One of the starkest differences between incumbent Democratic U.S. Sen. Mark Begich and his Republican opponent, Dan Sullivan, is on the issue of health care.
Begich, who's consistently pilloried for his 2009 vote for the Affordable Care Act by Sullivan and his allies, stands by his position and on Monday released a new radio ad in which he says that "every day, I work to try to fix it."
Sullivan, meanwhile, says he'd repeal the law he calls Obamacare and replace it based on a broad five-point plan that he outlined to a reporter Wednesday.
The contrast comes even as the likelihood of a full repeal appears minimal: Republicans would need 60 Senate votes to pass most substantial legislation affecting the law, which would likely be vetoed by Democratic President Barack Obama, who's in office through 2016.
Currently, Democrats have 53 seats in the 100-member chamber, with the split expected to be close to even after next month's election.
"The law is the law, and it's being implemented," said Diane Rowland, executive vice president at the nonpartisan Kaiser Family Foundation. "And where there's glitches around the edges, people are trying to figure out what the best workarounds are."
Both Begich and Sullivan agree that the health care bill has substantial flaws -- their conflict is over whether those flaws can be fixed.
Begich, who last year said he purchased insurance through the Affordable Care Act marketplace that costs $600 a month, argues the law was needed because of difficulties Alaskans faced in getting access to health care. Before the bill went into effect, one study estimated that 34 percent of individuals and families who applied for their own insurance plans were rejected – a problem that's fixed by the Affordable Care Act.
"I just knew that we had to do something to get better access for health care for Alaskans," Begich said in a phone interview Saturday.
Since the law was passed, Begich has introduced legislation that would create a new type of insurance plan that covers fewer costs for consumers but could cut monthly premium payments by nearly 20 percent. And he has sponsored a bill to give more small businesses access to health care tax credits.
He acknowledges that the administration of the law has been "a mess" but added that "the system is moving forward."
Begich said Sullivan's call to repeal and replace the law amounts to a "great talking point and applause line," and that doing so would jeopardize the coverage of the more than 15,000 Alaskans who signed up for plans under the Affordable Care Act.
Sullivan, a lieutenant colonel in the U.S. Marine Corps Reserve, gets his insurance through Tricare, a program for members of the military. He said in a phone interview late Wednesday that he was unsure of his premium costs.
The plan is "focused on the concept of freedom," Sullivan said, before ticking through planks that include transparency, tax reform, tort reform and lowering costs.
His campaign has characterized the Affordable Care Act as a failure based on recently announced premium increases by Alaska insurers -- as high as 37 percent -- and the 5,400 people who received cancellation notices last year because their insurance plans didn't meet the law's requirements, though many of those people ultimately ended up having their plans extended.
Sullivan does, however, want to preserve one key element of the Affordable Care Act – insurance coverage for individuals with pre-existing conditions. Sullivan wants to do that through high-risk pools, which have in the past forced those individuals to pay higher premiums than people get on the standard market.
As to other elements of the law that Begich cited in his defense of the measure, Sullivan said he was unfamiliar with a provision guaranteeing that women could not be charged different rates than men, though he added he doesn't support allowing gender-based discrimination if people "are similarly situated with regard to health issues."
Sullivan wouldn't directly answer a question about whether he supported a provision of the law requiring insurers that offer dependent coverage to provide it to children up to the age of 26, saying he would leave families to design their own health care plans with the help of their doctors.
Sullivan added that Begich wants to "cherry pick" popular elements of the Affordable Care Act, and he argued that the law itself was "unworkable," citing associated regulations that are "crushing American families, small businesses, and health care providers."
Officials at the Alaska and Anchorage chambers of commerce said their members had, in fact, struggled with elements of the law – primarily the uncertainty surrounding costs – though neither group has taken a position for or against the Affordable Care Act itself.
Uncertain premium costs are "a huge variable," said Andrew Halcro, the Anchorage Chamber of Commerce's president.
Asked who was responsible for the law's flaws, Halcro responded that problems with the nation's health care system had been ignored for too long by policymakers, and he added that "the Affordable Care Act was just kind of rushed through."
"But you could argue that with (any of) these huge policy changes, because there are all these opportunities for unintended consequences," he said. "This one is 110 moving parts, so your chances are greater."
Rachael Petro, the president of the Alaska State Chamber of Commerce, said in an email that her group is trying to provide its members with "good information," since the law "seems to be constantly changing."
"The constantly shifting sand which is the ACA is impossible to keep up with - and always leaves us wondering whether and what we will be able to offer our team members," she added, referring to her own organization.
The trade group representing Alaska's hospitals and nursing homes has been supportive of the health care bill, and remains so, said Becky Hultberg, its president, though she added that like most major pieces of legislation, it requires adjustment.
"Because of the environment in Congress, it's been very difficult to make those adjustments," she said in a phone interview.
At a legislative hearing Tuesday, Hultberg also laid out arguments for Alaska to grow its Medicaid program, the government health insurance system for the poor.
Under the Affordable Care Act, the federal government would have paid the full cost of expanding the program to benefit some 40,000 Alaskans through 2016, tapering to 90 percent by 2020. But Republican Gov. Sean Parnell rejected the expansion last year, saying at the time that the Affordable Care Act was a "failed experiment."
Begich places much of the blame for the failures of the law on Parnell's administration, noting that the state also opted not to apply for a federal grant to enhance its rate review process – which Begich argued was a contributing factor in the large premium increases announced last month.
"Did I ever expect the governor to take such a hard, partisan view over Alaskans? No," Begich said. "He put politics over the people of Alaska."
Parnell, in an emailed statement sent by spokeswoman Sharon Leighow, rejected Begich's arguments and was quoted as saying that Medicaid needs to be "reformed, not expanded." Expansion of Medicaid could actually result in higher costs for people buying insurance on the marketplace for individuals, since it could pull people out of that pool, the statement said.
Parnell's statement added that the recently announced premium spikes stem from Alaska's small insurance pool, which saw one insurer, Premera, paying out $7 million in claims for just 33 of its patients, and about $14 million in claims for the other 7,000 members.
"These high rates are the direct result of a one-size-fits-all approach from the federal government that is not appropriate for Alaska and other small-population states," Parnell was quoted as saying.
The "critical question," Sullivan acknowledged, is whether a full repeal and replacement of the law is realistic.
He framed the answer in the context of 36 U.S. Senate seats on the ballot this November, saying that if Democrats maintain their thin majority, "I don't think you're going to see any of these fixes."
"Will the president veto everything? I don't think so," Sullivan added. "I think it depends on what happens with regards to the election in November, but also what kind of reforms are put forward — and I think there's a bipartisan path on some of these."