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Mitch McConnell’s position on Kentucky’s Medicaid program and its health-insurance exchange, called Kynect, has become the subject of some controversy, with some bloggers claiming that he has given up on repeal of Obamacare and others saying that he is still committed to it but is misleading voters who like aspects of it. Here’s my sense of what’s happening, based in part on talking to people familiar with the senator’s thinking.

McConnell wants to repeal Obamacare and replace it with . . . something more conservative. He is vague on this crucial point.

His aides have pointed out to reporters that even without Obamacare, Kentucky would be free to maintain its own exchange and an expansive Medicaid program. Some people who were eligible for Medicaid even pre-Obamacare signed up for it only after the law was passed. (This is what health-policy types call the “woodwork effect”: People came out of the woodwork when the program was expanded.) They would stay eligible even if Obamacare were repealed, and therefore could re-enroll if they chose.

McConnell’s campaign is downplaying the fact that the exchange would inevitably function very differently in a world without Obamacare. No replacement will still have the individual mandate coercing healthy people to join the exchanges, for example, and a replacement would probably reduce subsidy levels as well. Some conservative Obamacare opponents nonetheless think that state exchanges could play a useful role in a post-Obamacare world. As for Medicaid: Assuming a replacement plan restored the earlier eligibility limits, Kentucky would either have to pay to cover people above that limit on its own or work out cost-sharing with the federal government.

I don’t think there’s anything wrong with McConnell’s making the point that states could have exchanges, and a lot of the increased Medicaid enrollment would persist, in a post-Obamacare world. Both of those claims are true, and do not amount to any abandonment of the goal of repealing and replacing Obamacare.

If McConnell does not want to commit to a specific replacement plan right now—for example, because his conference is (depressingly, to my mind) still divided on whether Republicans should advance a specific plan and on what it should contain—he would be on firmer ground if he acknowledged that repealing Obamacare would change Kentucky’s exchange and said he would seek a replacement plan that aimed to cover at least as many people as Obamacare covers.

That is a very feasible goal, one that the plan offered by Senators Burr, Coburn, and Hatch probably attains. Indeed, a replacement plan that cashed out much of Medicaid and let beneficiaries use the money to buy coverage in a reformed individual market would probably leave many of the people that McConnell is trying to reassure better off.



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