President Trump has proposed a budget that increases government spending from $4 trillion today to $5.5 trillion in 2027. Only in the alternative reality of Washington can this be described as “budget cuts.” Looking at individual programs, it is a gross mischaracterization to state that spending on Medicaid programs will be cut. The new budget proposes to increase federal Medicaid spending from $378 billion a year today to $524 billion a year in 2027. It shows how far removed Washington is from everyday Americans for this increase of $146 billion to be called a cut. The fundamental problem is that special interests are addicted to the rising path of spending. Altering this path by increasing spending at a slower rate opens change-makers to extraordinary attacks.

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The entire Republican reform effort hinges on getting the tax credits right. A poorly-designed credit will lead millions to lose their health insurance and incentivize them to remain poor. It will harm efforts to reform the Medicaid program, because the insufficient tax credits won’t form a viable alternative. On the flip side: there is great opportunity in getting health reform right. The right kind of means-tested tax credit could make individual health insurance markets work for tens of millions of Americans. That success, in turn, could improve the opportunities for long-term entitlement reform, by giving Americans a robust option to buy insurance on their own.

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Republican legislators and policy experts are kicking around a novel way to increase health coverage: automatically enrolling millions of uninsured Americans into low-cost insurance plans.

The idea has shown up on the opinion pages of the Wall Street Journal and been discussed in private meetings of the Senate working group on health care.

“It’s a viable idea,” says Andy Slavitt, who ran Medicare under President Obama and is an ardent Affordable Care Act advocate. “What’s appealing about it to Republicans and to Democrats is you want people to have free choice but not be free riders.”

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The Senate GOP will need to produce a bill that can claim to have significantly changed Obamacare, achieve at least the same amount of cost savings as the House bill did through the budgetary reconciliation process, and that will be able to garner support in both the Senate and the House. The Senate will also need to fix the simple fact that the age-adjusted, fixed-dollar tax credits to subsidize insurance coverage in the AHCA are too simple and insensitive to the income-related health needs of lower income Americans.

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GOP senators say they’re discussing a possible short-term bill if their health care talks drag on. It might include money to help stabilize shaky insurance markets with subsidies to reduce out-of-pocket costs for low-earning people and letting states offer less expensive policies. It’s unclear Democrats would offer their needed cooperation, but Republicans are talking about it. “We’ve discussed quite a bit the possibility of a two-step process,” said Sen. Lamar Alexander (R-TN), chairman of the Senate Health, Education, Labor and Pensions Committee. “In 2018 and ’19, we’d basically be a rescue team to make sure people can buy insurance.”

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House Republicans may face the possibility of having to vote again on the American Health Care Act (AHCA), which passed the House earlier this month. House Speaker Paul Ryan hasn’t yet sent the bill to the Senate because there’s a chance that parts of it may need to be redone, depending on how the Congressional Budget Office (CBO) estimates its effects. House leaders want to make sure the bill conforms with Senate rules for reconciliation, a mechanism that allows Senate Republicans to pass the bill with a simple majority. The CBO is expected to release an updated estimate next week.

The American Health Care Act (AHCA), which passed the House earlier this month, is a health care revolution. It isn’t about returning to the way things were. It’s about asking the country to imagine a system that has never existed before. Instead of offering a plan centered on Washington, D.C., the AHCA is centered on you. It empowers you and respects your relationship with your family and your doctor. It delivers to you increased access, benefits, choices and health savings. The opposition has been so intense precisely because the plan is so ambitious. One bogus argument government elites are using is the claim that thousands of Americans with pre-existing conditions will die if the AHCA becomes law. Actually, the bill includes “continuous coverage” protections for people with pre-existing conditions. For anyone with continuous coverage, pre-existing conditions do not apply.

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Those advocating for universal health coverage know very well that resources are limited, and that costs must be contained. They also understand that the burgeoning bureaucracy must be well paid. So the answer is to cut services. Some plans “incentivize” doctors to make more money by skimping on care. Others call for a “global budget”—the deliberate creation of scarcity. When the money is gone, treatment is canceled. There will be fewer beds, fewer CT scanners, fewer drugs, and fewer doctors. But all will be fair. No rationing by price, just by waiting lines, political pull—and death. There will be no medical bills to pay after a service, if you get any service. Only taxes in advance, service or no service.

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Now that the House of Representatives passed a revised version of the American Health Care Act (AHCA) to replace the Affordable Care Act (ACA) the ball is in the Senate’s court.  Despite calls to start from scratch, the Senate would be well advised to work off the structure of the AHCA. AHCA provides a solid foundation that could be improved with some tweaks. It repeals the ACA’s unpopular individual and employer mandates and penalties but preserves its well-liked protections for people with pre-existing conditions, the ban on lifetime coverage caps, coverage for children up to age 26 on their parents’ insurance and coverage of essential health benefits.

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Large employers are reexamining health care delivery systems and are looking for a more competitive marketplace, according to a new paper from the American Health Policy Institute. With health care policy front page news, it should be noted that the federal government is not the only institution taking a hard look at the subject and deciding whether changes are merited. Large employers who provide health care benefits to more than 170 million Americans are also reexamining current delivery systems. The paper illustrates longstanding concerns of large employers that have been intensified by the debate on the ACA, such as the lack of strong tools providing purchasers and consumers of health care with the information they need to evaluate the quality, cost, and effectiveness of the services being provided.

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