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The latest news on Obamacare from Business Insider

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    Obama smile laugh

    Americans are learning to love the Affordable Care Act, better known as Obamacare.

    As the law faces possible repeal and replacement by Republicans, a new poll from the Pew Research Center shows that the ACA's popularity is soaring and has hit its highest point since it was passed.

    54% of respondents in Pew's survey said they approve of the law, with just 43% disapproving. This is better than the 48% approve, 47% disapprove margin from December 2016.

    Additionally, of the 43% against the law, only 17% of people the total surveyed want Republicans to repeal the way entirely while 25% want the law modified instead, according to Pew.

    Every age group, ethnic group, and education level saw increased support for Obamacare between Pew's current poll and one conducted in October 2016.

    The result also matches up with other recent polls from a variety of outlets that show President Barack Obama's signature health law becoming ever-more popular with Americans.

    House Speaker Paul Ryan said that the GOP plans to introduce a repeal and replace bill for the ACA soon after the week-long President's Day break. Dissent among Republicans and recent pushback from constituents at town halls, however, has indicated that a repeal may be less than smooth than originally anticipated.

    Even former GOP House Speaker John Boehner said Thursday that repeal is "not going to happen."

    pew obamacare approval

    SEE ALSO: BOEHNER: A repeal and replace of Obamacare is 'not going to happen'

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    obama

    The Affordable Care Act, the law better known as Obamacare, may be on the precipice of repeal. But  its popularity keeps surging.

    Over the past few months, polls from a variety of outlets have showed a slow but steady increase in support for the healthcare law.

    Most recently, the Kaiser Family Foundation's tracking poll found that 48% of people surveyed approved of the law, while only 42% disapproved. It represented the largest spread for approval dating back to the beginning of the tracking poll in 2010.

    While the issue has always had a sharp partisan divide, the biggest shift in Kaiser's survey has come among independents.

    "The latest shift in favorability of the law is largely driven by the views of independents, among whom a larger share now say they have a favorable opinion (50 percent) of the law than an unfavorable opinion (39 percent)," said a post from Kaiser on the survey findings."This is the first survey since 2010 that has found a larger share of independents reporting a favorable view than an unfavorable view."

    Screen Shot 2017 02 24 at 9.51.17 AM

    In a another poll released Friday, Public Policy Polling found that 50% of people surveyed supported the ACA while only 38% were against it. That compared to the 46% who approved and 41% who disapproved in the Democratic firm's February 2 poll.

    The trend matches findings from the Pew Research Center released on Thursday that showed 54% approval for the law among those surveyed and 43% disapproval. Independents' positive opinions of the law also surged in the Pew poll.

    "Independents have grown in their support of the health care law in the past year. As was the case in December, about half (53%) now approve of the Affordable Care Act," said Pew's Hannah Fingerhut in a post on the poll. "In October, shortly before the election, 41% of independents approved of the law."

    And the general trend shows a slew of positive polls for the health law over the past two months. Here's the progression from the recent polling:

    • Public Policy Polling, February 24: 50% approve, 38% disapprove (+12% approve)
    • Kaiser Family Foundation, February 24: 48% approve, 42% disapprove (+6% approve)
    • Pew Research Center, February 23: 54% approve, 43% disapprove (+11% approve)
    • Politico/Morning Consult, February 22 : 46% approve, 45% disapprove (+1% approve)
    • Public Policy Polling, February 2: 46% approve, 41% disapprove (+5% approve)
    • Politico/Morning Consult, January 30: 47% approve, 45% disapprove (+2% approve)
    • NBC News/Wall Street Journal, January 17: 45% approve, 41% disapprove (+4% approve)

    The increase in approval may throw a wrench in the plan of Republicans to repeal and replace the law. As Democrats wage a campaign to save parts of the law that are popular, Republicans have begun to argue about just how much of President Barack Obama's signature law to keep.

    On the one hand, more conservative Republicans are arguing for a near total teardown of the law. Moderate Republicans, however, want to keep provisions such as the expansion of Medicaid coverage, which has become popular in red states that have expanded the program.

    The battle has also led to GOP lawmakers getting an earful about the ACA repeal from constituents at town halls and community meetings across the country this week. Congress is on break for a district work week, in which lawmakers leave Washington to interact with voters.

    SEE ALSO: BOEHNER: A repeal and replace of Obamacare is 'not going to happen'

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    paul ryan

    We finally have a more comprehensive idea of the Republican plan to repeal and replace the Affordable Care Act, the healthcare law better known as Obamacare.

    Politico's Paul Demko on Friday released a draft of the reconciliation bill designed by House Republicans that would repeal and replace the ACA.

    The draft bill includes provisions repealing large swaths of the ACA, including Medicaid expansion and the penalty for Americans who don't purchase health insurance. And it calls for shifting payments for expanded coverage to more block-style grants for both individuals and state governments.

    It is important to note that this is just a draft and the bill may be revised before it is introduced.

    Here's a quick rundown of the key parts of the draft bill. It would:

    • Penalize those who have a lapse in health coverage: A person who has let his or her health insurance lapse for a specified time will face a premium penalty up to 30% above the baseline when entering a plan. This is most likely designed to encourage people to sign up for care without a mandate.
    • Shift tax subsidies to block grants based on age: Instead of tax subsidies based on income, as in the ACA, the House GOP plan would give every American a chunk of money to purchase insurance based on their age. The lowest amount would be for people under 30, who would receive $2,000 annually.
    • Eliminate Medicaid expansion by 2020: Today the federal government provides states funding to expand Medicaid, the government program that provides insurance for low-income Americans. The bill would end that level of funding in 2020 and begin to provide lower amounts to states if they wish to continue covering people who have gained access to Medicaid under the ACA. Many Republican governors and senators do not want Medicaid expansion repealed.
    • Provide funding to states to establish high-risk pools and increase coverage: The federal government would provide $15 billion in both 2018 and 2019 and $10 billion each year through 2026 for "State Innovation Grants" for things like "covering high-risk individuals,""stabilizing premiums" in the individual insurance market, and "promoting access to preventative services." This seems to be funding for high-risk pools, essentially a separate market for those with preexisting conditions to get access to coverage.
    • Allow states to determine "essential health benefits": The ACA has a list of benefits that must be covered by a plan on the exchanges to qualify for a metal level. The House bill would allow states to instead determine those essential benefits starting in 2020.
    • Appear to prohibit federal funding to Planned Parenthood and abortion providers: Under the bill, no funding from the federal government to the states could be provided to any organization that "provides abortions" except in the cases of rape, incest, or the life of the mother. Planned Parenthood would appear to fall under this category. House Republicans have moved to defund the organization previously.
    • Allow those on an individual insurance plan from before the ACA to continue their coverage: Previously, those in individual health plans before Obamacare would eventually have to switch from their old plans onto a new exchange plan. The replacement bill would allow insurers to continue to offer these grandfathered plans and for people to stay on them in perpetuity.
    • Change the age band for cost of coverage: The ACA says premiums for elderly people can be no more than three times the cost of those for young people. The new plan would change that to five times.
    • Repeals the tax on tanning bed businesses and other minor Obamacare taxes: Almost all of the tax provisions from the ACA, including a 10% tax on tanning-bed locations, would be repealed.

    House Speaker Paul Ryan said in a press conference earlier this month that the plan was awaiting scoring from the Congressional Budget Office and the Joint Committee on Taxation. He also said the law should be introduced after Congress' break this week.

    Changes can still be made based on the scoring from the CBO and the JCT. Additionally, some provisions of the plan may not be supported by Senate Republicans, especially the changes to Medicaid funding.

    Based on the draft, the bill has not yet been named.

    Here's the full PDF of the House Republican's plan, via Politico »

    SEE ALSO: Obamacare just hit its highest popularity ever

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    kasich medicaid

    President Donald Trump and congressional Republicans have put the Affordable Care Act, the law better known as Obamacare, on the verge of repeal, but one of the law's biggest programs has continued to gain overwhelming support.

    A new tracking poll released on Friday by the Kaiser Family Foundation, a nonpartisan health policy organization, found that a significant majority of Americans support the new Medicaid program expanded by the ACA. 

    According to the poll, 65% of Americans said that Medicaid, the government-run health program, should continue largely as it exists today, despite Republican proposals to change the program.

    Before the ACA, few Americans qualified for Medicaid. Though eligibility varies from state to state, the most likely beneficiaries from the ACA's changes 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.

    States that expanded Medicaid under the new ACA requirements received federal funds to do so. Thirty-two states and the District of Columbia have taken advantage.

    BI Graphics_Medicaid ExpansionEven more Americans support the use of federal funds for the Medicaid expansion.  

    According to the survey, 87% of Americans living in a Medicaid expansion state run by a Republican governor support continued federal funding for the Medicaid expansion; 85% of Americans with a Democratic or Independent governor are in support. And 80% of Americans in states without the expansion — 19 in total — support keeping the expansion.

    The opioid epidemic is a big reason. 

    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 more than 60% dying from opioids. That number has been rising for years.

    Of the 10 states with the highest drug-overdose death rates, only Tennessee and Utah opted out of the ACA's Medicaid expansion.

    BI Graphics_Opioid Death ratesAnd there's evidence it's helped a significant number 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 professor Richard Frank and New York University dean Sherry Glied. About 220,000 of those people are receiving treatment for opioid abuse.

    Governors in states affected are taking notice, as well.

    Congress asked Republican governors to submit recommendations on the Affordable Care Act earlier this year. 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.

    Ohio Gov. John Kasich has been one of the most outspoken.

    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 earlier this month after signing a bill targeting Ohio's opioid crisis.

    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.

    Other states affected by the crisis have similarly leaned on the Medicaid expansion to fight the crisis. 

    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.

    Dr. Richard Vaglienti, who co-chairs West Virginia's Expert Pain Management Panel, a task force working to alleviate the opioid crisis, said 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

    west virginia pain clinic

    While Republicans have yet to officially release the ACA repeal plan that they will try to push through Congress, a leaked draft House Republican bill shows that Republicans may try to significantly roll back the Medicaid expansion.

    The plan calls for eliminating the current open-ended federal entitlement program in favor of "capped payments to states based on the number of Medicaid enrollees," according to Politico. 

    While that could change, it's likely Republicans will propose one of two options for Medicaid — the aforementioned "capped payments" or block-granting, fixed grants to states to be used for the state's Medicaid program in whatever way they see fit.

    Neither of those options are particularly supported by Americans, according to the Kaiser poll. When presented with capped payments, block-grants, or keeping the program the same, 65% of Americans said they would want the program to stay the same.  

    Governors on both sides of the aisle have expressed concerns 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. Pennsylvania Republican State Rep. Gene DiGirolamo told Business Insider 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.

    "I'm really, really worried about what's happening in Washington. And I say that as a Republican," DiGirolamo said. 

    SEE ALSO: Repealing Obamacare 'would have devastating impacts' for Pennsylvania

    DON'T MISS: Americans have flipped their opinion on Obamacare right as Republicans are set to repeal it

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    town hall republican

    Republican Rep. Leonard Lance faced a raucous, record town-hall crowd in his New Jersey district this week, where he was constantly told that he needed to "do your job."

    He said forcing President Donald Trump to turn over tax returns would be an "overreach from Congress" and that he didn't like Congress going after the "returns of a private individual." A constituent then yelled back: "He’s the president! He’s a public individual!"

    He faced four questions on Russian interference in the election. Others came on Obamacare. On immigration. On press freedom.

    Across the country this week, Republican lawmakers have faced down angry crowds of constituents questioning their policy proposals and support for Trump's administration. Congress was on a break for the week for a district work week, during which lawmakers leave Washington and meet with people in their home states.

    But for Republicans, the week off meant they were faced with angry crowds in town-hall meetings in states from Kentucky to Virginia to Arkansas.

    Republicans have denounced and Democrats have cheered the protests. To many, they resemble shades of the early days of the Tea Party movement after President Barack Obama's election.

    Getting angry

    Much of the concern and anger at the town halls has been directed at the imminent repeal of the Affordable Care Act. House Speaker Paul Ryan said last week that a bill to repeal and replace the law would come after the week-long break, and a version of the repeal bill leaked on Friday.

    Some constituents were angry about the potential repeal of the law. At a Wednesday night town hall, an angry constituent confronted Arkansas Sen. Tom Cotton, saying her husband was dying and had Alzheimer's. She said coverage through the ACA was cheap for her and her family and was worried

    "And you want to stand there with him at home, expect us to be calm, cool, and collected?" she asked Cotton. "Well, what kind of insurance do you have?"

    At another town hall, Sen. Chuck Grassley of Iowa was told by a local farmer that he needed Obamacare. He referenced Grassley's infamous, and since disproven, idea that Obamacare would create "death panels."

    "I'm on Obamacare. If it wasn't for Obamacare, we wouldn't be able to afford insurance," said Chris Peterson, Grassley's constituent. "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."

    Constituents at a town hall for Sen. Tim Scott and Rep. Mark Sanford of South Carolina, meanwhile, held up signs at town halls reading "Save the ACA." 

     

    Shades of 2009 and Republican pushback

    To many observers, these protests have recent precedent: the rise of the conservative Tea Party after Obama's election in 2008.

    "A lot of the tactics and a lot of the energy that we're seeing today focused at the Republican Congress in these town hall meetings is more than just reminiscent — it's downright deja vu,"Democratic strategist Jesse Ferguson told NPR.

    Other Democrats, however, have been pushing back against the comparison, saying that the two instances are different.

    Sen. Bernie Sanders, the former Democratic presidential candidate, said the protests were different because "unlike the Tea Party, this is not being funded by the billionaire class."

    Mitch McConnell protest town hall

    While GOP lawmakers have been getting an earful, they have also sought to fight back against the protests.

    Trump, for his part, tweeted a response to the protests on Tuesday night, calling them "Sad!"

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

    White House press secretary Sean Spicer also denounced the protests during a press briefing this week, saying the protesters were just trying to get "media attention."

    I think there’s a hybrid there," Spicer said in a briefing on Wednesday. "I think some people are clearly upset. But there is a bit of professional protester, manufactured base in there."

    Grassley, for his part, was a bit more muted in his criticism, saying the protestors weren't fake and that the protests should be expected given the outcome of the election.

    "I want to make clear it’s all legitimate," Grassley said. "If Hillary Clinton had been elected president, there’d be people from the conservative end of the spectrum to probably be doing the same thing."

    Yet, whether or not these protests will lead to any policy differences is so far unclear.

    Harvard professor and polling expert Robert Blendon, in an interview with Vox's Sarah Kliff, said that while overall approval of Obamacare has been improving to record levels recently, it remains deeply unpopular among Republicans.

    "For people in the House or Senate, they know a general poll doesn’t reflect who voted for them,"Blendon said."So what’s important to me, if I’m in the House, is whether Republicans are changing their minds. That is really the key."

     

    SEE ALSO: Calls for Trump to be replaced by Alec Baldwin after boycotting White House press dinner

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    Screen Shot 2017 02 27 at 10.11.56 AM

    John Oliver, the host of HBO's "Last Week Tonight," set his sights during Sunday night's episode on the Republican plan to repeal and replace the Affordable Care Act, the healthcare law better known as Obamacare.

    The HBO political commentator and comedian broke down the major parts of the GOP's replacement plan and railed against it.

    Oliver pointed to key points from a Republican fact sheet that went out to House GOP members last week. He broke down various parts of the proposal, from high-risk pools to Medicaid block grants. He said coverage was likely to be lacking, citing new Health and Human Services Secretary Tom Price's plan to replace the ACA.

    "Tom Price once proposed a tax credit of $1,200 for people aged 18 to 35 and $3,000 to people 50 and up, which is roughly a third of the cost of the most bare-bones plans on the market today," Oliver said. "A tax credit that small helps cover your health insurance the way a thong covers your dad's a-- — it doesn't — and there's something fundamentally wrong about that."

    Oliver also called out the lack of detail in the Republican guidelines, citing the use of a placeholder at the end of one draft of a bill. (The bill is not finalized, however.)

    "If you need any more proof of how unprepared Republicans are right now, let me show you one of the draft bills they circulated," Oliver said. "It is just seven pages long and it end abruptly with the word 'placeholder.'"

    Oliver concluded by saying the timeline for a Republican replacement was growing shorter, since insurance companies must submit plans for their 2018 exchange coverage in April.

    "Insurers are going to need an answer soon, so ticktock motherf------ because you don't get to placeholder your way out of this one again," Oliver said.

    Watch the full segment here:

    SEE ALSO: Americans have flipped their opinion on Obamacare right as Republicans are set to repeal it

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    Donald Trump

    President Donald Trump acknowledged during a Monday address to the National Governors Association that the Affordable Care Act was the subject of rising approval ratings.

    But he dismissed the sudden popularity of President Barack Obama's signature healthcare law, which is better known as Obamacare.

    "And it's interesting — it's sort of like you see it with politicians," he told the group of assembled governors from both major parties. "You see it with President Obama, when you know he's getting out of office and the clock is ticking and he's not going to be there, his approval rating goes way up. Even though, you know, not that active in the last period of time ... That's not him, that's like, almost everybody."

    "I see it happening with Obamacare," he continued. "People hate it, but now they see that the end is coming and they say, 'Oh, maybe we love it.' There's nothing to love — it's a disaster, folks, OK? So you have to remember that."

    The healthcare law's approval has jumped sharply in recent weeks, with the Trump administration and Congress promising to repeal and replace it.

    A recent poll from the Pew Research Center showed the ACA's popularity to be soaring, hitting its highest point since it was passed.

    The survey showed the law with 54% approval, with just 43% of respondents disapproving. The approval rating increased by 6 percentage points since December 2016.

    "Obamacare has failed," Trump said earlier in his remarks, later adding: "As soon as we touch it ... they're going to say 'it's the Republicans problem.' That's the way it is. But we have to do what's right because Obamacare is a failed disaster."

    Watch Trump's comments below:

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    mitch mcconnell chuck schumer paul ryan

    Senate Minority Leader Chuck Schumer isn't so sure Republicans can repeal and replace the Affordable Care Act, the law better known as Obamacare.

    In a "prebuttal" Monday to President Donald Trump's joint address to Congress on Tuesday, Schumer said the GOP's plan to overhaul the healthcare system is already falling apart and likely won't get done.

    "Dems are united on ACA, while GOP can’t agree on repeal timeline, what to replace it with, or even if they're calling it 'repeal & replace'," Schumer's account tweeted, referencing the GOP shift to saying their goal is to "repair" the law.

    "One month into the ACA fight, it’s the GOP, not the Dems, who are in disarray & pointing at one another like an Abbot and Costello show."

    The New York senator also said that "the odds are very high" that Obamacare will stick around.

    Some conservatives have grown frustrated with the pace at which congressional leadership has moved to repeal and replace the ACA. House Speaker Paul Ryan said earlier this month that a plan from the Republican House leadership would be introduced soon.

    A draft that leaked Friday, however, has elements that may be objectionable to some Senate Republicans, including changes to Medicaid funding. Rep. Mark Meadows, chair of the conservative House Freedom Caucus, told CNN he would vote against the draft bill that leaked.

    Trump, in a meeting with governor's on Monday, urged patience on the repeal, saying healthcare is "unbelievably complex." 

    Here are Schumer's tweets:

    SEE ALSO: Here's the first look at the House Republican plan to repeal and replace Obamacare

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    NOW WATCH: Trump's doctor and a hair surgeon explain what's going on with his hair


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    Screen Shot 2017 02 28 at 11.35.43 AM

    During a meeting with US governors on Monday, President Donald Trump said the reason for the slowdown on the repeal and replacement of the Affordable Care Act was in part because "nobody knew healthcare could be so complicated."

    Sen. Bernie Sanders disagrees.

    When asked by CNN's Anderson Cooper on Monday night about the "complicated" comment, Sanders immediately burst into laughter.

    "Some of us who were sitting on the health and education committee, who went to meeting after meeting after meeting, who heard from dozens of people, who stayed up night after night trying to figure out this thing, yeah, we got a clue," Sanders said. "When you provide healthcare in a nation of 320 million people, yeah, it is very, very complicated."

    Trump said in interviews before he took office that he wanted to repeal and replace the Affordable Care Act, the healthcare law better known as Obamacare, within weeks of his inauguration. At a press conference on January 11, however, Trump said the repeal-and-replace process would be "very complicated stuff."

    Recently, the timeline for a replacement bill has stretched out. Republicans are facing issues within their own party, as different factions of lawmakers disagree on how best to overhaul the healthcare system.

    "Maybe now, maybe the president and some of the Republicans understand you can't go beyond the rhetoric," Sanders said. "'We're going to repeal the Affordable Care Act, we're going to repeal Obamacare, and everything will be wonderful.' Well it's a little more complicated than that."

    Sanders, the independent Vermont senator who ran as a Democrat in the 2016 presidential campaign and who caucuses with Democrats, has been fighting with the party against the repeal, pointing to the more than 20 million people who have gained insurance under provisions of the ACA.

    "You mean to say that Democrats should work with Republicans to repeal this legislation?" Sanders said. "No, I don't think our job is to work with them to repeal the legislation — our job is to work with them to improve the legislation."

    Watch the exchange below:

    SEE ALSO: SCHUMER: The GOP is in 'disarray' over Obamacare repeal, and the 'odds are very high' it won't happen

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    paul ryandonald trumpThe biggest emerging obstacle to the Republican plan to change the US healthcare system might be the GOP itself.

    Conservative lawmakers are grumbling within their own party over the repeal and replacement of the Affordable Care Act, the law better known as Obamacare.

    Arguments over the future of President Barack Obama's signature healthcare law and a tweak in attitude from the administration of President Donald Trump have shifted the Obamacare changes into a slower gear.

    Battle brewing

    A draft of the House GOP’s plan to repeal and replace the law that was leaked to Politico on Friday has already faced pushback from some conservative lawmakers.

    Rep. Mark Meadows, the head of the influential House Freedom Caucus, and Mark Walker, the chairman of the Republican Study Committee, said on Monday that he would vote against the leaked draft of the bill if it were introduced. And some Republican senators are on the fence.

    A coalition of conservative members, including Sens. Rand Paul, Ted Cruz, and Mike Lee, have all expressed dissatisfaction with the framing of the debate, pressing the need for a total repeal of the law.

    Given the budget-reconciliation method Republicans plan to use for much of the law, the GOP only needs a simply 51-vote majority to pass the upper chamber. Without Paul, Cruz, and Lee, however, the party would not have enough votes to get even a reconciliation bill through the body.

    On the other end, some GOP senators in states that have expanded the Medicaid program under the law are unhappy with the House version of the bill because it does not preserve the expansion. GOP governors in states with Medicaid expansion have also been critical of any plan that does not continue to provide states with funding to expand the coverage program for low income individuals.

    Senate Majority Leader Mitch McConnell, when asked about the timing of Obamacare’s repeal and replacement, told reporters the GOP “was not there yet.”

    Trump’s slowdown

    It's not just Congress. The Trump administration itself has been setting up the possibility of a slower timetable for repealing and replacing Obamacare.

    In the days leading up to his inauguration, Trump told the New York Times that he did not want to wait long on healthcare. He said he expected a repeal vote "sometime next week" and a replacement "very quickly or simultaneously, very shortly thereafter."

    Now, however, Trump and his team seem to be pumping the brakes on their messaging. They have stressed the difficulty of the repeal process have urged patience.

    Trump told a meeting of governors this week that reform was coming soon, but he hinted how surprised he was at the reality of the process' complexity.

    "Nobody knew that healthcare would be this complicated," he said.

    In an interview with Fox & Friends on Tuesday, Trump also said he hasn’t had enough time to get the replacement done.

    "I’ve only been here for like four weeks," Trump said. "Somebody said, 'He hasn’t done healthcare yet,' but they've been working on healthcare for 30 years. I’ve only been here for — what is this, like my fifth week?"

    Trump did say, however, that "we're set to propose a plan."

    The Washington Post reported last weekend about internal disagreements over the future of the health law within the Oval Office. After meeting with Ohio Republican Gov. John Kasich, who is an advocate of Medicaid expansion and a less aggressive ACA repeal, Trump was reminded that that Kasich's suggestions did not represent the plan GOP leaders were pushing for — to which he reportedly said, "Well, I like this better."

    It remains unclear whether the administration will present its own ACA replacement plan. Trump’s administration has held meetings about the ACA with participants such as Health and Human Services Secretary Tom Price and chief of staff Reince Priebus, and Trump promised a plan once Price was confirmed.

    CNBC’s John Harwood, however, reported that most Republicans in Congress do not expect a separate plan from the administration and that the legislature will dictate the course of healthcare policy.

    With congressional lawmakers arguing over the course of policy and no apparent direction coming from the White House, all eyes will be on Trump’s speech to a joint session of Congress on Tuesday night, when he is, in part, expected to provide details of his vision.

    SEE ALSO: Bernie Sanders burst into laughter at Trump's claim that 'nobody knew healthcare would be this complicated'

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    NOW WATCH: 'Sit down! Quiet!': Watch Trump's heated exchanges with reporters in his longest press conference as president


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    Donald Trump Barack Obama

    President Donald Trump laid out a vision for the Affordable Care Act (ACA) on Tuesday that appeared to back away from earlier pledges to guarantee insurance coverage for people with pre-existing conditions and leaned on tax credits to ensure Americans can afford their premiums.

    Trump outlined the changes in a speech to both houses of Congress, laying out five principles for the replacement of the law better known as Obamacare.

    Trump cited increasing premiums and the withdrawal of insurers from the ACA's individual insurance exchanges, as evidence that the health care law is in need of a revamp.

    "Obamacare is collapsing — and we must act decisively to protect all Americans," Trump said. "Action is not a choice — it is a necessity. So I am calling on all Democrats and Republicans in the Congress to work with us to save Americans from this imploding Obamacare disaster."

    Trump laid out five broad ideas that he wants the Republican Obamacare replacement to address. They are:

    • "Ensure that Americans with pre-existing conditions have access to coverage": Importantly Trump refers to "access" for those with pre-existing conditions, not a guarantee that there will be coverage. This is backing down from previous statements Trump has made that everyone would be covered.
    • "Help Americans purchase their own coverage, through the use of tax credits and expanded Health Savings Accounts": Currently, Republicans are favoring block tax credits that would allow people to buy health coverage, rather than the current ACA tax cuts that are tied to a household's level of income.
    • "Give our great State Governors the resources and flexibility they need with Medicaid": This is the biggest sticking point for many Republican lawmakers, as those states that have expanded Medicaid wish to keep it, while more conservative members of Congress want to remove funding for that expansion. Trump's speech did not particularly clarify which side of the issue the president falls on.
    • "Implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance": This is unclear what Trump is referencing other than a promise to "bring down the artificially high price of drugs."
    • "Give Americans the freedom to purchase health insurance across State lines": The ACA actually has a provision that already allows interstate insurance sales, though few insurers or states have taken advantage of the provision. Additionally, many healthcare experts think this will do little to bring down insurance costs.

    Democrats booed and responded by holding their thumbs down during the speech. They are expected to respond to Trump's ACA pledge with former Kentucky governor Steve Beshear, who embraced the ACA during his time in office to a relatively high level of success.

    Interestingly, Trump used the example of the current governor of Kentucky saying "Governor Matt Bevin of Kentucky just said Obamacare is failing in his State." Kentucky has seen the largest drop in the percentage uninsured people between 2013 and 2016 due to the ACA.

    SEE ALSO: Democrats' pick to respond to Trump's speech was selected for one huge reason

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    Rand Paul

    Sen. Rand Paul on Thursday suggested he was getting tired of the House Republican process for repealing and replacing the Affordable Care Act, the healthcare law better known as Obamacare.

    In a series of tweets, the Republican senator from Kentucky said the House GOP had hidden its plan from other lawmakers and the public. He said the secretive nature was "unacceptable."

    "I have been told that the House Obamacare bill is under lock & key, in a secure location, & not available for me or the public to view," Paul tweeted. "This is unacceptable. This is the biggest issue before Congress and the American people right now."

    House GOP leadership has begun to develop a plan, a draft of which leaked Friday, but reports have indicated that many lawmakers have not been privy to the development.

    Paul has introduced his own version of a replacement and has joined with other conservative senators, such as Ted Cruz of Texas and Mike Lee of Utah, in calling for a total repeal of the ACA.

    Paul said the House plan did not go far enough in repeal.

    "What is the House leadership trying to hide?" Paul said. "My guess is, they are trying to hide their 'Obamacare Lite' approach. Renaming and keeping parts of Obamacare, new entitlements and extending medicaid expansion are not the #FullRepeal we promised."

    Some House conservatives, including members of the Freedom Caucus, have also come out in favor of a full repeal of the law rather than some form of compromise. The disagreement has led to a slowdown in the repeal-and-replace process.

    Paul said he wanted the process from House leadership to be more transparent.

    "I call on them to make this process transparent and to let the sunshine in," Paul concluded. "Today."

    Here is his full tweetstorm:

    SEE ALSO: TRUMP: Repealing and replacing Obamacare is 'not a choice — it is a necessity'

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    paul ryan

    Reporters and members of Congress were sent on something of a treasure hunt Thursday when they tried to view a House Republican Obamacare replacement plan that has received some top-level security.

    Billy House and Arit John at Bloomberg on Wednesday reported that the House GOP plan was being kept in a secretive reading room and was only available to read in that room for members of the House Energy and Commerce Committee and their staff starting Thursday.

    But reporters, and even members of Congress, were eventually let in to that room, and they found it empty with no apparent piece of legislation in sight. Subsequent reports said the secure location had been moved.

    "We're on a treasure hunt, I guess,"said Rep. Jan Schakowsky, a Democrat from Illinois.

    A draft of the House GOP plan was leaked last week, and it drew rebuke from Democrats and more conservative lawmakers in both the House and the Senate.

    It also appeared that the room in which the bill was being kept was being guarded by Capitol police officers. The Twitter account for Democratic members of the House Ways and Means Committee tweeted a picture of police officers standing outside a room in the Capitol, saying, "House Republicans are literally guarding their health care bill with Capitol Police. Is it *that* dangerous?"

    Rep. Chris Collins, a Republican, told Bloomberg that the House may mark up the bill — essentially, reviewing it in committee and making changes to the law — next week without a score from the Congressional Budget Office. The CBO provides nonpartisan estimates of the costs of all bills and coverage implications for those dealing with healthcare.

    Members from both sides of the aisle on Thursday decried the secrecy over the bill, with Democratic House Minority Leader Nancy Pelosi drawing attention to it during a press conference on Thursday and Republican Sen. Rand Paul railing against the methods in a tweetstorm.

    "I have been told that the House Obamacare bill is under lock & key, in a secure location, & not available for me or the public to view,"Paul tweeted. "This is unacceptable. This is the biggest issue before Congress and the American people right now."

    The secrecy isn't without precedent: The draft text of the Trans-Pacific Partnership, the multilateral trade deal negotiated under the Obama administration, was also kept under similar security.

    SEE ALSO: Republicans are hitting more roadblocks on their Obamacare repeal

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    national treasure

    In a bizarre twist to the process of the repeal and replacement Obamacare, House GOP lawmakers are holding their replacement plan in a secret room with limited access — and Democrats are on a scavenger hunt for it.

    Republicans are holding the bill in a secure room in the Capitol and making it only available to Republican members of the House Energy and Commerce Committee and their staff.

    Democratic representatives walked around the Capitol building looking for the room that was holding the bill and were unable to find where it was being kept.

    Democratic Rep. Pallone, Schakowsky, Crowley, Hoyer and more wandered around the building, checking different Republicans offices and even a few random rooms.

     

     In response, users of Twitter took ahold of the "scavenger hunt" to make some pointed jokes:

     

     

     

     

     

     

      

     As of this writing, the hunt is ongoing.

    SEE ALSO: The GOP is keeping its Obamacare replacement plan in a 'secure location' — and there is now a hunt to find it

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    Paul Ryan

    I can't figure out what Paul Ryan thinks he's up to on Obamacare replacement.

    The basic political problem he faces is simple: Republicans are in agreement that Obamacare should be repealed and replaced, but their agreement breaks down over what it should be replaced with.

    A bill that keeps too much of Obamacare's spending will alienate conservatives who believe they were sent to Washington to pass a "full" repeal. A bill that cuts too much makes moderate Republicans squeamish, especially those who come from states that depend on expanded Medicaid.

    So The Wall Street Journal reported early this week that Ryan's plan is to steamroll those objections: Bring a bill to the floor that comes down somewhere in the middle, and dare members on the conservative and moderate ends of his caucus to vote no.

    Will that work? Maybe. But all you have to do is Google "Boehner pulls bill" to see how efforts to force unpalatable "must-pass" legislation through the House havegonein recentyears.

    Based on his past experience trying to herd the Republican caucus, former Speaker John Boehner says he doesn't expect repeal and replace to happen.

    But Ryan seems intent to try, and Republican members of the House Energy and Commerce Committee are working on a repeal-and-replace plan in secret— a fact that has drawn objections not just from Democrats who want to protect Obamacare but also from Sen. Rand Paul, the Republican from Kentucky, who fears the plan they are developing will amount to "Obamacare-lite."

    Paul joined many House Democrats on Thursday in demanding the release of the draft bill. He brought a photocopier with him through the halls of the Capitol complex, saying he wanted to make copies of the bill widely available.

    Objections from the right and the left

    The problem with Ryan's approach is, sooner or later, the committee has to release the bill text, at which time it will face predictable objections from both the right and the left.

    You can see some of the most likely objections from Republicans' right flank in Thursday's tweets from Paul. Conservative Rep. Mark Meadows of North Carolina asked, "What is conservative about a new entitlement program and a new tax increase?" He was referring to provisions of an earlier "discussion draft" for the bill.

    On the other end of the caucus, you have members like Charlie Dent of Pennsylvania. They seem awfully nervous about undermining the Medicaid expansion, which is important for their states' insured populations and also for their states' budgets. Dent has been critical of "haste" and "arbitrary deadlines" for repealing Obamacare.

    Speaking of haste, Rep. Chris Collins says the Energy and Commerce Committee may even vote on the bill before they have a score from the Congressional Budget Office telling them what it will cost and how many people it will cover.

    This would be sort of a bizarre thing to do. But it also wouldn't keep moderate Republicans from getting squeamish when the CBO score, which is likely to show millions losing insurance, comes out before the full House votes on the package.

    rand paul

    The big problem is the Senate

    In recent years, fights over "must-pass" legislation in the House have tended to end with Republican leadership having to shift bills far to the right to secure passage, which would tend to mean greatly reducing spending and subsidies.

    Maybe, by doing that, Ryan will be able to get a bill through the House. But what about the Senate, where the Republican majority is narrower and the caucus is more moderate?

    Several Republican senators have expressed significant reservations about whether the replacement plan would do enough to protect those who depend on the Affordable Care Act. They have been adamant about the need to have a full replacement in place before repealing Obamacare.

    Republican Sen. Lisa Murkowski, for example, says she won't vote for a package that scraps the Medicaid expansion as long as Alaska lawmakers want it.

    Lisa Murkowski gun controlThe discussion draft House bill that leaked last week would most likely have been unacceptable to both Paul and Murkowski — handing out too many subsidies for his taste and cutting spending on Medicaid too much for her standards.

    This makes me think it's very unlikely that a bill that can be rammed through the House can also pass the Senate — and therefore that it is unlikely that Ryan's strategy will lead to enactment of legislation.

    But maybe that is what Paul Ryan is up to.

    As Brian Beutler of the New Republic notes, forcing a bill down the throats of House Republicans only to see it die in the Senate is not an effective strategy for repealing Obamacare. But it could be a very effective strategy for getting conservative voters to blame the Senate, not the House, for Republicans' failure to repeal Obamacare.

    The missing variable is Trump

    The one thing that would lead me to change this view that Republicans are not headed for repeal would be if President Donald Trump weighed in strongly to pressure Republicans in both chambers to vote for a specific bill they have major reservations about.

    Complicated legislation involving lots of trade-offs tends to pass when the president brings pressure to bear on his party in Congress, as with the Medicare prescription-drug benefit under George W. Bush or the Affordable Care Act itself.

    So far, Trump has shown no inclination to do that — in fact, he has warned his party against the trap of taking ownership over problems in the healthcare system. He settled none of the major internal Republican disputes over healthcare policy in his address to Congress on Tuesday.

    Politically, he's wise to talk a big game about healthcare while avoiding getting his fingerprints on it too much. But it's not a strategy that augurs for actual repeal and replacement.

    SEE ALSO: RAND PAUL: The GOP is keeping its 'Obamacare lite' bill 'under lock & key' in a basement

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    paul ryan

    WASHINGTON (AP) — The Capitol is suddenly awash with trouble-makers and rebels — and that's just the Republicans.

    Whatever GOP unity was produced by Donald Trump's victory in November has all but disappeared, and Republican leaders are confronting open rebellion in their ranks as they try to finalize health care legislation.

    In the Senate, a trio of conservatives that's been a thorn in the side of leadership is back at it again. And in the House, recalcitrant conservatives are banding together and threatening to foil House Speaker Paul Ryan's plans for swift passage of the legislation to repeal and replace former President Barack Obama's health law.

    "At this moment I don't plan to vote for it," one of the rebels, Rep. Thomas Massie of Kentucky, remarked Thursday after a leadership presentation on the emerging health legislation.

    Massie said leaders played clips of Trump's recent joint session speech, with the goal of convincing lawmakers that they are aligned with the president on the pending health bill.

    But Massie dismissed the effort as "very unconvincing." And he and other conservatives claimed to count 20-plus GOP opponents to the health bill, enough to sink it if all Democrats vote "no."

    Ryan and other GOP leaders, who are aiming to pass the legislation through the House and Senate by early April, have tried to keep a game face despite the turmoil.

    "We are in sync — the House, the Senate and the Trump administration," Ryan insisted to reporters Thursday. "I am perfectly confident that when it's all said and done, we're going to unify, because we all, every Republican, ran on repealing and replacing, and we're going to keep our promises."

    Maybe so, but first there will be some drama. And this week, there was plenty.

    After mostly lying low and playing nice for the last several months, Sens. Rand Paul of Kentucky, Mike Lee of Utah and Ted Cruz of Texas are now uniting against the health legislation, and like their conservative counterparts in the House, they command the votes to frustrate leadership efforts if they don't back down.

    rand paul

    The lawmakers are criticizing the developing legislation as "Obamacare lite." They object in particular to a system of refundable tax credits that form the centerpiece of the legislation, and which they say would amount to a costly new entitlement. Instead they're demanding a vote on a straightforward repeal-only bill.

    On Thursday, Paul infuriated GOP leaders on both ends of the Capitol by marching over to the House with a crowd of reporters and his own copy machine to demand to see the draft health bill, and criticize leadership for keeping it under wraps.

    "I'm also being told by others that I should sit back and take it, that when you see it you get it, you take the House version or nothing else," Paul declared with cameras rolling. "And I don't think that's the way the American process should work."

    The Kentucky senator's chaotic gaggle was followed by a bizarre and apparently spontaneous scavenger hunt by House Democrats who, after chancing upon reporters gathered to listen to Paul, formed an impromptu search party that roamed the Capitol and an adjacent office building in an ultimately futile hunt for the health bill.

    Paul's stunt provoked thinly concealed irritation from GOP colleagues, including Sen. Lamar Alexander of Tennessee, who chairs the health committee, of which Paul is a member. Alexander, a senior leadership ally, has been part of a group working on the replacement health care bill.

    "Well, Sen. Paul is a valuable member of the committee and I think I'll give him a call and see if he'd like to have more information," Alexander said. "He and his staff have been briefed about the bill. He's had a chance to attend all the same meetings the rest of the senators have. So if he feels like he needs more information I'll be happy to give it to him."

    Many Republicans say it's time, urgently, for the party to pull together and get behind a repeal-and-replace bill, after spending fully seven years promising exactly that to voters. They are not pleased that members of their own party are threatening their success.

    "We do have some problems with two or three people on our side that make it so if this becomes a partisan vote we won't have the votes," said Sen. Orrin Hatch, R-Utah, another senior lawmaker. "It's a problem, it's a big problem."

    Democrats who lived through their own share of drama before finally passing the Affordable Care Act can only stand back and jeer.

    "Who would have thought, one month into the fight over the ACA, it's the Republicans, not the Democrats, who are in disarray and pointing at one another like an Abbott and Costello show," said Senate Minority Leader Chuck Schumer of New York.

    SEE ALSO: The GOP's secret plan to repeal Obamacare won't work

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    donald trump

    In his speech to the joint session of Congress on Tuesday, President Trump took time to attack the Affordable Care Act, better known as Obamacare, and laid out a broad vision for the future of healthcare in the US.

    "Obamacare is collapsing and we must act decisively to protect all Americans," Trump said. "Action is not a choice — it is a necessity. So I am calling on all Democrats and Republicans in the Congress to work with us to save Americans from this imploding Obamacare disaster."

    The president went on to lay out five principles that he says he wants to see in an Obamacare replacement — from preexisting conditions to funding to help the poorest American buy coverage. Here's what these plans could mean for many Americans.

    1. 'Ensure that Americans with preexisting conditions have access to coverage.'

    Before the Affordable Care Act, Americans with health problems ranging from asthma to cancer could find it hard or even impossible to obtain health insurance, if they didn't have it through an employer or other group. 

    Obamacare's rule forbidding insurance companies from excluding these Americans with preexisting conditions has become one of the most popular parts of the law. Trump has longed vowed to maintain that. 

    But there are a few different things this could mean.

    In a leaked draft of the House GOP's repeal-and-replace bill, people cannot be denied coverage based on a preexisting condition, but many could be placed into separate marketplaces called "high-risk pools."

    In the ACA's individual health-insurance exchanges, healthy people and people with preexisting conditions are in the same pool. For insurers, this helps to balance the risk and costs and mitigate losses from the exchange. Since there are limits to how much people in the same pool can be charged, this also leads to healthier people having slightly higher premiums than they would otherwise and those with preexisting conditions to have somewhat cheaper premiums.

    Republicans would separate the two groups, bringing down costs for healthy people who want insurance through the individual marketplace. It would also most likely mean that those people with preexisting conditions would see their costs rise.

    Thirty-five states had their own high-risk pools before the ACA. The Kaiser Family Foundation, a leading nonpartisan health-policy think tank, found that the average cost for those enrolled in these pre-ACA high-risk pools was anywhere between 125% and 200% more than the average premium cost outside of the pools and many people did not enroll because of the prohibitive cost.

    Additionally, the key word in this part is "access." As health-policy experts have pointed out, access is not the guarantee for coverage, and the expensive plans in the high-risk pools, while theoretically accessible to people with preexisting conditions, could price many people out.

    2. Help people purchase insurance with the use of tax credits and health savings accounts.

    The next principle laid out in Trump's speech is designed to help Americans get affordable health insurance.

    The leaked Republican plan proposes giving all Americans a tax credit up front to buy insurance based on their age. The bill would create three age brackets. Those under 35 would get $2,000, for example.

    Currently, Obamacare has a different structure of tax credits. These are tied to a recipient's income and location, not age. This has allowed about 73% of people in the exchanges to get coverage for $75 or less in premiums per month, though they did leave some out since they were capped at an income of 400% of the federal poverty line.

    obama doctors

    Kaiser also looked at the House draft bill's proposals for these block grants, which are roughly in line with the ideas proposed in House Speaker Paul Ryan's "Better Way" plan and new secretary for health and human services secretary Tom Price's "Putting Patients First" act.

    The study by Kaiser found that, overall, the block credit would shift the balance of assistance.

    "For current marketplace enrollees, the House Discussion Draft and Price bill would provide substantially lower tax credits overall than the ACA. People who are lower income, older, or live in high premium areas would be particularly disadvantaged under the House Discussion Draft and Price bill relative to the ACA," the Kaiser report said.

    For Instance, under the current ACA credits, the average single beneficiary over the age of 60 with an income of $20,000 would receive $9,874 per year to pay for their insurance. Under the House draft, this tax credit would be capped at $4,000.

    Screen Shot 2017 03 02 at 2.38.37 PM

    It also seems that Trump is being less aggressive about repealing the tax credits than the most conservative members of his party. Hard-line Republicans want to repeal all funding for tax credits because they believe they are not fiscally responsible. By endorsing these tax credits, it shows that the president is more on the side of House Speaker Paul Ryan than conservatives such as the House Freedom Caucus or Sen. Ted Cruz.

    3. Allow states and governors the "flexibility they need with Medicaid to make sure no one is left out."

    This may be one of the most controversial statements from Trump within his own party.

    The ACA expanded Medicaid coverage from the federal government so that a person making up to 138% over the federal poverty line could get insurance through the government program. According to estimates this allowed more than 11 million low-income Americans who otherwise would not have access to insurance get covered.

    Some conservatives in the GOP want to roll back the federal funding for this program, while Republican lawmakers and governors in states that have expanded the program want to keep the expansion. These lawmakers fear that rolling back coverage for those on Medicaid could be politically costly: Polls show 80% of Americans want to keep the expansion.

    The House GOP's draft proposes this: repeal federal funding for the expansion by 2020 and then move to block grants.

    These would ultimately offer less funding to the states. 

    4. "Implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance."

    While this section is particularly vague, Trump did say that he wants to "bring down the artificially high price of drugs."

    Trump has advocated allowing Medicare to negotiate drug prices to bring down these costs for seniors, an idea that has been long supported by Democrats and opposed by Republicans.

    Other than that promise for lower drug costs, it is unclear what he means by this line.

    5. Allow the sale of health insurance "across state lines."

    This has long been an idea of Republicans, which would allow insurers to get a plan approved in one state — say, Oregon — and, as long as it is approved in that state, it can be sold in any other state.

    The idea is that it would allow insurers to be in more markets and compete with one another, and that could lower prices and be more attractive to consumers.

    One of the biggest problems is that most healthcare experts don't think it would do much to move the needle in bringing down costs.

    The biggest barrier for insurers in entering a market is developing contracts with local healthcare providers such as doctors' networks and hospitals. Even if a plan were approved in Oregon, the insurance company would still have to set up contracts with a hospital if they wanted to offer the plan in South Carolina. Given distances and cost, most policy experts agree this isn't an attractive option.

    Additionally, the ACA already has a limited provision that allows a similar sale of insurance across state lines. Despite a handful of states opening themselves for cross-state sales, no insurers have taken advantage of this.

    While it is unclear which of these reforms the legislature and Trump will be able to agree on — especially since the Republican Party seems divided on some of the ideas — the speech did provide the broad strokes of what Trumpcare could look like.

    Here are all the roads to repealing, and perhaps replacing, Obamacare.

    Trumpcare2

    SEE ALSO: Republicans are hitting more roadblocks on their Obamacare repeal

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    Rand Paul

    Republicans are facing increasing bipartisan pressure to reveal the details of their Obamacare repeal and replace bill, which may be ready for House committee markup next week. 

    Kentucky Republican Sen. Rand Paul is leading the fight to make the bill public. On Thursday, Paul, tailed by a pack of reporters, led a scavenger hunt through the Capitol for the bill, which is being kept in a "secure location." 

    “This is being presented as if it were a national secret, as it if it were a plot to invade another country," Paultold reporters as he tried to get into the Republican office where the bill was reportedly being held. "That's wrong. It should be done openly in the public."

    Paul rolled a copy machine with him through the building, hoping to get his hands on a paper copy of the legislation. 

    Democratic Rep. Paul Tonko joined Paul on the chase, saying he wants to read the bill "because it’s affecting one-sixth of the economy."

    Depite lawmakers' complaints, the House Energy and Commerce Committee, which is drafting the bill, is continuing to keep it hidden. On Friday morning, Paul tweeted that he was not giving up on the hunt.

    A draft of the bill, leaked to Politico last week, was met with strong criticism from a coalition of House and Senate Republicans, who argued it did not go far enough in repealing the Affordable Care Act. 

    Paul called the draft bill "Obamacare Lite" and Rep. Mark Meadows tweeted last week, "Every tax, every mandate, every regulation of #Obamacare needs to go."

    Republican Sen. Ted Cruz is accusing Republicans of reneging on their promises to radically alter the ACA. 

    "2 yrs ago, the GOP Congress voted to repeal Obamacare. That 2015 repeal language should be the floor, the bare minimum,"Cruz tweeted last week

    The House committee distanced itself from the leaked draft, which it said was outdated and no longer "viable."

    Republicans are internally divided over what a replacement law should look like and are particularly at odds over funding for Medicaid, the expansion of which has provided insurance for 12 million more Americans under the ACA.

    Conservative lawmakers, including Sen. Paul, Cruz, and Mike Lee, are pressing for a full repeal of the ACA and a replacement that looks nothing like it. But GOP lawmakers from states in which Medicaid has expanded under the ACA are opposed to any law that would cut funding from coverage for low income individuals.

    While the GOP only needs a simple 51-vote majority to pass the Senate, without Paul, Cruz, and Lee, the party would not have enough votes to pass the legislation. 

    In the days leading up to the inauguration, Trump promised a swift repeal and replace, but has recently indicated the process will be slower. 

    "Nobody knew that healthcare would be this complicated," Trump told a meeting of governors last week.

    During Trump's address to a joint session of Congress on Tuesday night, he laid out a few basic principles of a future law, including using tax credits to help individuals buy insurance and allowing for the purchase of coverage across state borders. But his speech provided little clarity as to what specific legislation the administration would support. 

     Bob Bryan contributed to this story.

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    U.S. President Donald Trump arrives aboard Air Force One, returning to Washington from a weekend in Florida, at Joint Base Andrews, Maryland, U.S. March 5, 2017. REUTERS/Jonathan Ernst

    WASHINGTON (Reuters) - Republican U.S. lawmakers expect to unveil this week the text of long-awaited legislation to repeal and replace the Obamacare healthcare law, one of President Donald Trump's top legislative priorities, a senior Republican congressional aide said on Sunday.

    Since taking office in January, Trump has pressed his fellow Republicans who control Congress to act quickly to dismantle former Democratic President Barack Obama's Affordable Care Act and pass a plan to replace it, but lawmakers in the party have differed on the specifics.

    Democrats have warned that Republicans risk throwing the entire U.S. healthcare system into chaos by repealing the 2010 law that was passed by congressional Democrats over united Republican opposition. Republicans condemn it as a government overreach, and Trump has called it a "disaster."

    The aide cited progress in meetings and phone calls starting on Friday and lasting through the weekend involving House of Representatives Speaker Paul Ryan, Health and Human Services Secretary Tom Price, White House budget chief Mick Mulvaney, Trump domestic policy adviser Andrew Bremberg and others.

    "We are in a very good place right now, and while drafting continues, we anticipate the release of final bill text early this week," said the aide, speaking on condition of anonymity.

    The aide called the expected bill a "consensus Republican plan," but offered no details.

    AshLee Strong, a spokeswoman for Ryan, said: "We are now at the culmination of a years-long process to keep our promise to the American people."

    The Obamacare law has proven popular in many states, even some controlled by Republicans, and it enabled about 20 million previously uninsured people to get medical insurance, although premium increases angered some.

    (Reporting by Susan Cornwell; Writing by Will Dunham; Editing by Peter Cooney)

    SEE ALSO: Trump has 5 priorities for his Obamacare replacement — here's what they could mean for you

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    paul ryan

    House Speaker Paul Ryan and the House GOP leadership are expected to roll out their plan to repeal and replace the Affordable Care Act (ACA), known as Obamacare, sometime over the next few days.

    The bill will be moved through a process known as budget reconciliation, meaning it would only influence the parts of the ACA that have to do with federal funding. It would pertain to massive parts of the law including Medicaid expansion, the mandate that everyone must buy insurance, and all taxes and tax credits under the law.

    One of the perks of this process for Republicans: They only need a simply majority in the Senate to pass the bill, avoiding an all-but-certain filibuster by Democrats.

    While the plan that has emerged in bits and pieces in recent weeks has the backing of many prominent members of the House, there is no guarantee that it will make it unscathed — or at all — to President Donald Trump's desk.

    Groups on the right and left of the political spectrum have gripes with Ryan's plan — and how those battles are fought will ultimately decide the fate of the ACA and millions of Americans' health insurance.

    Moderate objections

    One of the biggest fights that face Ryan and Republicans are changes to the ACA's Medicaid expansion.

    Under the ACA, states receive significant funding to grow the Medicaid program that provides health insurance to Americans living in or close to poverty. So far, 34 states and the District of Columbia have taken up the offer.

    A leaked draft of the House GOP's Obamacare replacement bill would shift funding for Medicaid expansion to block grants, chunks of funding that most health policy analysts say would increase the funding burden for states.

    The problem: Senators in states that have expanded Medicaid have found the program to be popular, and roughly two-thirds of Americans nationwide support the expansion, according to recent polls.

    Sen. Lisa Murkowski of Alaska has said that she will not vote for a bill that defunds the Medicaid expansion or shifts it to a block-grant system.

    Other Republican senators in states that have expanded Medicaid have also expressed concerns about maintaining coverage for those people who now have insurance through the program. Just over 11 million Americans that otherwise would not have coverage have gained insurance through Medicaid expansion, according to estimates from the Kaiser Family Foundation.

    Sen. John Thune of South Dakota called the Medicaid expansion the "the thorniest and most difficult issue to resolve."

    A number of Republican governors have also come out against a repeal of the Medicaid expansion. Perhaps the most vocal has been former Republican presidential candidate and Ohio Gov. John Kasich.

    Kasich met with Trump recently to explain the value of maintaining the status quo for Medicaid expansion and has called rollback of Medicaid expansion a "very, very bad idea."

    John Kasich

    Additionally, Doug Doucey, the Republican governor of Arizona, expressed misgivings about proposed Medicaid funding changes in a letter to Congress. He said the proposed "policy change will result in the single largest transfer of risk ever from the federal government to the states."

    Finally, states with Republican governors including Kansas, North Carolina, and Maine have all expressed a desire to expand Medicaid themselves.

    Conservative pushback

    While more moderate Republicans have been in favor of keeping some of the ACA's provisions for Medicaid, the right flank of the GOP has been saying that the leaked repeal plan does not go far enough.

    Members of the House and Senate have called the proposal "Obamacare-lite" and have said that it does not fulfill the Republican promise to get rid of the law.

    Rep. Mark Meadows, head of the conservative House Freedom Caucus, said he would not vote for the bill in the leaked form. (That leaked bill was a draft version, so changes could have been made in the interim.) Meanwhile, other House members appeared to push back on the plan.

    Rep. Mark Walker, the head of the Republican Study Committee, also said in a statement that the current proposal was inadequate.

    "There are serious problems with what appears to be our current path to repeal and replace Obamacare," Walker said. "In that form, and absent substantial changes, I cannot vote for the bill and, in good conscience, cannot recommend RSC members vote for it either."

    Paul Ryan Mitch McConnell

    For these members, the biggest issue has been the tax credits given out to Americans to buy health insurance. Conservative Republicans have argued the federal government shouldn't be involved in funding the credits. 

    This is a concern shared by conservative members of the Senate. Sens. Rand Paul, Ted Cruz, and Mike Lee have all come out against the House plan, saying it does not go far enough in its repeal.

    In a tweetstorm on Thursday, Paul criticized the plan and the House GOP leaderships strategy of keeping the bill a secret by placing it in a secure room only available to certain Republican lawmakers.

    "What is the House leadership trying to hide?"Paul said."My guess is, they are trying to hide their 'Obamacare Lite' approach. Renaming and keeping parts of Obamacare, new entitlements and extending medicaid expansion are not the #FullRepeal we promised."

    Democratic opposition

    Not only do Republicans have problems within their own party, but passage also won't be any easier given Democrats' plan to oppose the GOP at every turn.

    Senate Minority Leader Chuck Schumer and House Minority Leader Nancy Pelosi have made it clear that they have no plans to cooperate on repeal and replace legislation. Even former President Barack Obama told Democratic lawmakers in a closed-door meeting right before he left office not to "rescue" Republicans in their attempts to repeal and replace the ACA.

    Democrats do not control either chamber of Congress and have little power to stop any reconciliation bill without Republican defections, but the internecine warfare in the GOP could complicate things for the party. Given the thin margin Republicans hold in the Senate (52 to 48), only a few defections from the GOP and a united front from Democrats (and the two independent senators who nearly always vote with them) would defeat any repeal bill.

    Even a coalition of Paul, Cruz, and Lee voting with Democrats against a bill (albeit for vastly different reasons) would be enough to halt it.

    The internal GOP arguments led Schumer to say that he does not even think the Republicans can advance an ACA replacement. He tweeted before Trump's address to Congress that "the odds are very high that we’ll keep the ACA."

    Trump wild card

    The final fight is one against the uncertain policy goals of Trump himself.

    While Trump laid out a vision for healthcare in his speech to the joint session of Congress that followed along the outline of the leaked House GOP plan— especially the call for tax credits, directly rebuking the conservative wing of the party — uncertainties remain that could throw a wrench in the repeal and replace plans.

    Reports from The Washington Post said Trump seemed open to Kasich's plan for keeping Medicaid expansion and the president has at times shifted positions on his healthcare goals.

    Additionally, Trump has made some big promises when it comes to the law. He has said that the plan will eventually cover all Americans, be cheaper than the current system, and provide better care overall. Most health policy experts agree that expanding coverage to all people while the government spends less on healthcare is virtually impossible, so it is unclear how Trump will come down in the debate over the ACA's future.

    SEE ALSO: Trump has 5 priorities for his Obamacare replacement — here's what they could mean for you

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