Kasich-care: Priorities like Obamacare, without mandates

COLUMBUS – John Kasich likes Obamacare’s expansion of Medicaid to more low-income Americans.

He wants to ensure insurance coverage for people who have pre-existing conditions. He likes insurance exchanges. And he thinks everyone should have health insurance – even young, healthy people who need an incentive to sign up.

Yet he says he’d push to repeal President Barack Obama’s health care law and replace it with something else – something better, he says – if his presidential campaign were to prove successful.

The “repeal” position is essential for Kasich’s GOP candidacy. Indeed, many in the party are skeptical of his support for Medicaid alone. Candidates in Fox News’ bottom-seven debate this month even fielded questions about why Kasich “got it wrong” in expanding Medicaid in Ohio. Kasich had to defend his Medicaid move in his first question in the prime-time debate.

Kasich’s ideas about health care illustrate the difficulty the Ohio governor may have distancing himself from a law that so many of his fellow Republicans detest. Because a lot of what the governor wants to do is already part of Obamacare.

Related:John Kasich 2016 campaign coverage

Through several rounds of inquiry from an Enquirer reporter – to which Kasich once responded, “We’ve got to go back to this question for the 50th time?” – Kasich dribbled out some definites.

The common theme: accomplish many of the goals of Obamacare, sometimes by similar means, but without many of the federal mandates. The Ohio governor says he would have to “balance” policy priorities with an ethic of less government control.

“We want to be a lot more creative,” he says.

Medicaid: standing firm; business mandates: no

So, what does his version of health care reform look like?

First, Kasich isn’t backing off his support for expanding Medicaid.

As a governor, he’s consistently said he was bringing Ohio taxpayers’ money back into the state to help provide health care for Ohioans who are poor or have mental illnesses or drug addictions. As president, that “taxpayer money” from each state would become his responsibility, especially since he’s vowed to find ways to balance the federal budget.

Kasich has insisted he wouldn’t cut back on the expansion of Medicaid to more low-income Americans. Instead, he says, he’d want to send the federal money back to states, with more freedoms on how to implement the program. (Think the waiver Indiana got to charge Medicaid participants monthly premiums, which Kasich essentially wants to replicate in Ohio.)

“I’d like to have fewer strings,” Kasich said last month. He implied states might be able to cover the same population on Medicaid for less money. Ohio’s Medicaid spending, after all, cost $2 billion less than estimates in the fiscal year that ended in June.

As a governor, “I don’t care if they give me a little less money, but I’d like to have the ability to apply it and keep people healthy the way I want to do it,” Kasich said. “I’d rather have the states be empowered.”

Probably the biggest change to Obamacare that Kasich has clearly endorsed: He’s all but said he’d scrap the controversial (and, thus, delayed) mandate that businesses with at least 50 employees provide coverage for their full-time employees.

“I think it’s very, very difficult to do something like that,” he told The Enquirer this summer. “What we really need to do is make it easier for businesses to group together, to offer insurance.”

What’s clear: Discomfort with any kind of mandate

From there, it gets a little vague, except for Kasich’s clear discomfort with the idea of mandating just about anything.

Take his least controversial stance: Kasich praises the concept of ensuring that people with pre-existing conditions can get coverage, but stops short of using the word “mandate.”

That leaves an opening for a solution such as Marco Rubio’s suggestion that the federal government support high-risk insurance pools, which existed in many states before Obamacare.

On the campaign trail, Kasich often shares a list of values he thinks the U.S. needs to re-emphasize. Chief among them? Personal responsibility.

So surely he endorses the mandate that everyone get insurance, especially young, healthy people who historically hadn’t paid their share and whose mishaps therefore ate up emergency room costs?

Doesn’t sound like it.

“There is an element of personal responsibility. If you’re a young person, and you get in a motorcycle accident, and you don’t have insurance, we’re all paying for it,” Kasich told The Enquirer. But “if in fact there was a mandate, I have no idea how it would be enforced. Is the government going to come around, go into everybody’s office asking?”

Kasich also thinks people should be able to shop for health insurance on an exchange, promoting the free-market concept of competition.

“I don’t need to have a federal exchange to do that,” Kasich said. “It would be fine for the private sector to be able to list all the insurance that’s available.”

When Obamacare passed, however, Kasich’s administration declined to pursue establishing a state exchange. Officials said the law didn’t allow them to customize it enough for their liking.

But isn’t this Obamacare?

Tell Kasich this sounds remarkably like Obamacare, and he demurs.

“Look,” Kasich told The Enquirer. “Insurance costs have been going up, they have disrupted a very robust market here, and I just don’t think that there’s any answer (in Obamacare). The biggest issue is cost, and it doesn’t deal with it.”

In Ohio, some insurance prices have increased. The state insurance department reports an 80 percent increase in the average cost of individual and small-group insurance policies from 2013 to next year’s proposed prices.

Nationally, Obamacare generally has pushed up the costs of insurance for young, healthy people and made coverage more affordable for those who are older or sicker, said Larry Levitt, senior vice president at the Kaiser Family Foundation, a nonpartisan health-policy analysis group.

“If you allow people who are sick to get insurance, someone has to pay for it,” he said.

And that brings up one more salient point.

Analysts and leaders on all sides agree Americans aren’t getting a good value for their health care money. Kasich proposes brokering agreements between insurers and hospital systems so they agree to share profits and loss.

Fewer hospital visits from children with asthma, for instance, would lead to higher profits for insurance companies and bigger losses for hospitals. That model is in place at the Nationwide Children’s Hospital in Columbus, Kasich says.

Doctors should be paid based on how their care contributes to their patients’ good health, the governor says, not on how many office visits or tests they rack up. Kasich officials point to a characteristic of Ohio’s Medicaid payment system that incentivizes health care companies’ hitting benchmarks for quality care or patient health.

Kasich returns to the premise that a deregulated market, or individual states, should be the vehicle for establishing the facets of Obamacare that he likes, with difficult agreements brokered by a hypothetical Kasich administration, but not mandated by law.

Providers doing well; Gov: ‘So what?’

But scrapping the system in place – thanks to Obamacare – and relying on the free market seems impractical to some. “I don’t know that the health care industry wants a return to the pre-(Affordable Care Act) world,” Levitt said. “Insurers and hospitals have both been doing quite well.”

“So what?” Kasich told The Enquirer, in response to a similar statement by a reporter. “I’m not opposed to challenges. I’d rather have a better system than what we have now.”

Still, Kasich’s health care talk opens him up to attacks by more conservative Republican candidates. (His approach resembles that of his moderate policy rivals. New Jersey Gov. Chris Christie, like Kasich, expanded Medicaid. Jeb Bush points to cost-saving reforms in Medicaid when he was Florida governor and says he’d push for fewer mandates.)

Still, the implication from conservatives: Can you really trust Kasich to get rid of the hated Obamacare?

“You’re going to hear the phrase ‘Obamacare-lite,’ ” said John Pitney, a politics professor at Claremont McKenna College and former research director for the Republican National Committee.

For instance, Wisconsin Gov. Scott Walker used the point to hit Kasich Thursday in an interview with WMUR, a TV station in early-primary New Hampshire.

“I didn’t take the Medicaid expansion under Obamacare,” he said. “I think that’s important to a lot of Republicans – that I didn’t further Obamacare.”

Still, Pitney said, Kasich’s pledge to “repeal and replace” Obamacare is probably good enough for most Republican voters, even if his solution ends up resembling Obamacare in many ways. For starters, elements of Obamacare – such as the mandate to cover people with pre-existing conditions – are popular.

“You’re not going to do away with it entirely. It’s already taken root,” Pitney said. “Obamacare is a pre-existing condition.”