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The latest news on Obamacare from Business Insider

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    trumpWith his widely followed, and positively reviewed, address to Congress last week, President Trump showed how easy it could be to unite Washington around a big-budget centrist agenda on health care, immigration, taxes, infrastructure and the military. But the continued accusations surrounding his campaign’s alleged Russian connections, and the President’s conspiratorial responses, have insured that the battle lines have only hardened. However, anyone with even a casual concern with ballooning government debt should take notice just how easily both parties in Washington would agree to vastly expand the gushing red ink if a political truce can be brokered. Those fears should galvanize around the newly-issued Republican replacement for Obamacare.  If such a monstrous bill could successfully navigate Congress, we would find ourselves stuck deeper in a deficit deluge than we can possibly imagine.  
     
    Obamacare attempted to rewrite the laws of economics by preventing insurance companies from charging high-risk customers more than low-risk customers. But to make this work without bankrupting the companies, all agreed that the young and healthy would need to be forced to buy insurance.  The flaw that doomed the law was that the penalties for not buying were too low to actually motivate healthy people to buy.  Consumers were charged just a few hundred dollars per year to forego insurance that would have cost many thousands. Given that they could always decide to get insurance in the future, at no added cost, the choice was a no-brainer. Without these healthy people keeping costs down, insurance premiums have risen alarmingly. 
     
    Ironically, the Supreme Court noticed this flaw as well. In sustaining the Law’s constitutionality, Justice Roberts argued that the relative lightness of the penalties was insufficient to compel anyone to buy insurance and, as a result, he considered them to be a “tax” that could be voluntarily avoided rather than a coercive penalty to force commercial activity. (Presumably had the tax been high enough to actually work, it would have rendered Obamacare unconstitutional – see my 2012 commentary).
     
    However, the Republican replacement plan, which removes all taxes on individuals who don’t buy insurance, and all penalties on employers who do not provide insurance to their employees, will actually make the problem far worse.
     
    The only reason healthy people buy health insurance is that they know that if they wait until they get really sick no insurance company will sell them a policy.  The same principal holds true for all insurance products.  You can’t buy auto insurance after you get into an accident. You can’t buy life insurance at a reasonable cost after your doctor has given you six months to live. The fact that your car is already wrecked, or your arteries already clogged, are pre-existing conditions that no insurance company would be expected to ignore. 
     
    Allowing voters the low-cost option to buy health insurance after they actually need it is very popular. It’s like promising motorists they can stop paying their monthly auto insurance premium and just buy a policy after they have an accident.  If the government were to require this, all auto insurance companies would quickly go out of business (unless they were bailed out by the government).
     
    Obama’s solution was to use the penalties to force healthy people to buy insurance before they actually needed it.  As the years wore on, the relatively low cost of the subsidized exchange plans and the availability of those plans to anyone proved popular.  However, the mandates and penalties, as well as skyrocketing premiums for non-subsidized policies, were clearly unpopular.  
     
    Paul RyanThe Republicans have taken the “brave” political approach of keeping the parts that are popular (subsidized access, pre-existing conditions waivers, expansion of children’s coverage until age 26) and jettisoning those that are not (the mandates and the penalties).  The new plan pretends to offer a replacement to the Obamacare penalties by allowing insurance companies to charge a 30% increase to the premium for those who come back into the system after having previously allowed their coverage to lapse. But the problem here is that the premium increase is far too small to force anyone healthy to buy insurance. In fact, it is so low that any healthy person currently insured may decide to drop coverage.
     
    The effect of this law, were it actually enacted, would be the death of the health insurance industry.  As the law removes the requirement that larger employers provide insurance, I believe that big companies would look to self-insure employees for routine care.  For example, employer and employees could pay into a common risk pool that would set their own deductibles and co-pays. For employees who incur medical charges in excess of the cost of an actual policy, the pool could provide funds to pay for outside insurance at the increased 30% premium. As a result insurance costs would be encountered only if there is a need.
     
    Self-employed individuals would only buy insurance if the total cost was less than the tax credit provided by the new plan.  If they can’t find such coverage, they would likely buy a new form of insurance that this law may create: A policy that would pay for health insurance premiums if the user ever got sick enough to need them.  Such insurance would be very cheap, as the maximum exposure to the insurance company is only 130% of the premium for a standard health insurance policy.   
     
    In the end, the only people buying health insurance would be those who can buy it for free using their tax credits and really sick people for whom insurance premiums are cheaper than their medical bills.   But as insurance companies lose money on the latter group, they will be forced to raise their premiums on the former.  This puts us right back in the box we are stuck in with Obamacare.
     
    As premiums soar well above the amount of the tax credits, more people will drop out.  Unless the amount of the tax credits rises substantially, which will cost a fortune, all health insurance companies will eventually go out of business.  The end result will be socialized medicine, only it will be Trump not Obama that gets the blame.  It seems to me that this would be a political loser for the conservative cause. I would rather we go down in flames with Obamacare as then, at least, we will have a chance at a free market solution that could actually work.
     
    The government has a very poor track record with containing the cost of a service when it gives consumers money to buy it. Think student aid and college tuition.   Plus the plan is constructed in a way that makes it ripe for potential abuse.  Whenever the government is giving away money, people always game the system to get it.  Think about the wide-spread fraud in welfare, food stamps, disability, and even cell phone credits. Trumpcare will be no different. Many people will buy catastrophic plans with extremely high deductibles just so they can pocket the difference between the tax credits and the costs of the plans.  If they actually incur a medical condition that results in a high out-of-pocket expense, they can just switch their coverage to one with a much lower deductible.  Such a switch may even be possible without the 30% premium for lapsed coverage. 
     
    If Trump and the Republican leadership can push this monstrosity through, despite the obvious mathematical shortcomings, look for them to make similar efforts on infrastructure and defense spending. All this adds up to uncounted trillions in new debt, and a giant step closer to the utter bankruptcy of the nation. But the real danger lies in the possibility that the law is voted down by conservative Republicans and Trump turns instead to Democrats.
     
    In contrast to the former mission statement of the Republican Party, Trump believes that government solutions can work as long as they are “smart.”  The opening weeks of the Trump presidency were dominated by combative rhetoric, conservative and pro-business appointments, and nationalistic executive orders. And while this approach sent Democrats and the media into convulsions, it solidified the loyalty of Trump’s political base, and allows him to pivot toward the center if he wants. If he could peel off some “Red State” Democrats, he would be in a position to enact some of the biggest spending increases that the country has ever seen, even if fiscally conservative Republicans bolt.
     
    If those conservatives defeat the new health care bill, Trump could look to partner with Democrats in a heartbeat. Of course, to get that support, he would have to make the current bill even more generous. Let’s hope that his self-inflicted wounds continue to prevent such an unholy alliance.

    SEE ALSO: Investors must choose wisely when it comes to investing in unconstrained funds

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    Nancy Pelosi Chuck Schumer

    WASHINGTON — Critics of GOP healthcare legislation got fresh ammunition from a report that estimates the bill would increase the ranks of the uninsured by 14 million people next year alone and 24 million over a decade.

    The findings from the nonpartisan Congressional Budget Office could make prospects for the legislation backed by President Donald Trump even tougher, with a few House and Senate conservatives already in open revolt and moderate Republicans queasy about big cuts to the Medicaid safety net for the poor.

    But with the legislation headed for votes in the House Budget Committee within days and floor action next week, its supporters at the White House and on Capitol Hill showed no sign of retreat. Instead, they attacked the parts of the CBO report they didn't like while touting the more favorable findings, including smaller deficits from their bill and lower premiums over time.

    "I'm pretty encouraged by it — it actually exceeded my expectations," House Speaker Paul Ryan of Wisconsin said on Fox News Channel shortly after the report was released Monday evening.

    Ryan said the CBO findings about millions losing coverage were to be expected because the GOP legislation removes the penalty in former President Barack Obama's Affordable Care Act aimed at coercing people into buying coverage.

    "If we're not going to force someone to buy something they don't want to buy, they're not going to buy it, and that's kind of obvious," Ryan said.

    The GOP legislation would use tax credits to help consumers buy health coverage, expand health savings accounts, phase out an expansion of Medicaid and cap that program for the future, end some requirements for health plans under Obama's law, and scrap numerous taxes.

    Ryan pointed to other CBO figures, including that the GOP bill reduces federal deficits by $337 billion over a decade, and begins to bring down insurance premiums by about 10% starting in 2020, though that comes only after premiums sharply rise in 2018 and 2019.

    Democrats scoffed at Ryan's positive spin, calling the CBO analysis damning evidence that Republicans are interested only in giving hundreds of billions of dollars in tax breaks to the rich, which their bill would accomplish, while yanking health coverage from the poor.

    "I hope they would pull the bill. It's really the only decent thing to do," House Minority Leader Nancy Pelosi said. "How can they look their constituents in the eye when they say to them '24 million of you will no longer have coverage.'"

    At the White House, Health and Human Services Secretary Tom Price rejected portions of the CBO's findings, in comments that seemed to contradict Ryan's.

    "We believe that the plan that we're putting in place is going to insure more individuals than currently are insured," Price said. "So we think the CBO simply has it wrong."

    Donald Trump Tom Price

    It was unclear exactly what impact the CBO news would have on the debate. Republicans were already planning to move forward with no Democratic votes, aiming for action by the full House next week and the Senate the week after that. Senate prospects look particularly dicey, given the GOP's slim 52-to-48 majority and vociferous objections from several Republicans including Rand Paul of Kentucky and Tom Cotton of Arkansas.

    Senators were just beginning to absorb the CBO findings Monday night. The approaching winter storm had delayed the arrival of House members to the Capitol.

    "It's awful. It has to be a concern," Sen. Bill Cassidy, a Louisiana Republican, said of the budget office findings. "President Trump said he wanted as many people covered as under Obamacare."

    "At the end of the day, we should pause and try to improve the product in light of the CBO analysis rather than just rejecting it," Republican Sen. Lindsey Graham of South Carolina said.

    Price planned to meet with GOP senators Tuesday to discuss the issue.

    All along Republican leaders have assumed that once it comes time to vote, few if any Republicans will dare vote "no" on the repeal and replacement of the Affordable Care Act, better known as Obamacare, that their party has been promising for seven years. They are relying on Trump's popularity with conservative voters to close the deal, and Trump on Monday announced he would be traveling to Kentucky for a rally early next week.

    But the Congressional Budget Office report seemed likely to increase some Republicans' discomfort with their approach, especially those representing states that expanded Medicaid coverage under Obama's law. Roughly 14 million fewer people would have Medicaid coverage over a decade, as the GOP bill cuts $880 billion from the federal-state health program for the poor and disabled, the CBO said.

    Trump pledged during the presidential campaign that he would not cut Medicaid, but the bill would violate that pledge as well as fail to meet Trump's stated goal of "insurance for everybody."

    The CBO report also undercuts a central argument that Trump and other Republicans have cited for swiftly rolling back Obama's healthcare overhaul: that the health insurance markets created under the 2010 law are unstable and about to implode. The congressional experts said that largely would not be the case and the market for individual health-insurance policies "would probably be stable in most areas either under current law or the (GOP) legislation."

    ___

    Associated Press writers Matthew Daly, Alan Fram, Stephen Ohlemacher, Mary Clare Jalonick, Richard Lardner and Andrew Taylor contributed to this report.

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    Paul Krugman

    Paul Krugman on Tuesday raged against the American Health Care Act, the GOP's proposed healthcare bill, arguing it would potentially be devastating for those who voted for President Donald Trump.

    The Nobel laureate and New York Times economics columnist said in a series of tweets that the AHCA, which has become alternatively known as Ryancare (for House Speaker Paul Ryan) or Trumpcare, would make healthcare in the individual marketplace more expensive for older Americans. Krugman argued it would amount to a betrayal of Trump's own voters.

    "Can we talk about working-class Trump voters for a minute? Will they ever realize or admit how completely they were scammed?" Krugman wrote. "It's not just the fake populism, although that's a big deal. Older working-class voters would take an enormous hit under Trumpcare."

    Krugman cited the Congressional Budget Office's analysis, released Monday night, estimating that a 64-year-old making roughly $26,000 annually would see net premiums rise from $1,700 annually under the Affordable Care Act, the healthcare law better known as Obamacare, to $14,600 under the AHCA, which he said was an example of "promises broken."

    "But also bear in mind that Trump voters believed they were choosing someone effective, who knew how to get things done," Krugman said. "And here we are. The first and most important legislative initiative is stupid as well as cruel — complete incompetence in drafting and selling."

    Krugman concluded by saying the AHCA showed just how little Trump, who had no previous government experience before entering the Oval Office, knew about running the US.

    "So Trump voters thought they were getting a smart guy who'd fight for them; got a self-dealing blowhard with no idea how to govern," Krugman said. "And all of this should, of course, have been obvious all along."

    Krugman has been highly critical of Trump on Twitter since the election, calling into question his ties with Russia, Cabinet appointments, and early policy decisions.

    Check out the full tweetstorm below:

    SEE ALSO: The CBO says as many as 24 million more Americans could be uninsured under 'Trumpcare'

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    Paul Ryan

    Not everyone would gain the same benefits under the American Health Care Act, the bill House Republicans have introduced to replace the Affordable Care Act, the healthcare law better known as Obamacare.

    Because of differences in the tax-credit structure under the AHCA, older and poorer people would receive less assistance to gain access to care, according to analysis done by nonpartisan groups. Additionally, not every state would benefit in the same way.

    The Kaiser Family Foundation, a nonpartisan health-policy think tank, broke down the AHCA's tax-credit structure compared with the Affordable Care Act's.

    The key difference is that while the ACA adjusts for income level as well as the cost of living based on place of residence, the AHCA would give a flat credit based on age ranging from $2,000 annually for those under 30 to $4,000 a year for people over age 60.

    Based on Kaiser's analysis, this would shift the cost of healthcare mostly for seniors and poorer Americans, who would see their insurance subsidies fall dramatically under the AHCA.

    kff premiums age and income

    This also matches with the nonpartisan analysis done by the Congressional Budget Office in a report released Monday. The CBO said the high cost of premiums caused by declining assistance would drive many elderly people out of the market and contribute to its estimate that 24 million fewer Americans would have health insurance by 2026.

    The CBO included a comparison similar to Kaiser's, showing how net premiums, or premiums after tax-credit subsidies, would change under the new law based on income and age. Young Americans and those with higher incomes could end up paying less, but projections suggest older Americans closer to the federal poverty line would see a stark increase in premium costs over the next decade:

    net premium change v2

    Additionally, unlike the ACA, the AHCA does not adjust its tax credits based on the cost of living for the location where the beneficiary lives. Thus, rural areas where healthcare providers are limited and usually more expensive would see a bigger slash to benefits.

    Based on an analysis by the Center for Budget and Policy Priorities of how states using the federal Healthcare.gov exchange could be affected by the new law, the biggest loser would be Alaska, with a tax-credit decline of $10,243 on average for individual insurance enrollees. Also, the individual enrollee's tax credit in North Carolina, West Virginia, Oklahoma, Alabama, Nebraska, and Wyoming would decrease by more than $4,000 on average.

    cbpp obamacare repeal map v2

    SEE ALSO: The GOP's Obamacare replacement is going to disproportionately affect one group

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    donald trump cabinet

    Republican Sen. Tom Cotton of Arkansas on Tuesday blasted the insistence by GOP leadership and the Trump administration that their proposed healthcare overhaul would come in three phases.

    In defending the American Health Care Act, GOP leaders such as President Donald Trump, House Speaker Paul Ryan, and Health and Human Services Secretary Tom Price have insisted that the bill is just step one of three.

    But during a Tuesday appearance on conservative radio host Hugh Hewitt's show, Cotton dismissed their line of thinking, calling it "political talk" and saying flatly that there was "no three-phase process."

    Cotton said:

    "Hugh, there is no three-phase process. There is no three-step plan. That is just political talk. It's just politicians engaging in spin. This is why. Step one is a bill that can pass with 51 votes in the Senate. That's what we're working on right now. Step two, as yet unwritten regulations by Tom Price, which is going to be subject to court challenge, and therefore, perhaps the whims of the most liberal judge in America. But step three, some mythical legislation in the future that is going to garner Democratic support and help us get over 60 votes in the Senate. If we had those Democratic votes, we wouldn't need three steps. We would just be doing that right now on this legislation altogether. That's why it's so important that we get this legislation right, because there is no step three. And step two is not completely under our control."

    Put another way, the AHCA is designed to need only a simple majority to pass the Senate, as it is being moved through a process known as budget reconciliation. Any other bill introduced affecting statutory measures would need 60 votes in the Senate, or Democrats could filibuster it. Cotton was suggesting he thought it unlikely that any other bill could make it through the chamber.

    Add on, as Cotton said, that any regulation instituted by Price at HHS could be challenged, and all of a sudden the AHCA could be Republicans' only chance at controlling an overhaul of the healthcare system.

    Cotton has previously criticized the AHCA because of its proposed adjustments to the ACA's Medicaid expansion, for which Arkansas accepted funding, saying the House GOP should "pause" and "start over" on the healthcare plan.

    The senator on Tuesday also addressed the score given to the bill by the nonpartisan Congressional Budget Office. Cotton said that while "the CBO director is not Moses" and "he's not walking down from the mountaintop with stone tablets," there was good reason to take the report seriously.

    "All that said, I think the Congressional Budget Office is directionally correct," Cotton said. "They're right that coverage levels will go down in the coming years under the House bill. They're also right, I'm afraid, that insurance premiums will continue to go up in the near term, for three to four years, before they start perhaps falling in the long term."

    Cotton said that given those realities, the House GOP needed to seriously edit the bill before it arrived in the Senate.

    "However, I suspect that the political consequences of those near-term changes means that the long term will never actually arrive," Cotton said.

    He added: "That's why I believe it's so important that the House take a pause and try to fix some of these fixable problems in their committees, which is the easiest place in Congress to fix them, whereas the Senate floor is the hardest place to fix them."

    SEE ALSO: Here are the biggest winners and losers from 'Trumpcare'

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    paul ryan kevin mccarthy

    In their sales pitch for the American Health Care Act, House Speaker Paul Ryan and other Republicans have maintained that replacing the Affordable Care Act is necessary because the healthcare law, better known as Obamacare, is "collapsing."

    The nonpartisan Congressional Budget Office, evidently, disagrees.

    In the CBO's report predicting the effects of the AHCA, the nonpartisan budget office on Monday said the individual health-insurance marketplace under both the current system and the proposed system would be stable.

    "In CBO and JCT's assessment, however, the non group market would probably be stable in most areas under either current law or the legislation,"the report said.

    The CBO said the ACA had maintained stability mostly because of its structure of providing tax subsidies for lower-income people to purchase insurance. While premiums have increased in the exchanges, Obamacare's tax credits adjust for income and cost of living, so a vast majority of people on the exchanges could access coverage for less than $100 a month.

    "Under current law, most subsidized enrollees purchasing health insurance coverage in the non-group market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference," the CBO report said.

    On the other hand, the CBO also said the AHCA would maintain that stability despite lowered tax credits.

    "Even though the new tax credits would be structured differently from the current subsidies and would generally be less generous for those receiving subsidies under current law, the other changes would, in the agencies' view, lower average premiums enough to attract a sufficient number of relatively healthy people to stabilize the market," the report said.

    Some of this stability would come from the lower total number of people on the exchanges — the CBO projected that 24 million Americans would lose their insurance by 2026 under the new legislation, with a good chunk coming from the individual market. Other factors would come from the AHCA's state innovation grants, which the CBO said would allow states to find ways to stabilize their markets.

    This isn't necessarily a new revelation from the CBO: It has previously said the ACA would maintain a stable market. Additionally, despite Ryan's and other GOP leaders' insistence that Obamacare is entering a "death spiral," an analysis from the Brookings Institution showed that the ACA's exchanges did not fall under that definition.

    SEE ALSO: Here are the biggest winners and losers from 'Trumpcare'

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    Donald Trump

    Despite the American Health Care Act drawing support from House Speaker Paul Ryan, Senate Majority Leader Mitch McConnell and President Donald Trump, the leadership's biggest problem still remains — senators in their own party.

    Republican senators have cast doubt on the AHCA — which would repeal and replace Obamacare — after the Congressional Budget Office estimated in a report Monday that the law would cause as many as 24 million more Americans to lack health insurance by 2026.

    "It's awful. It has to be a concern," said Sen. Bill Cassidy of Louisiana, who has introduced his own alternative to the AHCA. "President Trump said he wanted as many people covered as under Obamacare."

    Republicans from stronghold states such as South Carolina, Louisiana, and Arkansas have expressed misgivings about the legislation after the CBO report, putting the future of the healthcare law in doubt.

    'We need to do better'

    "We need to do better,"Sen. Steve Daines of Montana said in a statement following the CBO report.

    Sen. Lindsay Graham of South Carolina said the CBO score should cause Republicans to delay their bill until they can make changes.

    "At the end of the day we should pause and try to improve the product in the light of the CBO analysis rather than just rejecting it,"said Graham, who has previously said the GOP should "slow down" on the healthcare overhaul.

    And Sen. Tom Cotton of Arkansas launched into a lengthy rebuke of the AHCA on conservative radio host Hugh Hewitt's show. He said that while the CBO director "isn't Moses" when it comes to estimating the number of people losing coverage, he believed the CBO was "directionally correct" about the coverage losses.

    Sens. John McCain of Arizona and Susan Collins of Maine, meanwhile, also expressed concerns over the potential effects described in the report.

    Little margin for error

    The biggest problem for Republican leaders is that only a few defections from the party are enough to derail the AHCA's path to Trump's desk.

    The party holds a 52-seat majority in the Senate, so losing only three votes would prevent the law from passing. Given the number of senators that have previously said they have objections with the bill and the lawmakers that expressed doubts after the CBO score, there is a real chance that the GOP could have many more defectors.

    Plus, Senate procedural rules could stop the bill in its tracks. The Byrd Rule does not allow a bill going through budget reconciliations — as in the case of the AHCA — to include anything that does not impact the budget's bottom line. Analysts and lawmakers have said that various aspects of the AHCA could violate the provision and stop the bill in its tracks.

    The bill passed two House committees last week and will be considered by the House Budget Committee on Thursday.

    SEE ALSO: A top Republican senator blew up Trump's '3-phase plan' for healthcare overhaul

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    Barack Obama

    One Republican talking point about the Congressional Budget Office score showing that their health plan would cause 24 million people to lose health insurance is this: A large chunk of that coverage loss is because their plan repeals the individual mandate.

    Under Obamacare, those people will be forced to buy health insurance. Under the Republican plan, they have the freedom not to buy insurance they don't like. Aren't they better off?

    This is a bad argument. And it's an argument Republicans make because they know the individual mandate is the most unpopular part of Obamacare but don't understand why it is so unpopular.

    People don't want to be forced to buy health insurance, but that's not because they want the freedom to go uninsured.

    People want to be offered health insurance that they're happy to buy. And the Republican plan, which would leave 52 million Americans uninsured by 2026, fails to do that in lots of cases.

    Now, that's partly because in a lot of cases, the only way you're going to get Americans to happily buy health insurance is to price it far below cost. This is how the Medicare prescription drug benefit works: It's not mandatory, but participation is near-universal because premiums cover only about 14% of the costs, and the government picks up the other 86%.

    Republicans might protest that's not what "choice" means. You might like the choice of heavily-subsidized housing or heavily-subsidized restaurant meals, but that doesn't mean the government should give them to you.

    But this often is what "choice" means in the political context. "School choice" is a policy of giving children free or heavily subsidized education. And health are, like education, is a sector of the economy in which voters have come to expect the government to pick up part of the tab — whether through Medicare, Medicaid, the enormous tax subsidy for employer-sponsored insurance, or the Obamacare subsidies that have proven surprisingly popular once you try to repeal them.

    Republicans got mileage for years by talking about choice in healthcare. Now that it's time for them to actually make law, they are poised to learn that most voters who wanted choice did not mean "a system where 52 million Americans will make the 'choice' to be uninsured."

    SEE ALSO: Republicans don't understand their own criticisms of the agency that's about to score their healthcare bill

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    paul ryan

    The Congressional Budget Office announced Monday that the American Health Care Act, the GOP leadership's plan to repeal and replace the Affordable Care Act, would shrink the federal budget deficit by more than $330 billion over the next decade.

    The deficit shrinkage would come, according to the report, from massive spending cuts to Medicaid, the government-run health program that provides insurance primarily to pregnant women, single parents, people with disabilities, and seniors with low incomes.

    Roughly $880 billion would be cut from federal Medicaid spending over the next decade under the proposed legislation, according to the CBO report.

    The spending cut would primarily be due to the rollback of the expansion of Medicaid established under the Affordable Care Act, better known as Obamacare. Eligibility for Medicaid was expanded under the law to include any adult living under 138% of the federal poverty level — an income of $27,821 for a family of three in 2016. Thirty-two states, including the District of Columbia, have chosen to participate, leading to more than 11 million people nationwide gaining coverage.

    The CBO estimated that changes to eligibility under the AHCA would most likely result in a loss of 14 million people from the Medicaid rolls by 2026. And while that would account for a significant portion of the budget savings, the AHCA is hiding a much more "fundamental" change in how Medicaid would operate, said Richard Frank, a professor at Harvard Medical School professor.

    "It's no longer an open-ended matching program," Frank told Business Insider. The AHCA "fundamentally changes the kind of contract that exists between the states and the federal government."

    Since its establishment in 1965, Medicaid has been an open-ended entitlement program. Anyone who meets the eligibility requirements has a right to enroll, and if costs go up because of new, expensive treatments or increasing healthcare needs, states receive more federal money. While states fund a big portion of their individual Medicaid programs, the federal government matches up to a certain percentage, with bigger matches for poorer states.

    The AHCA would change the federal Medicaid funding to a per-capita spending cap, meaning the federal government would send states a fixed amount of money per Medicaid enrollee, regardless of whether that would cover needs or care, starting in 2020. That amount would increase yearly according to the medical-care component of the consumer price index — between 2% and 5%, depending on the year.

    Frank said that using medical-care CPI as a benchmark for Medicaid would become a problem for states because it doesn't take into account changes to population or unexpected crises.

    Screen Shot 2017 03 14 at 3.05.27 PMOne of the most obvious pitfalls would come with the aging of the baby boomer generation, Frank said.

    By 2050, the population of people 65 and is expected to have increased to 83.7 million — nearly double the 43.1 million in 2012 — according to a 2014 US Census Bureau report, with big increases in the number of people over the age of 85 as well.

    Under the AHCA, the cost to cover Medicaid recipients in those categories would be determined by their 2016 spending patterns and then increased according to medical-care CPI. The problem, according to Frank, is that healthcare costs for elderly people would increase at a far higher rate than medical-care CPI.

    In addition, the per-capita system would divide Medicaid recipients into different categories, such as elderly people or people with disabilities, to determine the size of payments.

    However, those categories are broad. For instance, 65-year-olds are in the same category as 85-year-olds, even though healthcare costs go up substantially as people age. Frank estimated that the AHCA plan would lead to a 9% shortfall in the coming decades, or about $10 billion a year that states would have to make up for.

    "Even under the best-case scenario for the per-capita cap, you are going to fall behind. That assumes there are no new drugs or treatments. Together, that's problematic," Frank said. "The states are going to take a big hit here."

    Current CBO projections say Medicaid spending under the per-capita system would be about 25% less than it would be under the ACA by 2026.

    The choice for states

    bi graphicsopioid death ratesTo stay above water, states would either have to spend more money on their Medicaid programs — a daunting proposition for poorer states like West Virginia, where one-third of its population is on Medicaid— or cut costs.

    Because Medicaid is already one of the lowest-cost providers of healthcare, a state could either cut benefits, which would affect the quality of coverage, or reduce who is eligible for the program, which could hurt people with disabilities, older people, or people suffering from substance abuse.

    One of the first things to go could be treatments for substance use and mental illnesses, Frank said.

    Another provision of the AHCA would remove the ACA's Essential Health Benefits, which require all health plans to include certain services, from some Medicaid plans. Before the ACA's implementation, mental-health care and substance-use treatments tended to be "sparsely covered" by Medicaid providers, Frank said.

    With the US in the midst of a drug-overdose crisis, that could be devastating. About 1.29 million people in the US are receiving treatment for substance-use disorders or mental illnesses thanks to the Medicaid expansion, according to research conducted by Frank and Sherry Glied, a dean at New York University.

    Without the Medicaid expansion, the 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.

    Even if state Medicaid programs didn't cut coverage for substance-use treatments, the per-capita proposal would likely be devastating in terms of the opioid epidemic.

    Opioid-overdose deaths increased by about 15% in 2014 and 2015, and Medicaid has paid for more than 50% of substance-use treatment services in some states, according to official statistics. Medicaid recipients' access to treatment has increased by between 20% and 25% over the past several years, according to Frank.

    Those numbers far outpace a growth in spending fixed to medical-care CPI.

    If the AHCA were to become law, Ohio, Pennsylvania, and West Virginia — among other states suffering the brunt of the opioid crisis — would be ill-suited to handle the loss in funds, government officials and treatment experts say. And that's to say nothing of states like Florida, where a disproportionately aging population could suffer.

    The AHCA Medicaid plan wouldn't likely be popular with the public. When presented with a choice of accepting the Republicans' proposals to limit Medicaid spending or keeping the program the same, 65% of respondents said they would want the program to stay the same, according to a tracking poll released late last month the Kaiser Family Foundation.

    A Morning Consult/Politico poll released on Wednesday found that only 48% of Americans said they supported the current proposal to change Medicaid.

    SEE ALSO: The GOP's Obamacare replacement includes many Republican governors' biggest fear — and it could doom the bill

    DON'T MISS: The Obamacare repeal 'could be a disaster' for states fighting the opioid epidemic

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    doctor patient pacemaker

    The American public is warm to House Republicans' plan to overhaul the US healthcare system, but it doesn't like the actual changes proposed by the law, two new polls suggest.

    A poll from Morning Consult and Politico found that 46% of Americans approved of the new GOP bill, the American Health Care Act, while only 35% disapproved.

    But respondents were not as keen on the legislation's proposed policies.

    Morning Consult and Politico found that the most popular parts of the new healthcare bill were actually holdover elements from the Affordable Care Act, the healthcare law better known as Obamacare. The provision that insurers can't deny coverage based on a preexisting condition — an ACA holdover — was the most popular element, with 71% of those surveyed approving of the idea.

    Second-most popular was allowing children to stay on their parents' insurance until they turn 26 — also an ACA provision — with 68% support.

    The major changes in the AHCA, on the other hand, had lower support, with the elimination of the individual mandate to purchase health insurance and the increase in allowances for health-savings accounts coming in as the most popular new provisions (50% approval for each).

    Below 50% support was the rollback of Medicaid expansion funding after 2020 (48%), replacing income-based tax credits with flat, age-based tax credits (39%), and prohibiting states from using federal funding for Planned Parenthood (38%).

    The least popular element was the provision designed to encourage people to maintain health coverage: a 30% increase in premiums for people who allow their insurance to lapse in the year before. That had only 18% support. The individual mandate from the ACA, in which people paid a tax for not having insurance, received 37% support.

    At the same time, the Kaiser Family Foundation, a nonpartisan think tank focused on health policy, found that Americans generally thought the outcomes from the AHCA would be negative.

    Kaiser found that 48% of people surveyed thought the costs for those buying their own insurance would increase under the AHCA, against just 23% of people who expected costs to decrease. The poll also found that more people thought the AHCA would increase costs rather than decrease them for every group — young, elderly, urban, rural, and low-income — except high-income Americans.

    The survey was conducted before the nonpartisan Congressional Budget Office released an unflattering report on the AHCA on Monday.

    The Kaiser poll found that 49% of respondents supported Obamacare, versus 44% who disapproved of the law, the second month in a row in which the law was above water in terms of approval and its highest rating since 2010. Also, 51% of people surveyed by Kaiser said lawmakers should not vote to repeal the ACA, while 45% supported some sort of repeal vote.

    SEE ALSO: Here are the biggest winners and losers from 'Trumpcare'

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    An authoritative voice on the right has been largely missing in action from the healthcare debate: Matt Drudge.

    The internet news mogul, who harnesses the power to anchor much of conservative media behind the narrative of his choosing, has yet to enter the fray on the debate over the House GOP's plan to repeal and replace the Affordable Care Act.

    The silence is deafening, particularly as Breitbart, which typically mirrors the Drudge Report, moves to savage the healthcare proposal spearheaded by House Speaker Paul Ryan. In the past, Drudge, too, has seemed to derive pleasure from mocking and ridiculing Ryan.

    "I'm surprised," Matt Lewis, a conservative columnist for The Daily Beast, wrote in an email. "This seems like a hot story, so I don't think it's about clicks. I can only theorize that (unlike Breitbart) Drudge is more interested in helping Trump than in hurting Ryan."

    Drudge has featured a small handful of stories about the healthcare debate on his website in the last couple weeks, usually slanted against the House GOP plan. But he has largely refrained from flexing his muscles and ripping the legislation like Breitbart, which until recently was run by White House chief strategist Steve Bannon. On Tuesday afternoon, for instance, there was not a single story about the proposed bill on his website.

    "Trying to figure out why Drudge has done something is usually very easy in retrospect, but extremely difficult in real time," said John Ziegler, a former talk show host and conservative media columnist who writes for Mediaite. "Drudge's two greatest motivations appear to be traffic and money and creating chaos."

    "I think with the healthcare bill he is conflicted and doesn't see a horse to ride," Ziegler added.

    Drudge was a fierce supporter of President Donald Trump throughout the 2016 campaign. The internet tycoon used his highly trafficked website to push narratives favorable to Trump, while simultaneously slinging mud at the billionaire's opponents.

    Trump has offered tepid support for the House GOP's plan to repeal and replace the Affordable Care Act, but he has signaled he may be willing to work with hardline conservatives in Congress to make changes to it, a move that would likely be welcomed by Drudge and the editors at Breitbart.

    The thinking at Breitbart seems to be that the website can use its sizable readership to influence the process and push Trump toward the right. But as Ziegler put it, perhaps Drudge "sees no good angle yet" and is waiting to see how things pan out before making a move.

    "It feels to me, and this is just a feeling, that Drudge is preparing to flip on Trump if he doesn't start really kicking ass, taking names, draining the swamp, and lowering Matt's tax rates," Ziegler said.

    Indeed, Drudge has hinted at dissatisfaction with the Republican Party, but has focused his ire on establishment figures, avoiding leveling criticism directly at Trump. In a tweet on Tuesday, for example, Drudge contended the GOP "lied about wanting tax cuts" and asked, "Can we get our votes back?"

    While it's not clear why he has held his fire thus far amid the raging healthcare debate, one thing on which everyone seems to agree is that it's impossible to predict what Drudge will do next.

    "He is his own man. Beats his own drum," a person close to Drudge said on the condition of anonymity. "He often just follows his own interests."

    "And clearly that formula works for him," the person added, "as Drudge is the must-read for all in power."

    SEE ALSO: Matt Drudge is the man who could have stopped Donald Trump

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    Donald Trump Paul Ryan

    Even as major leaders of the Republican Party are publicly campaigning in favor of the House GOP's bid to repeal and replace the Affordable Care Act, the healthcare law better known as Obamacare, it seems as if no one wants full credit for the bill.

    The teams of both House Speaker Paul Ryan and President Donald Trump have pushed back on taking on full responsibility for the contents of the American Health Care Act, billing it as a team effort.

    The White House press secretary, Sean Spicer, was asked directly about efforts by both Trump spokeswoman Kellyanne Conway and Health and Human Services Secretary Tom Price to push back on reporters' calling the bill "Trumpcare."

    "The president is proud of it. The president is proud of the fact that we're working with Congress. But this is a bill that is not his — it's a joint effort that we've worked with the House and the Senate on,"Spicer said in a press briefing on Tuesday.

    "He's proud of it. He's proud of the impact that it's going to have on American patients. So I don't think this is about labels and names — this is about getting a job done."

    Ryan also seemed to step back from taking full credit for the bill in an interview Wednesday. Many conservative and liberal blogs have taken to deriding the proposed law as "Ryancare."

    During an interview with Fox Business anchor Maria Bartiromo, Ryan stressed that Trump had a part in crafting the bill.

    "Obviously, the major components are staying intact because this is something we wrote with President Trump," Ryan said. "This is something we wrote with the Senate committees. So just so you know, Maria, this is the plan we ran on all of last year. This is the plan that we've been working with House, Senate, White House together on."

    The approach from each camp was reminiscent of President Barack Obama's approach to Obamacare, the name Republicans first used to deride the law. Obama eventually said he welcomed the Obamacare moniker while he was campaigning for reelection.

    SEE ALSO: The CBO score has made Trumpcare's biggest test even tougher

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    Paul Ryan

    The Wall Street Journal's editorial board, an important right-leaning voice, called the GOP's American Health Care Act a historic opportunity to curtail government spending and lower taxes in a Wednesday editorial

    Calling the bill "an enormous pro-growth fiscal bonus," the editorial board focused on the law's projected economic effects, as determined by the Congressional Budget Office, rather than the law's effects on healthcare coverage. 

    The editorial comes amid an intensifying battle within the Republican Party over the bill. President Donald Trump has pledged his full support for the AHCA, an effort led by House Speaker Paul Ryan, while conservative Republicans are calling it"Obamacare lite." Trump reportedly warned House Republicans of a "bloodbath" in the 2018 midterm election if the AHCA fails. 

    The Journal's board argued that the bill, which would reduce the federal budget deficit by $337 billion over a decade, is a unique opportunity for conservatives to prevent a debt crisis, large tax increases, and cuts to entitlement programs other than Medicaid. 

    "CBO shows the bill is a far-reaching advance for the market principles and limited government that conservatives usually favor," the board wrote. 

    The board hailed the bill's significant cuts to Medicaid — $880 billion over a decade, which the CBO estimates would help cause 14 million people be removed from the rolls of the program by 2026. 

    "When was the last time a government program got 25% smaller?" the board wrote. "As with welfare, we should want fewer Americans to need Medicaid."

    While conservative Republicans support large cuts to Medicaid, more moderate GOP leaders, particularly lawmakers from states where Medicaid expansion under Obamacare has been popular, have been critical of cuts. 

    The editorial also praised the bill's tax cuts, including a 3.8% reduction in the capital gains tax, which it called Obamacare's "most damaging tax." Democrats have criticized Trump for apparently reversing his position on capital gains taxes, about half of which affect the top 0.1% of earners. 

    The editorial board argued that Republicans would regret taking a hardline against the replacement legislation. 

    "If conservatives fumble this repeal-and-replace moment, they won’t get another chance," the board wrote. "And they’ll have squandered their best opening in a generation to control the size and scope of the federal Leviathan."

    SEE ALSO: The CBO says as many as 24 million more Americans could be uninsured under 'Trumpcare'

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    File photo: Information cards are stacked on a table during an Affordable Care Act outreach event for the Latino community in Los Angeles, California September 28, 2013. REUTERS/Jonathan Alcorn

    NEW YORK (Reuters) - Enrollment in the individual insurance plans created under Obamacaredeclined to 12.2 million Americans, the U.S. government said on Wednesday as Republican lawmakers and the Trump administration sought to repeal the healthcare law.

    As of the end of January, enrollment was down by about 500,000 people from 2016. It is about 1.6million people short of former President Barack Obama's goal for 2017 sign-ups, the government said.

    The U.S. House of Representatives is working on passing a bill that would gut the 2010 Affordable Care Act, often called Obamacare, in part by replacing the income-based tax credits that helped reduce the monthly premiums for the majority of participants with age-based credits.

    The White House and congressional leaders said on Tuesday they were weighing changes to their plan to dismantle Obamacare as Republicans' questions mounted following an estimate that it would cause 14 million Americans to lose insurance next year.

    The finding made it tougher for President Donald Trump to sell his first major piece of legislation, even to fellow Republicans in Congress.

    The data released on Wednesday by part of the U.S. Department of Health and Human Services includes people who selected or were automatically enrolled in a plan between Nov. 1 last year and Jan. 31 either through the federal HealthCare.gov website or one of the state-based exchanges.

    Of those enrolled, 10.1 million people or 83 percent received the advance premium tax credits, one of the lynchpins of the law alongside the expansion of Medicaid for the poor. About one-third of the enrollees were new to the market.

     

    (Reporting by Caroline Humer; Editing by Chizu Nomiyama and Alistair Bell)

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

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    President Donald Trump is hitting the road starting Wednesday to drum up support for the GOP's replacement of Obamacare, with strategic visits to states in the southern part of the US.

    The two campaign-like stops will try and win over two different audiences that need to come onboard for Trump and Republicans to pass the the American Health Care Act — the bill that would repeal and replace the Affordable Care Act.

    With strong opposition from both parties, think tanks, and industry groups, Trump's ability as a campaigner — and a salesman — will be on full display during his visits.

    Nashville, Tennessee

    The first stop on the "Trumpcare" tour comes in Nashville, Tennessee, on Wednesday.

    The state is a perfect place for Trump to make his dual-pronged case that Obamacare is collapsing, and that his base should support the GOP's alternative.

    For one thing, experiences in Tennessee highlight the increasing premium costs faced by some Americans under Obamacare. In 2017, the average benchmark silver plan offered on the individual health insurance exchanges in Tennessee increased by 63%, according to the Department of Health and Human Services.

    Secondly, the decrease in choice that Trump and Republicans bring up so often is also an issue in the state. Four of the state's exchange regions have just one insurer offering plans.

    Even Tennessee's state insurance commissioner Julie Mix McPeak said in August that the exchanges in the state are "very near collapse."

    "I'm doing everything I can to prevent a situation where that turns to zero," she said at the time.

    The statistics provide ample opportunity for Trump to hammer at the negatives of Obamacare, countering the rise in popularity for the ACA, which has been hitting its highest approval ratings ever in numerous polls.

    Louisville, Kentucky

    The other scheduled stop on Trump's tour will come Monday in Louisville, Kentucky.

    This presents a different challenge for Trump, because the ACA was generally a positive for many Kentuckians. It forces the president to build a case for why the AHCA is a better alternative.

    After the passage of the ACA, former Democratic Gov. Steve Beshear embraced the ACA by taking on both the Medicaid expansion offered by the ACA and creating the state-based individual health insurance market called Kynect.

    Compared to the broader ACA, Kynect was relatively popular with those in Kentucky, and the percentage of the people without health insurance fell the most of any state between 2013 and 2016, declining from 20.4% of Kentuckians uninsured to 7.8%, a 12.6 percentage point fall.

    The stats will force Trump to not only have to make the case for why the ACA is collapsing, but also why the AHCA would be better. This will prove more difficult, since analysis from the Congressional Budget Office and health policy experts have shown that support in the form of tax credits will decrease for recipients in Kentucky on average.

    The visit is also about a single politician as well: Sen. Rand Paul, a fellow Republican. Paul has been one of the loudest critics of the AHCA and criticized the GOP's plans to repeal and replace Obamacare even before the introduction of the law.

    The visit to Paul's home state will be a chance for Trump to push back on his criticism that the AHCA does not go far enough in its repeal of the ACA, and that there needs to be a bigger overhaul of the healthcare market. Trump even tweeted at Paul that the senator would "come along with the new and great healthcare program."

    SEE ALSO: Americans like the Republican Obamacare replacement in theory — but they don't like what it does

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    Screen Shot 2017 03 15 at 5.38.16 PM

    House Speaker Paul Ryan on Wednesday suggested it was too early to speculate whether the American Health Care Act, the GOP's bill to repeal and replace Obamacare, will pass the Republican-controlled House of Representatives.

    Asked whether it would pass by CNN's Jake Tapper, Ryan deflected and said the bill is still going through a legislative process.

    "It's not coming up this afternoon, it's going through the legislative process. That legislative process has not been finalized," Ryan said.

    Ryan refused to accept the premise of the question.

    "That's, no offense, kind of a goofy question or a false premise because this goes through four committees. We've gone through two so far," Ryan said. "By the way, the two committees it went through? Unanimous Republican votes in each of those committees, and those committees compromise a cross-section of our House majority."

    Ryan's insistence comes as several GOP House lawmakers have said that they will not vote for the AHCA as it is currently written and many others have expressed serious doubts about the bill.

    Ryan previously said that he could "guarantee" that when th AHCA "comes to the floor, we'll have 218" votes to pass it.

    The tougher task may come with its passage in the Senate, where only three Republicans need to vote against the bill for it to not pass. Ryan said that once the bill is out of the House, "we'll see what they do."

    The AHCA will be considered by the House Budget Committee on Thursday in the next step of the legislative process.

    Watch Ryan's comments below:

     

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    The American Health Care Act, the House GOP leadership's bill to repeal and replace Obamacare, may have hit a serious roadblock Wednesday evening.

    Rep. Mark Meadows, who leads the conservative House Freedom Caucus, told reporters that he has enough votes to block the AHCA in a vote in the House.

    According to reports from CNN and BuzzFeed, Meadows told reporters as many as 40 to 50 members ready to vote "no." And 20 more are on the fence, he said.

    Without those votes and with all Democrats likely voting against the legislation, the bill would not be able to advance beyond the House.

    Meadows and the House Freedom Caucus believe the bill does not go far enough in its repeal of Obamacare, the law officially known as the Affordable Care Act. They have argued for changes to strip out some of the ACA's regulations and proposed elements of the new AHCA.

    Meadows, according to reports, said he has a number of changes the Freedom Caucus wants to make to the AHCA. They plan to present it to members on Friday. 

    The developments add more uncertainty to the legislation after a number of moderate Republicans in the Senate also suggested that they would not vote for the bill in its current form, screeching to a halt the AHCA's progression in the upper chamber.

    Negotiations

    Perhaps sensing the resistance, both President Donald Trump and House Speaker Paul Ryan opened the door wider for changes to the AHCA during media appearances on Wednesday.

    Speaking to Fox News' Tucker Carlson on Wednesday, Trump said that the AHCA was "preliminary" and that the GOP is "going to have a negotiation" on the bill.

    "I'm, in a little way, I'm an arbitrator," Trump told Carlson. "We have the conservatives, we have the more liberal side of the Republican Party, we have the left, we have the right within the Republicans themselves, we got a lot of fighting going on, we have no Democrats, again, no matter what we do, we're never going to get a Democrat. Maybe we'll get one along the way."

    Ryan echoed the comments during his weekly press briefing on Wednesday, saying now that Republicans have received a score from the Congressional Budget Office, they can make "refinements and improvements" to the AHCA.

    "What's happening in this legislative process is we're getting feedback from various members on how we can improve the bill now that we have the [CBO] score we know exactly what we're dealing with," Ryan said."So now that we have the score, we can incorporate feedback to improve this bill, to refine this bill, and those kinds of conversations are occurring between the White House, the House, and the Senate and our members. It's premature to get into the conclusion of those things."

    Ryan also said the GOP is looking for a "sweet spot that gets us a big vote count, that gets us our passage, that makes all members happy."

    After presenting an initial timeline to advance the AHCA to a full House vote by next week, Ryan also backed off his planned schedule on Wednesday. He said House Majority Leader Kevin McCarthy would have a better sense and that the GOP was dealing with "snow day issues" after the Capitol was closed for business on Tuesday.

    In the end, however, Ryan said that he was "confident our members will keep their word" to repeal and replace Obamacare.

    The bill faces its next major test as it heads for a mark up, a process of adding amendments and making changes, with the House Budget Committee on Thursday.

    SEE ALSO: Trump heads out on a 'Trumpcare' tour

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    A copy of Obamacare repeal and replace recommendations (L) produced by Republicans in the U.S. House of Representatives sit next to a copy of the Affordable Care Act known as Obamacare as U.S. Health and Human Services Secretary Tom Price addresses the daily press briefing at the White House in Washington, U.S. March 7, 2017.   REUTERS/Carlos Barria

    WASHINGTON (AP) — The White House and Republican leaders are talking to rank-and-file lawmakers about revising the GOP health care overhaul, hoping to keep a rebellion by conservatives and moderates from snowballing and imperiling the party's showpiece legislation.

    Four days after a congressional report projected the bill would pry coverage from millions of voters, signs of fraying GOP support for the legislation were showing. The measure would strike down much of former President Barack Obama's 2010 overhaul and reduce the federal role, including financing, for health care consumers and is opposed uniformly by Democrats.

    In a fresh test of Republicans' willingness to embrace the legislation, the House Budget Committee was considering the measure Thursday. Republicans expressed confidence the bill would be approved, but the vote could be tight. The panel can't make significant changes but was expected to endorse non-binding, suggested changes to nail down votes.

    The bill would eliminate the tax penalty that pressures people to buy coverage and the federal subsidies that let millions afford it, replacing them with tax credits that are bigger for older people. It would cut Medicaid, repeal the law's tax increases on higher earning Americans and require 30 percent higher premiums for consumers who let coverage lapse.

    Overt GOP opposition grew after the nonpartisan Congressional Budget Office projected Monday that the legislation would push 24 million Americans off coverage in a decade and shift out-of-pocket costs toward lower income, older people. Obama's law has provided coverage to around 20 million additional people

    House Speaker Paul Ryan, R-Wis., told reporters Wednesday that leaders could now make "some necessary improvements and refinements" to the legislation. But he declined to commit to bringing the measure to the House floor next week, a schedule Republican leaders have repeatedly said they intended to keep.

    At a late rally in Nashville Wednesday, President Donald Trump said: "We're going to arbitrate, we're all going to get together, we're going to get something done."

    Vice President Mike Pence met with House GOP lawmakers and pressed them to unite behind the legislation.

    "'It's our job to get it out of here and get it to the Senate,'" Pence told Republicans, according to Rep. Dennis Ross, R-Fla. That would let Trump pressure "Democrats in these red states to come on board,'" Ross said, referring to Republican-leaning states where Democratic senators face re-election next year.

    But insurgents still abound.

    Demonstrators protest over the repeal and replacement of Obamacare outside the offices of Republican congressman Darryl Issa in Vista, California, U.S., March 7, 2017.    REUTERS/Mike Blake

    Conservatives want to end Obama's expansion of Medicaid to 11 million additional low-income people next year, not 2020 as the bill proposes. They say a GOP proposed tax credit to help people pay medical costs is too generous, and they want to terminate all of Obama's insurance requirements, including mandatory coverage of specified services like drug counseling.

    Rep. Mark Meadows, R-N.C., head of the hard-line conservative House Freedom Caucus, continued pushing for changes. He claimed at least 21 members of his group would oppose the measure as written; the bill would fail if 22 Republicans join all Democrats in opposing it.

    But underscoring the push-pull problem GOP leaders face in winning votes, moderates feel the tax credits are too stingy, especially for low earners and older people. They oppose accelerating the phase-out of the Medicaid expansion and are unhappy with long-term cuts the measure would inflict on the entire program.

    Terminating the Medicaid expansion in 2020 and not 2018 "is sacrosanct to me," said moderate Rep. Tom MacArthur, R-N.J.

    paul ryan obamacare

    In a new complication, Sen. Charles Grassley, R-Iowa, said the measure lacked the votes to pass in the Senate, where Republicans hold a precarious 52-48 majority. That left House members angry over being asked to take a politically risky vote for legislation likely to be altered.

    Moderates "don't like the idea of taking a vote in the House that may go nowhere in the Senate," said Rep. Charlie Dent, R-Pa.

    Amid the maneuvering, a federal report said more than 12 million people have signed up for coverage this year under the very statute that Republicans want to repeal. That figure underscored the potential political impact of the GOP's next move.

    ___

    Associated Press reporters Erica Werner, Darlene Superville and Kevin Freking contributed to this report.

    SEE ALSO: Republicans have released their long-awaited plan to repeal Obamacare

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    Paul Ryan

    The American Health Care Act, the House GOP bill to overhaul the US healthcare system, passed the House Budget Committee on Thursday, but Republicans may have gotten a preview of the worries to come.

    The bill, the American Health Care Act, was moved on to the House Rules Committee by a vote of 19 to 17. The Democrats on the committee were joined by three Republicans in voting against moving the AHCA ahead.

    GOP Reps. Mark Sanford, Dave Brat, and Gary Palmer all voted against the bill, putting it one vote away from being tied up in the Budget Committee.

    All three representatives are members of the House Freedom Caucus, a conservative group that has come out against the AHCA.

    The Freedom Caucus has taken issue with the AHCA's tax credits and what it considers a failure to fully repeal the Affordable Care Act, the healthcare law better known as Obamacare, as the GOP has promised. Mark Meadows, the head of the Freedom Caucus, said Wednesday night that he had enough votes to block the AHCA from moving past the House.

    The "no" vote by the three Freedom Caucus members indicates that the conservative group is getting serious about blocking the bill. No Republicans voted against the bill when it was considered by two previous committees.

    Meadows also said he would roll out a package of amendments to the bill to make it more palatable to conservatives and moderates alike.

    Both House Speaker Paul Ryan and President Donald Trump insisted in interviews on Wednesday that the negotiation process for the AHCA was ongoing and that changes to the bill could be made.

    In terms of the AHCA's next steps, the Budget Committee can now consider resolutions that will be advanced to the Rules Committee and full House floor for consideration as amendments.

    Ryan's original plan for the AHCA was to bring it for a full House vote next week, a promise he backed away from at a press conference on Wednesday.

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    President Donald Trump nodded in agreement during a Wednesday interview with Fox News' Tucker Carlson when told the American Health Care Act, the bill to repeal and replace Obamacare, would cause the most damage to people who voted for him in November.

    During the interview, Carlson mentioned an analysis by Bloomberg that showed that counties that voted more heavily for Trump in the election would see their tax credits to purchase insurance fall dramatically and likely see the number of people without insurance increase.

    "Oh, I know. I know," Trump responded. "It's very preliminary, Tucker."

    According to the analysis, people in counties that voted for Trump would see $6.6 billion in annual tax cuts, while people living in counties that supported Democratic nominee Hillary Clinton would get a tax break of $21.9 billion.

    Additionally, since the AHCA's tax credits would be flat totals based on age instead of income and cost of living, some states would see a sharper decrease in their average premiums.

    Based on an analysis by the Center on Budget and Policy Priorities, the seven states in which Americans would see their tax credits decline the most are Alaska, North Carolina, West Virginia, Oklahoma, Alabama, Nebraska, and Wyoming. Each of those states voted for Trump. In fact, the 13 states that would see the steepest declines in tax credits all swung toward Trump in November.

    cbpp obamacare repeal map vs electoral map

    Despite the disproportionate effect the bill could have on his own voters, Trump said the bill would eventually pass. But he suggested changes to the existing version.

    "A lot of things aren't consistent," Trump said. "But these are going to be negotiated.

    "And by the way, if we're not going to take care of the people, I'm not signing anything," he added. "I'm not going to be doing it, just so you understand."

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