While Republicans in Congress shout, "Repeal Obamacare," GOP governors in many states have quietly accepted the law's major Medicaid expansion. Even if their party wins control of the Senate in the upcoming elections, they just don't see the law going away.
Nine Republican governors have expanded Medicaid for low-income people in their states, despite their own misgivings and adamant opposition from conservative legislators. Three more governors are negotiating with the Democratic administration in Washington.
Rather than demanding repeal, the governors generally have sought federal concessions to make their decisions more politically acceptable at home. That approach is in sharp contrast to the anti-Obamacare fervor of their party in Congress.
Ohio Gov. John Kasich doesn't think the Affordable Care Act, with its Medicaid expansion provisions, will be repealed, even if Republicans win a Senate majority and consolidate their hold on the House in next month's election.
"That's not gonna happen," the Republican governor told The Associated Press during a recent re-election campaign swing.
He said that opposition to the Medicaid expansion "was really either political or ideological," adding, "I don't think that holds water against real flesh and blood and real improvements in people's lives."
Kasich's campaign office said Monday that the governor remains opposed to the law. He has cast the Medicaid expansion in Ohio as a moral choice to help the poor.
While "repeal" remains the mantra for many Republicans in Washington, it's up against some hard facts.
As Kasich suggested, millions of people now have a tangible benefit that would be taken away if the health law were repealed. Any GOP replacement law would probably have to give most of those people a way to remain insured, and that would involve considerable taxpayer expense and government regulation.
And even if Democrats lose their Senate majority, President Barack Obama still has the power to veto legislation. Republicans would have to muster a two-thirds majority in both chambers of Congress to override that.
"What we would anticipate is most likely to happen, even with a Republican Senate, is we'd have to work within the confines of where we are," said Marty Carpenter, spokesman for Republican Gov. Gary Herbert of Utah. Herbert wants federal approval to deliver the Medicaid expansion through private insurance companies — as some other GOP governors have done.
Iowa Gov. Terry Branstad, another Republican seeking re-election, says "major changes" are required to the health care law. But he expects his state's Medicaid expansion to stand.
"I think our system and our approach is working, and I think other states are starting to look at our approach," Branstad said.
In a recent debate with his Democratic election opponent, Senate Republican leader Mitch McConnell of Kentucky said that Obama's health care law must be pulled up "root and branch." But he hastened to add that the state could somehow still keep its insurance marketplace, which owes its existence to Obama's law.
Here are some of the hurdles that congressional Republicans would face, even if they won big on Nov. 4.
— A straightforward repeal bill could be filibustered in the Senate, giving Democrats a chance to turn the tables on Republicans who have used that tactic in recent years.
— Democrats used budget rules to avoid a filibuster and pass the law in 2010. That same budget process might be used by Republicans to unravel the law. But they might not kill all of it, only the parts with a direct impact on the federal budget, leaving an unworkable jumble of insurance rules. And Obama could still veto it.
— Forcing a government shutdown or a debt default to try to get rid of the health law would probably backfire politically. Republican leaders want to avoid that, though some conservative activists say nothing should be off the table.
— There's no consensus among Republicans over how to replace Obamacare. Some believe a new plan would have to come from the party's 2016 presidential nominee.
Still, the nation can expect repeal votes if Republicans win the Senate, to fulfill campaign promises. What might happen after an Obama veto is less clear.
Sen. John Barrasso, R-Wyo., a member of the GOP leadership, says Republicans will target unpopular provisions and try to get some Democrats to join them.
"Obviously, we are going to try to fully repeal the law," said Barrasso. "The reality is President Obama is going to be in office, and we know how that is going to turn out if we get a bill to his desk. If we cannot get a full repeal, we will try to bring forth a number of bills that target the worst parts of the law."
The bottom line: Former Utah Gov. Mike Leavitt, a Republican who served as Health and Human Services secretary for President George W. Bush, says Washington lawmakers and state governors are playing on different levels.
"In the Washington world, things are about control of the news cycle and preparing for the next election," said Leavitt. "Governors are more interested in finding a way they can be comfortable in their own skins and solve problems."