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The latest news on Obamacare from Business Insider

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    tom price hhs

    Democratic Sen. Sherrod Brown suggested Tuesday that President Donald Trump may have lied about developing a replacement plan for the Affordable Care Act during a contentious line of questioning with the prospective secretary of health and human services.

    Brown asked Tom Price, Trump's HHS nominee, point blank whether Trump lied during a press conference when he said that he was working with Price on a replacement bill for the law better known as Obamacare.

    "President Trump said that he's working with you on a replacement plan for the ACA which is nearly finished and will be revealed after your confirmation, is that true?" Brown asked during a Senate Finance Committee hearing.

    "It's true that he said that, yes," said Price, which was followed by laughter from those assembled.

    "So did — not that he's ever done this before — but did he lie?" Brown said. "Did the president lie about this? Is he not working with you? He said he's working with you. Is that not true? I know we don't use the word lie here because we're polite when presidents say statements that aren't true, but did he lie to the public ?"

    "I've had conversations with the president about healthcare, yes," Price said.

    "Which wasn't quite the question," Brown said.

    While Price did not say that he was working directly with the president on the ACA replacement, as Trump claimed, the specifics of such talks remain unclear.

    A CNN report on January 16— before Price's first confirmation hearing — cited transition sources saying Price has stayed out of the conversation on crafting a replacement bill for the ACA to avoid conflict with his own plan he proposed in Congress in 2015.

    Brown went on to ask Price if the replacement pushed by the administration and GOP will continue to provide protections like the inability for insurers to deny coverage based on a preexisting condition or Medicare coverage for preventative care.

    "Our commitment is to make certain that every single American has access to the highest quality coverage and care possible," Price said.

    "I'm still not sure if the president lied, not to you but to us the public, about whether he's actually working with you," Brown said. "It sounds like he did."

    SEE ALSO: 2 GOP senators just unveiled a curious first attempt in the bid to replace Obamacare

    Join the conversation about this story »

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    IUD intrauterine device Bayer's Skyla

    After President Donald Trump's win in November, women in the US started encouraging one another over Twitter to get long-acting birth control.

    And it appears that encouragement sprang women into action in the months that followed.

    Between October and December 2016, IUD prescriptions and insertion appointments were up 19%. In 2015, no such spike was observed, according to data from AthenaHealth, a company that provides electronic health records to medical practices. 

    The data comes from the offices of 2,500 doctors on AthenaHealth's platform, Vox reports, so it's just a snapshot of the entire country. 

    An IUD, short for intrauterine device, is a long-acting form of birth control that's better at preventing pregnancies than the pill or condoms. There are a few different kinds of IUDs that last between three to 10 years. 

    The spike in visits happened in both counties that voted Democrat and counties that voted Republican, AthenaInsight reports.

    This isn't the first time the spike in IUD placements has been noted. In December Planned Parenthood of Illinois had seen appointments for them up 82% since the election, The Chicago Tribune reported.

    The Affordable Care Act covers the device, as well as other forms of contraception like birth control pills. But under legislation that comes as part of Trump's repeal and replace plan, future coverage is now less certain, meaning women could be on the hook for much higher costs

    SEE ALSO: Here's how much an IUD costs with Obamacare — and without

    DON'T MISS: There's now a genetic test for women's fertility called Fertilome

    Join the conversation about this story »

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    rand paul

    • Sen. Rand Paul introduced the Obamacare Replacement Act on Wednesday.
    • The bill would remove parts of the Affordable Care Act, including the individual mandate and minimum standards for care. It would also provide a two-year window for people with preexisting conditions to sign up for care.
    • It also includes new provisions such as an expanded ability for insurers to sell plans in multiple states and a $5,000 tax credit that people can put toward a health savings account.

    Sen. Rand Paul, the libertarian-leaning Republican and onetime presidential candidate, introduced his version of a replacement for the Affordable Care Act, better known as Obamacare.

    The bill, named the Obamacare Replacement Act, would eliminate several provisions of the ACA, including the individual mandate and minimums on coverage standards. The bill's fact sheet doesn't mention any provision to allow parents to keep a child on their insurance until they turn 26.

    Interestingly, Paul's plan would provide a two-year window for people with preexisting conditions to sign up for care. It would then revert to pre-ACA rules in which people with preexisting conditions could still get coverage in the group market. It's unclear what would happen to people with preexisting conditions in the individual market after the two-year open-enrollment period.

    Additionally, the bill would provide every American a tax credit worth up to $5,000 for contributions to a health savings account to put toward health insurance and other healthcare costs.

    "Getting government out of the American people's way and putting them back in charge of their own healthcare decisions will deliver a strong, efficient system that doesn't force them to empty out their pockets to cover their medical bills," Paul, who is also an ophthalmologist, said in a press release announcing the bill.

    However, Paul also said that a repeal of the ACA should not move forward without a replacement ready to go.

    "There is no excuse for waiting to craft an alternative until after we repeal Obamacare, and the Obamacare Replacement Act charts a new path forward that will insure the most people possible at the lowest price," the release said.

    Paul was the only Republican senator to vote against a resolution that kicked off the ACA repeal process, citing concerns that a repeal without replacement would increase the federal budget deficit.

    According to the fact sheet, Paul's bill would change the healthcare market in several other ways. Here are the highlights:

    • Allow insurance companies to sell plans "across state lines." This is a popular Republican idea but was included in a more limited form in the ACA. While each insurance company currently has to comply with state insurance regulators, Paul's plan would eliminate this need for compliance. Health policy analysts have said there is little evidence that insurers would take advantage of this provision or that it would drive down costs.
    • Allow HSAs to be used without a high-deductible plan. Currently, HSAs are used only in conjunction with high-deductible plans. Paul's bill would eliminate the link. Additionally, it would allow HSA money to be spent on insurance premiums and prescription drugs.
    • Allow individuals and small businesses to pool together to get insurance. While the ACA allows small businesses to pool together to get more favorable care, this has not been used much. In addition, Paul's plan would allow individuals to pool together to access care — another longtime Republican idea —but his plan would allow this "through their membership in a trade or professional association."

    This is the second replacement bill to be advanced in the past week by Republicans; the first was a bill from Sens. Bill Cassidy and Susan Collins. Paul's bill, however, would eliminate more of the ACA's programs and protections than Cassidy and Collins' bill would.

    SEE ALSO: 'Did he lie?': Democratic senator grills Trump health pick about whether he is developing Obamacare replacement

    Join the conversation about this story »

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    Mark Bertolini, Chairman and CEO of Aetna, participates in a panel discussion at the 2015 Fortune Global Forum in San Francisco, California November 3, 2015. REUTERS/Elijah Nouvelage/File Photo

    On Monday, a federal judge blocked Aetna’s $34-billion acquisition of Humana. Combined they would have formed the second largest health insurer, behind the also under-attack Anthem-Cigna merger. The court cited antitrust grounds related to Medicare Advantage insurance plans, where their combined pricing power would ultimately raise the costs that consumers pay for coverage.

    But Wall Street loved the deal that had been announced with such great hoopla in 2015. It was the year of the mega-mergers. The bigger the better. Money was growing on trees. And investment banks would have made a bundle.

    How big would the combined entity have been? In January this year, Aetna had a Medicare Advantage enrollment market share of 7.2%, and Humana of 16.9%. The largest player was UnitedHealth with 23.7% (chart). The merger would have given Aetna-Humana a share of 24.1%. And the top two players would have controlled nearly 50% of the US market. And in numerous areas, one of them would have totally dominated. That fits the definition of an oligopoly.

    US District Judge John Bates put it this way in his 158-page opinion filed Monday:

    Federal regulation would likely be insufficient to prevent the merged firm from raising prices or reducing benefits, and neither entry by new competitors nor the proposed divestiture to Molina [another health insurer] would suffice to replace competition eliminated by the merger.

    And thus, Judge Bates said, the merger would “likely substantially lessen competition” for Medicare Advantage plans in 364 counties and also in certain Florida public insurance exchanges.

    But the judge also revealed a shadier side to the deal.

    Aetna threatened the government last summer with pulling out of 11 of the 15 states where it participated in the Obamacare individual insurance markets, claiming it was a “business decision.” The threat was made while the Department of Justice was investigating the merger but before it filed its antitrust lawsuit. It was a shot before the bow. After the lawsuit was filed, Aetna followed through on its threat.

    And Judge Bates put his finger on it: It wasn’t just a “business decision,” he wrote. There was more to it. “Aetna tried to leverage its participation in the exchanges for favorable treatment from DOJ regarding the proposed merger.”

    Aetna then tried to cover up that connection between the threat to pull out of those markets and the antitrust investigation to the point where the “repeated efforts to conceal a paper trail about the decision-making process” bordered on “malfeasance,” he wrote.

    Judge Bates determined that there was “persuasive evidence that when Aetna later withdrew from the 17 counties, it did not do so for business reasons, but instead to follow through on the threat that it made earlier.”

    Aetna said it is “giving serious consideration to an appeal.” But if the deal remains in its current collapsed form, a lot of money is going to reverse course, and not just in the stock market and among merger arbs: according to the DealBook, the three investment banks advising the companies could lose $88 million of their $101 million in fees:

    Citigroup, which advised Aetna, would have received $45 million in fees. So far, it has already been paid $5 million. It could lose around $40 million

    Lazard, which also advised Aetna, would have received $15 million. So far, it has been paid $5 million. It could lose around $10 million

    Goldman Sachs, which advised Humana, would have received $41 million. So far, it has been paid $3 million. It could lose around $38 million.

    And Aetna gets to pay Humana a breakup fee of about $1 billion, if the deal remains in its collapsed form.

    The ripples might spread further. Last summer, while it was at it, the DOJ also sued to block Anthem’s acquisition of Cigna, which would create the largest health insurer in the US. Originally, the deal was valued at $54 billion. The case went to trial last year but the court hasn’t ruled yet.

    If that deal collapses, the investment banks advising both companies will lose $93 million in fees, of the total fees of $126 million. And perhaps the judge might throw in a few revelations as well. We cannot wait.

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    donald trump mike pence john kelly

    President Donald Trump has promised to deliver better healthcare at a lower cost while allowing every American access to coverage, raising the stakes in how he will address the future of healthcare in the US.

    In an interview with ABC News' David Muir that was broadcast Wednesday night, Trump said the Affordable Care Act, the healthcare law better known as Obamacare, was a disaster — a line Trump had used before his election and has used since.

    "It's too expensive," Trump told Muir. "It's horrible healthcare. It doesn't cover what you have to cover. It's a disaster. You know it and I know it."

    Trump also correctly pointed out that certain states — he cited Arizona and Minnesota — were seeing large increases in premiums on the individual market exchanges established by the ACA.

    In response, Trump made numerous promises about what he said the Obamacare replacement would entail.

    He said he wanted "good coverage at much less cost" and "a much better healthcare plan at much less money."

    Yet perhaps the largest promise from Trump was the number of people he suggested his replacement would cover. Since the ACA's passage, more than 20 million Americans have gained access to health insurance, and the US uninsured rate has hit its lowest point ever.

    Despite these gains, Trump said he didn't think the ACA had provided enough people with coverage. He told Muir his replacement would cover those the ACA had not.

    "It's going to be — what my plan is is that I want to take care of everybody," Trump said. "I'm not going to leave the lower 20% that can't afford insurance." (Only about 10% of the US population currently does not have coverage.)

    Trump reiterated his promise later in the interview.

    "So I want to make sure that nobody's dying on the streets when I'm president," Trump said. "Nobody's going to be dying on the streets. We will unleash something that's going to be terrific."

    Muir pressed the president on whether a replacement would mean that no one who had gained coverage because of the ACA would lose it.

    "We want no one. We want the answer to be no one," Trump said, though he acknowledged that such a feat would be difficult.

    So far, a flurry of proposals put forward by Republicans — including two Senate bills introduced by GOP lawmakers in the past week — do not appear to maintain coverage for all Americans with coverage under the ACA, much less guarantee it for all Americans.

    Most congressional Republicans — including House Speaker Paul Ryan and Trump's pick for secretary of health and human services, Rep. Tom Price — have talked about providing "access" to coverage for all Americans but have stopped short of promising that all people will have coverage.

    Health-policy analysts have said these three promises are also in conflict with one another. To expand coverage — especially to every single American — the cost to the government would have to increase, not decrease, to fund tax credits and coverage-expansion programs.

    Republicans have begun repealing the ACA and are in Philadelphia over the next few days to, among other things, craft a replacement.

    SEE ALSO: Rand Paul just introduced his Obamacare Replacement Act

    Join the conversation about this story »

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    Donald Trump

    WASHINGTON (AP) — The Trump administration says it is pulling back advertising to promote as open enrollment draws to a close for this year.

    The Health and Human Services Department said in a statement Thursday that the government has withdrawn about $5 million in ads as part of an effort to cut costs. The statement said HHS has already spent more than $60 million to promote sign-ups this year under former President Barack Obama's health care law.

    Former Obama officials immediately accused the new administration of "sabotage."

    Calling the decision "outrageous," former CEO Kevin Counihan said in a statement that the move could keep young, healthy people from getting into the insurance pool, thereby driving up costs. "We know that more young people enroll during the final days of open enrollment, but they need to be reminded of the Jan. 31 deadline," Counihan said.

    A call to the national call center Thursday night found it to be up and running. An operator read a reporter a script saying that the transition to a new administration has not affected coverage for 2017, and people are still able to sign up.

    The HHS website still featured a link for open enrollment and a blog promoting the law. and its state counterparts offer subsidized private health insurance for people who don't have access to coverage on the job. This year the online insurance markets have been rocked by sharply higher premiums and dwindling choice of insurers, although nearly 9 in 10 customers receive final assistance.

    President Donald Trump and leading Republicans have portrayed the markets as on the verge of collapse, and have cast their own effort to repeal and replace the Obama health overhaul as a rescue mission. Most independent experts say the situation is not as dire, although fixes are needed to strengthen the markets.

    Some 11.5 million people had signed up nationwide through Dec. 24, or about 290,000 more than at the same time during the 2016 enrollment season. It's not clear, however, whether the Obama's administration's goal of 13.8 million enrolled for 2017 will be met.

    More than 20 million people have gained coverage since the health care law passed in 2010, bringing the nation's uninsured rate to a historic low of around 9 percent. In addition to subsidized private insurance, the law offers states an option to expand Medicaid for low-income people.

    The advertising cutback was first reported by Politico.

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    donald trump mike pence paul ryan

    President Donald Trump has taken a bold step to wreck the Affordable Care Act, the healthcare law better known as Obamacare.

    According to Politico's Paul Demko, the new administration has pulled all advertisements for and has frozen efforts by the Department of Health and Human Services to encourage people to sign up for plans through the ACA.

    The pulling of ads includes those that have already been paid for and placed, according to Politico. For the 2015-2016 open-enrollment period, HHS spent about $35 million on ads encouraging people to sign up.

    Americans without health insurance through their employer or Medicare or Medicaid can sign up for plans through the ACA's public exchanges through January 31 for a 2017 plan.

    Typically, the run-up to deadlines is accompanied by a significant uptick in sign-ups. As Politico reported, this is especially true for young people, who are needed to balance the risk in the individual market pools.

    Trump has maintained that the law will "collapse on its own." But projections from the nonpartisan Congressional Budget Office indicate that the number of people enrolled will continue to increase and eventually stabilize, not go into the "death spiral" as Republicans predicted.

    The end of the open-enrollment period is crucial because the share of total enrollees who are ages 18 to 34 increases substantially during that time.

    This is important because the pools in some states have been filled with an outsize number of older and sicker people over the past few years, causing many large insurers to lose money on the exchanges.

    In turn, some insurers have left the exchanges in some states, exacerbating cost increases. While some states have mitigated these issues by expanding Medicaid and other provisions, it is crucial for the stability of the exchanges to get young people to sign up.

    According to a report from The Huffington Post, an HHS official said the pulled ad buy was worth about $5 million.

    If the Trump administration's move causes fewer young people to join the exchanges this year, the problems that GOP lawmakers have predicted might come to pass.

    It is unclear just whether the scaling back has affected the law so far because the HHS under Trump has also scaled back its communication about Obamacare.

    The HHS Twitter account has not mentioned the ACA deadline — after tweeting about it multiple times a day — since a tweet on January 19, the day before Trump's inauguration.

    It is unclear how many Americans have signed up for care since the department has halted communications and stopped issuing its typically biweekly enrollment update since the Trump administration took office. The most recent update, on January 10, pegged enrollments through the ACA's provisions at 11.54 million.

    Andy Slavitt, a former director of the Centers for Medicare and Medicaid Services, tweeted his displeasure with the move, saying it was "misguided actions which purposely hurt ACA consumers."

    Trump has long been opposed to the ACA, calling it a "disaster" and promising to repeal and replace it.

    Republican lawmakers kicked off the repeal of the law by advancing a budget resolution through the House and Senate that directs committees to draft a replacement bill using budget reconciliation.

    So far, there has not been a concrete proposal for a replacement from Republican leadership, but a few GOP senators have introduced plans that are significantly different.

    SEE ALSO: Trump is making a massive promise about his Obamacare replacement

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    Donald Trump

    One Obamacare talking point you often hear from Republicans is that it inappropriately imposed a national, one-size-fits-all solution, wherein states should be allowed to develop policies on healthcare that best meet their residents' needs and desires.

    Another talking point you often hear is that health insurers operating in any state ought to be able to sell policies to residents of any other state.

    This is called "interstate sale," and it would mean that health insurance would be regulated by the state where it is sold, not necessarily the state where the insured person lives.

    As Republicans fret over how to repeal and replace the Affordable Care Act amid President Donald Trump's ascension to office, it would be possible for them to develop a policy approach that aligns with one of these principles — but not with both.

    Interstate sale means no regulatory role for states

    Historically, insurance regulation is a matter for state government — which is why many states have an elected office of Insurance Commissioner, and why property and casualty insurance generally cannot be sold across state lines.

    If you allow interstate sale of health insurance, states will no longer have effective power to regulate health insurance. Insurers will relocate to whichever state has the most favorable regulatory climate for insurers and sell policies for the whole country from that state.

    This would not necessarily be a terrible thing by itself. Roughly, this is how credit cards work now: Banks can issue credit cards from anywhere, so they do so from the states with the rules they like best.

    You may have noticed that your credit card bills come from Delaware or South Dakota — this is why.

    In practice, interstate issuance of credit cards means regulation is handled by the federal government. And in my opinion, it is generally handled adequately by the federal government.

    The feds could take on a similar role with health insurance if they set their minds to it. This might be better especially for consumers in small states, which tend to have few health insurers selling individual policies.

    Without regulatory power, states can't develop their own solutions

    The problem would come from allowing interstate sale while at the same time expecting states to develop their own approaches to making health insurance coverage adequate and affordable. One of the important tools states would need to meet this responsibility is insurance regulation.

    States would need to set rules about how insurers can underwrite policies, who they must cover and at what price, what benefits they must cover, and similar matters. But if they set those rules when interstate sale is legal, insurers will be free to ignore the rules by selling from another state.

    Last week, House Speaker Paul Ryan touted a list of Republican policies to free the health insurance market, interstate sale among them. He told CBS' Charlie Rose:

    "We want more choices. That's why we want things like interstate shopping. Let insurance compete across state lines. We have — we have a lizard selling us car insurance on Geico. We have Flo selling us home and auto insurance. Why can't we have a vibrant marketplace like that for health insurance?"

    "The health market is much more shielded from competition," Ryan's spokesman Brendan Buck told me. "He was using that as an example of how other insurance products must do much more to compete for your business."

    It's true that the individual health insurance market is, for a variety of reasons, less vibrant and competitive than the markets for auto and home insurance in most states.

    But it's somewhat odd to point to Flo and the Gecko as an argument for interstate sale, given that Progressive Insurance and Geico are vibrantly competing in 51 separate state-level markets, regulated by separate regulators, who sometimes impose stringent rules about what they may charge and what they must cover, especially in the case of auto insurance.

    Geico gecko

    People want health insurance to be more than just insurance

    The key difference between health insurance and other insurances, which makes health-insurance markets less fluid than other insurance markets, is not who regulates the plans. It's that health insurance is more than just an insurance product.

    Americans have come to expect that health insurance will cover some fraction of their routine and expected health care expenses. There is also strong public opposition to medical underwriting — the practice of charging people more, or denying them coverage altogether, if they are known to have a pre-existing condition.

    Homeowner's insurance has the equivalent of medical underwriting: If your house is at risk of hurricane damage, you'll have to pay more to insure it. This makes it feasible (in most places) to have a fairly free and competitive market in homeowner's insurance.

    You could deregulate health insurance so that it is treated roughly like homeowner's insurance, and if you did so you'd probably get a more competitive and vibrant, national market in health insurance — for healthy people.

    Unfortunately, this approach would make insurance unaffordable for many people with preexisting conditions, unless their coverage was subsidized to a degree much greater than Republicans have historically been willing to fund through high-risk pools.

    Doing so would cost hundreds of billions of dollars over a 10-year budget window. During the Obama administration, Republicans in Congress could not even agree to spend $5 billion on a high-risk pool pilot program intended as an alternative to Obamacare.

    Republicans can't have it both ways anymore

    Paul RyanThere have been two broadly contradictory messages from Republicans on Obamacare. One is that the program is too expensive because it requires insurance to be too generous, covering too many things for free or close to it. Under this critique, health insurance is not enough like a regular insurance product.

    The other is that co-payments and deductibles are too high, making health care too unaffordable — which is to say, under this critique, health insurance is too much like a regular insurance product.

    They can change public policy to respond to one of these critiques, but not both.

    Republicans could further insurance-ize health insurance by pushing more Americans toward catastrophic plans that cover only high and unexpected health costs, while expecting people to pay for their own routine care, perhaps with money they deposit in health savings accounts.

    But, as Republicans presumably know from running against the high co-payments and high deductibles associated with the Affordable Care Act, this would be unpopular.

    Leaving sick people in the lurch when shopping for insurance would be unpopular, too.

    Ultimately, whether health insurance is handled by states or the federal government, it's going to need to have some characteristics we wouldn't expect in other insurance markets, allowing for coverage of routine care and coverage for people who already know they're sick — and that means we can't expect buying it to be like buying from Geico.

    SEE ALSO: Marco Rubio embarrassed himself again by making an empty threat

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    aetna ceo mark bertolini

    Aetna, one of the five large public health insurers, said that it may totally pull out of the Affordable Care Act (ACA) exchanges because they do not know what the future of the law will be.

    The ACA is better known as Obamacare. 

    Asked about the insurer's future in the ACA's individual insurance exchanges beyond 2017, CEO Mark Bertolini said on the company's quarterly earnings call that the current move by Republican lawmakers to repeal the law has left the company will little choice but to stay away.

    "We have no intention of being in the market for 2018," said Bertolini. "Currently, where we stand, we'd have to have markets worked up ... prices worked up for April 2017 to apply, and there is no possible way that we'll be able to do that given the unclear nature [of where] that regulation is headed."

    Insurers must submit plans for their coverage offerings, including updated premiums prices, by April to participate in the 2018 plan year. With no cohesive replacement plan yet advanced by Republicans, Bertolini seems uninterested in pursuing the market.

    Bertolini also expressed concerns about the current state of the ACA, saying "the intended goals of the ACA have not been achieved." He also said that changes would need to be made for a replacement to be sustainable. From the call (emphasis added):

    "As the public exchanges enter their fourth year, it is clear that in the absence of a significant shift in regulatory policy, the risk pools for the ACA-compliant individual commercial products will continue to deteriorate. However, we remain optimistic that the next wave of healthcare reform will focus on affordability, quality, and addressing the needs of the millions of Americans who remain uninsured or lack access to affordable healthcare. To that end, we continue to actively engage in constructive dialogue with law makers and regulators and are committed to working towards preserving the positive aspects of the ACA and developing consumer-based approaches that deliver access to affordable quality healthcare to all Americans."

    On the call Aetna executives said the company's pre-tax operating loss on ACA exchange products was $450 million for the full-year 2016. 

    Bertolini later said Aetna may consider staying in some exchanges should they be profitable in 2018, but would re-evaluate for 2019 and 2020 based on the replacement plan advanced by lawmakers.

    Aetna has threatened to leave the marketplace before. The insurer announced it would scale back their offerings on the public exchanges in August 2016. At the same time it was discovered that the company told the Department of Justice in a letter in July that if a proposed merger with rival Humana was blocked, the company would leave the ACA market entirely.

    The merger with Humana was blocked by a federal judge on January 23. The judge, in his ruling, determined that Aetna's drawdown in the ACA exchanges was a ploy to get the Humana deal through the anti-trust ruling and leverage their participation in the Obamacare markets against the DOJ.

    Aetna has said it will review a possible appeal of the decision.

    SEE ALSO: Trump made a move that could help wreck Obamacare

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    obama trump

    Tuesday marks the final day of open enrollment on the Affordable Care Act's exchanges.

    Facing down the possibility of repeal, Americans can still sign up for health insurance coverage for 2017 through the end of the day. But the uncertainty facing the law known as Obamacare may already be affecting the number of people signing up.

    President Donald Trump's administration has ceased nearly all communications and outreach trying to get Americans to enroll — which may cause big problems in the health insurance market.

    Uncertainty abounds

    The last few weeks of enrollment are particularly important — not only is there an uptick in overall sign ups, but a higher percentage of young people typically sign up.

    Younger enrollees are needed to help adjust the risk pool in the individual market. With too few young people, the risk pool becomes older, sicker, and more expensive to cover for insurers.

    In years past, this has led to large losses for insurers on exchange-based plans, as well as questions over the long-term sustainability of the exchanges.

    Yet the Trump administration yanked roughly $5 million in advertising focused on getting people to sign up. Additionally, communication from the Department of Health and Human Services, which runs the exchanges, has decreased significantly since Trump's inauguration.

    It also appears that Trump and the GOP's desire to move forward with a repeal and replacement of the law may have put a drag on the last few weeks of enrollment. Before going radio silent, HHS reported that it was dealing with a heavier number of calls than usual from people asking if they should still sign up for care.

    "Strong demand is especially striking in light of the unique headwinds created by discouraging rhetoric from ACA opponents," former HHS Secretary Sylvia Burwell said in a statement right before Trump's inauguration. "More than 40,000 people have contacted our call center expressing concerns about whether they should sign up for coverage, with a sharp uptick in these questions last weekend."

    Obama doctors Obamacare

    The Washington Post has reported that the grassroots organization Enroll America — which aims to sign up as many people for plans through the ACA as possible — has had 30% fewer appointments to assist in sign-ups than during the 2015-16 enrollment period.

    The increased uncertainty and possibility of a drop in young enrollees has insurers worried. The possibility of facing an even more expensive risk pool, instead of steady or improving enrollment as HHS had predicted before the open enrollment period, could cause insurers already worried about the exchanges' uncertain future to leave them preemptively.

    Aetna CEO Mark Bertolini, who runs one of the nation's five largest public insurers, said during a quarterly earnings call on Tuesday that due to the uncertainty, the company has no plans to expand the number of states where it offers ACA plans.

    "We have no intention of being in the market for 2018. Currently where we stand, we'd have to markets worked up prices worked up for April 2017 to apply, and there is no possible way that we'll be able to do that given the unclear nature that regulation is headed," Bertolini said. "We will, however, participate where we think it is appropriate in 2018 as we currently evaluate our performance in helping support the transition to whatever comes forward in 2019 or 2020."

    Advocates for the ACA and health-policy experts say the steps by Trump and the GOP's insistence on a repeal will help create the "death spiral" that Republicans claimed was happening — except this time, the GOP would be in line for the blame.

    Even former Vice President Joe Biden dared Republicans to repeal the law, warning: "Go ahead repeal it. Repeal it now, see what happens."

    A Republican replacement

    While open enrollment wraps up, Republicans have been moving forward with the repeal of the law and attempting to craft a replacement for the ACA.

    Several GOP lawmakers, including Sen. Rand Paul, have issued plans for replacements. But a cohesive replacement supported by the wider Republican leadership, however, has not been advanced.

    And GOP members of the House and Senate passed a budget resolution that directed committee leaders to draft a repeal bill using the budget reconciliation. Once drafted, the repeal bill would only allow parts of the law regarding the budget to be repealed

    Republicans have exhibited some trepidation about repealing Obamacare without a full replacement bill ready. Trump, House Speaker Paul Ryan, and Senate Majority Leader Mitch McConnell have all expressed the desire to replace the ACA as close to a repeal as possible.

    Despite assurances from Trump that the new GOP plan will eventually cover every American at a lower cost and with better coverage, it appears that the new administration may already be causing some worrying problems in the individual insurance market already.

    All of the upheaval comes at a time when the ACA has never been more popular. Recent polls from NBC News/The Wall Street Journal and Morning Consult/Politico showed the highest level of approval for the law among Americans since its passage.

    In fact, both polls show more Americans in support of Obamacare than against it.

    SEE ALSO: Trump made a move that could help wreck Obamacare

    SEE ALSO: This is what could happen if Obamacare is repealed

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    • Republicans' plan to repeal and replace Obamacare has created uncertainty around the law's individual health insurance exchanges.
    • Insurers are considering not offering plans on the exchanges in 2018 because of the unclear future.
    • If insurers pull out of the exchanges because of the uncertainty, it could cause the "death spiral" Republicans have been talking about for years.

    The Republican plan to repeal and replace the Affordable Care Act, better known as Obamacare, has introduced a high level of uncertainty in the health insurance market, and the CEOs of major insurers are concerned about the future.

    Over the past few weeks, several insurance executives have expressed concern and uncertainty about their business strategy regarding the ACA's individual insurance exchanges.

    The exchanges, where people who are not covered through their employer or Medicaid or Medicare can buy insurance, are a key part of the ACA that's being targeted by the GOP's repeal strategy.

    Because Republican lawmakers are still in the midst of repealing the law and have not laid out a cohesive plan for replacement, insurance executives are taking a cautious look into the future.

    Insurers are nervous

    "We have no intention of being in the market for 2018,"Aetna CEO Mark Bertolini said during his company's earnings call on Tuesday. "Currently, where we stand, we'd have to have markets worked up ... prices worked up for April 2017 to apply, and there is no possible way that we'll be able to do that given the unclear nature [of where] that regulation is headed."

    Insurers must submit plans, including premium prices, for the 2018 plan year to federal and state regulators in April 2017.

    Given the short turnaround, it may be even harder to get insurers to commit to offering plans on the exchanges in 2018.

    Anthem CEO Joseph Swedish echoed similar concerns during his company's earnings call on Wednesday, despite the fact that the company expects its ACA plans to be "break-even to slightly profitable in 2017."

    "While the direction in Washington has been positive, we still need certainty about short-term fixes in order to determine the extent of our participation in the individual market in 2018," Swedish said.

    Several high-profile insurers, including Aetna, UnitedHealth Group, Cigna, and Humana — four of the five large public insurers — decreased their exposure in the ACA exchanges in 2017 because of financial losses.

    Mark Bertolini, Chairman and CEO of Aetna, participates in a panel discussion at the 2015 Fortune Global Forum in San Francisco, California November 3, 2015. REUTERS/Elijah Nouvelage/File Photo

    Despite the already declining insurer participation, it seems the uncertainty created by the repeal plan has only hastened the abandonment of the exchanges.

    Even insurers that have been profitable on the exchanges are talking about leaving because of the repeal plan.

    Mario Molina, CEO of Molina Healthcare, told Politico's Victoria Colliver that despite being successful on the exchanges, his company may not stick with the ACA if its future is unclear.

    "People keep asking me, 'Are you going to stay in?'" Molina told Politico. "I don't know. It's kind of like asking whether you're going to buy a car in 2018. I'm not going to commit to something when I don't know what the product looks like."

    In a testimony before the Senate on Wednesday, Marilyn Tavenner, the CEO of the leading health insurance lobby group America's Health Insurance Plans and former head of the Centers for Medicare and Medicaid Services, told lawmakers that quick action is needed for insurers to be able to make 2018 work.

    "Right now, plans are trying to price for '18, and the uncertainty around cost-sharing subsidies and the tax credits would cause them to hesitate to price because we need to understand what the funding support is going to be, because that affects premiums," Tavenner said.

    Tavenner also said the companies "need predictability for long periods of time" in order to offer effective plans.

    Creating a 'death spiral'

    Republicans have maintained that the law is collapsing on its own and is in a "death spiral" because of insurers' losses and declining numbers of insurers participating, eventually leading to lower consumer enrollment.

    The nonpartisan Congressional Budget Office, however, projected that enrollment and costs would stabilize over the next 10 years. With insurers pulling out, however, health policy experts have said the uncertainty could end up creating the "death spiral" that the GOP has feared.

    President Donald Trump has expressed a desire to quickly get a replacement plan in place, which may mitigate some of the uncertainty and minimize disruptions in the individual exchanges. He also has said he doesn't want the exchanges to collapse and leave people with higher costs or no coverage, even though he said the Democrats would "own it."

    SEE ALSO: Obamacare's final countdown

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    Even with the looming threat of a repeal, more and more Americans say they support the Affordable Care Act, better known as Obamacare.

    A poll released by Public Policy Polling on Thursday showed that 46% of Americans said they support the ACA, while 41% oppose the law.

    Additionally, PPP found that 62% of people polled said they wanted to keep the ACA and make changes to it, while 33% said they wanted it repealed and the US to start over with a new healthcare law.

    "Obamacare continues to become more popular the more talk there is about repealing it," PPP said in a release.

    The poll follows two others that show the ACA is becoming more popular with Americans. An NBC News/Wall Street Journal poll last month found that 45% of Americans said they approved of the law and 41% disapproved, and a Morning Consult/Politico poll this week found 47% said they approved while 45% disapproved.

    Interestingly enough, PPP also found that President Donald Trump's approval rating was 47% approval and 49% disapproval, meaning that the healthcare law has a better net approval rating than the president.

    The increase in popularity comes as Republicans begin the process of repealing significant parts of the law through the budget reconciliation process. The GOP has cited increasing premiums and several insurers abandoning the law's insurance exchanges as reasons for the repeal.

    Democrats, on other hand, have fought for the law, pointing to things such as the more than 20 million people who have gained access to insurance through it, as well as provisions such as a statute preventing insurers from denying coverage because of a preexisting condition.

    The three-month open enrollment period for the ACA's exchange-based plans ended Tuesday night. Because of decreased communications from the Department of Health and Human Services since President Donald Trump was inaugurated, the final number of Americans who signed up for plans during the period is unclear.

    SEE ALSO: The biggest health insurers are freaking out about the uncertainty surrounding Obamacare's repeal

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    Paul Ryan Mitch McConnell

    WASHINGTON — While insisting they've not abandoned their goal of repealing President Barack Obama's healthcare overhaul, Republicans are increasingly talking about "repairing" it as they grapple with disunity, drooping momentum, and uneasy voters.

    The GOP triumphantly shoved a budget through Congress three weeks ago that gave committees until January 27 to write bills dismantling the law and substituting a Republican plan. Everyone knew that deadline was soft, but now leaders are talking instead about moving initial legislation by early spring.

    And as the party struggles to translate its longtime political mantra into legislation that can pass Congress, some Republicans have started using different language to describe the effort.

    "It's repairing the damage Obamacare has caused. It's more accurate" than repeal and replace, said Sen. Lamar Alexander of Tennessee, who chairs the Senate health committee. He notes that President Donald Trump and many Republicans want to keep popular pieces of the overhaul like requiring family policies to cover children up to age 26.

    "It probably lessens people's anxiety that we won't pull the rug out from under them," Rep. Pat Tiberi, of Ohio, who chairs a House health subcommittee, said of the term "repair."

    The refined rhetoric comes as much of Washington's focus has shifted to Trump's nomination of Judge Neil Gorsuch for the Supreme Court vacancy and Democratic attempts to derail GOP efforts to confirm Cabinet members. That and controversies surrounding Trump's temporary refugee ban have sapped some energy from the healthcare drive.

    It also comes with polls spotlighting the GOP's risks. A recent Associated Press-NORC Center for Public Affairs Research poll found 53% wanted to keep Obama's law in some form, and 56% were "extremely" or "very" concerned that repeal meant many would lose insurance.

    House Speaker Paul Ryan has been saying Republicans want to "rescue" the health system and Thursday embraced all of the competing phraseology, saying, "The best way to repair a healthcare system is to repeal and replace Obamacare."

    But talk of a repair dismays other Republicans, including hard-line conservatives. They say their message since Democrats enacted the 2010 law was that the GOP would repeal it, a goal later amended to "repeal and replace."

    "You've got to repeal the law that's the problem. That's what we told the voters we were going to do," said Rep. Jim Jordan, of Ohio, a leader of the conservative House Freedom Caucus.

    barack obama3

    Jordan cites problems that have accompanied the statute, including rising premiums and deductibles and diminished insurance choices in the individual market in some communities. He says healthcare would improve if Obama's law vanishes.

    "If you start from that premise, repair shouldn't be your mind-set," Jordan said.

    Democrats say the GOP's evolving language signals retreat. They say Republicans will threaten healthcare's availability and raise rates, angering the 20 million people who gained insurance under the law and tens of millions of others who benefit from the statute's coverage requirements.

    "It puts the burden on them to come up with the so-called repairs," No. 2 Senate Democratic leader Richard Durbin of Illinois said. "What a departure from repeal it, walk away from it, and America will be a better place."

    Behind the scenes, Republicans continue shaping proposals to void Obama's statute. Potential targets include the law's requirement that people who don't get coverage at work buy policies, the subsidies many of them receive, and the tax increases imposed to finance its programs.

    But they've encountered internal disagreements.

    Some Republicans want to abolish the law's broadening of Medicaid to provide health coverage to more lower-earning people, while others are from states that accepted the expansion. Most want to include language blocking federal payments to Planned Parenthood, but some don't, and some want to let states keep Obama's law intact.

    There are disputes over whether to quickly repeal the law's tax increases on higher-income people and the health industry and over how to provide money so people don't abruptly lose coverage and insurance companies fearing losses don't stop selling policies.

    With insurers crafting their 2018 rate structures over the coming two months, the insurance industry's leading trade group made its jitters clear to Congress this week. Marilyn Tavenner, the president of America's Health Insurance Plans, told Alexander's committee that insurers needed to know soon whether lawmakers would continue the federal payments that let companies reduce out-of-pocket costs for many lower-earning customers.

    Losing those subsidies "would further deteriorate an already unstable market and hurt the millions of consumers who depend on these programs for their coverage," she warned.

    At a hearing Thursday before a House health subcommittee, Republicans revealed four "discussion drafts" of potential bills. They included letting insurers charge older customers higher rates and shortening the law's 90-day grace period for consumers to pay premiums.

    Another would replace the law's unpopular individual mandate with a requirement that people maintain "continuous" coverage if they want to avoid paying more for policies.


    AP Congressional Correspondent Erica Werner contributed to this report.

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    Obama Trump

    President Donald Trump's administration has already had a massive effect on the Affordable Care Act, the healthcare law better known as Obamacare.

    In a press release, the Centers for Medicare and Medicaid Services — which oversees the ACA's public insurance exchanges — provided its typical biweekly update on the end of Obamacare's open enrollment period, which ran from November 1 through January 31.

    The period, during which people without insurance through an employer or Medicare or Medicaid could sign up for coverage, ended with 9.2 million people signed up for plans through the platform, not including state-based exchanges.

    What's most startling, however, is how much the sign-ups slowed after Trump took office.

    According to the previous biweekly update from the Obama administration, 8.8 million people had signed up through January 14, meaning roughly 800,000 people were enrolling each week. Based on the updated figures from Trump's CMS, 200,000 Americans signed up for coverage in each of the final two weeks.

    This also means that enrollment fell by 400,000 people from the open enrollment period ending in 2016. For reference, there were 100,000 more people enrolled than in the previous year at the last update.

    The slow pace at the end could potentially damage the law's health. The late sign-up period is critical, as the percentage of young people obtaining coverage usually increases, which helps with balancing risk pools for the exchanges.

    In the previous three years of the exchanges, the people who have signed up through the exchanges have been older and sicker than expected. This has led to higher costs for insurers, which then are passed on to consumers.

    The Obama administration hoped to get more young people to sign up through outreach, especially as the sign-up period came to a close. Instead, communication about the open enrollment period came to a screeching halt after the Obama administration turned the keys over to Trump and his team. The effect on enrollment is clear.

    The Twitter account for the Department of Health and Human Services ceased tweeting about signing up for coverage, and Trump's team rolled back a significant number of TV ads touting

    Obama's HHS officials also reported a higher number of concerned calls regarding the repeal of the law, and independent enrollment advocates reported a lower-than-average number of appointments for assistance in signing up for a plan.

    Tonal shift

    In addition to showing a serious drop-off in enrollments, the CMS update also signaled a shift in how the government will talk about the ACA.

    Typically, the CMS releases have conveyed not only data, but also general support for the law, touting what they portrayed as an increase in plan selections from the previous year and the ability for people to gain access to health coverage easily. For example, previous emails frequently noted the percentage of people who could get covered for less than $75 or $100 a month.

    But in the first communication about the sign-ups from the Trump administration, the tone was drastically different. After providing the number of sign-ups for plans on, the email pointed to increased premiums associated with many of the exchange-based plans.

    "On January 31, 2017, open enrollment for 2017 coverage ended with more than 9.2 million plan selections in states that use the eligibility and enrollment platform," the CMS release said. "Those selections were made from a market that experienced a 25 percent increase over the previous year in the average premium for the benchmark second-lowest cost silver plan as well as a 28 percent decline in the number of issuers participating over the past year."

    SEE ALSO: Obamacare just keeps getting more popular

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    VoteVets, a nonprofit for veterans, ran this ad during MSNBC's "Morning Joe," a show President Trump reportedly watches. The ad focuses on The Affordable Care Act and immigration restrictions. 

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    For years, Republicans have promised to repeal the Affordable Care Act, the healthcare law better known as Obamacare.

    When Donald Trump was elected president, Republicans seemed to have finally gotten the chance to do just that. Trump, House Speaker Paul Ryan, Senate Majority Leader Mitch McConnell, and numerous Republican lawmakers quickly pledged that a repeal and replacement of Obamacare was on the horizon.

    Recently, however, there seems to have been a tonal shift in the way GOP lawmakers are addressing their approach to the law. Instead of leaning on the "repeal and replace" terminology, Republicans have begun to say they are "repairing" the ACA, a softening in their rhetoric.

    Repair, not repeal

    An increasing number of House Republicans have shifted to the "repair" terminology when referring to the Obamacare issue.

    "I think it is more accurate to say repair Obamacare because, for example, in the reconciliation procedure that we have in the Senate, we can't repeal all of Obamacare,"Sen. Lamar Alexander, the chair of the Senate Health Committee, said last week.

    Also last week, Sen. Orrin Hatch, the head of the Senate Finance Committee, told CNN that the GOP wanted to "try and repair the law."

    There may also be a source for the change. Bloomberg reported that conservative pollster Frank Luntz told Republicans at a summit in Philadelphia that the "repair" language was more amenable to Americans and to use it instead of "repeal and replace."

    Ryan told Fox News, however, that repair still meant repeal and replace.

    "To repair [the] American healthcare system, you have to repeal and replace this law, and that's what we're doing," he said in an interview with "Fox & Friends."

    A changing timeline

    Along with the change in rhetoric, however, the timeline for any proposed changes is also being slowly extended.

    Initially, indications from the GOP were that the repeal would come swiftly. Both Ryan and McConnell wanted to repeal the law within Trump's first 100 days and replace it soon after.

    Trump, for his part, was adamant about swift action. During the transition, Trump said he wanted an Obamacare replacement done within weeks and derided a plan to pass a bill that would delay the repeal for a few years while the replacement was crafted.

    This timeline has been extended, however, with Ryan shifting the goal posts back to the end of 2017.

    "We are going to be done with legislating, with respect to Obamacare and healthcare, at the end of this year," Ryan said at a press conference on Tuesday.

    In an interview with Fox News host Bill O'Reilly that aired Sunday, Trump said the Obamacare replacement was "in the process and maybe it'll take till sometime into next year."

    Republicans lawmakers have not reached a consensus on a timeline, with the leadership still touting a quick process but lower-level GOP members expressing doubt over the ability to make such a large change so swiftly.

    Paul Ryan Mitch McConnell

    The reason behind the shift

    Numerous reasons could help explain Republican's change in tone and timing.

    Many parts of Obamacare, for example, are still incredibly popular. Provisions such as the ability for children to stay on their parents' plan until they turn 26 and the inability of insurers to deny coverage based on preexisting conditions are popular with an overwhelming majority of Americans.

    The broader law is also gaining in popularity, with three recent polls showing more Americans in favor of the ACA than against it, with record-high approval in some polls.

    Additionally, Democrats have frequently been touting the over 20 million people who have gained access to health coverage through the law. Concern over the possibility of large losses in coverage has hounded Republicans in recent weeks to the point in which Trump promised in an interview with ABC that the new plan would cover "everyone."

    Thus, the Republicans may be attempting to pivot the messaging away from a blatant repeal to a softer tone. While the plan has always been to replace the law, co-opting the popular parts into their message and pointing out the deficiencies at the same time seems to be a new part of their strategy.

    The shift may also be an attempt to appease insurers, which are increasingly getting concerned about the viability of the individual health-insurance markets. A large number of insurers said they may roll back their exposure to the individual market given the rhetoric from Republicans.

    In the meantime, it appears that the Trump administration has done all it can to undercut the existing structure of the law. Data from the Centers for Medicare and Medicaid Services on Friday showed that enrollment for the federal exchanges through declined by 400,000 from the year before.

    The drop came after a sharp fall-off in enrollment following Trump's inauguration as the administration significantly decreased the amount of advertising and promotion of the exchanges. Before Trump's inauguration, 800,000 Americans were enrolling each week, but that dropped to 200,000 a week after his inauguration.

    SEE ALSO: The Trump administration has already dealt a blow to Obamacare

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    A sizable chunk of the American public seems to have some confusion about the Affordable Care Act, the healthcare law better known as Obamacare.

    That is, they may not know it as Obamacare.

    According to a Morning Consult poll published in The New York Times on Tuesday, just over one in three Americans surveyed did not realize that Obamacare and the ACA were the same thing.

    Seventeen percent of respondents incorrectly said they were two different policies, while 18% said they did not know whether they were the same or different.

    The information gap also showed up when people were asked about their approval of the law. When asked whether they approved or disapproved of Obamacare, Americans were split, as 45% approved and 46% disapproved.

    When asked, however, whether they supported the Affordable Care Act, 44% of people approved while just 40% disapproved.

    Knowledge about the particulars of a potential repeal of the law was also lacking: 39% of people surveyed said they did not know or incorrectly stated that Medicaid subsidies would not go away if Obamacare is repealed.

    According to the post from Kyle Dropp of Morning Consult and Brendan Nyhan of Dartmouth University, the knowledge gap on Medicaid credits was split on a partisan line.

    More than half (53%) of Republicans said they were unsure or responded incorrectly when asked about the impact of repeal on Medicaid subsidies. Only 21% of Democrats said they didn't know or incorrectly answered the question on Medicaid subsidies.

    The split comes as Republicans are taking steps to repeal the ACA in Congress while also attempting to draft and coalesce around a replacement. Recently, however, Republicans have shifted their tone regarding the ACA, choosing to call their plan a "repair" of the law rather than a "repeal."

    At the same time, polls have shown the ACA's popularity slowly climbing as Democrats push the more popular aspects of the law, such as the more than 20 million people who have been covered through its various provisions.

    The poll was conducted by Morning Consult, surveying 1,890 Americans on January 25 and 26 online with a margin of error of 2 percentage points in either direction.

    SEE ALSO: The GOP is changing its tune on the repeal of Obamacare

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    The latest

    Tuesday, February 17: The road to Trumpcare looks like it's about to head down the long and winding road. (More on that below.) After a week of slowly pivoting their repeal of Obamacare to a "repair" both House Speaker Paul Ryan and White House Press Secretary Sean Spicer tell reporters that Republicans hope to have the "legislation" of healthcare and Obamacare repeal and replace down "by the end of the year."

    This is slower than previous projections of replacement being done in President Donald Trump's first 100 days.

    Spicer, however, did not clarify exactly what Trump wants to see in a replacement plan when asked during his daily press briefing.

    Read the full story here»

    Tuesday, January 17: The nonpartisan Congressional Budget Office says in a new report that repealing major parts of Obamacare without a replacement plan could lead to an additional 20-25% hike in premiums above existing projections. And it says 18 million Americans would lose their healthcare outright.  

    Democratic lawmakers pointed to the report as another reason why repeal would be harmful to Americans. GOP lawmakers criticized the report since it does not include an analysis of a Republican replacement.

    Read the full story here»

    Friday, January 13: Congress has taken the first steps toward partial repeal of the Affordable Care Act (ACA), better known as Obamacare.

    Republicans in both the House of Representatives and the Senate passed a resolution that begins the process of repealing President Obama's signature healthcare law.

    The resolution directs members of relevant committees to draft a repeal bill through the budget-reconciliation process.

    With dissent among Republicans over whether or not to complete the repeal process before a replacement plan is finalized and strident Democratic resistance to any repeal of the ACA, it appears that there is a significant fight ahead over the future of American healthcare, which could lead the process down the long, winding road to Trumpcare.

    Road to Trumpcare

    BI Graphics_The road to Trumpcare_Martha car piece

    President-elect Donald Trump, along with Republican leaders in Congress, says he's committed to repealing and replacing Obamacare with something "terrific." Republicans have put forth a variety of different replacement plans, but it's unclear what the final version will look like. And the path to get to the implementation of a replacement could take many forms.

    Imagine it's like a board game where there are a number of ways to get to a replacement. One is fast and efficient, another winding and full of obstacles. We call it "The Road to Trumpcare," and we'll be updating the game as Congress and the new administration make their moves.

    The player in our game is a hypothetical Obamacare participant. We'll call her Martha. She's a 29-year-old from Tennessee and self-employed. Martha used the federal platform to sign up for her insurance two years ago and has been reenrolling every year; she receives some tax credits for her premiums since she makes roughly $45,000 a year.

    While an overwhelming majority of Americans get their health insurance from employers or a government-based program like Medicare or Medicaid, Martha is one of more than 11.5 million people who signed up for an exchange-based plan for 2017. Over 80% of these people, according to the Department of Health and Human Services, also receive subsidies for their coverage.

    Martha is a bit frustrated that there are fewer choices on the platform this year, and her premiums are increasing, but she is glad to have coverage because she has Crohn's disease, which could have excluded her from coverage before ACA.

    To get a better understanding of what a repeal-and-replace could mean to someone such as Martha, here are the four major scenarios for how lawmakers can address or not address the future of Obamacare.

    The Replacement Superhighway

    BI Graphics_The road to Trumpcare_Replacement superhighwayThe fastest and least disruptive path for Republicans to follow would be to repeal Obamacare and advance a replacement bill at the same time.

    The GOP could use a procedure called budget reconciliation in the Senate to strip away most of the provisions of Obamacare, specifically those that cost the government money, without the need for a single Democrat vote. Then, simultaneously, Republicans would need to go through typical lawmaking to pass a replacement bill and create some sort of new exchanges.

    House Speaker Ryan and Trump both seemed to favor this option. In fact, Ryan told CNN that some of the repeal and replace measures could be "in the same bill."

    According to Cynthia Cox, associate director for the Program for the Study of Health Reform and Private Insurance at the nonpartisan health think tank Kaiser Family Foundation, this would be the ideal option for patients in the event of a repeal.

    "This would provide both insurers and patients a clear picture of what's going to happen fairly quickly, which would prevent disruptions to the market," said Cox. "Though, a lot of this depends on the replacement bill that the Republicans come up with."

    What does this mean for Martha?

    This would likely be the least disruptive for Martha's coverage since it would ensure that there would be no period in which the exchanges that she uses are not funded or have no federal support. For one thing, as long as Martha reenrolls in her plan during the current Obamacare-enrollment period, she will have insurance through 2017.

    A quick replacement could be in place for the 2018 plan year, and depending on what the replacement is, Martha may not notice any effect on her coverage at all.

    What could go wrong?

    A lot of this hinges on the details of the Republicans' plan. Since Martha receives subsidies to help cover the costs of her plan, a number of the replacement proposals floated by the GOP could affect how much she receives. Additionally, a number of plans would institute high-risk pools, which are separate markets reserved just for people with preexisting conditions. These existed before the ACA and generally had astronomically high costs and limited utilization.

    The other issue is that any change to the law may be rejected by Democrats. If Republicans want to make any larger changes outside the budget process they would need Democrats on board. If the GOP advances a bill that changes coverage in some way or rolls back parts of the ACA that do not deal with the federal budget, Democrats may block a replacement using the filibuster. Additionally, if even a few Republicans in the Senate don't like the replacement, that could sidetrack the process. If the GOP moves ahead with the repeal while Democrats object to changes to the law, it could make the road that Martha is on even more winding.

    The long and winding road

    BI Graphics_The road to Trumpcare_Winding roadsOne of the first scenarios floated by Republicans was a partial repeal of the law under what is called budget reconciliation — delaying until a later date so that Republicans can craft a full replacement bill. This would pass a law that says the ACA will be repealed in the future, somewhere between two and four years, effectively delaying the end of the ACA.

    In theory, this allows GOP lawmakers to advance the political goal of repeal while giving enough time to develop a comprehensive plan for replacement. The exchanges set up by Obamacare could be intact, meaning that the more than 20 million people with ACA-based plans would still be covered, while Republicans devise a plan that would replace the ACA and keep these people covered, as numerous GOP lawmakers have promised.

    Since the delay aspect could stretch the replacement process out up to four years, this would allow the GOP time to build a consensus on a replacement. It would also be politically beneficial since it would push the repeal out past the 2018 midterms or 2020 presidential election.

    Republicans could avoid political fallout if the replacement plan falls short of expectations, and they could build a larger majority in the Senate to pass the bill without worrying about a filibuster.

    According to Cox, while the plan sounds good, there are a few problems that could arise with this strategy.

    "Depending on the parts of the law that are repealed through the reconciliation process, you could see destabilization in the individual insurance market," Cox told Business Insider.

    According to Cox, without an individual mandate for people to sign up for insurance, there would be significant numbers of younger people leaving the individual market, which would lead to a pool of even older and sicker people in the exchanges.

    In a worst-case scenario, this would lead to a breakdown of the individual insurance market. Businesses hate uncertainty, so it is likely that with the exchanges' futures in doubt, insurance companies would simply pull out completely. Healthy policyholders could see the writing on the wall and not renew their policies, leaving only the sickest patients in the marketplace causing, as Cox called it, "a real death spiral," repeating the turn of phrase used by Republicans to describe Obamacare's growing issues.

    Also, by leaving just the sickest Americans in these exchanges, premiums for those who remain behind would be much higher than the current increases.

    "If the individual mandate were to be repealed without countermeasures, it would cause very large increases in the cost of premiums," Cox said. "These increases would make what we've seen in the market so far look small."

    There are, of course, ways to mitigate this. For one, Republicans could extend and enhance certain measures, called reinsurance and risk corridors, which help to provide money for insurers that take on a higher percentage of sick patients. This would help decrease the large losses some insurers are reporting and possibly inspire more companies to offer plans on the exchanges.

    Many GOP lawmakers, however, have referred to these provisions as "bailouts," so that may be politically untenable.

    What does this mean for Martha?

    This plan takes her down our game's long and winding road, full of stops and starts and pitfalls along with way. As debates over the repeal continue, Martha could be stuck in a car she has no control over, stalled out and awaiting updates about her coverage. The process could take years.

    Republicans, through reconciliation, would have options to pull funding for the law in a few different ways while crafting a replacement. They could simply roll back the taxes associated with the law, they could also repeal the individual mandate that all people have to buy insurance, or they could pull all funding including subsidies people like Martha get or eliminate Medicaid expansion. All these would create a different level of disruption to the market.

    In the best-case scenario for Martha, the individual mandate is maintained to ensure stability of the individual market until some other plan is proposed. While Martha doesn't see her premiums or deductibles shrink, nothing goes too awry. Also, lawmakers provide enough assurances to insurers that they stay in the market, preventing a monopoly-like situation in Martha's market and higher costs.

    In the worst-case scenario, these four factors go the opposite way. Insurers, facing the uncertainty of the next two to four years, decide to exit the markets leaving Martha with just one or even no choices for coverage. With only a small penalty, people healthier than Martha leave the exchanges, which leads to an even sicker group of people being covered by the exchanges and higher prices for Martha. The "death spiral" predicted by GOP lawmakers for Obamacare truly does set in and prices shoot to astronomical levels, well above projections made before the passing of the law. Concerned that allowing a lapse in her coverage could cause her to be denied coverage in a replacement because of her preexisting condition, Martha sticks with the ever more expensive coverage

    The leave-as-is loop

    BI Graphics_The road to Trumpcare_Leave as is loopA third option for ACA changes would be to simply pass a few bills that make minor but needed adjustments to the law without a full-on repeal.

    Democrats may be more amenable to this option. They have long pushed for reforms to the ACA, recognizing the increasing premium costs. Some ideas floated by Democrats have been to expand premium subsidies, strengthen the penalty for not enrolling, and provide more assistance to insurers that take on a larger number of sick patients.

    This would leave a majority of the framework of the law — Medicaid expansion, the exchanges, and the statutory aspect — while providing tweaks to encourage younger, healthier people to sign up and balance the market.

    Politically this may be tough for Republicans since they've made ACA repeal a talking point in elections for the better part of a decade, but if there were enough face-saving concession it could placate this worry.

    What does this mean for Martha?

    Essentially, Martha would see few changes in her healthcare. The exchanges would still be intact and all the provisions protecting her care would also be in place. There may be some positive changes, new provisions could bring down various costs, or another insurer may be available in her area, but not much else.

    The repeal-without-replacement cliff

    BI Graphics_The road to Trumpcare_Repeal without replacement cliffA final, though perhaps least likely option, would be for Republicans to simply repeal the bill and not worry about replacement.

    After running against the bill for so long, the GOP could just repeal it and label it a disaster, making small changes along the way but not introducing a full-scale replacement.

    This seems the least likely of the options, however, since Republicans have repeatedly said that they want to ensure continuing coverage and uphold the popular parts of Obamacare. Also, the political blowback from those losing coverage would be significant.

    What does this mean for Martha?

    Martha would likely lose any type of coverage come 2018 and be back to the pre-ACA world. She could try to access health insurance through the individual health insurance market, but with a preexisting condition there is no guarantee she could get access to coverage.

    She could hope that her state implements a high-risk pool, where higher risk patients can get catastrophic insurance that covers the worst-case scenarios, but these plans are incredibly expensive and few people chose to access the pools when they did exist pre-ACA.

    This, in many ways, would be the worst-case scenario for Martha.

    Democratic response

    In terms of direct action, there are few choices for Democrats to block moves on the law made by Republicans.

    Obviously, unless there is a change to the rules, Senate Democrats could filibuster any statutory changes to the ACA. Outside of that, it appears that they simply have to influence the Republican agenda.

    Perhaps most potent for Democrats would be to use Republicans' repeal against them. Some of the highest rates of utilization for ACA plans come from heavily Republican areas, and waging a public-relations campaign to get the conservative base to push back on any changes to the bill, the Democrats may have a way to get at least some of what they want.

    Politico reported that many Democrats, while vehemently opposing a repeal of the ACA, would be willing to work with Republicans to find some way to keep various part of the law in a replacement bill.

    "If it makes sense, I think there'll be a lot of Democrats who would be for it," Democratic Sen. Claire McCaskill told Politico.

    Whether Democrats go along with a replacement may come down to the amount of influence they can exert over the law.

    An uncertain future

    For now Martha, in our game, is hurtling down the road in her car. She doesn't like the increasing costs but wants to keep her coverage.

    What turns The Road to Trumpcare takes are, for now, unknown, but more than 20 million real Americans are waiting anxiously to find out.

    SEE ALSO: One-third of Americans don't appear to know Obamacare and the Affordable Care Act are the same thing

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    During a CNN debate over the future of the Affordable Care Act (ACA), also known as Obamacare, Sen. Bernie Sanders asked Sen. Ted Cruz if healthcare should be a right for all Americans. Republicans are currently working to repeal the ACA, but this could lead to millions of people being uninsured.

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    The percentage of Americans without health insurance hit an all-time low in 2016, mostly due to the impact of the Affordable Care Act (ACA), better known as Obamacare.

    Despite the substantial decrease in the national rate, there is a substantial variance in the uninsurance rate between states.

    According to new data from Gallup-Healthways, the highest uninsured rate is in Texas, where 20.5% of people do not have coverage. This is also the ninth straight year that Texas has had the highest uninsured rate according to the survey.

    Massachusetts and Hawaii, which notably had expansive health coverage laws prior to the ACA, are tied for the lowest percentage of people without coverage at 3.2% each. 

    Additionally, the survey looked at which states had the biggest decreases in the uninsured rate between 2013 and 2016.

    All 10 of the biggest drops came in states that expanded Medicaid via the Affordable Care Act, led by Kentucky. Right behind Kentucky's 12.6 percentage point drop was Arkansas with a 12.3 pp fall and West Virginia with a 11.5 pp drop.

    On the other end, those states that did not see a dramatic reduction in their uninsured population share one of two traits,according to the survey.

    "Of the 11 states with the smallest reductions, six have not expanded Medicaid," said the Gallup-Healthways survey release."Among these 11, the states that have expanded Medicaid — Massachusetts, Hawaii, Vermont, Delaware and Minnesota — were already among the states with the lowest uninsured rates in the nation in 2013 and therefore had the least room for improvement."

    state uninsurance rate map feb 2017

    SEE ALSO: One chart shows just how devastating healthcare costs are for American families

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