Republicans have made a great deal of progress toward broad agreement on a general policy approach over the past half-decade. The GOP has been preparing for the opportunity to enact conservative health care reform for years, and it now faces both a party electorate and a health care system that will not allow for endless indecision. It is too soon to know what the final product will look like, and whether a series of reconciliation bills or some uneasy combination of partisan and bipartisan measures will emerge. But it does seem likely that a year of intense action on health care is beginning.

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Rep. Tom Price, President-elect Donald Trump’s choice to head the Department of Health and Human Services, faced a contentious Senate hearing Wednesday as Democrats questioned his ideas for the future of Americans’ health coverage and whether his personal investments in health-care companies presented conflicts during his years in Congress.

Price began by laying out central elements of his years-long attempt to replace the Affordable Care Act. In doing so, he signaled ways in which Trump’s more populist message could collide with the core beliefs of congressional Republicans. He told senators that “it is absolutely imperative” for the government to ensure that all Americans “have the opportunity to gain access” to insurance coverage.

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President-elect Donald Trump says the program he plans to institute as a replacement for the Affordable Care Act will “get private insurance companies to take care of a lot of the people that can afford it.”

“We’re going to have a plan that’s going to be great for people. And it’s going to be much less expensive. And you will be able to actually have something to say about who your doctor is and your plan,” Trump told Fox News’ “Fox & Friends” in an interview that was taped Tuesday and aired Wednesday morning. “We have to cover people that can’t afford it. And that’s what I’m talking about. And we’ll probably have block grants of Medicaid back into the states. … Nobody is going to be dying on the streets with a President Trump.”

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Two Republican senators are working on legislation that would let states decide whether they want to keep Obamacare or move to a different system. Sens. Bill Cassidy of Louisiana and Susan Collins of Maine both hinted on the Senate floor Tuesday about a bill that would preserve Obamacare, but only for states that choose to keep it. Cassidy said the bill would be essentially the same as a bill he introduced in the last Congress called the Patients Freedom Act. It lets states decide if they want to stay in Obamacare if it is working or leave. “The state could go with the alternative, which we will lay out, the state could opt for nothing — no Medicaid expansion and no help for lower-income folks — or the state could opt to stay in Obamacare,” Cassidy said.

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Donald Trump’s pledge to “repeal and replace Obamacare” was one of his biggest crowd pleasers. Moving forward on his broad replacement themes—expanding health savings accounts (HSAs) and state flexibility—could lead to some surprising and intriguing reforms.

During the campaign, Trump supported the familiar Republican themes of tax-free HSAs and allowing families to deduct health insurance premiums in their tax-returns. He pledged that “we must also make sure that no one slips through the cracks simply because they cannot afford [health] insurance.” This opens the door to a serious and conceivably bipartisan discussion about how to replace the complex structure of ACA subsidies and tax breaks.

In addition to redesigning subsidies, another element is an expanded role for states. The familiar Republican call to take the federal money for Medicaid expansion as a block grant and turn it into subsidies for families to buy private coverage has received plenty of the attention. But the broader theme of giving states much greater flexibility could become a different pathway to the goal of affordable and adequate health coverage for all.

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“As Republicans try to repeal the Affordable Care Act, they should be reminded every day that 36,000 people will die yearly as a result.”
— Sen. Bernie Sanders (D-Vt.), in a tweet, Jan. 12, 2017

Sanders has tweeted as a definite fact an estimate that a) assumes Republicans will gut Obamacare without a replacement b) assumes the worst possible impact from that policy and c) assumes that data derived from the Massachusetts experience can be applied across the United States.

Those are three very big assumptions. Take away any one of them, and Sanders’s claim that repeal of the law will cause 36,000 people to die a year falls apart.

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This morning, the Congressional Budget Office released a report arguing that the partial repeal of Obamacare being contemplated by Republicans would wildly increase the number of people without health insurance, in ways that are difficult to understand. Here are four problems with the CBO’s analysis.

1. The CBO’s estimates assume no Obamacare replacement

2. The CBO massively overestimates the impact of Obamacare’s individual mandate

3. The GOP repeal bill is likely to treat Medicaid differently than the CBO does

4. CBO’s 2010 estimates of Obamacare’s coverage expansion were off by more than 10 million

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A spokesman for Donald Trump sought Monday to elaborate on the president-elect’s plans to replace the Affordable Care Act, vowing that the new administration would lower health-care costs by infusing more competition into the marketplace, including by allowing insurers to sell health plans across state lines.

Trump’s goal is “to get insurance for everybody through marketplace solutions, through bringing costs down, through negotiating with pharmaceutical companies, allowing competition over state lines,” Sean Spicer, the incoming White House press secretary, said during an interview on NBC’s “Today” show.

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It’s clear that whatever replaces Obamacare must focus on quality and incremental local solutions, not one-size-fits-all government mandates.

In this respect, the federal government’s biggest task for replacing Obamacare is to get out of the way and let state policymakers and health care providers innovate.

First off, let’s get clear what Americans want: They’d like many choices of affordable health insurance plans that allow them to choose their doctors. They want to buy a plan when they are young, then keep their plan from job to job and into retirement. And they’d like it to be truly affordable. These “must haves” are obvious to people of any political orientation.

Instead of approaching this challenge like designing a single system or product (the way Obamacare was constructed), Congress needs to help these conditions develop organically, while preserving freedom of choice for Americans.

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Late last year, House Speaker Paul Ryan (R., Wis.) told a group of senior GOP lawmakers that the person they needed to watch in the Senate in 2017 was Elizabeth.

“Elizabeth Warren?” one lawmaker asked.

“No,” Mr. Ryan replied, according to a lawmaker in the room, “Elizabeth, the Senate parliamentarian.”

Elizabeth MacDonough, the sixth person and first woman to hold the title of chief Senate parliamentarian, will play a crucial role in determining what can be included in legislation enabling the Senate to roll back major parts of the Affordable Care Act with just a simple majority, rather than the 60 votes usually needed.

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