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The latest news on Obamacare from Business Insider

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    Paul ryan donald trump kevin brady

    • President Donald Trump asked aides why everyone can't be covered under Medicare, according to a new book.
    • The Medicare-for-all idea has been advanced in a bill offered by Sen. Bernie Sanders and Democrats.
    • Trump also reportedly had "little or no interest" in the Obamacare repeal fight.

    President Donald Trump reportedly mused to top aides about a healthcare policy that aligns with Bernie Sanders' healthcare platform, according to the explosive new book "Fire and Fury" by author Michael Wolff.

    Wolff wrote that when the president was discussing healthcare and the possible repeal of the Affordable Care Act, he asked aides, "Why can't Medicare simply cover everybody?"

    The idea of Medicare-for-all has grown popular in recent years among the left wing of the Democratic Party. Sanders introduced last year a bill that would expand the government healthcare program for seniors, drawing support from an array of Democratic senators, including Cory Booker, Kamala Harris, Elizabeth Warren, and 13 others.

    Advocates for the idea say expanding Medicare would help to cover nearly all Americans and could allow the government to negotiate prices to bring down costs. Experts disagree about its potential effects.

    In the early days of his presidency, Trump promised to "take care of everybody" with his healthcare plan at a lower cost. The eventual repeal and replace bills Republicans advanced would have reduced the number of people with insurance by anywhere from 21 million to 24 million over the next 10 years and caused premiums for many to increase.

    In the book, Wolff also wrote that Trump had little interest in the policy side of the healthcare debate and was willing to turn over the reigns on the repeal and replace bill to House Speaker Paul Ryan.

    "Trump had little or no interest in the central Republican goal of repealing Obamacare," Wolff said.

    SEE ALSO: Republicans are already acknowledging they need to fix their gigantic tax law — but that could be impossible

    Join the conversation about this story »

    NOW WATCH: A mother and daughter stopped speaking after Trump was elected — here's their emotional first conversation after the long silence

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    Former U.S. President Barack Obama speaks during the North American Climate Summit in Chicago, Illinois, U.S., December 5, 2017. REUTERS/Kamil Krzaczynski

    • The CDC responded to a letter from Democratic senators regarding reports of seven banned words in official reports.
    • The CDC said that while no words are banned, it suggests the use of certain terms.
    • For instance, the CDC requests that budget documents say "Obamacare" instead of "the Affordable Care Act."

    The Centers for Disease Control and Prevention (CDC) unveiled its style guidelines for official budget reports in a letter to Democratic senators on Tuesday.

    The guidelines first drew attention in December, when reports indicated that the CDC had banned the usage of seven words from budget reports, including "evidence-based" and "transgender."

    Democratic senators responded to the reports by asking the CDC to ask if the department requires the use of certain language in budget documents.

    CDC Director Brenda Fitzgerald said the agency has not "banned, prohibited, or forbidden employees from using any words" and the changes were not official administration policy.

    "As this excerpt makes clear, there are no 'banned' words," the letter from Fitzgerald reads. "These are merely suggestions of what terms to use and what overused words to avoid."

    According to the excerpt from the style guide, there are only three words "to avoid" in budget reports: "vulnerable,""diversity," and "entitlement."

    The guide also says all reference to the "Affordable Care Act," or "ACA," be changed to "Obamacare," and references to the law's "Marketplaces" should be changed to "Exchanges." 

    Brain Schatz, one of the Democratic senators who received the letter, slammed the guidelines, arguing they suggest  employees should favor more partisan language.

    "CDC acknowledged that it provides guidance on words to avoid using and suggests alternative terms. For instance, in an excerpt from an official document, CDC recommends the use of the colloquial term 'Obamacare' over 'ACA' or 'The Affordable Care Act,' the official name for the law," a statement from the Democratic lawmakers said. "Schatz and the co-authors of the letter slammed the use of such guidance, which favors more politically charged language. "

    SEE ALSO: Congress may be getting ready to create a whopper of a fiscal cliff

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    NOW WATCH: Here are the 12 best Trump memes of 2017

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    • An early Trump administration plan to dismantle the Affordable Care Act through executive action was released publicly Wednesday.
    • The list was designed to show conservative Republicans how the Trump administration would take apart the healthcare law outside congressional action.
    • The list includes seven provisions that have already been enacted — like shorter open-enrollment periods — and a few that have not, like "skinny" Obamacare exchanges.

    Republicans have so far failed to repeal and replace the Affordable Care Act in Congress, but President Donald Trump's administration appears to be carrying out a plan to undermine the law on its own.

    Politico's Jennifer Haberkorn on Wednesday reported that Tom Price, then the health and human services secretary, attended a meeting with lawmakers last year in which a one-page document was presented that listed 10 steps the Trump administration planned to take to dismantle the law.

    The steps do not need congressional approval and were designed to help reshape the seminal healthcare law, which came to be known as Obamacare, without input from Congress.

    HHS has already implemented seven of the proposed changes, such as cutting the open-enrollment period for federal Obamacare exchanges in half during Trump's first year in office.

    According to Politico, the 10-step list represented an attempt to win over conservatives during the repeal-and-replace fight. Some members, such as those in the House Freedom Caucus, insisted on a full-repeal strategy rather than the bill Republican leaders pushed.

    The list provided a way to show reluctant members that the bill was not the only repeal measure that the Trump administration was pursuing.

    Many advocates for Obamacare and health-policy experts said the changes on the list could undermine some of the protections afforded by Obamacare, destabilize the exchanges, and cause an increase in the number of uninsured.

    The document was obtained by Democratic Sen. Bob Casey via a request to HHS. Casey originally heard about the document from media reports last March.

    Here's a rundown of the 10 steps on the document:

    1. Restrict special enrollment periods: Require stricter identification requirements for people signing up for Obamacare plans outside open enrollment. (Enacted)
    2. Back pay of premiums during grace periods: Allow insurers to collect prior unpaid premiums when a person reenrolls with an insurer after dropping coverage.
    3. Shorten open enrollment: Decrease the length of the open-enrollment period. The enrollment window for the federally run exchanges was trimmed to six weeks in 2017 from 12. (Enacted)
    4. Network adequacy oversight: Instead of federal oversight to ensure all Obamacare providers had sufficient networks of doctors and providers, HHS wanted to give that oversight power to the states. (Enacted)
    5. Roll back Essential Health Benefits: EHBs are 10 baseline types of care that must be covered by any Obamacare plan for it to qualify for sale. HHS wanted to give the oversight authority to determine what qualified as satisfying the EHB requirements to the states. (Enacted)
    6. Speed up the Section 1332 wavier-approval process: These waivers allow states to modify Obamacare exchanges or bypass some regulations if they can show the changes will improve costs and coverage in their state. HHS wanted to make this process faster and less rigorous. (Enacted)
    7. Regulate steering of patients from Medicaid to ACA plans: HHS wanted to crack down on insurance brokers and providers telling patients to sign up for plans through the exchanges instead of through Medicaid or Medicare.
    8. "Permit lower cost direct enrollment pathways for issuers, brokers, and states": While this is vague, it appears to be designed to loosen restrictions on methods that nonfederal groups could enroll people in plans. (Enacted)
    9. Loosen rules on benefit design: Allow insurers more options on how to structure pricing for certain health benefits. (Enacted)
    10. "Encourage states to build 'skinny' exchanges": While vague, this appears to be a possible rule to allow states to enlist more private-sector assistance in setting up Obamacare exchanges with less robust offerings.

    SEE ALSO: Trump inexplicably exempted Florida from the massive offshore drilling overhaul, and some of his fiercest allies are pushing back

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    • The percentage of Americans without health insurance increased to 12.2% in 2017, a 1.3 percentage point increase from the year before, according to a survey by Gallup-Sharecare.
    • This is the largest one-year increase since the start of the survey in 2008.
    • Gallup-Sharecare said that individual market instability and uncertainty around healthcare policy from Washington DC contributed to the increase.

    The number of Americans without health insurance rose at the highest rate in years during 2017 according to a new Gallup-Sharecare survey.

    According to the survey released Monday, 12.2% of Americans were without health coverage in the fourth quarter and the uninsured rate jumped 1.3 percentage points from the same quarter the year before — which translates to 3.2 million more uninsured Americans.

    According to Gallup-Sharecare, this is the largest year-over-year increase in the uninsured rate since the survey began in 2008.

    "The 1.3-point increase in the uninsured rate during 2017 is the largest single-year increase Gallup and Sharecare have measured since beginning to track the rate in 2008, including the period before the Affordable Care Act (ACA) went into effect," Gallup-Sharecare said in a release.

    Gallup-Sharecare cited a number of reasons for the increases uninsured rate, including the number of insurers pulling out of the Affordable Care Act's individual insurance marketplaces. According to the pollsters, the increase during 2017 also falls partly on uncertainty from Washington DC.

    "Further, media coverage of the policies to repeal and replace the healthcare law may have caused some consumers to question whether the government would enforce the penalty for not having insurance" Gallup-Sharecare said. "Congressional Republicans made several attempts to repeal or replace the healthcare law during 2017, ultimately passing a tax bill in December that repealed the individual mandate."

    While the 12.2% uninsured rate is still much lower than the pre-ACA rate of 18%, Gallup-Sharecare said that the policies from President Donald Trump could cause the number of people without coverage to continue to increase.

    "It seems likely that the uninsured rate will rise further in the years ahead. President Donald Trump signed a tax bill into law in December that included a repeal of the individual mandate," Gallup-Sharecare wrote. "Without this requirement to have health insurance, it is likely that some Americans will drop their coverage. Rising insurance premiums, which are expected to continue to increase, could also result in some Americans forgoing health coverage."

    SEE ALSO: Congress is hurtling towards a government shutdown — and Trump is making everything worse

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    NOW WATCH: A reporter who met with the former spy behind the Trump-Russia dossier explains why it’s not 'fake news'

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    • Congress must pass a funding bill by the end of January 19 to avoid a government shutdown.
    • Lawmakers may include changes to three major Obamacare taxes in the bill.

    Congress is attempting to avoid a government shutdown by the end of Friday, and their efforts could make significant changes to the healthcare landscape as well.

    According to reports, delays of the implementation for a number of taxes built into the Affordable Care Act, or Obamacare, could be included in the funding bill.

    A delay of the medical device tax— a 2.3% tax on the sale of certain devices — which was not enforced in 2016 and 2017 but goes back into effect in 2018, could be added. Additionally, a one-year delay of both the so-called Cadillac tax on high-end insurance plans and the Health Insurance Tax on all plans could be added to the bill.

    GOP Rep. Kevin Brady, the chair of the Ways and Means committee, told reporters on Thursday that the Cadillac tax was of particular interest for Republican members.

    These taxes are detested by many conservative Republican House members, and could make the spending bill more palatable for those members who have objections to other items included in the bill.

    The Cadillac tax has been frequently delayed as it is not politically popular with constituents on either side of the aisle. There was concern among device and insurance industry insiders that the dysfunction in Congress could lead to the other taxes being implemented.

    In addition to the ACA taxes, another large healthcare issue that could be addressed in the bill is funding for the Children's Health Insurance Program (CHIP), which covers roughly 9 million children. Lawmakers told reporters that the program could get a six-year funding extension as part of the bill this week.

    SEE ALSO: This is the central spending issue that could make or break the government shutdown fight

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    NOW WATCH: This congressman wants to target the USPS to help stop the opioid crisis

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    • Changes to Kentucky's Medicaid program — including a work requirement — were approved on Friday.
    • Advocates warned that they would take the state to court in order to block the Medicaid changes.
    • In response, Governor Matt Bevin filed an executive order that would end the state's Medicaid expansion if a court blocked any part of the changes.
    • Ending the program could leave up to 480,000 Kentuckians without healthcare coverage.

    Kentucky Governor Matt Bevin is threatening to drop nearly 500,000 people from the state's Medicaid rolls if recent changes made to the program are challenged in court.

    The federal Department of Health and Human Services (HHS) approved a complex set of change to the state's Medicaid system that would, in part, require all "able-bodied" recipients work or volunteer in order to gain access to coverage.

    Activists have said they'll challenge the changes in court, and Bevin issued an executive order on Tuesday that says he will end the state's Medicaid expansion if they succeed in striking down any part of his new rules.

    The expansion, part of the Affordable Care Act, gives people making between 101% and 138% of the federal poverty line access to Medicaid. According to the most recent statistics, 480,000 Kentuckians have coverage through the expansion.

    The new changes to Medicaid, approved Friday, would require those that are able to work or volunteer at least 20 hours a week in order to gain access to Medicaid. If a person does not meet the work requirement, they could be locked out of gaining coverage for six months. Disabled people, pregnant women, and certain other vulnerable people would not be subject to these requirements.

    Opponents of the recent move say that the measure is unnecessarily restrictive and could violate federal law on Medicaid. A number of advocacy groups have threatened to take the issue to court.

    Based on the executive action, Bevin is attempting to head off these legal challenges. The new executive would plug the plug on the Medicaid expansion — and nearly half a million people's coverage — if a federal court strikes down any element of the new changes approved by the HHS within six months of the decision.

    Bevin long-promised to make serious changes to Kentucky's healthcare system, including shifting the state's Obamacare exchange from a state-based marketplace to the federal platform. The Republican originally promised to end the Medicaid expansion if he was elected, but later pivoted and said he would accept changes to the system.

    SEE ALSO: The Trump administration just opened the door to an enormous change to Medicaid

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    NOW WATCH: A reporter who met with the former spy behind the Trump-Russia dossier explains why it’s not 'fake news'

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    • House Republicans rolled out their bill to avoid a government shutdown and fund the government for around a month.
    • The funding extension will push back the deadline for a shutdown from January 19 to February 16.
    • The bill will also include extras like funding for the Children's Health Insurance Program and a delay of some Obamacare taxes.

    House Republicans released their plan to fund the government for a short time and avoid a shutdown at the end of the week.

    The plan will extend the deadline for a shutdown until February 16 from the current January 19 dropoff using a continuing resolution (CR). The CR will extend the current level of funding for most federal programs for nearly a month.

    In addition to the funding extension, the plan tacks on a series of healthcare, tax, and military funding changes.

    Some of those extras reportedly include:

    • Funding for the Children's Health Insurance Program (CHIP) for six years: The funding for the CHIP program lapsed in September, but was sustained through a series of short-term cash infusions from Congress. The extension will help ensure that the roughly nine million children who get healthcare coverage from the program remain insured.
    • Delay of some Obamacare taxes: The bill will suspend the medical-device and health insurers taxes as well as delaying the implementation of the so-called Cadillac tax on high-end insurance plans.
    • Extension of a number of key programs: The bill also extends funding for a number of critical programs including:
      • The Department of Energy's Inspector General through June 30
      • NASA's core space exploration programs were given enough to "maintain the planned launch capability schedules."
      • The Department of Agriculture's Child Nutrition programs to May.
      • The Department of Defense's missile defense system
      • The Small Business Administration's general small business loan program.
      • The Department of Housing and Urban Development's voucher program for areas impacted by federally-declared disasters.

    Whether or not the bill will pass is questionable. Democrats have demanded that any funding bill include a codification of the Deferred Action for Childhood Arrivals (DACA) immigration program which is not included in the bill.

    This means that the GOP will likely have to get all of its members on board to pas the bill. This could be tricky since Republican defense hawks have bristled at the idea of another CR instead of steady, long-term funding for the military.

    Outside of the House fight, the plan will also need some support from Senate Democrats in order to avoid a filibuster in that body.

    SEE ALSO: The bill to avoid a government shutdown could include a slew of changes to Obamacare's taxes

    Join the conversation about this story »

    NOW WATCH: A reporter who met with the former spy behind the Trump-Russia dossier explains why it’s not 'fake news'

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    paul ryan mitch mcconnell

    • Republicans released their plan to fund the government through February 16 on Tuesday night.
    • The bill does not include a solution to the Deferred Actions for Childhood Arrivals (DACA) program, meaning Republicans will likely have to pass the bill by themselves.
    • This leave GOP leaders with a number of issues with defense hawks and conservatives in the House possibly opposing the bill and the need for 10 Democratic votes in the Senate.

    On Tuesday night, House Republicans released their plan to fund the government over the short term and avoid a government shutdown at the end of the week.

    The bill would extend the deadline for a shutdown to February 16 from the current January 19 cutoff. While the bill has a number of provisions to win over conservatives in the House — including delays to some Obamacare taxes — it still faces challenges as it tries to make its way through Congress over the next three days.

    An all-GOP strategy

    Conspicuously absent from the funding bill is anything to do with immigration, specifically the Deferred Action for Childhood Arrivals (DACA) program. Codification of the program, which protects from deportation roughly 700,000 undocumented immigrants who entered the US as minors, was a requirement of Democrats in order to get their support for a funding bill.

    Given that the bill does not include anything addressing DACA, it appears that Republican leaders in the House are planning to go forward with a GOP-only strategy. While Republicans in the House have a majority and can theoretically pass the bill without the Democrats, the strategy carries some risks.

    For one thing, the use of a short-term bill — known as a continuing resolution — is not going to go over well with two groups within the GOP conference.

    Defense hawks, staunchly military-focused members, have balked at the use of another continuing resolution. The short-term bills have been used since September to delay the shutdown deadline, and defense hawks say that they weaken military effectiveness by leaving funding in limbo and simply maintaining last year's spending levels instead of increasing money to meet the military's needs.

    GOP Rep. Bradley Byrne summed up those concerns while talking to reporters on Tuesday.

    "Continuing resolutions are hurting the readiness of our troops, endangering our troops, and for those of us defense hawks, we find it very difficult to support CRs,"Byrne said."The alternative is to let the Democrats crash the whole government, and that's what they are trying to do.

    Another concern is the hardline conservative House Freedom Caucus, who were turned off by the continuous use of these resolutions and want to decrease spending. Freedom Caucus chair Mark Meadows told reporters on Tuesday that many of the group's members were not fans of strategy and that the Obamacare tax delays— designed to win over conservatives — were simply "gimmicks."

    A source close to the Freedom Caucus told Busines Insider that while the Caucus was not taking a concrete position yet, there was signifcant pushback among members.

    "[The Caucus has] no official position, but they generally did not support leadership’s current strategy," the source said. "There’s general support for doing what leadership said we were going to do six weeks ago, to fully fund our military for a year and CR non-defense discretionary for a month while we continue negotiations."

    Meadows said Tuesday that given the resistance to the bill, there may not be enough GOP lawmakers on board with the plan yet.

    "Based on the number of 'no' and undecided votes, there is not enough votes for a Republican-only bill," Meadows said, according to Politico.

    The Senate presents another problem

    Even if the Republican House leadership can bring their conference together and get the bill passed, there's still the problem of the Senate.

    Support from at least 10 Senate Democrats is needed in order to guarantee passage of the bill — any less and another member can filibuster the measure for its lack of DACA solution.

    The item that could win over some members, according to Isaac Boltansky at policy research firm Compass Point, is a six-year extension of the Children's Health Insurance Program (CHIP).

    "We continue to believe that a sufficient number of Senate Democrats will cross the aisle to pass this deal, especially given the CHIP funding," Boltansky wrote in a note to clients after the bill was released.

    Also some Democratic members, especially in states where President Donald Trump won in 2016, have expressed hesitation to shut the government down on Friday over the DACA issue. This opens the door for their support.

    SEE ALSO: House Republicans just released their plan to avoid a disastrous government shutdown

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    NOW WATCH: A reporter who met with the former spy behind the Trump-Russia dossier explains why it’s not 'fake news'

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    • Idaho wants to allow insurers to offer plans that do not meet regulations laid out by the Affordable Care Act, or Obamacare.
    • Experts say the legality of the move is questionable.
    • Also unclear is whether the Department of Health and Human Services, which has helped undermine Obamacare under President Donald Trump, will step in to prevent the move.

    A new health insurance proposal in Idaho is set to test the Trump administration's commitment to allow states to modify — or flat-out ignore — the Affordable Care Act's rules and regulations.

    Amid Congress' failure to repeal and replace the ACA, or Obamacare, the Department of Health and Human Services under President Donald Trump has worked unilaterally to undermine many of the law's key elements. The administration has argued the changes are designed to enhance consumer choice and bring down costs.

    But a new waiver request from Idaho proposes to go beyond undermining the law and simply ignoring it. It would allow insurers to sell healthcare coverage in the state's marketplace that does not meet Obamacare's requirements to qualify for the exchanges.

    It would require that insurers offer some plans that are ACA compliant. But "state-based" plans would not need to meet certain requirements of the law, such as care for 10 basic medical needs that all ACA-compliant plans must cover.

    Experts say the "state-based" plans could revert back to pre-ACA rules that allowed insurers charge more for people with a preexisting condition.

    "In the Wild West, Idaho is allowing insurers to: Impose preexisting condition exclusions for people who were uninsured. Charge higher premiums for sick people. Exclude certain benefits," tweeted Larry Levitt, senior vice president at the Kaiser Family Foundation, a nonpartisan health policy group.

    The legality of the move is questionable and could embroil the state in a lengthy court battle.

    "I don’t see how this is reconciled with the basic ACA requirements," Scott Harrington, a healthcare management professor at the University of Pennsylvania, told The Wall Street Journal.

    It's unclear whether new HHS leadership will challenge the proposed changes. HHS is required to step in and enforce ACA rules if a state does not or can't comply with them, and the department already does so in four states.

    Newly confirmed HHS Secretary Alex Azar, whom the Senate confirmed to the position on Wednesday, has a big decision to make, Levitt said.

    "If a state is not enforcing the ACA’s insurance rules, the federal government is supposed to step in and do it," he tweeted. "Idaho could be an early challenge for the new HHS Secretary."

    But enforcement of the health law would run counter to the actions of the healthcare regulatory structure under Trump in his first year. The HHS and Centers for Medicare and Medicaid Services undertook a series of changes in 2017 that many health policy experts said were targeted at dismantling the ACA.

    Tom Price, the previous HHS secretary, laid out a 10-step plan to undermine the law. Price resigned after reports surfaced regarding his overuse of government-funded air travel. 

    Premiums for a benchmark silver plan in the ACA marketplace for 2018 increased by 37%, more than the year prior, and many insurers cited meddling from Washington as a key reason for the increases.

    SEE ALSO: Steven Mnuchin is trying to fix 'the first serious economic misstep by the Trump administration'

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    • Conservative groups connected to the powerful Koch brothers are declining to push for Obamacare repeal in 2018.
    • The move is the latest sign Republicans are shifting their focus away from the healthcare law.

    Republicans in and out of Washington appear to be punting on a repeal of the Affordable Care Act, the law known as Obamacare, as they shift their focus to other priorities. 

    According to Axios' Caitlin Owens, conservative groups backed by the influential Koch brothers are turning their attention away from Obamacare repeal and focusing on other issues instead, like selling the GOP tax law.

    The decision appears to be the latest indication that the GOP is shelving one of their top policy priorities for much of the past decade — at least for now. 

    The possibility of repeal was already small given the slim Republican majority in the Senate, which has shrunk to just 51-49. Given resistance from moderate Sens. Susan Collins and Lisa Murkowski to every ACA repeal bill in 2017, the possibility of getting a bill through even on a partisan basis was almost impossible.

    Senate Majority Leader Mitch McConnell came close to admitting as much in December after Democratic Sen. Doug Jones won in Alabama.

    "Well, we obviously were unable to completely repeal and replace with a 52-48 Senate," McConnell told National Public Radio. "We'll have to take a look at what that looks like with a 51-49 Senate, but I think we'll probably move on to other issues."

    On the House side, some lawmakers raised a fuss about possible repeal in early 2018, but talk quickly cooled off as leadership from both chambers set priorities for the year.

    Reports have also indicated that the Senate and House may not come together on identical budget proposals for fiscal year 2019. That would be a key step in any potential Obamacare repeal, because it unlocks the process known as budget reconciliation and would allow the GOP to pass an Obamacare repeal bill with a simple majority vote in the Senate.

    Without reconciliation, Democrats could block any attempt at repeal with a filibuster.

    While the focus appears to be shifting away from the ACA, the GOP may feel less pressure to pass a repeal bill. The Trump administration chipped away at the regulatory underpinnings of the law in 2017, and the recently passed tax law also does away with Obamacare's individual mandate.

    So even without a full blown repeal and replace, the GOP can still claim some victories on the healthcare front.

    Given the political reality, major donor disinterest, and how deeply unpopular previous repeal attempts were, it looks like Obamacare will remain the law of the land in 2018.

    SEE ALSO: Idaho is pushing the envelope on ignoring Obamacare rules in a huge test for the Trump administration

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    • JPMorgan, Berkshire Hathaway, and Amazon announced a joint venture Tuesday in an attempt to bring down healthcare costs.
    • The White House economic adviser Gary Cohn said the new venture was "the exact same thing" as an executive order signed by President Donald Trump in October that allowed expanded access to association health plans.
    • There are some key differences between Trump's order and the new Amazon-JPMorgan-Berkshire venture.

    An unexpected announcement Tuesday from JPMorgan, Berkshire Hathaway, and Amazon on a healthcare venture sent shockwaves through the market, but the top White House adviser Gary Cohn said he had already seen it before.

    Cohn, the National Economic Council director and President Donald Trump's top economic adviser, said the new megaventure seemed similar to an executive order Trump signed in October.

    "We're doing the same thing here at the White House," Cohn told CNBC. "If you look what we did earlier last year, we created association healthcare plans, which is the exact same thing that those three companies did."

    Cohn is referring to an executive order that allows for the expanded use of association health plans. The plans allow pools of workers, mostly from small businesses, to join together to access the group healthcare market rather than go through the individual insurance exchanges.

    They also allow the workers and small businesses to go around the Affordable Care Act exchanges and access plans that may not meet certain ACA requirements.

    "We created associated healthcare plans where small businesses could pool their employees together to get more purchasing power so they could save money on healthcare," Cohn said.

    The administration rolled out the new AHP rules on January 4.

    There are a few key differences, however, between the JPMorgan-Berkshire-Amazon announcement (though it remains vague) and the AHP order.

    For one, the companies indicated that the new venture would initially focus on technology rather than on employee insurance coverage.

    "The three companies, which bring their scale and complementary expertise to this long-term effort, will pursue this objective through an independent company that is free from profit-making incentives and constraints," the trio of companies said in a press release. "The initial focus of the new company will be on technology solutions that will provide US employees and their families with simplified, high-quality, and transparent healthcare at a reasonable cost."

    The new combined venture also appears to be a separate not-for-profit entity, whereas AHPs use outside insurance firms that may not be nonprofits.

    And while both initiatives are attempting to leverage a larger pool of employees to help bring down costs, the AHP order is targeted at small businesses and self-employed people — while the three companies in Tuesday's announcement have a combined 1.1 million employees globally.

    SEE ALSO: Amazon, Berkshire Hathaway, and JPMorgan are creating a new healthcare company to tackle the 'hungry tapeworm' of rising costs

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    • Blue Cross of Idaho will being to offer plans that do not comply with Obamacare's basic regulations after a change by the state's government.
    • The so-called Freedom Blue plans would cap the benefits a person could receive in a year and charge people more due to a preexisting condition.
    • Neither of those features are permitted under the Affordable Care Act.
    • It is unclear whether the Department of Health and Human Services will step in and prevent Idaho from selling these plans.

    Blue Cross of Idaho announced Wednesday it would take advantage of the state's new loophole for Affordable Care Act regulations, prompting questions over how the Trump administration will respond.

    In January, Idaho's government announced it would allow insurers to offer "state-based plans" that did not adhere to regulations set out by the Affordable Care Act, or Obamacare.

    The plans would not have to cover all essential health benefits, which are 10 items of basic care areas any ACA plan must provide. They could charge people more based on their health history. Both of those conditions currently disqualify a plan from being sold on Obamacare's exchanges.

    Blue Cross Idaho, the largest Obamacare insurer in the state, said it plans to start selling "Freedom Blue" plans that do not comply with the regulations. The company will continue to offer ACA-compliant plans, which is required by Idaho to sell the less-regulated options.

    According to The Wall Street Journal, the monthly premium for a 45-year-old under a "Freedom Plan" would vary from $194.67 to $525.69, depending on preexisting conditions and other health risks. The current bronze level ACA-compliant plan from the insurer runs about $343.09 a month.

    These plans would also cap the benefits an individual could receive at $1 million a year, again violating the ACA's rules.

    It's unclear how the Trump administration will respond

    The Department of Health and Human Services has followed President Donald Trump's directions by allowing states to loosen regulations on Obamacare marketplaces. But the Idaho plan is the most envelope-pushing plan yet.

    Larry Levitt, a senior vice president at health policy think tank The Kaiser Family Foundation, tweeted that the Idaho plan is clearly flouting the law.

    "Idaho is allowing health insurance plans that charge sick people more than healthy people, have an annual limit on coverage, and don’t cover maternity care," Levitt said. "That’s simply not allowed under the ACA."

    Levitt said that while this may lower premiums for some healthy people, many "middle-class people with preexisting conditions will pay more."

    HHS is required by the ACA to step in and take over regulation of any state that does not meet regulatory standards, and the department has done so in four states already.

    Asked about the Idaho situation during a hearing before the House Ways and Means Committee, HHS Secretary Alex Azar said no one from Idaho has contacted the HHS about a waiver. When that happens, he said, the department could step in.

    "We will look at that whenever it comes to us, of course there are rules and there's a rule of law that we need to enforce," Azar said.  

    Levitt said that if HHS does not intervene in Idaho, the changes would likely open the door to more loosely regulated plans and allow state regulators to undermine ACA exchanges in their own states.

    "If HHS does not step in and enforce the ACA's insurance rules in Idaho, it won't just be about Idaho," he said. "Other conservative states will no doubt then start to allow insurance plans that don't comply with the ACA."

    SEE ALSO: Idaho is pushing the envelope on ignoring Obamacare rules in a huge test for the Trump administration

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    • Blue Cross of Idaho has announced health-insurance plans that do not conform with all rules of the Affordable Care Act, or Obamacare.
    • The Trump administration could step in and enforce the ACA, preventing the sale of these plans, or decide to allow the sales to go forward.
    • The decision will have big consequences for people on the ACA exchanges as well as many other states looking to get around some of Obamacare's rules.

    The state of Idaho is making a huge play to undermine Obamacare. But whether it succeeds depends on whether the Trump administration plays along.

    Last week, Blue Cross of Idaho announced that it would begin to offer health-insurance plans that did not abide by the regulations set out in the Affordable Care Act, or Obamacare.

    The Freedom Blue plans would violate the ACA's regulations in a few key ways:

    • They would charge sicker people more than healthy people.
    • They would have a maximum annual payout to beneficiaries of $1 million.

    Matthew Fiedler, a fellow at the Brookings Institution's Center for Health Policy, said Idaho would clearly be in violation of the law if the Freedom Blue plans went forward.

    "Idaho's proposal transparently violates federal law," Fiedler told Business Insider. "Few things are as clear cut."

    Nicholas Bagley, a law professor focusing on health policy, agreed. He called the plans "crazy-pants illegal."

    And Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health-policy think tank, held a similar view.

    "There's just no question that what Idaho is allowing is on the face of it not permitted under the ACA," Levitt said. "Probably most egregious is that these new plans charge sick people more than healthy people, and that's clearly prohibited by the ACA."

    Experts say, however, that the big question is what President Donald Trump's administration will do about it.

    A looming choice

    If a state does not enforce the ACA's regulations, the Department of Health and Human Services is obligated to intervene and uphold the law. In fact, the department is already doing just that in four states.

    But given the Trump administration's long campaign to loosen ACA regulations and destabilize its insurance exchanges, experts say they aren't sure whether HHS will take action in Idaho.

    "HHS has a responsibility to step in and enforce the law," Fiedler said. "Whether they will or not, I do not know."

    HHS Secretary Alex Azar, newly confirmed on January 24, told lawmakers in hearings on Tuesday and Wednesday that the department was keeping an eye on Idaho's moves.

    "We'll be looking at that very carefully and measure it up against the standards of the law," Azar said during a Senate Finance Committee hearing on Thursday.

    Bagley said Blue Cross' move represented a gamble that the Trump administration would not enforce the law.

    "States are vested with primary responsibility for enforcing the ACA, with HHS stepping in only if the states fail to substantially enforce the law," he said. "Blue Cross is betting that HHS won't step in and that the courts won't interfere. Neither is a safe bet."

    Blue Cross says it will begin to sell the plans in early March, with coverage starting in April.

    What it means for consumers

    The Idaho plans would change the face of the individual health-insurance exchanges in states where they are offered.

    While the unregulated plans would be cheaper for healthy people, they would steer healthier people away from the ACA marketplace. That could lead sicker people to see their costs go up.

    The federal government's subsidies could counteract such increases for individuals making below $50,000, but sicker Americans making more than that could be hit with serious cost increases.

    "The main result here is that middle-class people who are healthy will be able to get cheaper coverage, while middle-class people who have preexisting conditions and are ineligible for premium subsidies will pay more," Levitt said.

    Fiedler noted that the plans healthy people would get could have far less generous benefits.

    "Among enrollees with incomes too high to qualify for subsidies, however, healthier people will tend to leave the ACA-compliant market, while those with significant healthcare needs will remain," he said. "As a result, middle-income people with significant health needs will pay more for their coverage. Healthy middle-income people will pay less, although the coverage they obtain will often be much less robust."


    If the HHS does not step in, experts say, other states could rush to try the same maneuver.

    "If the Trump administration allows Idaho to go forward with this and doesn't step in to enforce the ACA's insurance rules, it sends a clear signal to other conservative states that they can also just flout federal law," Levitt told Business Insider.

    Dean Cameron, the director of the Idaho Department of Insurance, told reporters that "dozens" of other states expressed interest in following along.

    But even if other states go through with the change, insurers would take on a huge risk, Fiedler said.

    "In some cases, enrollees may be able to sue their insurer for selling them a plan that lacks legally required protections," Fiedler said. "In addition, a future administration could decide to enforce the law, which exposes insurers offering these plans to substantial fines. Blue Cross Blue Shield of Idaho's decision to take on these risks strikes me as reckless."

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    • The Department of Health and Human Services debuted a new rule expanding the use of short-term health insurance plans.
    • The rule would allow people to use short-term plans that do no comply with Obamacare regulations for up to 12 months.
    • People are currently only allowed to use such plans for three months.
    • Health policy experts say the plan will increase costs for the government and many sick people in the middle class who get their insurance through the Obamacare exchanges.

    The Trump administration on Tuesday debuted a new rule that would allow Americans more access to short-term health insurance plans, in a move that some experts warn could have serious consequences for the Affordable Care Act, or Obamacare.

    The new rule would permit people with individual health insurance to purchase short-term coverage for up to one year.

    Currently, these short-term plans — which are designed to fill gaps in coverages in case someone loses their job or experiences a major life change — can't be used for more than three months.

    The Trump administration says the expanded use of short-term health plans will allow people greater flexibility and lower prices for healthy people.

    "The status quo is failing too many Americans who face skyrocketing costs and fewer and fewer choices," Alex Azar, the secretary of the Department of Health and Human Services, said in a statement announcing the move. "The Trump Administration is taking action so individuals and families have access to quality, affordable healthcare that works for them."

    These short-term plans offer skinnier sets of benefits and do not have to abide by all regulations under the Obama-era health law. For instance, the plans can charge people more based on their health history, cap the amount of benefits a person can receive, and do not have to cover what are known as essential health benefits— 10 baseline types of care.

    Given the "skinny" nature of the plans, they typically cost less up front and can save healthier people money.

    But many health policy experts warn that shifting more healthy people from Obamacare markets to these short-term plans could drive up costs for sicker people who remain in the individual ACA marketplaces.

    According to the administration's memo on the new rule, between 100,000 and 200,000 people are expected to take advantage of the new plans and shift out of the Obamacare marketplaces.

    Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health policy think tank, said lower-income people in the ACA marketplace will be protected since they receive subsidies to offset the cost of insurance. But he predicted middle-class people would get hit hard.

    "Short-term insurance plans will cherry pick healthy people, leaving ACA-compliant plans to cover a sicker pool with higher premiums," Levitt tweeted. "With the expansion in short-term insurance plans, low-income people will be protected from higher premiums by subsidies. Middle-class people with pre-existing conditions will feel the full brunt of higher premiums."

    He said the expansion would force the federal government to offset cost increases for some people by hiking tax credits they get on their premiums. The administration's memo said the need for increased premium assistance would cost the federal government between $96 million and $168 million per year.

    "Keep in mind that HHS projects this change will cost the government $96-$168 million more every year," Rachel Sachs, an associate professor of law at Washington University in St. Louis, tweeted after the rule's release. "So the government will spend millions more to provide fewer people with comprehensive insurance."

    Loren Adler, associate director at the University of Southern California and Brookings Institutions' Schaeffer Initiative for Health Policy, similarly pointed to the large cost.

    "This is a VERY expensive rule for taxpayers," Adler tweeted.

    The new rule is another in a series of major changes to the nation's healthcare system from the Trump administration over the past year, including allowing new work requirement for Medicaid recipients and the repeal of the ACA's individual mandate.

    SEE ALSO: Idaho is making a radical healthcare change that 'transparently violates federal law' — and it leaves Trump with a dilemma

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    • President Donald Trump's Council of Economic Advisers released a report Wednesday on the administration's healthcare policies.
    • In the report, the CEA noted that the increase in opioid-related deaths exploded around the same time as the implementation of the Affordable Care Act, or Obamacare.
    • Republicans have suggested that Obamacare's expansion of Medicaid may have contributed to the opioid crisis, though research disputes the assertion.

    President Donald Trump's Council of Economic Advisers released a report Wednesday detailing the administration's work to roll back the Affordable Care Act, and at one point in the report noted that the law's passage came around the same time as the opioid crisis worsened.

    The post criticized the law known as Obamacare for its focus on bringing down the number of uninsured Americans, which the CEA said did not necessarily translate to a healthier population.

    "Determinants of health other than insurance and medical care — such as drug abuse, diet and physical activity leading to obesity, and smoking — have a tremendous impact and have exacerbated recent declines in life expectancy, despite the ACA’s increased coverage," the post said.

    As part of the post, the CEA authors also discussed the growing number of overdose deaths from opioids.

    "This Administration is focused on reversing the harm caused by the ACA by fostering competition, choice, and innovation while also addressing the many factors beyond insurance that influence health," the post reads. "The Administration is particularly concerned about the opioid crisis that exploded during the ACA expansion."

    While the CEA did not directly tie the ACA to the growing opioid crisis, other Republicans have recently been more explicit about a possible link between the law's implementation and the opioid crisis.

    Sen. Ron Johnson, chair of the Homeland Security and Governmental Affairs Committee, released a report in January linking Medicaid generally and the law's expansion of Medicaid specifically to the increase in overdose deaths.

    "This report is not meant to suggest that Medicaid, or any other federal program, is the only factor contributing to the opioid epidemic," Johnson's report said. "But if Medicaid is helping to drive the epidemic, it stands to reason that expanding the program — particularly to people most susceptible to abuse — could worsen the problem. The epidemic has indeed spiraled into a national crisis since the Obamacare Medicaid expansion took effect in 2014."

    DJ Norquist, chief of staff for the CEA, told Business Insider that Johnson's report resembles their offices thinking on the issue.

    "We agree with Senator Johnson that government policies are an overlooked part of the problem," Norquist said in an email.

    In a 2017 study in Health Affairs, health policy researchers Andrew Goodman-Bacon and Emma Sandoe found that the evidence linking the ACA's Medicaid expansion and the opioid crisis was tenuous at best.

    "While we do not reject the possibility that public policy has played a role in our current prescription abuse crisis, on balance we find little evidence to support the idea that Medicaid caused or worsened the epidemic," the study said.

    SEE ALSO: The Trump administration just made another big move to reshape the healthcare system

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    • The Trump administration rolled out a new proposal this week that would allow expanded access to short-term health insurance plans.
    • While the plans may bring down monthly costs for some healthy consumers, experts say they could cause serious trouble for sicker Americans.

    The Department of Health and Human Services this week announced a new proposal that would expand the use of short-term health insurance plans, opening the door for more people to use the "skinny" coverage products while taking another swipe at the law known as Obamacare.

    Under the proposed rule, people could enroll in low-cost plans with skimpier benefits for up to 12 months, an increase from the current three-month limit imposed by the Affordable Care Act, or Obamacare. The rule would also attempt to make it easier for people to reenroll in the short-term plans, which are generally designed for people between jobs or close to retirement.

    The change, the Trump administration says, is meant to give more low-cost options to healthy people who do not get their coverage from an employer or government program. But many experts say the new plans could also open the door to problems that could result in sicker people paying much more.

    Dania PalankerKevin Lucia, and Emily Curran, health policy researchers at Georgetown University, pointed to a series of potential trouble spots that could arise under the plans.

    One potential problem they identified would come if an individual falls sick during the short-term plan period. For instance, if an individual enrolls in a 12-month short-term health plan in March and discovers a health problem in July, an insurer could determine the issue predated the person's enrollment. The insurer could then treat the sickness as a preexisting condition and deny some coverage — even if the person had no knowledge of the illness before enrolling.

    "Even if they are offered coverage, people with preexisting health conditions may never have claims paid under short-term coverage," said a report from the trio. "Insurers may comb through members’ medical histories to determine if a service was for a preexisting condition in order to deny a claim."

    The Trump administration recognized this possible pitfall in a report on the proposed rule.

    "Depending on plan design, consumers who purchase short-term, limited-duration insurance policies and then develop chronic conditions could face financial hardship as a result, until they are able to enroll in PPACA-compliant plans that would provide coverage for such conditions," the administration's report said.

    A questionable history

    Additionally, many of the short-term plans have a pattern of past misuse. Bloomberg's Erik Larson and Zach Tracer laid out how some short-term plan providers have a history of overcharging consumers and not delivering on promised care.

    Issues have also arisen when a person is even able to sign up for the plans in the first place. May short-term insurers use rigorous questionnaires to determine whether a person had a pre-existing condition.

    For instance, some short-term plans ask if someone weighs more than a certain amount, has ever been pregnant, or experienced symptoms related to a slew of health problems over the five previous years. An answer of "yes" to any of those questions could make a price's plan increase dramatically.

    The Georgetown researchers noted that currently offered short-term plans have out-of-pocket payment maximums well above the current limits under Obamacare. That could lead to people signing up for the short-term plans because of cheap monthly premiums and paying much higher amounts when they need care.

    Obamacare, and the restrictions on short-term plans, were designed to prevent these sorts of problems for people with preexisting conditions. But it came at a cost, said Larry Levitt, a vice president at the Kaiser Family Foundation, a nonpartisan health policy think tank.

    "The ACA provided protections for people with pre-existing conditions, but raised premiums for middle-class healthy people who don't qualify for subsidies," he tweeted. "An expansion in short-term insurance plans rolls that back some."

    SEE ALSO: The Trump administration just made another big move to reshape the healthcare system

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    • Seema Verma, the administrator for HHS' Centers for Medicare & Medicaid Services, blocked a move by the state of Idaho that would have undermined Obamacare.
    • Verma said that Idaho's new plan to let insurers sell plans that did not comply with Obamacare ws not legally permissible.
    • Health policy experts were closely watching the Idaho situation because it could have opened the door for other states to flaunt the rules of Obamacare.

    The Department of Health and Human Services announced it will block a new health care initiative by the state of Idaho, preventing the state from circumventing key Obamacare rules.

    Seema Verma, the administrator for HHS' Centers for Medicare & Medicaid Services, said in a release Thursday that the governor of Idaho was informed of the decision.

    Idaho's new process would have allowed insurers to sell plans that did not comply with regulations that are part of Obamacare, which is formally named the Affordable Care Act (ACA), as long as the company also sold ACA-compliant plans.

    Blue Cross of Idaho announced soon afterwards that the insurer would offer these skinny plans which would have charged sick people more than healthy people.

    Verma said that while Idaho's desire to bring down costs — the stated reason for the policy — was admirable, it was also illegal.

    "CMS is committed to working with states to give them as much flexibility as permissible under the law to provide their citizens the best possible access to healthcare,"Verma said. "However, the Affordable Care Act remains the law, and based on our review of Idaho Bulletin No. 18-01, CMS has reason to believe that Idaho would be failing to substantially enforce the provisions in Part A of title XXVII of the Public Health Service Act (the Part A market requirements) as amended by the ACA."

    Experts raised concerns about both the legality of the move and the changes to the insurance market in Idaho as a result. For sick people who needed the coverage of a more generous ACA-compliant plan removing healthy people from the market would have likely driven up prices.

    In the event that a state does not enforce the ACA, the HHS is technically obligated to step in and enforce the law. Health policy experts were curious to see whether the Trump administration came in given its history of undermining the ACA over the past year.

    If Idaho was allowed to move ahead it could have opened the door for other conservative states to flout the law but, for now, that opening appears to have been shut.

    SEE ALSO: Idaho is making a radical healthcare change that 'transparently violates federal law' — and it leaves Trump with a dilemma

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    • The federal government will shut down Friday unless a spending bill is passed.
    • The deal should be reached after the budget agreement in February set the spending caps for the government.
    • Potential additions, dealing with everything from immigration to Obamacare, could pose complications.

    For the third time in as many months, the federal government is facing a fast-approaching government shutdown and racing to complete the deal to avoid a lapse in funds.

    The possibility of a government shutdown appears less likely than the last two times Congress has gone through this process, but aides and analysts say nothing is guaranteed. The deadline to pass a spending bill and avoid a shutdown is the end of the day Friday.

    Congress is likely to avert a shutdown because of the February deal reached by the two parties' leaderships, which increased the federal budget caps. The agreement set the levels of how much the government can spend over the next two years — the current discussions revolve around how exactly that $1.3 trillion will be divided up.

    Chris Krueger, strategist at Cowen Washington Research Group, said the broad deal reached in February will help smooth out the process this time around.

    "There could be another Rand Paul-type shutdown of a few hours, but this ship sailed once the gigantic sequester relief bill passed last month," Kreuger said in a note to clients Monday. "The pie has been baked, they are just quibbling over the scraps."

    But there could be some bumps along the way. As part of the shutdown negotiations, both sides are attempting to add various policy goals — on everything from the tax code to healthcare.

    Riders could trip up the bill

    One of the biggest sticking points appears to be efforts to attach provisions that would shore up the marketplaces of the Affordable Care Act, or Obamacare. The changes, which have the support of many Democrats and some Senate Republicans, would allocate funds to mitigate losses for insurers in the market in hopes of keeping down premium costs.

    Conservatives, on the other hand, believe the move would be a bailout for insurance companies. Many Republicans also want to include language in the budget deal that would prevent these funds from going to groups that provide abortion services, like Planned Parenthood, which would risk losing the support of Democrats.

    Also, Politico reported that the White House and Democrats have attempted to work toward an immigration agreement that would trade funding for the president's proposed wall along the Mexican border for a codification of the Deferred Action for Childhood Arrivals immigration program that protects from deportation nearly 700,000 unauthorized immigrants that came to the US as minors.

    The talks about the proposal broke down as the two sides remain at an impasse on a pathway to citizenship for the DACA recipients, according to the report.

    Other items, such as corrections to technical errors in the recently passed GOP tax reform law and funding for a tunnel between New Jersey and New York City, could also become part of the fight.

    Intraparty disagreements

    The add-ons have also split parties amongst themselves.

    For instance, GOP Rep. Mark Meadows — the head of the hardline conservative House Freedom Caucus — called for the spending bill to strip funding from sanctuary cities that do not cooperate with federal immigration enforcement laws.

    Other Republicans were quick to dismiss the idea, since it would cause a major political fight with Democrats that could risk the danger of a shutdown.

    "think that that’s — I don’t think that’s gonna happen in the Senate," GOP Sen. John Boozman told Business Insider. "I mean that’s — Congressman Meadows might feel like that’s a good idea but practically speaking, that would be very difficult to actually get done."

    Sen. Roy Blunt, the vice chair of the Republican conference, told Business Insider last week that the decisions were being made by leaders.

    "Everybody kind of has everything they like attached to it," Blunt said. "That’s gonna be decided in a room that I’m not in."

    At the same time, Blunt did not expect too many additions to the spending bill.

    "Nothing’s done until it’s done, but I think we’ll not have very many riders on this bill," he said.

    Despite the fast-approaching deadlines and various policy arguments, the bill is expected to make it through both chambers before the deadline at the end of the week.

    "Given the considerable work done to date, and the scheduled recess at the end of the week, we believe the odds of a government shutdown are only 25%," Isaac Boltansky, a policy analysts at Compass Point Research and Trading, wrote in a note to clients on Monday.

    The giant bill is expected be released late Monday with a vote coming from the House on Wednesday and the Senate soon after.

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    • The government will run out of funding at the end of the day Friday.
    • A massive $1.3 trillion spending bill to avoid a shutdown is in the works.
    • But Congress is struggling to get its act together, with the House already pushing back the bill's release and a planned vote.
    • There are still ongoing debates over immigration, infrastructure, and gun-related provisions in the bill.

    With the clock ticking on the next government shutdown deadline, Congress is rushing to get a massive $1.3 trillion spending bill passed in time to avoid a third lapse in funding this calendar year.

    Despite the stated desire from leaders of both parties to avoid overstepping the Friday night deadline, they have not yet released a huge omnibus spending bill. And the timeline for a vote is already slipping.

    After initially planning to release the bill on Monday to secure a Wednesday vote, House Speaker Paul Ryan told Republicans in a conference meeting Wednesday that they would instead release the bill Tuesday for a planned Thursday vote.

    That would give the Senate just 24 hours to pass the bill with no changes and prevent a shutdown.

    "There are some unresolved issues, we’re working through them while we speak," Ryan told reporters at a weekly press conference. "We’re hoping to close it today."

    Sen. John Cornyn, the second-highest ranking Republican senator, told reporters on Tuesday that the Senate could push the process into the weekend due to procedural delays.

    "It’s going to extend our week into the weekend perhaps, it just means we are going to be here into the weekend perhaps," Cornyn said.

    The Texas Republican also suggested that a short-term funding bill to "keep the lights on" may be passed to ensure no interruption in funding. This would also help avoid another scenario similar to February, when Sen. Rand Paul held up a vote on the spending agreement and single-handedly forced a shutdown that lasted a few hours.

    Outside of procedural concerns, Cornyn also took aim at the way the negotiations on the bill were being conducted.

    "This is really a terrible way to have to do business," Cornyn said. "To deal with a $1.3 trillion spending bill as one big, where the final decisions are left to four people is not the way the founders intended the legislative branch to work under our constitution."

    Conservatives are mad

    Lawmakers from both parties are quibbling with the bill's provisions, saying it leaves off key policy goals or includes too much new spending.

    Among the issues being discussed as potential additions to the legislation are funding for a tunnel between New Jersey and New York City (which President Donald Trump has threatened to block) and an immigration deal that would trade funding for a border wall for an extension of the Deferred Action for Childhood Arrivals, or DACA, program.

    "It sounds like the Democrats in the Senate are getting all kinds of wins in terms of riders," Rep. Mark Meadows, chair of the hardline conservative House Freedom Caucus, told Business Insider.

    Meadows said outside of the bill fully funding military requests, conservatives would get little items of 

    "There may be some nuggets in there that are real encouragements and would be conservative wins," he said. "But I’m not real optimistic."

    A GOP aide told Business Insider that Meadow's assertion that the bill contained no wins for conservatives was "ridiculous" and a short-term deal to extend the deadline through the weekend was unlikely.

    Senate Minority Leader Chuck Schumer said during a speech on the Senate floor on Tuesday that the bill would have issues that either side would dislike but were necessary to reach a compromise.

    "It has some things no one likes and it has some things not everybody likes, but most people like," Schumer said. "It was a fair compromise, the basic structure of it and hopefully we can get to an agreement."

    Other items that appear to also be on the cutting-room floor are an Obamacare stabilization package — seemingly derailed over language regarding abortion funding — and a provision to strengthen gun background checks to the spending package.

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    • Republican Sens. Susan Collins and Lamar Alexander are pushing to include extra Obamacare funding in this week's must-pass spending bill.
    • But, lawmakers from both parties have issues with the plan and it may be dead on arrival.

    Two Republicans' last-ditch effort trying to shore up the Affordable Care Act looks like it's falling apart.

    The measure, from by Republican Sens. Susan Collins and Lamar Alexander, would increase funding for key programs to attempt to reduce premiums in Obamacare's individual insurance markets while also deregulating some of the insurance plans in the same markets.

    The authors and other lawmakers claim the move would bring down premiums for people obtaining coverage through the exchanges.

    "It is the right thing to do," Collins said Monday. "It would result in rate decreases that would provide substantial relief."

    But an attempt to include the provisions in this week's spending bill appear to have hit a wall.

    The measure received pushback over the past few days from members of both parties. Republicans felt that allocating more money to the Obamacare marketplaces would be a tacit admission that the law was here to stay, while Democrats were unhappy with some of the technical aspects of the bill.

    What's in the plan

    • It would provide funds for the cost-sharing reduction payments that help offset costs for insurers to cover lower-income patients. These are the payments President Donald Trump ended in October.
    • It would create a reinsurance program that would mitigate losses for insurers that cover an overall sicker pool of people.
    • It would allow people over the age of 30 to buy "copper" plans with limited benefits and loosen regulation around short-term stopgap plans.
    • It would allow governors to obtain waivers to loosen Obamacare regulations in their state without the state legislature's approval.

    The authors believed that by combining the more Democratic-friendly funding options with GOP-friendly easing of regulations, they could strike a compromise. Instead, it's left lawmakers on both sides of the aisle unhappy.

    Everyone has a problem with it

    For Republicans, it's a no-go because it works within the existing frame of Obamacare.

    "The idea you’re going to vote for billions of dollars to stabilize a system you never supported in the first place?" GOP Rep. Tom Cole said Tuesday. "Pretty hard to choke down."

    Democrats, meanwhile, pushed back on language that would ban using the new funds at providers that also provide abortion services.

    "I am disappointed that Republicans are pushing a partisan bill that includes an unacceptable last-minute attack on women's health on what should be bipartisan work to lower healthcare costs," Sen. Patty Murray, an author of the earlier Alexander-Murray stabilization bill, told reporters Monday.

    Given the pushback, it is reportedly no longer being included in the massive spending bill set to be released this week.

    Attaching the Obamacare provisions to the spending bill, which needs to pass to avoid a government shutdown on Friday, is the last hope for the bill. When asked by reporters of the bill's chances of coming back without being a part of the shutdown negotiations, Alexander simply said: "Zero."

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