As Hillary Clinton, President Obama, and most Senate Democrats coalesce around a government-run insurance agency as part of the solution to Obamacare cost woes, a large problem remains unaddressed: Insurers hate the public option.

Democrats, including the Clinton campaign, are showing little sympathy.

In recent months, several insurance plans have pulled out of Obamacare exchanges, citing losses. Many areas of the country will see double-digit premium increases in 2017 as insurers try to recoup their losses and bring rates in line with medical claims. The insurance industry has made it clear that participating in exchanges has, thus far, not been easy.

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Former President Bill Clinton attacked President Barack Obama’s signature health care legislation Monday, calling it a “crazy system” that “doesn’t make any sense” during a Michigan campaign event for Hillary.

“It doesn’t make any sense. The insurance model doesn’t work here,” Clinton said about the government-run marketplaces Obamacare set up. Clinton said that Obamacare “works fine” for people with “modest” incomes or who are eligible for government subsidies, or Medicare. But he added that, “the people that are getting killed in this deal are small business people and individuals who make just a little too much to get any of these subsidies.”

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Democratic presidential nominee Hillary Clinton took a shot at President Obama’s landmark health care program in private remarks to donors even as she pledged to defend the law, according to audio of her remarks obtained by the Washington Free Beacon.

Parts of the Affordable Care Act, better known as Obamacare, “need fixing,” Clinton told donors during a September 2015 fundraiser at the Marriott Marquis hotel in Washington, D.C.

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Proposals to make changes to the Affordable Care Act from both sides of the political aisle show that President Obama’s health care law will almost certainly needs changes to survive.

The president, Hillary Clinton, and nearly one-third of the Senate have endorsed a new government-sponsored health plan, the so-called public option, to give consumers on Obamacare exchanges an additional choice. A significant number of Democrats, for whom Senator Bernie Sanders spoke in the primaries, favor a single-payer arrangement.

Donald Trump and Republicans in Congress, on the other hand, would go in the direction of less government, reducing federal regulation and requirements so insurance would cost less and no-frills options could proliferate. Mr. Trump would, for example, encourage greater use of health savings accounts, allow insurance policies to be purchased across state lines and let people take tax deductions for insurance premium payments.

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A look at transcripts of Clinton stump speeches since she kicked off the general election campaign on Labor Day finds the Democratic candidate almost never talks about Obamacare. She doesn’t promise to expand it. She doesn’t promise to protect it. She doesn’t extol its benefits. She just doesn’t mention it.

There’s no doubt Obamacare is in trouble. Enrollment in the exchanges has fallen far short of projections. The purchasers of policies have turned out to be older, and in need of more care, than expected. Major insurers are pulling out of the exchanges altogether. Premiums are going up. Deductibles are skyrocketing, meaning many are left to pay most of their healthcare costs themselves.

Two issue briefs published today by The Commonwealth Fund and authored by several RAND Corporation economists (led by Christine Eibner) will be noted by casual readers for their presumably “scientific” conclusions that (1) a set of Clinton proposals will increase the number of insured Americans by over 9 million and decrease average spending by up to 33% for those with moderately low incomes; and (2) a sketchy set of Trump policy stances would increase the number of uninsured individuals by 16 million to 25 million relative to the current-law ACA baseline and disproportionately affect low-income individuals and those in poor health.

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The bitter, long-running fight over ObamaCare’s individual and employer mandates is all over but the shouting.

The problems plaguing the ObamaCare exchanges as enrollment lags, premiums spike and insurers from Aetna to UnitedHealth head for the exits have reached a critical stage, even as the penalties are about to spike for far too many millions of people who get a bad deal from the law. This year, 8 million people paid the individual mandate penalty — not too far from the 10.6 million who had coverage via the exchanges at the end of June. The status quo won’t survive the inevitable political backlash, nor should it. ObamaCare is like a car with a bad muffler: It can keep traveling down the road, even as everyone it passes begs the driver to pull over and get it serviced.

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While health care has not been central to the 2016 Presidential campaign, the election’s outcome will be a major determining factor in the country’s future health care policy. A number of issues have garnered media attention, including the future of the Affordable Care Act (ACA), rising prescription drug costs, and the opioid epidemic.

Hillary Clinton and Donald Trump have laid out different approaches to addressing these and other health care issues. Central among these is their position on the future of the ACA. Hillary Clinton would maintain the ACA, and many of her policy proposals would build on provisions already in place. Donald Trump, in contrast, would fully repeal the ACA, and although his policy proposals and positions do not offer a full replacement plan, they do reflect an approach based on free market principles.

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Several RAND Corporation health economists have offered very rough estimates of the coverage and cost effects of the hazy health policy proposals by the two major presidential candidates, Hillary Clinton and Donald Trump. In choosing to fill Trump’s policy vacuum with their own void of limited health policy modeling, the RAND researchers conclude that Trump’s proposals would increase the number of uninsured individuals within a range of 16 to 25 million individuals (relative to current-law ACA arrangements), with disproportionate losses suffered by those with low incomes or in poor health. However, Trump doesn’t spend much more taxpayer money to achieve these results, and his plans in health policy would increase the federal deficit by somewhere between $0.5 billion to $41 billion.

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A liberal attempt to revive the public option is opening old wounds between the Democratic Party’s liberal and moderate wings. Thirty-three mostly-liberal Democrats, including all the Senate leadership, have signed onto a nonbinding Senate resolution to add the public option to Obamacare. But missing from the list are vice-presidential nominee, Sen. Tim Kaine and a half-dozen other moderates who face reelection in 2018. Kaine’s absence is especially striking since Hillary Clinton embraces the public option.

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