Health care legislating ain’t pretty. In many cases, it’s downright coyote ugly. Particularly in the absence of a coherent and consistent majority in favor of substantially revising the status quo. Hence, today’s Senate Republican leadership “discussion draft” bill.

To be fair, leaders can’t go where they don’t have enough followers. So a good bit of today’s exaggerated reactions on the Right involves failure to come to terms with the divergence between past feel-better rhetoric and today’s grimmer political realities. There are neither enough votes nor popular support to repeal Obamacare simplistically, or engineer a softer landing toward substantial reform of the ACA — let alone offer a long-term path toward market-based health policy in practice. A long parade of mistakes in politics and policy were made AFTER March 2010 that helped deliver us to today’s limited set of legislative options.

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Senate Republicans plan to vote before the July 4 recess on their legislation to repeal and replace ObamaCare.

Senate Majority Leader Mitch McConnell (R-Ky.) has little margin for error, as he can afford just two defections from his conference with all Democrats expected to oppose the bill. Vice President Mike Pence could then be called in to break the tie.

Here’s a look at where McConnell’s conference stands on the legislation, which was unveiled on Thursday.

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The House-passed bill left large numbers of Americans uninsured, in part because very low-income households could not afford to enroll in private coverage even with the House’s tax credits. Medicaid is the nation’s safety net insurance program. In practical terms, there is no real alternative to Medicaid for a person below the poverty line. Under the approach recommended here, federal Medicaid funding would be dispensed to the states to strengthen the safety net for the poor, even as there would be less support for expanding the program to persons with higher incomes.

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Enough insurers are planning to sell coverage on the Affordable Care Act’s insurance exchanges next year to keep them working — if only barely — in most parts of the country.

Competition in many markets has dwindled to one insurer — or none in some cases — and another round of steep price hikes is expected to squeeze consumers who don’t receive big income-based tax credits to help pay their bill.

“What we’re seeing is a deterioration in these markets, but the markets haven’t imploded, they haven’t gone into a rapid downward decline,” said Dan Mendelson, president of the consulting firm Avalere.

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Republicans are facing a critical test of Senate unity in the Trump era as leaders prepare to unveil a healthcare bill that they have grappled over in secrecy to reconcile the conflicting demands of party factions.

President Donald Trump’s policy ambitions depend on Republicans’ ability to bridge deep internal divisions, and after false starts on healthcare in the House of Representatives earlier this year the drama now moves to the Senate.

Mitch McConnell, the Senate majority leader, has promised to release a draft healthcare bill on Thursday, incorporating substantial revisions to a measure that passed the House in May. But whether it will secure enough votes to pass the Senate remains in doubt.

Healthcare reform has become a quagmire for Mr Trump, who campaigned on a pledge to repeal his predecessor’s Obamacare reforms. But he has seen efforts falter as his party disagrees on who should get health insurance and how it will be paid.

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Much of the public discussion about health care and health insurance reform abounds with misinformation. Medicaid, in particular, has become a political tool, with daily posts and articles about reforms to the program that distort the record for political gain. But there is little mention of the need to empower governors to take ownership of the program.

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The government’s price tag for a single-payer health care system would be astonishing. When Sen. Bernie Sanders (I-VT) proposed a “Medicare for all” health plan in his presidential campaign, the nonpartisan Urban Institute figured that it would raise government spending by $32 trillion over 10 years, requiring a tax increase so huge that even the democratic socialist Mr. Sanders did not propose anything close to it.

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As the Republican Congress struggles to “repeal and replace” Obamacare, the political landscape is steadily shifting.

Since the Democratic Congress enacted Obamacare in 2010 (without a single Republican vote), Democrats have increasingly been on the defensive about their creation. The individual mandate that Obamacare relied upon to corral healthy young people into insurance pools has failed to do the job – partly because the tax penalty was not severe enough, and partly because the Obama administration felt compelled to create 14 different types of “hardship exemptions” that exempted millions of young people from the penalty.

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Recall that under Democratic Governor Peter Shumlin Vermont committed to a single-payer for the state but had to abandon the effort in 2015. Why? The cost was staggering — $4.3 billion when Vermont’s entire fiscal 2015 budget, including both state and federal funds, was about $4.9 billion. That’s right: essentially doubling the size of the government.
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While Senate Republicans are drafting their healthcare plan behind closed doors, they’ve given reporters a general idea of what might be in it.

  1. It will slow down the phase-out of the Medicaid expansion
  2. Tax credits will be beefed up
  3. It will keep some ObamaCare taxes
  4. It will include more funding to combat the opioid crisis
  5. It will try to stabilize the ObamaCare exchanges
  6. It will include more funding to handle preexisting conditions