WASHINGTON (Reuters) - The U.S. Senate voted on Friday to confirm Representative Tom Priceas the top U.S. healthcare official, putting a determined opponent of Obamacare in position to help President Donald Trump dismantle the healthcare law.

The Senate voted 52-47 to approve the conservative Georgia Republican and orthopedic surgeon as the secretary of the Department of Health and Human Services (HHS), a massive department with an annual budget of more than $1 trillion.

In his new job, Price will have authority to rewrite rules implementing the 2010 Affordable Care Act, as Obamacare is officially called. Price could move quickly to rework Obamacare regulations while waiting for Republicans in Congress to keep their pledge to scrap the law entirely.

Republicans, who have the majority in Congress, are trying to craft a replacement for Obamacare but have not agreed on one. Twenty million Americans gained health insurance under the law.

Price's nomination was dogged by questions about his trading in hundreds of thousands of dollars in health company stocks while working on healthcare legislation. Democrats boycotted the committee vote on his nomination, saying he had made misleading statements about shares he bought. Price says his actions were legal and ethical.

A member of the House of Representatives since 2005 and currently chairman of the budget committee, Price is the author of legislation to repeal Obamacare and replace it with age-adjusted tax credits for the purchase of health insurance.

Democrats criticized Price for his stock trading as well as his opposition to Obamacare, his ideas about restructuring the Medicare program for the elderly, and his support for cutting federal funds to Planned Parenthood, a women's healthcare organization that provides abortions.

The Department of Health and Human Services oversees Medicare and Medicaid, the government health insurance program for the poor. It also encompasses the Centers for Disease Control and Prevention and the Food and Drug Administration. 

(Additional reporting by Brendan O'Brien in Milwaukee; Editing by Robert Birsel)

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Lawmakers got an earful from constituents in Tennessee on Thursday night during a town hall to talk about the future of the Affordable Care Act, the healthcare law better known as Obamacare.

Republican Rep. Diane Black held a town hall about the law at Middle Tennessee State University in Murfreesboro, Tennessee, and was confronted by multiple constituents who pushed back against the GOP's plan to repeal and replace the ACA.

One man, Mike Carlson, confronted Black about the repeal, saying the law had allowed him to gain access to lifesaving coverage.

"I am an overweight person. I have to have coverage to make sure I don't die," he said. "There are people who have cancer that have that coverage that have to have that coverage to make sure they don't die. And you want to take away this coverage and have nothing to replace it with. How can I trust you to do anything that's in our interest at all?"

Another person in attendance, Jessi Bohon, pointed to her Christian faith as a reason to support the law.

"It's in my understanding that the ACA mandate requires everyone to have insurance because the healthy people pull up the sick people, right?" she said. "As a Christian, my whole philosophy in life is to pull up the unfortunate. So the individual mandate, that's what it does, the healthy people pull up the sick."

Bohon also criticized a proposal favored by Republicans that would put sicker people in high-risk pools for those with preexisting conditions, saying "we are effectively punishing our sickest people" by using the pools. Bohon pointed to previous state high-risk pools, which have exhibited high costs and poor coverage.

Bohon asked why the government wouldn't just "fix" the ACA or provide Medicaid for all instead of repealing the law.

Black pushed back on both Carlson's and Bohon's statements, according to CNN, saying the Republicans' would replace the ACA with a law that would offer coverage to all Americans. Black said that while the ACA had provided coverage for more than 20 million Americans, there were still people lacking insurance and the GOP planned to fix that.

The uninsured rate today is 8.6%, according to the Department of Health and Human Services, the lowest ever. Tennessee, which has not expanded its Medicaid program under the ACA, has an uninsured rate of 11.8%.

Bohon said she was a teacher and received coverage through the state's government, according to the CNN report. Both Carlson and Bohon voted for Hillary Clinton, the report said.

Tennessee saw one of the highest increases in premiums for Obamacare in 2017, with costs for the average silver-level plan increasing by 63% from the year before.

Watch Carlson's and Bohon's statements below:

SEE ALSO: Here's how many people in every state don't have health insurance

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NOW WATCH: Here's how powerful an executive order is and how it could be reversed

Gary Cohn, the former Goldman Sachs chief operating officer who is now the chief economic adviser to President Donald Trump, is working on a variety of economic matters for the president, according to a new profile of his role, but also a big health-related issue: the repeal of Obamacare.

According to a profile of Cohn's first few weeks in the White House from The New York Times' Kate Kelly, Cohn not only has taken a large role in the new administration when it comes to matters such as job growth and regulation but has also been involved in the Trump administration's plans to repeal and replace the Affordable Care Act, the healthcare law better known as Obamacare.

Cohn — a longtime Democrat — has had meetings with Republicans leaders including House Speaker Paul Ryan, Rep. Jeb Hensarling, who is the head of the House Financial Services Committee, and House Majority Leader Kevin McCarthy about the replacement bill, according to the report.

During his career at Goldman Sachs, Cohn did not have a job related to healthcare; he instead worked in mortgages and commodity trading before becoming CEO Lloyd Blankfein's right-hand man. Though Cohn lacks direct health-policy experience, the ACA does contain significant tax and economic elements to which Cohn could bring expertise.

The Times report said Cohn was also considering noneconomic statutory parts of the law as well — citing such provisions as one that allows children to stay on their parents' insurance until they turn 26 and another regarding special enrollment periods that allow people to sign up for ACA-based exchange plans outside the two-month open-enrollment period.

Cohn is also working with a "healthcare specialist" on the Obamacare plan but did not specify the role of that person, the report said.

The insight gives a sense of the leadership involved in the Republican crafting of a replacement plan. While two plans have been introduced by GOP lawmakers during this legislative session, a complete, cohesive replacement has not yet been put forward by the GOP leadership.

The report makes no mention of newly confirmed Secretary of Health and Human Services Tom Price, who Trump during a press conference in January said was involved in the crafting of a replacement. Reports have refuted that characterization, saying the administration was keeping Price away from the replacement planning process so as not to have a conflict between his proposal and the administration's work during his confirmation hearings.

Price himself would not confirm that he was working with the president on Obamacare during his confirmation testimony to the Senate Finance Committee.

It is unclear what Price's role will be in the replacement process now that he has been confirmed.

Both the House and the Senate approved a budget resolution in January that would allow Republicans to repeal large swaths of the ACA that affect the federal budget; however, numerous procedural steps would still be needed to repeal the law.

Read The New York Times' full Cohn profile here »

SEE ALSO: 'I have to have coverage in order to make sure that I don't die': GOP lawmakers get blasted on Obamacare at town hall

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One day in 2014, Steve Pullins made a phone call that saved his life.

At the time, he was bumming on friends' couches in Cincinnati without a job and suffering his worst relapse in years. When he wasn't drinking, he was smoking crack cocaine, and when he wasn't doing either of those he was using heroin to stave off cravings.

He knew he needed help. He'd been clean for a seven-year stretch before his latest downward spiral, and he called Ohio's food-assistance hotline. While he waited for someone from the government to pick up, a recording came on talking about the state's new Medicaid program.

He had a realization. At 56 years old, he could have healthcare for the first time in his life. He applied immediately.

"When you have an addiction, you don't think about insurance. You are only thinking about another way to kill yourself," Pullins told Business Insider. "My life changed."

A year earlier, around the time Pullins' relapse began, Ohio Gov. John Kasich made a decision — controversial for a Republican — that changed the lives of thousands of addicts such as Pullins. Using federal funds available to any state, Kasich chose to expand the state's Medicaid program under the Affordable Care Act, better known as Obamacare, despite opposition from many on the right.

Before the ACA, few Americans qualified for Medicaid, the government-run health program. Though eligibility varies from state to state, the most likely beneficiaries were pregnant women, single mothers, the disabled, and seniors with low incomes.

The ACA opened Medicaid up to more than 11 million new people nationwide (a number that continues to grow), though it's up to states to decide if they want to participate. New federal requirements established that any adult living under 138% of the federal poverty level — an income of $27,821 for a family of three in 2016— was eligible.

Pullins had heard about Obamacare on the news. It was impossible to avoid. But before he called the hotline, he never imagined he would make the cut for Medicaid. A few weeks later, he received a letter from CareSource, a nonprofit that serves Medicaid members in Ohio, granting him coverage. His new insurance paid for drug treatment. He could see an eye doctor and dentist. Now, after 19 months, he says he hasn't drunk alcohol, used drugs, or smoked a cigarette. He credits Obamacare and its Medicaid expansion.

"I tell everyone, 'If you don't have it, you need to get it, brother,'" he said. "I know this chance would not have been possible if I hadn't gotten the continuing care that Obamacare has provided."

After the 2016 presidential election, the future of Obamacare, and its Medicaid expansion, is in doubt, and with it the fate of current and former addicts like Pullins covered by the ACA.

Thirty-two states and the District of Columbia took advantage of the Medicaid expansion provision in the ACA. And there's evidence it's helped a lot of people. The Department of Health and Human Services estimated in January that the number of hospitalizations of uninsured people due to substance use has dropped in expansion states by 75% as of 2015.

And 1.29 million people are receiving treatment for substance use disorders or mental illnesses thanks to the Medicaid expansion, according to research conducted by Harvard Medical School Health Economics professor Richard Frank and New York University dean Sherry Glied. About 220,000 of those people are receiving treatment for opioid abuse.

Without the Medicaid expansion, the vast majority of those people would either fall into the "treatment gap"— unable to receive substance-use treatment because of a lack of insurance or public funds — or be forced to wait months or years to get into a publicly funded treatment program.

President Donald Trump campaigned hard for a repeal of the ACA, calling it a "mess" repeatedly and promising to "repeal and replace" it. With Trump in office, Republicans have begun the lengthy and complicated process to repeal, replace, or at least significantly revise the law. In mid-January, Congress passed a budget resolution directing the legislature to draft a repeal and replacement to the ACA. With a simple majority vote, lawmakers could eliminate or radically change the Medicaid expansion.

The decision in Ohio and elsewhere to expand Medicaid has been critical to fighting the worsening opioid epidemic. Over the past decade, the US has suffered rising rates of prescription and illicit opioid use, leading to skyrocketing deaths from drug overdoses. In December, the Centers for Disease Control and Prevention said that 52,404 people died from drug overdoses in 2015, with over 60% dying from opioids. That number has been rising for years.

'Hard to conceive' of Medicaid going away

Medicaid doesn't solve addiction on its own. While suffering the death of his stepfather from dementia in early 2015, Pullins relapsed. But thanks to Medicaid he got back into treatment at the Center for Addiction Treatment in Cincinnati, the only nonprofit treatment facility in the region, and he has received continuing care since.

Like many other health professionals and government officials in Ohio, Sandi Kuehn, the CEO of CAT, says the expansion has helped fight the epidemic.

"It has been a godsend for a lot of people that have addiction or mental-health issues," Kuehn told Business Insider. "It's hard to conceive of it going away."

Since Ohio opted for the expansion, about 30-40% of CAT's patients are now covered by Medicaid. According to Kuehn, it has allowed the facility to increase the number of people it can treat. Because CAT operates completely on grant money from the state, county, and municipal governments, and does not accept third-party insurance, more patients covered by Medicaid has meant more money to treat other patients.

CAT isn't alone. Ohio, which has the third-highest drug-overdose death rate with 29.9 deaths per 100,000 people, has insured 702,000 new people and is providing substance-abuse treatment to 108,000 of those people. And health-provider groups surveyed by the Ohio Department of Medicaid expressed "a uniformly positive view" of the expansion in an extensive review of the program.

In a letter to House Majority Leader Kevin McCarthy, Kasich "strongly"recommended retaining the Medicaid expansion. "Thank God we expanded Medicaid, because that Medicaid money is helping to rehab people," Kasich said this month after signing a bill targeting Ohio's opioid crisis.

'A disaster' waiting to happen

Ohio is far from the only state to have leaned on the Medicaid expansion to fight the opioid epidemic. Of the 10 states with the highest drug-overdose death rates, only Tennessee and Utah opted out of the ACA's Medicaid expansion.

Pennsylvania — which has the sixth-highest drug-overdose death rate in the US at 26.3 deaths per 100,000 people — has insured 670,000 new people and is providing substance-abuse treatment to 63,000 of those patients thanks to the Medicaid expansion, according to official figures released last month.

West Virginia — which has the highest drug-overdose death rate in the US with 41.5 deaths per 100,000 people — has provided coverage to more than 172,000 people and is treating 22,000 of those people for mental illness or substance-abuse disorders.

Those figures have upset the usual partisan divide over the ACA.

Pennsylvania Gov. Tom Wolf, a Democrat, has lauded the expansion as opening "the door to treatment" that otherwise would not be available — much less affordable — to those without insurance. And Pennsylvania Republican State Rep. Gene DiGirolamo told Business Insider that doing away with the Medicaid expansion "would be a disaster."

Expanding Medicaid "was a life-saving, very smart decision. [Gov. Wolf] did the right thing. A lot of people have received help," Deb Beck told Business Insider. She is the president of the Drug and Alcohol Service Providers Organization of Pennsylvania, a coalition of drug- and alcohol-abuse prevention, addiction treatment, and education programs and providers.

West Virginia Sen. Shelley Moore Capito, a Republican, said she supports a "full repeal," though she has said she doesn't want to see the Medicaid population thrown "into the cold."

Democratic Sen. Joe Manchin and newly inaugurated Democratic Gov. Jim Justice, a Republican until 2014, have been critical of the ACA, but they have both continued to applaud the Medicaid expansion and called for it to remain in place.

The widespread support for Medicaid in the expansion states is due in large part to the severity of the opioid crisis and the fact that the crisis has strongly affected poor, blue-collar, and rural populations, many of whom have since joined Medicaid.

Pennsylvania Auditor General Eugene DePasquale warned of "devastating consequences" for the state's "rural, working poor" if the expansion is rolled back. DePasquale and other Pennsylvania officials suggested that job losses and significant losses in healthcare and substance treatment would result.

Dr. Richard Vaglienti, who cochairs West Virginia's Expert Pain Management Panel, a task force working to alleviate the opioid crisis, said that rolling back the expansion is not a "feasible" option for West Virginia. One-third of the state is enrolled in Medicaid, according to the Kaiser Family Foundation.

"I don't want to go as far as saying it would be catastrophic, but it wouldn't help," Vaglienti told Business Insider. "We are in a particularly precarious position."

What comes next

Republican governors, who have been asked to submit recommendations to Congress, are split on how to repeal the ACA and whether the Medicaid expansion should stay.

Generally, Republican governors in charge of states that opted into Medicaid —16 in total — have acknowledged its importance to their states in recommendation letters solicited by Republican congressional leaders.

Governors of states that didn't opt in were more critical and called for rolling back the program. Congressional Republicans are also split over the Medicaid issue. Some proposals call for a rollback, others a limit on funding the program.

It appears unlikely that the Medicaid expansion will be eliminated wholesale. In January, Kellyanne Conway, President Trump's White House counselor, said on NBC that the administration is calling for turning control of Medicaid over to the states and capping funding for the program. Block-granting, as the program is called, has long been a part of House Republicans' "Better Way" agenda and would provide fixed grants to states to be used for the state's Medicaid program in whatever way they see fit. Currently, Medicaid is an open-ended entitlement program where the amount of funding is dictated by enrollment each year.

Conway said that block-granting would ensure "those who are closest to the people in need will be administering" the program. But governors on both sides of the aisle expressed concern in letters to congressional leaders about block-granting, which they fear could be used for federal budget cuts, according to The New York Times.

The problem with turning Medicaid into block-grants, according to Gary Mendell, the CEO of Shatterproof, a national nonprofit advocating addiction treatment, is that it will be unable to cope with unexpected issues like the opioid epidemic or expected ones such as the aging of the baby-boomer generation.

Republicans will likely grow the initial funding figure by a fixed measurement such as gross domestic product growth or the consumer price index, according to Mendell, which would likely cap funding growth at somewhere between 1 and 4%. Opioid-overdose deaths have increased by 33% over the past five years, which suggests that the need for Medicaid coverage for those suffering from addiction is unlikely to drop anytime soon.

"The dollars won't be there," Mendell said. "They won't be there for any epidemic that happens — not just the current opioid epidemic."

States will face a choice, according to Frank, the Harvard health economist. Either cut benefits, which would affect the quality of coverage, or cut who is eligible for the program, which could hurt people with disabilities, older people, or people suffering from substance abuse, depending on what each state decides.

If Congress and Trump decide to completely eliminate the Medicaid expansion, Pennsylvania, Ohio, and West Virginia, among other states suffering the brunt of the opioid crisis, will be ill-suited to handle the loss in funds, government officials and treatment experts say.

Pennsylvania is suffering a $600 million budget shortfall as of December and could go as high as 1.7 billion by July, according to the Pittsburgh Post-Gazette. DiGirolamo said there are "no extra dollars" to insure residents or provide addiction treatment to those who lose coverage because of an ACA-repeal. The situation is equally dire in West Virginia.

As a former addict and the manager of a sober house in Cincinnati, Pullins has seen how the Medicaid expansion has helped rehabilitate those affected by the crisis. When asked what he thinks might happen in the event that the program is eliminated or changed, he was unequivocal.

"If you don't have health insurance, the only way addicts know how to medicate themselves is to continue to get high." he said. "If you can't help a person, you throw them back into the street. What do you think that person is going to do?"

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The House Freedom Caucus, a conservative wing of congressional Republicans, voted Monday night to support a swift and aggressive repeal of the Affordable Care Act, complicating GOP efforts to unite around a plan to repeal and replace the healthcare law better known as Obamacare.

According to reports, the Freedom Caucus said it would not back a repeal if it did not include all of the elements of a repeal bill that debuted in 2015. It also said it wanted to quickly repeal the law, even if no replacement bill was ready.

The 2015 repeal bill, which was passed by the GOP in Congress but vetoed by President Barack Obama, included repeals of the individual mandate, the Medicaid expansion, and the taxes to fund premium subsidies that aid people in paying for coverage.

Republicans had already been drafting a repeal bill via budget resolution that would allow them to repeal any part of the ACA that involves the federal budget.

But the vote by the Freedom Caucus could complicate the timeline of a repeal-and-replace plan. Disagreements over which elements to repeal and which to include in a second overhaul bill may make a cohesive vote from Republicans harder to come by.

Some more moderate lawmakers have softened their approach and considered keeping some of the ACA's provisions as part of the repeal. Even in some deeply red states, GOP lawmakers have been bombarded at town halls by constituents who have expressed concerns about the law's repeal.

With Democrats vowing to oppose the changes at every turn, Republicans need to ensure they rally around a single bill to accomplish repeal. According to Politico, the Freedom Caucus said 50 members had signed on to its outlook on the repeal.

Part of the concern from Freedom Caucus members is that not acting swiftly and decisively on a repeal could threaten the long-term success of an overhaul of Obama's healthcare law, with support for the changes potentially losing steam and becoming bogged down in Congress.

By pushing for a fast and total repeal, Freedom Caucus members hope to force moderate Republicans and some Democrats into crafting a replacement.

"It's our hope that in doing so it will bring some others along for a replacement bill once they understand that it has been repealed that you get some Democrats and certainly more moderate Republicans to work in earnest with replacement," Rep. Mark Meadows, a Freedom Caucus member representing North Carolina, told Politico.

Republicans have been considering measures to stabilize the individual markets set up by the ACA to ensure that American with coverage through these exchanges are able to keep it while a replacement is developed. Some GOP members have stressed a need to "repair" the law before they repeal and replace it.

Additionally, numerous Republican governors and lawmakers in states that have expanded Medicaid through the ACA have expressed a desire to keep this aspect of the law to cover more poor families in their state. If a bill similar to the 2015 repeal bill were to be passed, it would end federal funding for that expansion.

Health-policy experts have been concerned that a repeal, or serious steps toward a repeal without a replacement, could lead insurers to leave these markets, potentially destabilizing them and causing large cost increases and coverage lapses. In fact, some large insurers are already questioning their involvement in individual markets next year, given the uncertainty over the GOP plan.

House Speaker Paul Ryan has offered a few timelines on the repeal and replacement of the law. He has said "the legislating" will be done by the end of this year, that it will be done by the end of the summer, and that it will be done by the end of the first quarter of the year.

Even with the statement by conservative members of the House, the timeline for the repeal remains unclear.

SEE ALSO: 'I have to have coverage in order to make sure that I don't die': GOP lawmakers get blasted on Obamacare at town hall

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During her testimony to the Senate Banking, Housing, and Urban Affairs Committee, Federal Reserve Chair Janet Yellen outlined the potential economic impact of a repeal of the Affordable Care Act (ACA), better known as Obamacare.

When asked by Democratic Sen. Bob Menendez about the effect of the recent budget resolution passed by Republicans that would repeal significant parts of the ACA on the broader US economy Yellen said, "We would have to look at what the shifts in healthcare have on the economic outlook."

She continued, "Healthcare, as you mentioned, does account for a very significant share of spending and a loss of access to health insurance could have a significant impact on spending of households for other goods and services. Beyond healthcare itself, it could have impacts on the economy."

Over the past two years, healthcare spending as a percentage of GDP increased at a level usually seen during recessions according to the Centers of Medicare and Medicaid Services, and out of pocket costs for Americans have been climbing at a rapid pace.

While this shift may already be restricting discretionary spending, as Yellen notes, a sudden loss of insurance could cause households to shift even more household spending away from discretionary goods and services and towards healthcare.

Yellen went on to say that the increase in health coverage and access to insurance under the ACA has helped improve the labor market.

"In addition, access to healthcare for some individuals has likely increased their mobility and diminished the phenomenon called job lock where people are afraid to leave jobs because of losing health insurance and that could have implications for the labor market as well that we would try to evaluate," said Yellen.

While these issues could be mitigated by a possible replacement plan offered by Republicans, Yellen made it clear that a large overhaul of Obamacare could have implications for the entire US economy.

SEE ALSO: Conservatives just made Obamacare repeal more difficult

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Humana is pulling out of the Affordable Care Act market.

The company, one of the five large publicly traded health insurers, said in a press release Tuesday that it would pull all its business from the individual marketplaces starting January 1, 2018.

The announcement comes the same day that Humana and rival Aetna terminated their merger agreement.

Humana said it was hoping that the individual marketplaces set up by the law known as Obamacare would stabilize.

But the company said that in reviewing data from 2017 enrollment on the exchanges, it saw "further signs of an unbalanced risk pool."

From Humana's statement (emphasis added):

"All of these actions were taken with the expectation that the company’s Individual Commercial business would stabilize to the point where the company could continue to participate in the program. However, based on its initial analysis of data associated with the company’s healthcare exchange membership following the 2017 open enrollment period, Humana is seeing further signs of an unbalanced risk pool. Therefore, the company has decided that it cannot continue to offer this coverage for 2018. Through the remainder of 2017, Humana remains committed to serving its current members across 11 states where it offers Individual Commercial products."

President Donald Trump said Humana's pull-out was evidence of the law continuing to "fail."

"Obamacare continues to fail,"Trump tweeted."Humana to pull out in 2018. Will repeal, replace & save healthcare for ALL Americans."

In previous years, large insurers have suffered losses on the Obamacare exchanges because of a risk pool that has been sicker and older, and thus more expensive to cover than expected.

Obama officials hoped that a larger number of young people would sign up through the exchanges during the open-enrollment period that ran from November 1, 2016, to January 31, 2017, and would help balance the costs. Instead, enrollment plummeted in the two weeks after Trump took office, and sign-ups came in lower than the year before.

That was critical, since more young people enroll in the last two weeks of the open-enrollment period.

Health-policy experts had theorized that the uncertainty of the GOP plan to replace the law, combined with the Trump administration's decision to not promote enrollment efforts in the critical weeks, could do serious damage to the exchanges, cause insurers to reconsider their involvement in the exchanges as Humana did on Tuesday, and lead to the "death spiral" Republicans has been claiming was happening for years.

SEE ALSO: Cigna is suing Anthem for $13 billion after walking away from their merger

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The Centers for Medicare and Medicaid Services on Wednesday morning announced new proposed rules for the Affordable Care Act's individual insurance exchanges.

The proposals from CMS include several changes to enrollment periods and timelines for insurers in an attempt at "stabilizing the individual and small group health insurance markets," according to a press release.

The proposed changes would be the first administrative tweaks to the law, also known as Obamacare, under President Donald Trump's administration. They contain a combination of long-considered ideas and serious departures from the previous administration.

Perhaps the two most striking proposed changes are cutting in half the exchanges' 2018 open enrollment period and lowering minimum standards for care to qualify for the exchanges.

The CMS proposes an open enrollment period — during which people without health insurance through their employer or Medicaid/Medicare can sign up for coverage — from November 1 to December 15, 2017. Open enrollment periods have been three months, from November 1 to January 31.

Additionally, the rules would lower the "de minimis range used for determining the level of coverage," according to the release. Essentially, the ACA established minimum standards for coverage (here's a full breakdown from CMS) in order to be certified on the bronze, silver, and gold plan levels. The new rule would allow insurers to cover slightly fewer areas of health and still be at a certain metal level.

The CMS projects the rules would result in increased out-of-pocket costs for Americans in the short term but that lower premiums would offset this in the long run.

"The proposed change in [actuarial value] could reduce the value of coverage for consumers, which could lead to more consumers facing increases in out-of-pocket expenses, thus increasing their exposure to financial risks associated with high medical costs,"the proposal says. "However, in the longer run, providing issuers with additional flexibility could help stabilize premiums, increase issuer participation and ultimately provide some offsetting benefit to consumers."

Patrick Conway, the acting CMS administrator, said: "This proposal will take steps to stabilize the marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated."

Here's a quick rundown of some of the other proposed changes:

• Give insurers more time to figure out their 2018 plans. Insurers have expressed concerns about the uncertainty regarding the repeal and replacement of the ACA planned by Republicans. This uncertainty, coupled with enrollment data, has already led one of the largest insurers — Humana — to announce plans to leave the market. Others are considering their offerings. Insurers must submit 2018 plans to the federal and state governments in April. The proposal says that if the other changes are accepted, CMS would issue "separate guidance" on the deadline for insurers.
• Increase scrutiny during special enrollment periods. The rules would force people who enroll outside of the open enrollment period to provide additional documentation to be allowed access to coverage. It would allow people who lose employer coverage because of a job status change to gain access, and it would prevent people from waiting until they get sick to sign up for a plan. This has long been an idea to prevent abuse of the special enrollment periods; the Obama administration had proposed something similar.
• Force beneficiaries to pay back owed premiums before getting the next year's coverage. The rules would allow insurers to "to collect premiums for prior unpaid coverage" before the person can sign up for a plan from the same insurer for the next year.

Some of these changes were proposed by the Obama administration in August to address the imbalance in the exchanges.

The open-enrollment tweak may be the most significant departure from the Obama era, however. The CMS rules proposed in August tried to expand outreach and sign-ups for the open enrollment period, allocating more money toward advertising efforts. Trump's team pulled back from a good portion of a $5 million ad buy for the 2017 open enrollment period.

A shortened open enrollment period could also make it much more difficult to increase sign-ups or keep the number of people enrolled at the same level in 2018. The number of people who signed up during the open enrollment period fell in 2017 from the year before, mostly because of a significant deceleration in sign-ups after Trump took office.

The new proposed rules drew some criticism from health-policy experts. Larry Levitt, a senior vice president at the health-policy think tank Kaiser Family Foundation, tweeted that the rules"strike me as making things less consumer friendly and more insurer friendly."

The proposed changes are open for public comment until March 7, according to filings with the Federal Register.

SEE ALSO: One of the US's largest health-insurance companies is dumping Obamacare

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Aetna CEO Mark Bertolini is not hopeful for the future of the individual health insurance exchanges created by the Affordable Care Act (ACA), also known as Obamacare, based on comments he made on Wednesday.

Bertolini, whose company is one of the five large public health insurers, said that the exchanges are in a "death spiral" during a speech at a Wall Street Journal conference.

"It’s not going to get any better, it's getting worse," said Bertolini according to Politico's Paul Demko.

The idea behind Bertolini's comments are that as premiums increase on the exchanges, fewer young and healthy people will sign up for coverage.

This will leave a higher percentage of older, sicker people on the exchanges, making them more expensive for insurers. The losses from this sicker risk pool will cause insurers to pull out of the exchanges, fewer choices on the exchanges will lead to higher prices, and thus even fewer healthy people will sign up to balance the pool.

Bertolini has long expressed doubts about the exchanges. Aetna pulled its offerings from roughly 70% of the places it was doing business last year and the CEO said during a recent earnings call that the company is considering its footprint in 2018.

During the block of a proposed merger between Aetna and Humana, however, a federal judge ruled that Aetna and Bertolini had cut their exposure to Obamacare to induce cooperation from Department of Justice to approve the merger.

In a letter to the DOJ in July, Bertolini said that the company would reduce its footprint in the exchanges if the DOJ blocked the deal. Bertolini claimed this was due to the loss of cost savings from the merger, but the judge said the move showed that "Aetna tried to leverage its participation in the exchange for favorable treatment" for the deal.

During the 2016-2017 open enrollment period, the total number of people signing up for insurance through the federal Heathcare.gov exchange fell by 400,000. Much of this drop was due to a significant slowdown in enrollments after President Donald Trump took office and pulled large amounts of funding for enrollment outreach.

Despite the drop in enrollment, health policy experts said the exchanges were not necessarily in a "death spiral" and their future depended on the repeal and replace process being undertaken by Republicans.

This, however, was not enough to appease Humana —another of the big five insurers — which said it would pull all of its Obamacare plans from the exchanges in 2018.

Additionally, the Trump administration rolled out proposals for new rules that would cut the exchanges' open enrollment period in half and institute other reforms in an attempt to stabilize the individual heath insurance market.

SEE ALSO: The Trump administration just proposed massive changes to Obamacare

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Pennsylvania Gov. Tom Wolf did not mince words in a recent letter to House Speaker Paul Ryan.

"This is not hyperbole – access to treatment through Medicaid is keeping Pennsylvanians alive who might otherwise face overdoses or worse,” wrote Wolf, a Democrat, to Congress' top Republican leader.

Government officials and politicians on both sides of the aisle in Pennsylvania are warning that a repeal of the Affordable Care Act, better known as Obamacare, would have disastrous consequences in the state — one that has been especially stricken by the nation's opioid crisis amid a messy state budget outlook.

Pennsylvania, like many states, has benefitted from numerous ACA programs, which have provided significant funds for state medical programs and expanded insurance coverage in the state. 

Overall, 479,000 Pennsylvanians have gained insurance coverage through the ACA-established individual markets or the law's provision that allows children to stay on their parents' coverage until 26, the Department of Health and Human Services (HHS) reported in December.

In 2015, Pennsylvania joined 31 other states and the District of Columbia in taking advantage of the Medicaid expansion provision in the ACA, which provided states funds to expand Medicaid to any any adult living under 138% of the federal poverty level — an income of $27,821 for a family of three in 2016. Through the expansion, 670,000 people have gained coverage.

All in all, that's more than 1 million Pennsylvanians who could be affected by what happens in Washington.

"There would be no way for the state to continue to provide health care for those folks," Ted Dallas, secretary of Pennsylvania's Department of Human Services, told the Pittsburgh Post-Gazette last month. "Repeal without replacement would have potentially devastating impacts across the state."

President Donald Trump campaigned hard for a repeal of the ACA, calling it a "mess" repeatedly and promising to "repeal and replace" it. With Trump in office, Republicans have begun the lengthy and complicated process to repeal, replace, or at least significantly revise the law.

In mid-January, Congress passed a budget resolution directing the legislature to draft a repeal and replacement to the ACA. With a simple majority vote, lawmakers could eliminate or radically change the Medicaid expansion and funding for subsidies on the individual market.

A loss in funds would be particularly devastating for Pennsylvania, which is currently suffering a $600 million budget shortfall as of December and could go as high as $1.7 billion by July, according to the Pittsburgh Post-Gazette.

A report from the Pennsylvania Budget and Policy Center, a liberal-leaning think tank, estimated that the deficit could grow by an additional $1.4 billion after an ACA repeal, due to the loss in federal funding and subsidies. 

The same report found that 137,000 workers in healthcare, construction, and other sectors would lose their jobs due to a repeal. 

I’m really, really worried about what’s happening in Washington. And I say that as a Republican. — Pennsylvania Republican State Rep. Gene DiGirolamo

Pennsylvania Republican State Rep. Gene DiGirolamo told Business Insider that if a repeal eliminates coverage for all or some of the Pennsylvanians that have gained it through the ACA, it will fall back on the state to treat them in hospitals and emergency rooms. That makes DiGirolamo very nervous because, he said, there are "no extra dollars" to insure residents who lose coverage due to a repeal.

"There is not a whole lot we can do with the budget situation we're in," DiGirolamo said.  

Pennsylvania Auditor Gen. Eugene DePasquale and Treasurer Joe Torsella warned in a joint press conference in January that a repeal or even a rollback would have reverberating consequences across the state, both in terms of job losses and the state budget.  

"It will exacerbate an already difficult and troubled budget situation," Torsella said.

'A disaster' waiting to happen

Compounding discussions about the future of healthcare in Pennsylvania is the state's opioid crisis.

Pennsylvania — which has the sixth-highest drug-overdose death rate in the US, at 26.3 deaths per 100,000 people — is providing substance-abuse treatment to 63,000 of those patients thanks to the Medicaid expansion, according to official figures released last month.

Wolf, the state's governor, has lauded the expansion as opening "the door to treatment" that otherwise would not be available — much less affordable — to those without insurance.

And DiGirolamo said that his biggest worry with a repeal is doing away with the Medicaid expansion, which he says "would be a disaster."

Without the expansion, the vast majority of those people would either fall into the "treatment gap"— unable to receive substance-use treatment because of a lack of insurance or public funds — or be forced to wait months or years to get into a publicly funded treatment program. 

Losing the Medicaid expansion would have a far wider effect for addicts than just the 63,000 people currently receiving treatment in the state, DiGirolamo said.

In Pennsylvania, the Department of Drug and Alcohol Programs (DDAP) allocates federal and state dollars for substance abuse treatment to Single County Authorities (SCA), organizations in each county that work on the ground to provide services to people in need.

Prior to the ACA, says DiGirolamo, the SCAs were constantly underfunded and therefore unable to provide treatment for all those suffering — a major issue for a state in the midst of a drug epidemic. Because the ACA opened up eligibility for Medicaid to a lot of people in need, who then received coverage for treatment through the program, less people have looked to the SCAs for aid. It has freed up considerable funds to reduce the treatment gap.

DiGirolamo worries that the elimination of the Medicaid expansion could wreak havoc on those funds.

"Medicaid has taken enormous pressure off of our counties," DiGirolamo said. "I don’t know what our counties would do if [the federal government] took away the expanded Medicaid program."

SEE ALSO: The Obamacare repeal 'could be a disaster' for states fighting the opioid epidemic

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NOW WATCH: Watch protesters and Trump supporters get into a fiery argument on the National Mall right after the new president was sworn in

The Internal Revenue Service is making a small change to how they evaluate one line of a tax document this year.

And it could have big implications for the Affordable Care Act (ACA), the law better known as Obamacare.

Essentially, line 61 on the IRS 1040 tax form asks the filer whether they have health insurance, which is mandated by the ACA.

But following President Donald Trump's executive order on Obamacare in which he instructed federal agencies to remove the "burden" of the law, the IRS decided that it would not reject those 1040 forms with a question that asked whether the filer had health insurance left blank.

The IRS was originally planning to not process forms that left the line blank for the 2016 tax year. Therefore, a person either had to buy insurance or inform the IRS they were uninsured and pay the ACA's individual mandate penalty. 2016 was the same year that the full cost burden of the penalty went into effect, totaling $650 per adult.

Health policy experts had predicted that the stricter imposition of the penalties could drive more enrollment and help rebalance the Obamacare exchanges' risk pool, which have so far been sicker and more expensive for insurers than expected.

The tax agency said it could still go back and ask a filer about leaving the form blank if it wants to, but it may not necessarily do that for every American that leaves line 61, in the IRS term, "silent."

So instead of contributing to the stabilization of the individual market, the change allows those that want to avoid the penalty a simpler way to potentially do so.

In a statement to Reason, an IRS official said the recent executive order allows them to make the step and accept "instances where a taxpayer doesn't indicate their coverage status."

"Processing silent returns means that taxpayer returns are not systemically rejected, allowing them to be processed and minimizing burden on taxpayers, including those expecting a refund,"the IRS told Reason.

SEE ALSO: The Trump administration just proposed big changes to Obamacare

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NOW WATCH: 'It's a lie': Jake Tapper calls out Trump during a fiery interview with Kellyanne Conway

House Speaker Paul Ryan said during his weekly press conference Thursday that Republican members of the House were planning to introduce a bill that would repeal and replace the Affordable Care Act, the healthcare law better known as Obamacare.

"After the House returns following the Presidents Day break, we intend to introduce legislation to repeal and replace Obamacare," Ryan said.

Ryan said lawmakers were waiting on analysis from the Congressional Budget Office and the Joint Committee on Taxation before releasing the bill.

Next week is scheduled to be a "district work week" as House members return to their states, so the earliest a bill would come is February 27.

Ryan went on to repeat a common line that Obamacare is already failing, citing the recent decision by Humana— one of the country's largest health insurers — to pull all of its business from the individual insurance exchanges created by the law. Ryan also cited comments by Aetna CEO Mark Bertolini, who said at a conference on Wednesday that the law was in a "death spiral."

Ryan also said the bill would address concern from some Republican senators and governors from states that have expanded Medicaid. Many of these Republicans have had success in controlling costs and expanding coverage with Medicaid expansion and are wary of a repeal bill that would include taking away that funding.

Other Republicans are concerned that the expansion of Medicaid has put undue stress on the federal budget and should be rolled back.

"We're going to have to find a solution that accommodates each of these two concerns," Ryan said. "I've asked Greg Walden, who is the chairman of our commerce committee, and he along with Orrin Hatch are working with governors to come up with a solution so that whether a state chose to take the money [for Medicaid expansion] or didn't, that going forward ... that we do it in a way that doesn't disadvantage either of the two sides of that coin."

The details of the proposed legislation were not immediately clear, but a policy brief sent to Republicans on Thursday looks incredibly similar to Ryan's "Better Way" plan. While a significant part of the document reiterates why the GOP needs to replace Obamacare, it does law out some elements of a replacement such as tax credits to buy insurance and expand health savings accounts.

Republicans have been working toward a repeal and replacement of Obamacare for years, and they have promised swift action since President Donald Trump was elected. The plan, however, hit some speed bumps as moderate and conservative Republicans disagreed on the timing of the repeal and what to include in a replacement bill.

SEE ALSO: A Trump order led the IRS to make a small change on Obamacare that could have a big effect on its future

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NOW WATCH: Trump's Attorney General pick wants access to everyone's phones — here's why that's a problem

One of the most Republican arguments during a multi-year blitz against the Affordable Care Act has been that the exchanges set up by the law — on which people who do not get insurance through an employer or Medicare/Medicaid can get coverage — are in the midst of a potential "death spiral."

The idea is reasonably simple. The increase in premiums has led healthier people to drop out of the exchanges, leaving a sicker group of people signing up. Sicker people are more expensive for insurance companies to cover, so the insurers sustain losses.

Since the insurance companies don't like to lose money, some of them leave the exchanges, the theory goes. The remaining insurance companies on the exchanges jack up premiums to make up for losses, and since there are fewer options left, average people have to accept the hikes. Since the prices are even higher, more people leave the exchanges — and so the pattern goes.

Republicans have pointed a plethora of factors to suggest the "death spiral" is happening: the decrease in enrollment from the most recent period that wrapped up on January 31, insurers leaving the ACA exchange markets, and increasing premium costs.

Even some insurance CEOs have caught onto the terminology. Aetna CEO Mark Bertolini said the exchanges were in a "death spiral" on Wednesday (though that may have something to do with his mega-merger with rival Humana getting rejected).

But the "death spiral" attack is contrasted by new evidence from Matthew Fiedler, the former chief economist on the White House Council of Economic Advisers under President Barack Obama and current fellow at the Brookings Institution. He analyzed state-level data from the most recent open-enrollment period and found that premium increases are not having a significant effect on sign-ups.

Simply put, for a "death spiral" to be existent, data would have to show declining participation in the exchanges as premiums increase — since healthy people would be more likely to drop out and simply pay the fine rather than get coverage.

As a chart from Fielder shows, that's not happening yet.

Based on state-level data from the just-concluded enrollment period, state-level sign-ups compared to the previous year were not affected by the average rate of premium increases. Fielder said this indicates there is no death spiral.

"As shown by the black dashed line, there was essentially no relationship between premium changes and sign-up changes, which implies that premium changes had little or no effect on sign-ups," Fielder wrote in a post on Brookings."By contrast, for the individual market to have faced a death spiral, premium increases would have needed to cause large reductions in enrollment, akin to the relationship depicted by the red dashed line."

Technically, anyone can opt out of signing up for health coverage and pay a fine — this year, the full fine under the law will go into effect at $650. But most people thought that even with higher premiums, health insurance was worth paying for instead of the fine.

According to Fiedler, the slight decrease in sign-ups was to be expected, given the fact that most enrollees receive tax credits that increase along with premiums. (In fact, HHS estimated over 70% of people on the exchanges could get coverage for less than $75 a month.) But for those that do not receive tax credits, the increases had minimal effects.

"And for enrollees who are not eligible for tax credits, pre-ACA research on how consumers’ insurance enrollment decisions depend on premiums implied that enrollment would decline only modestly when premiums rose," Fiedler wrote.

"Similarly, the observed relationship between premium changes and enrollment growth during the ACA’s first few years also implied that any adverse effects of premium increases on enrollment — whether on the Marketplace or in the individual market as a whole — would be limited."

As other health policy experts have noted, the recent premium increases have only brought these costs up to the level projected by the Congressional Budget Office in 2009 for the 2017 plan year.

Fiedler is not as sure about the future. Republicans and President Donald Trump's administration could issue new laws and regulations or induce enough uncertainty into the exchanges to cause more insurer exits and consumer apprehension. Or they could repeal the law altogether.

In fact, in Fiedler's opinion, most of the decline in enrollees for 2017 was due to the decrease in outreach by the Trump administration— supported by the fact that sign-ups fell off a cliff following his inauguration.

You can check out Fiedler's full analysis over at Brookings»

SEE ALSO: A Trump order led the IRS to make a small change on Obamacare that could have a big effect on its future

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NOW WATCH: Mexican architects visualized Trump's proposed $25 billion wall to show how unrealistic it would be

President Donald Trump's election gave Republicans something they had wanted for years. At long last, they seemingly had the system in place to keep one of their longest standing political promises: repealing and replacing Obamacare.

The Affordable Care Act, the massive healthcare bill from President Barack Obama, had been a target for Republican leaders like House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell since before the bill was even signed into law.

But a month into Trump's presidency and controlling both branches of Congress, Republicans are finding that repeal and replace is easier said than done. From disagreements over the future of the healthcare system to unclear communication, cracks are beginning to form in the overhaul. And people are starting to get restless.

"The House passed six Obamacare repeals when Obama was president and there was no chance of them being signed into law," conservative author Ann Coulter wrote in a post on her blog. "Back then, Republicans were full of vim and vigor! But the moment Trump became president, the repeals came to a screeching halt."

Her post was titled, "The Silence of the Lambs Congress."

'Were we just against Obamacare because it was proposed by the Democrats?'

Serious ideological differences have emerged within the party regarding exactly what the future of healthcare should look like.

More moderate Republicans have considered keeping certain aspects of Obamacare that have become well-liked among their constituents — and, more broadly, with the American public in general. Recent polls have shown Obamacare has more support than opposition for the first time in the law's history, and in some of the surveys, positive opinion of the law is at an all-time high.

One of the more popular aspects of the law has been the expansion of Medicaid coverage for poorer Americans. The expansion was primarily funded by the federal government and optional for states, though 32 and the District of Columbia have taken up the offer.

Republican senators and governors in states that have expanded Medicaid have called for the new replacement bill to include funding for Medicaid expansion rather than rolling it back. The expansion has been shown to bring down the costs of coverage in the individual market and has helped improve the uninsured rates in states that have expanded.

On the other end of the spectrum, however, more conservative members of the party want a more radical approach to healthcare reform, permanently pulling back large parts of the ACA's provisions.

Sen. Rand Paul reportedly walked out of a meeting of Republican lawmakers on Tuesday because he felt the discussion was turning toward preserving parts of Obamacare.

"I hear things that are unacceptable to me," Paul told Politico afterward. "If they don’t seem to care what conservatives think about complete repeal of Obamacare, they’re going to be shocked when they count the votes."

Though some Republican leaders denied those issues were on the table, it was clear that Paul — who introduced his own version of a repeal-and-replace bill a few weeks ago — did not find the alternatives being discussed palatable.

On the House side, the House Freedom Caucus — made up of some of the more conservative members of the party — voted this week to not back a repeal of Obamacare unless it went as far as a 2015 repeal bill that was vetoed by Obama. That legislation repealed as much of the law as possible.

The House Freedom Caucus, much like Paul, is against the expansion of Medicaid and wants to cut off the funding for that program.

One of their members, Rep. Raúl Labrador, laid out the frustration on Wednesday, decrying the lack of changes being proposed by more moderate GOP members.

"Something that Republicans need to be concerned about is that if we're just going to replace Obamacare with Obamacare-lite, begs the question, were we just against Obamacare because it was proposed by the Democrats?"Labrador said. "And if that's our position then we're very hypocritical. Then we really were just taking a political positions, not a policy-based position."

Even in the administration, two countervailing ideas have emerged.

On the one hand, the Trump administration's moves since taking office have attempted to undermine the law. The Department of Health and Human Services scaled back their efforts to enroll people for Obamacare plans during the last two weeks of the open-enrollment period in January, leading to a decrease in enrollment for the year. 

Additionally, new rules proposed by the administration this week would cut the open-enrollment period in half and weaken the minimum standards of care to qualify for various plan levels on the exchanges.

On the other hand, the same rules took up some suggestions from the Obama administration in strengthening special enrollment periods and helping to balance risk pools.

Mixed messages

The GOP divergence on Obamacare has shown up not only in policy preferences, but also in how Republicans talk about the law.

For one thing, it is hard to get a grasp on just how long the process of repeal and replace is supposed to take.

While Ryan has said he hopes to complete the Obamacare replacement process by the end of the year's first quarter, he has also said in interviews that it could be the end of the summer or the end of the year. (A Ryan spokesperson said in an email to Business Insider that the speaker plans to complete the process by March.)

Ryan said Thursday that the House GOP was planning to roll out a bill on Obamacare when the body comes back from its week-long Presidents Day break.

Senate Majority Leader Mitch McConnell has been less definitive about a timeline. He said only Friday that repeal and replacement of the law would happen  "when we get the votes." 

Trump hasn't made the communication any clearer. In an interview on January 10, Trump said he wanted the replacement done "next week." In an interview with Bill O'Reilly on February 6, however, the president it could take into 2018 to get the replacement done. (Ryan has said Trump was referring to implementation, not legislation.)

Outside of leadership, the messages are just as muddled. On the one end, the House Freedom Caucus wants a repeal as soon as possible, while some Republican lawmakers are inclined to wait until a full replacement bill is vetted and ready to go.

On the policy communication side, the differences between the moderate and conservative parts of the Republican party are also starting to show.

Many Republicans have begun to soften the way they are talking about the repeal and replace, instead referring to the endeavor as a "repair."

Growing dissatisfaction

Amid the dysfunction, a growing chorus of conservative commentators are becoming impatient with the slow progress of reform.

Conservative commentators from Fox News' Sean Hannity to internet mogul Matt Drudge to Coulter have all expressed displeasure with the slow pace of replacement.

Last week, Hannity aimed an extended tirade at congressional Republicans, charging that they have failed to so far "abolish Obamacare" and pass many other of their policy proposals.

"These spineless, gutless, timid politicians have all three,"Hannity said. "They have the House, the Senate, and the White House. What's their excuse now?"

Ryan appeared on Hannity's show Thursday night, where he laid out his March timeline for the Fox News commentator. It seemed to encourage the host.

"When I heard 'repair,' my head nearly exploded," Hannity told Ryan.

"That's not the plan. The plan ... repeal and replace this law, like we said," Ryan responded. "We ran on a plan to repeal and replace it. Tom Price helped write that plan. He is now Donald Trump's secretary of HHS."

Coulter also took the GOP to task for their insistence on repealing the law when Obama was in office, but doing nothing since Trump became president.

"What was in the last six Obamacare repeals? If we looked, would we find, 'All work and no play makes Jack a dull boy' carefully typed out 1 million times? Seriously, what does Paul Ryan's day look like?" she wrote.

And Drudge, who runs the influential conservative website the Drudge Report, took a shot at the delay of Obamacare's repeal.

"No Obamacare repeal, tax cuts! But Republicans vote to shut Warren?"Drudge tweeted with a link to an article about Republicans voting to silence Democratic Sen. Elizabeth Warren, later adding the lack of movement on this and other policies means the Republican party should be "sued for fraud."

Even conservative groups are getting impatient. Heritage Action spokesperson Dan Holler told the New York Times that the delay is worrying.

"If the House has not passed a repeal bill and sent it to the Senate by mid-March, that would be serious cause for concern,"Holler said.

SEE ALSO: Republicans say Obamacare is already in a 'death spiral' — but one chart shows it's not

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Republicans members of Congress, away from Washington for the Presidents Day week, are getting an earful as constituents have come out in force to voice displeasure for some of the party's policy positions, particularly the plan to repeal and replace the Affordable Care Act.

Sen. Chuck Grassley of Iowa held an event on Tuesday in which constituents voiced concerns about losing coverage if the law better known as Obamacare is repealed.

"I'm on Obamacare. If it wasn't for Obamacare we wouldn't be able to afford insurance," said Chris Peterson, a farmer from Grassley's state."With all due respect, sir, you're the man that talked about the death panel. We're going to create one big death panel in this country if people can't afford insurance."

The remark was in regard to Grassley's claim when the law passed that a provision of the law that analyzed the economic benefit of drugs for Medicare was akin to a "death panel,"a claim that was widely debunked.

"Don't repeal Obamacare, improve it," the constituent added.

Sen. Tim Scott and Rep. Mark Sanford of South Carolina faced similar questions at a town-hall event in Mount Pleasant, South Carolina, just outside of Charleston. According to the Charleston Post and Courier, signs saying "Save the ACA" were posted around the meeting, and the lawmakers faced questions about a wide range of policies coming from President Donald Trump's administration.

The recent town halls mirror those held by other GOP politicians earlier in the month that featured impassioned defenses of the ACA and anger over the GOP plan to drastically change the healthcare law.

Rep. Diane Black of Tennessee and Rep. Jason Chaffetz of Utah also faced questions about their desire to repeal Obamacare.

One town hall participant in Tennessee told Black that he needed coverage from the ACA to "make sure that I don't die."

The Tampa Bay Times reported that a gathering with Republican Rep. Gus Bilirakis earlier this month was similarly fiery, with constituent Evan Thornton pleading with the GOP lawmaker for his life.

"I'm an independent who voted for you," Thornton said to Bilirakis according to the Times."Please don't take my life away. Please don't let me die."

The strident defenses of the law come as public opinion has shifted on the ACA. Recent polls suggest that more Americans are in favor of the law than against it, favoring slight changes rather than a large overhaul. In fact, some of the polls have marked the ACA at a high point in popularity.

Most of the concerns brought up in the town halls appear to be related to the more than 23 million who are estimated to have gained coverage from various provisions of the ACA. Constituents, along with Democratic lawmakers, have argued that any significant repeal and replace of Obamacare could endanger the coverage for some or all of those people.

While Trump has promised to make sure everyone currently covered under the law receives coverage, most Republicans have emphasized they are targeting access to care not a guarantee of coverage.

Despite disagreements between GOP lawmakers in the House and Senate, House Speaker Paul Ryan announced on Thursday that the House Republican leaders would be introducing their version of a repeal and replacement bill when Congress reconvenes next week.

For his part, Trump dismissed the rash of town-hall protests in a Tuesday evening tweet.

"The so-called angry crowds in home districts of some Republicans are actually, in numerous cases, planned out by liberal activists," he wrote. "Sad!"

SEE ALSO: Republicans are struggling to get their act together on Obamacare repeal — and some conservatives are getting restless

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FAIRVIEW, Tenn. (AP) — Republican Rep. Marsha Blackburn returned to her district Tuesday in Tennessee and was greeted by tough questions on topics from health care reform to President Donald Trump's cabinet appointees. She also was met with protests.

While 100 people crammed into her town hall gathering about 30 miles from Nashville, another 100 people outside chanted about immigrant rights, Planned Parenthood and other topics in protest against the congresswoman and the president.

Blackburn's town hall was among several protests lobbed at GOP members of Congress returning home this week on break to their districts around the U.S. Now many Republican lawmakers are opting against holding public town halls, instead organizing conference calls or meeting privately.

The crowd inside Blackburn's event held up signs that said "agree" and "disagree," and at times yelled out "alternative facts" and "shame on you for lying" after Blackburn's responses.

"I have always said, you may not agree with me, but you're always going to know where I stand," Blackburn told the protesters outside Fairview City Hall afterward. "Having a good, solid, respectful debate, that is something that serves our country well."

A month into Trump's presidency, protests continue over his immigration policies, Cabinet selections and the GOP's push to repeal the Affordable Care Act, without all the specifics on how to replace it. At the town halls, protesters are probing their lawmakers to see if they will veer from some of Trump's more controversial decisions, and if they will promise coverage for those currently served by the Affordable Care Act.

Trump took to Twitter on Tuesday to address the town halls.

"The so-called angry crowds in home districts of some Republicans are actually, in numerous cases, planned out by liberal activists. Sad!" he tweeted.

In two small Iowa towns, overflow crowds similarly lobbed questions Tuesday at Republican Sens. Charles Grassley and Joni Ernst.

About 18,000 callers participated in a telephone town hall with suburban Chicago Rep. Peter Roskam, who has been criticized for canceling smaller in-person meetings and declining debates.

Protesters booed in Montana when Sen. Steve Daines canceled his speech to state lawmakers. And at a protest town hall in Allentown, Pennsylvania, home of Sen. Pat Toomey, the protest group called Tuesdays with Toomey hung an empty suit in place of the senator.

Similarly, a liberal group in Maine is holding its own town halls against GOP Sen. Susan Collins.

Also Tuesday, the most powerful member of the U.S. Senate faced jeers from nearly 1,000 as he arrived to address a group of local business leaders. In Lawrenceburg, Kentucky, they chanted as Senate Majority Leader Mitch McConnell entered the American Legion Post 34 Fairgrounds in a black limousine.

McConnell said he was "proud" of the demonstrators for expressing their views but told the mostly friendly audience inside that the protesters "had their shot," adding: "Winners make policy and the losers go home."

Sandra Brown, 45, said politics shouldn't matter as Congress moves to replace the health care law. She spoke at the Tennessee town hall about how the Affordable Care Act helped cover her pre-existing condition.

Blackburn said the plan for efforts to repeal and replace the law includes maintaining coverage of pre-existing conditions and young adults on their parents' plans.

"Whatever they do, it needs to be affordable for everybody," Brown said after the Tennessee town hall. "Because even the people that voted for a Republican, they're not going to be very happy if they've been promised they're going to repeal this Affordable Care Act and then they replace it with a garbage policy. They're going to be affected as well."

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WASHINGTON (AP) — Michael Schwarz is a self-employed business owner who buys his own health insurance. Subsidized coverage through "Obamacare" offers protection from life's unpredictable changes and freedom to pursue his vocation, he says.

Brett Dorsch is also self-employed and buys his own health insurance. But he gets no financial break from the Affordable Care Act. "To me, it's just been a big lie," Dorsch says, forcing him to pay more for less coverage.

Schwarz and Dorsch represent two Americas, pulling farther apart over former President Barack Obama's health care law. Known as the ACA, the law rewrote the rules for people buying their own health insurance, creating winners and losers.

Those with financial subsidies now fear being harmed by President Donald Trump and Republicans intent on repealing and replacing the ACA. But other consumers who also buy their own insurance and don't qualify for financial help feel short-changed by Obama's law. They're hoping repeal will mean relief from rising premiums.

The ACA sought to create one big new market for individual health insurance in each state. It required insurers to accept all customers, regardless of medical problems. And it provided subsidies to help low- and moderate-income people afford premiums.

These newly vested ACA customers joined consumers already in the market, to make a new insurance pool. Policies offered to all had to be upgraded to meet new federal standards for comprehensive benefits, raising premiums. And many of the new customers turned out to be sicker than insurers expected, pushing rates even higher.

Consumers who didn't qualify for government financial help wound up bearing the full cost of premiums. They also faced the law's new requirement to carry health insurance or risk fines.

"One (group) is angry and one is incredibly grateful," said Robert Blendon of the Harvard T.H. Chan School of Public Health. If Trump and congressional Republicans aren't careful, their actions could stoke fresh grievances without solving longstanding problems of access and cost.

Consider what happened to Schwarz and Dorsch this year, as premiums for a standard plan through HealthCare.gov jumped an average of 25 percent.

Schwarz and his wife are in their mid-20s and live in Tampa, Florida. He has his own commercial photography business and she's pursuing a graduate degree in speech-language pathology.

The sticker price of their HealthCare.gov policy went up about 20 percent, but what they pay monthly is about $115 lower than last year. Not only did their subsidy cover the rise in premium, they're also getting more help because their income went down when Schwarz's wife returned to school full time.

"Being uninsured is not an option," said Schwarz. If Republicans take away his subsidy, "I would have to change careers and find a job that offered health insurance," he said.

Dorsch and his wife live in Wilmington, Delaware, and are in their mid-50s. He has a wholesale business supplying electronics to retail stores and has been buying his own health insurance for years. He gets no financial help from the ACA.

Dorsch said their insurance company wanted to raise the monthly premium to $2,050, or nearly $25,000 a year. They settled for a skimpier plan that still costs $1,350 a month and has a very high deductible.

"In four years my health insurance has more than doubled and I have less coverage," said Dorsch. "It's ludicrous."

He voted for Trump. "He saw the reality that Obamacare has been a nightmare for most Americans, unless you are poor or in a very difficult situation," said Dorsch.

The Congressional Budget Office estimates that the pool of people buying individual health insurance is basically split down the middle among subsidized customers like Schwarz and those who get no help, like Dorsch.

Republican proposals to tie tax credits to age, not income, would help Dorsch. But they may not be generous enough for Schwarz.

"It's trying to find the way to help the one without hurting the other that's really tricky," said Nicholas Moriello, a health insurance broker from Newark, Delaware. "If we had a way to help the person whose premium has become unaffordable without hurting the person we are currently subsidizing."

Caroline Pearson, of the consulting firm Avalere Health, studied consumers on government marketplaces like HealthCare.gov — where nearly 90 percent get subsidies — and compared them with those who purchase directly from an insurer and pay full cost.

Among Avalere's findings:

— The majority of consumers in the government marketplaces live in lower-income neighborhoods with high unemployment. However, among those who purchase directly from an insurer, about 30 percent live neighborhoods with a median income of $100,000 or more.

— Consumers in the subsidized market are generally costlier to cover. For those with a standard plan, per-person medical claims averaged $376 per month in 2015, compared to $312 for unsubsidized customers who bought policies directly from an insurer.

— The subsidized market is important in states that voted for Trump. In Florida, for example, 70 percent of individual policyholders purchase through HealthCare.gov. In Georgia, it's 62 percent.

"Obamacare helped a lot of lower-income people with high health needs who previously couldn't afford insurance," said Pearson. "It overlooked the fact that there are a lot of people who are relatively healthy and who didn't want the increased benefits. More sick people drove up premiums, which is resulting in some people feeling like they are worse off."

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CATLETTSBURG, Ky. (AP) — While the Affordable Care Act has brought health coverage to millions of Americans, the effects have been profound, even lifesaving, for some of those caught up in the nation's opioid-addiction crisis.

In Kentucky, which has been ravaged worse than almost any other state by fentanyl, heroin and other drugs, Tyler Witten went into rehab at Medicaid's expense after the state expanded the program under a provision of the act. Until then, he had been addicted to painkillers for more than a decade.

"It saved my life," he said.

Addicts and mentally ill people who gained access to treatment programs for the first time are worried about how that might change as President Donald Trump and Republicans in Congress try to make good on their promise to repeal and replace "Obamacare."

Repeal could end coverage for 1.8 million people who have undergone addiction or mental health treatment and could cut $5.5 billion in spending on such services, said Richard Frank, a health economist at Harvard Medical School.

Some GOP governors insist addicts have nothing to fear from repeal because, they say, Medicaid will continue to pay for treatment. But Democrats and others are dubious.

Currently the federal government covers a certain percentage of each state's Medicaid costs, however high they might go. As part of the plan to junk Obamacare, the Trump administration has expressed support instead for giving states a fixed amount of money for Medicaid and letting them design their own programs.

But Raymond Castro, senior policy analyst for New Jersey Policy Perspective, a left-leaning think tank, said these block grants are likely to come with less money. And that could force states to cut benefits.

Republican New Jersey Gov. Chris Christie, who has made the opioid crisis his top priority in his final year in office, said he would support a shift to block grants because of the flexibility they give states. But he said the people receiving treatment through the Medicaid expansion now shouldn't be forgotten.

"Whatever changes are made to the ACA should be made with those people in mind, because we don't help ourselves by kicking those people off coverage," Christie said.

In areas overwhelmed by the opioid crisis, the uncertainty is worrisome to people receiving treatment.

In Pennsylvania, nearly 63,000 newly eligible Medicaid enrollees received drug and alcohol treatment in 2015, the first year of the state's expansion.

One of them was 44-year-old Pittsburgh restaurant hostess Erika Lindgren, who credits the health care law with quickly getting her into a 26-day rehab program in 2015 and covering the daily medications she takes to fight opioid cravings.

When she was uninsured, getting into rehab involved waiting lists and daily phone calls to see if a publicly funded bed had opened up. With coverage under the Affordable Care Act, "I was able to pack my bag at that moment," she said. "I was in an in-patient rehab within an hour and a half of making that call."

"I am scared to death to lose my coverage," she added. "It saves my life every day."

In Wildwood, New Jersey, Ashley Grant, a 30-year-old recovering heroin addict who has been sober since June, is hoping to regain custody of her three children. She has signed up for Medicaid under the health law expansion and is waiting to be approved so she can afford weekly counseling. A county program helps pay for a monthly anti-relapse shot.

"They should make it easier for people with addiction to get insurance," she said.

Care for mental illness, too, expanded under the Affordable Care Act.

Marquitta Nelson, a 60-year-old homeless Chicagoan with severe depression, is getting psychiatric care and treatment for asthma, arthritis and other conditions since she obtained Medicaid coverage under the health law expansion. She is waiting to be assigned to a shelter and staying with a friend.

"Am I expected not to take my medications and wig out and be walking up and down the street, not coherent?" Nelson said.

While the law expanded coverage, it did not always translate into more treatment.

For those buying insurance in the marketplace, many plans still exclude or limit residential treatment and clinics that dispense methadone, which is used to treat addictions to heroin and painkillers. Deductibles for some plans are so high that people still cannot afford help.

Despite those hurdles, the health care law was beginning to shift the system and giving hope to many, said Samuel Ball, chief executive of the nonprofit National Center on Addiction and Substance Abuse in New York.

"At a point where we feel we're turning a corner, to have the whole rug pulled out from under us is very concerning," he said.

___

Johnson reported from Chicago. Associated Press writer Josh Cornfield in Trenton, New Jersey, contributed to this story.

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Health insurance provided by your employer is free from income and payroll tax, regardless of how expensive the insurance is.

But House Republicans are considering changing that as part of a plan to pay for changes to the Affordable Care Act, according to a recent report from Bloomberg. Your health insurance would be excluded from tax only up to a cap. Above that, you would be taxed.

This would be a good idea.

The tax exclusion for health insurance distorts healthcare markets, encouraging people to spend more on healthcare than they otherwise would. It also helps drive up healthcare costs by making consumers less sensitive to prices. Imposing a cap would both raise revenue and help to control overall healthcare costs.

Unfortunately, as Republicans may be about to learn, this good idea would be very unpopular. They're preparing to stick their fingers in an electrical socket.

People hate having to pay new taxes

In 2008, then Republican candidate John McCain ran for president on a similar idea: The tax exclusion for health insurance should be replaced with a flat tax credit — enough to offset the tax paid on an ordinary plan, but not providing additional benefits for people with very expensive plans.

Barack Obama, unsurprisingly, ran television ads attacking McCain for wanting to "tax your healthcare benefits for the first time ever."

After winning the election, Obama needed to find new revenues to pay for an expansion of healthcare coverage. Instead of capping the insurance tax exclusion, Democrats found a clever workaround: They would impose a "Cadillac tax" of 35% on health-insurance premiums paid by employers over a high cap.

Because the Cadillac tax would be charged to the employer, not the employee, it is not technically a tax on employees' health benefits. But economically, the effects are the same: Employers are discouraged from offering very expensive plans. And the higher cost of offering health benefits tends to reduce the amount employers pay in salaries, at least in the long run.

The Cadillac tax became law as part of the ACA, but partly because of the political sensitivities — many of the beneficiaries of the expensive plans that would be subject to the tax are union members — it wasn't supposed to be effective until 2018. In 2015, the tax was delayed for another two years, until 2020, as part of a budget deal.

It isn't obvious the tax will ever become effective.

Most healthcare policy is about how to divide the pie

While there is a lot of talk about innovation, competition, and consumer choice, the politics of healthcare are mostly about who will receive services and who will pay for them.

The ACA didn't revolutionize the American healthcare system. It just created new rules about who pays and who benefits.

The ACA created new benefits to pay for health insurance for people with low and lower-moderate incomes. It paid for these changes by cutting Medicare (benefits for older people) and by raising taxes — mostly on high earners, but also on certain healthcare products and services, thereby spreading costs to everyone who receives healthcare.

If Republicans change the law again, the changes would mostly be about how to redivide the pie. They'd want to benefit Republican constituencies, especially high earners who pay Obamacare taxes.

The problem they are finding is that if you take the pie slices away from low and lower-moderate earners who got coverage because of the ACA, they will notice. Healthcare providers, who depend on payments for care made possible by the ACA, will also notice.

Continuing to provide those beneficiaries with enough coverage so they don't get angry would be expensive — hence the need to find new sources of revenue, especially if Republicans wish to repeal the high-earner taxes in the ACA that bother them so much.

Given that need, the tax exclusion for employer-sponsored insurance is a tempting place to look for money. Excluding health benefits from income and payroll taxes costs the federal government approximately $250 billion a year.

Affluent professionals and union members are adept at protecting their tax benefits

The problem: The group of people who benefit most from the tax exclusion for employer-provided health insurance is politically powerful — perhaps even more powerful than the very rich.

The politics of capping the tax exclusion for health insurance would be similar to the politics of Obama's doomed proposal to abolish the tax benefits for deposits into 529 college-savings accounts. As Obama correctly pointed out, 529 plans mainly benefit affluent families whose children are very likely to attend college whether or not their parents receive a tax break.

When I wrote in defense of scrapping the 529 tax break, I got a lot of angry mail from affluent people indignantly protesting their non-affluence, including one woman who wrote about how her family was "barely scraping by" on $250,000 a year in Los Angeles.

This is exactly what lawmakers would hear if they tried to cap the tax exclusion for employer-sponsored health insurance. After all, when members of Congress aren't hanging out with ultra-wealthy donors, they tend to spend time with the sort of pretty-wealthy professionals who have high-quality healthcare plans that would be newly subjected to tax at a pretty high rate.

They'd also hear from their well-organized union-member constituents, many of whom prize the high-cost healthcare plans their unions negotiated for them.

There is a reason nearly all healthcare policy is unpopular

Healthcare is very expensive — too expensive for most households to bear the risk of major medical events on their own. As healthcare costs have climbed, employers and the government have held down premiums by shifting a greater share of routine costs to the insured.

This ensures that people remain protected against catastrophic costs, but it means they pay more out of pocket every year, and they don't like it.

If the Cadillac tax eventually becomes effective, or if Republicans succeed in capping the health-insurance tax exclusion, employers will respond by shifting more routine costs to employees to stay under the cap.

People would hate that. They'd also hate paying taxes on their benefits — directly or indirectly — if their employers didn't strategize to get under the cap.

But everything else you might do would be hated by somebody, too.

If you throw people off their health-insurance plans, they'll hate that. If you reduce the package of benefits that healthcare plans have to include — so that, for example, women's plans don't necessarily cover maternity care — people who are left without the care they need will hate that.

And if you don't do anything to offset the rising cost of healthcare, the government will have to borrow more and more money, and sooner or later it would have to pay for that with some sort of tax increase or spending cut that people would hate.

Changing healthcare policy is thankless, which is why the tax exclusion for employer health insurance is largely unchanged since World War II, and which is why I suspect the extent of policy changes as part of the ACA "repair" will continue to shrink.

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Former Republican House Speaker John Boehner doesn't think the GOP can fully repeal and replace the Affordable Care Act, the healthcare law better known as Obamacare.

Boehner said at a healthcare conference in Orlando, Florida, on Thursday that the Republican plan to overhaul President Barack Obama's signature law was "not going to happen." He said the idea of an imminent repeal and replace was "happy talk,"according to a report from Politico's Darius Tahir.

Boehner retired from Congress in 2015, and his successor, House Speaker Paul Ryan, announced last week that House Republicans were planning to introduce their Obamacare replacement bill after the legislature's weeklong Presidents' Day break.

Senate Republicans have objected to parts of the House GOP plan, however, and Boehner on Thursday said those differences would make it hard for the party to come together on a new plan.

"I started laughing,"Boehner said, discounting the possibility of a fast replacement. "Republicans never ever agree on healthcare."

Boehner repeatedly butted heads with Obama during his tenure as speaker, but he also drew criticism from conservative factions within his own party saying he was too willing to compromise.

According to the report, Boehner concluded his talk by saying "most of the framework of the Affordable Care Act" was "going to be there" in the end.

The repeal of Obamacare has long been on the to-do list for Republicans, even during Boehner's tenure. Disagreements on the replacement aspect and unclear communication, however, have led to a slowdown on the change.

Additionally, parts of the law have grown popular with the American public, with the law's overall popularity ticking to record levels since the election of President Donald Trump. Even in their own districts, Republicans are catching an earful from voters against the ACA's repeal.

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