It took the winding down of GOP primary season for the Republican Party's increasingly incoherent position on the Affordable Care Act to attract national media attention, and nobody did more to thrust it under the press' nose than Senate Minority Leader Mitch McConnell—the original gangster of anti-Obamacare absolutism.
This will only strike you as ironic if you ignored ACA's stunning successes in Kentucky, and the uncompromising demands of McConnell's primary, as they unfolded simultaneously. Now as a general election candidate, he must square his root-and-branch repeal position with the inescapable fact that full repeal would reverse those successes and leave nearly a half a million newly covered Kentuckians without health insurance.
On Friday, McConnell attempted to obscure this obvious conundrum by claiming the fate of Kynect—the state's popular and prosperous online insurance exchange—is "unconnected" from the fate of the ACA statute itself.
While observers quickly noted, contra McConnell, that Kentucky created Kynect—and that Kynect survives today—with generous federal support, I surmised by implication that McConnell was actually playing a far more deceitful game. At a very crude level, Kynect is just a website. If the Kentucky state government wants to maintain a website called "Kynect" after Obamacare has been wiped off the books, it will be free to do so. And McConnell appeared to be banking on the likelihood that most Kentuckians won't realize Kynect-sans-ACA would be basically superfluous—exploiting confusion over which aspects of the Kynect experience are within Kentucky's power to maintain.
On Tuesday, McConnell's campaign confirmed this intention.
“If Obamacare is repealed, Kentucky should decide for itself whether to keep Kynect or set up a different marketplace,” said McConnell campaign spokeswoman Allison Moore.
Of course, Kynect is popular not just because the people who used it to shop for insurance were satisfied with its technical functioning, but because they liked the federally subsidized, federally regulated plans it offered. These are the equal partners of Kynect's success. Take away the latter, and it becomes a dressed up version of ehealthinsurance.com, which did a perfectly good job of selling health plans in the dysfunctional pre-ACA individual insurance market, but was somehow unable to reduce Kentucky's uninsurance rate by 40 percent on its own.
To the tens and thousands of Kentuckians booted off their new private health plans, and the hundreds of thousands of Kentucky Medicaid beneficiaries returned to the ranks of the uninsured, it would become a useless system. The Medicaid expansion would be gone. The premium tax credits would be gone. The coverage guarantee and the benefit guarantees and the risk pooling would be gone. Kynect could become a hub for health plans affordable to young, healthy and relatively affluent individuals, but only if the state modified the system to allow carriers to underwrite their customers—to cherry pick the healthy and forsake the ill.
Kentucky could also, in theory, attempt to replicate the ACA market with new regulations. But even if you assume state legislators would want to try, it's unlikely they could afford the subsidies required to make plans affordable absent federal assistance (which would disappear). Without affordability, state leaders would be hard pressed to mandate coverage. And without a mandate, the market wouldn't support rules guaranteeing coverage and prohibiting health status discrimination.
Ironically, no state in the country understands this better than Kentucky, whose 1990s-era experiment with pooling risk and guaranteeing coverage without an individual mandate was a textbook fiasco.
McConnell surely remembers all this. He was Kentucky's junior senator at the time. But the same can't be said for some large number of Kentuckians who hate Obamacare and love Kynect. Despite intensifying cries of foul from the state press, McConnell appears determined to capitalize on their bewilderment rather than level with them about what he has in store.
Brian Beutler is a senior editor at The New Republic.