s an important structural change,” he said. And that may mean that Congress finally moves beyond the Obamacare wars, and delves deeper into things like personalized medicine, immunology and health technology. Lawmakers from both parties have already expressed an interest in expanding telehealth, which has been crucial during the pandemic. Congress, he said, would be left trying to figure out how to nurture innovation — without breaking the bank.

Not everyone on the Hill is ready to turn to that. While Becerra is likely to be confirmed with some bipartisan support, most of the “no” votes from the Republican side will arise from Becerra’s strong support of abortion rights — not broader disagreements over the direction of the health care system. That, and contraception coverage, particularly his involvement in a lawsuit involving an order of Catholic nuns called Little Sisters of the Poor, were by far the most acrimonious exchanges in his hearings before the Senate Finance and HELP committees this week.

Becerra deflected attacks on his past support for single-payer, or Medicare for all, by noting that he will work for a Biden administration, which is committed to strengthening the ACA. Several proposals to expand on the law, including more generous subsidies to purchase health insurance, are in Biden’s stimulus plan now pending in Congress.

Becerra also remarked that as a member of the House Ways and Means Committee for 24 years, he helped write the historic law. “I was in those rooms,” Becerra told Sen. Bob Menendez (D-N.J.), who reminisced about drafting the ACA.

Robert Blendon at the Harvard School of Public Health, who has been polling on health care for years, said the current Republican quandary echoes the old debates between the Richard Nixon and Ronald Reagan wings of the party. Nixon, embracing what would become known as “managed competition,” favored a high-level federal framework to protect people from high health costs, with states in charge of setting the rules for a robust private insurance market.

In some ways, Nixon envisioned Obamacare Lite — or more accurately, Obamacare Very Very Lite. The ACA is a more robust, more expensive, and more heavily regulated framework, with states overseeing health insurance markets and the feds writing the rules and picking up much of the tab.

The Reagan wing, in contrast, didn’t see much of a federal role in protecting access to care or shielding people from health cost calamities. Reaganites, Blendon said, believed Nixon’s vision would be the first step on the slippery slope to single-payer.

Sometime between now and the 2022 elections, Republicans will have to move beyond that divide. Whatever they come up with, it will likely focus on giving states more leeway to regulate their health insurance markets. Even if Republicans are no longer threatening to upend the ACA, they still complain that its coverage is still too costly.

“Republicans want access to insurance,” Blendon said. “They just don’t want their health care controlled by federal government.” But how to guarantee that access — and who does the guaranteeing if not the federal government — remains the unanswered question.

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