The most popular parts of the Affordable Care Act (ACA) are the most expensive. Universal coverage is a top priority not only for Democrats but also for President Trump. Both Republicans and Democrats want to preserve many costly coverage features of the ACA, including those that prevent insurers from precluding people with preexisting conditions and those that eliminate lifetime or annual coverage limits. The challenge is how to preserve these features and make insurance affordable.

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One of the more interesting television commercials I see is an ad sponsored by Cancer Treatment Centers of America. The message: if you have cancer, we want you.

Welcome to a small glimpse of how the market for health care might be different.

If we had a genuinely free market for health care, ads like this would not be rare and unusual. There would be centers of excellence for heart disease and diabetes and dozens of other afflictions. Through television, radio, the Internet and other means, these centers would be seeking out people with problems and offering to solve them – just like in other markets.

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In an interview aired Wednesday, President Trump said that his overriding legislative priority is to pass health care reform, but he won’t wait indefinitely to turn his attention to overhauling the nation’s tax code. Trump told the Fox Business Network, “We’re going to have a phenomenal tax reform, but I have to do health care first. . . . I don’t want to put deadlines. Health care is going to happen at some point. Now, if it doesn’t happen fast enough, I’ll start the taxes.” The White House had hoped to pass a tax bill before the congressional recess in August, though officials have conceded the deadline is slipping. Trump suggested that it is important to pass the health care bill first, because it would provide “hundreds of millions of dollars” in savings that could be used to offset a net tax cut.

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Rep. Mark Meadows intends to deliver an Obamacare repeal and replacement plan to House Speaker Paul Ryan, R-Wis., on Tuesday that would leave in place the existing law’s mandates for insurers to cover people with pre-existing conditions.

“What I’m getting to him is based on conversations that I’ve had with (Tuesday Group co-chairman) Tom MacArthur and leadership, but I wouldn’t say that it’s approved at this point,” Meadows, chairman of the Freedom Caucus, told USA TODAY. “What we’re trying to do is work through issues that are important to all of us but make sure that pre-existing conditions are taken care of.”

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On April 6, the House Rules Committee discussed an amendment to the American Health Care Act (AHCA) that would allocate $15 billion over 10 years to be used to develop an invisible high-risk pool (IHRP)—a risk-sharing mechanism meant to alleviate issues caused by the uneven distribution of health care costs. In a marketplace with some form of guaranteed issue, efficient risk-spreading mechanisms are a must. The creation of a IHRP program is a logical next step. However, if the program is improperly funded and fails to account for geographical differences between states and regions, it will only result in a marketplace marked by the same problems plaguing the current marketplace: rising premiums and lack of insurer competition.

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Here is something you can take to the bank. If Republicans can’t produce an alternative to Obamacare that solves the real problems of ordinary people, they will never be able to pass a health reform bill. But if they do solve problems, they will have no trouble getting support — even from Democrats.

That means getting the focus right. Over the past three years there have been a series of Republican proposals that have been excessively focused on Obamacare rather than on a conservative approach to health reform. These proposals have been hell bent on repealing Obamacare taxes and Obamacare mandates instead of solving the problems that Obamacare has created or exacerbated.

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Republicans left Washington on Friday without a health-care deal, despite renewed negotiations after last month’s fiasco and a burst of White House diplomacy. Perhaps the two-week recess will be a cooling-off period and we hope the House’s factions can agree on a deal. If they can’t, then at least we’ll learn who’s responsible for defeat.

President Trump and Republicans campaigned on repeal and replace, and the President at least wants to keep his word. The ObamaCare exchanges are also fragile and precarious, and consumers harmed by rising premiums and declining choices are likely to blame the party in power.

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House Republicans continue to work toward a health care deal but are currently in a holding pattern as they await further details from the Trump administration on proposed changes to the bill. “We don’t have bill text or an agreement yet,” Speaker Paul Ryan told reporters after meeting with the GOP conference Tuesday morning. He declined to discuss details of proposed changes, saying “productive conversations” were happening at the “conceptual level” regarding how to lower insurance premiums while maintaining “solid protections for people.” House Freedom Caucus members said the same thing Monday night after leaving a meeting where Vice President Mike Pence and Trump administration officials, including White House Chief of Staff Reince Priebus, discussed the proposed changes with them.

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The deal House Republicans reached on Thursday addresses a key problem with their alternative to the Affordable Care Act: steep premiums. The provision, which House Republicans decided to add to their Obamacare replacement bill before they face constituents during the Easter recess, would dole out $15 billion to states over about a decade to help insurers cover the sickest people in the health care system and reduce premiums for individual health plans.

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It looks like House Republicans have been trying over the past few days to coalesce around a revised version of the AHCA. One key revision has involved a more assertive temporary federal reinsurance scheme to quickly lower premiums and stabilize the transition period to a new system. But maybe the most significant, and least familiar, new proposal has involved allowing states to obtain waivers from some Title I regulations in Obamacare.   The devil will be in the details, and they will matter enormously here, but the general concept of returning regulatory power to the states through waivers that are connected to the bill’s spending measures is an interesting way to deal with the constraints Republicans confront and could have real promise.

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