The Affordable Care Act’s insurance exchanges have become too risky for major health insurers, and that’s creating further doubt about coverage options consumers might have next year.

Anthem CEO Joseph Swedish said Wednesday his company is waiting to see whether the government makes some short-term fixes to the shaky exchanges before it decides how much it will participate next year. The Blue Cross-Blue Shield carrier is the nation’s second largest insurer and sells coverage on exchanges in 14 states.

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Uninsured rates in low-income families have fallen under the Affordable Care Act, yet more than a third of Americans continued to face difficulties paying their medical bills in 2016, a survey found.

Adults in poor families were among the greatest beneficiaries of the ACA, with uninsured rates falling as much as 17 percentage points since it became law in 2010, according to a study from the Commonwealth Fund.

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Many Obamacare supporters claim the law has expanded health coverage to upwards of 20 million Americans, but new data shows that isn’t accurate.

As part of Congress’ continued push to repeal Obamacare, the House Budget Committee held a hearing this week titled “The Failures of Obamacare: Harmful Effects and Broken Promises.”

Heritage Foundation expert Ed Haislmaier was one of four expert witnesses who testified.

Haislmaier presented new data regarding gains in health coverage since the full implementation of Obamacare began in 2014.

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While the final figures will be somewhat different once the more complete end of year data is available, at this point it is reasonable to expect that for the three-year period of 2014 through 2016, the net increase in health insurance enrollment was 16.5 million individuals. Of that figure, 13.8 million were added to Medicaid and 2.7 million were the net increase in private-sector coverage enrollment.

In general, enrollment data indicate that the implementation of the ACA appears to have had three effects on health insurance coverage: (1) a substantial increase in individual-market enrollment; (2) an offsetting decline in fully insured employer-group plan enrollment; and (3) a significant increase in Medicaid enrollment in states that adopted the ACA Medicaid expansion.

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About 27 percent of people under 65 are thought to have some sort of pre-existing condition that will most likely leave them without individual insurance if the law is repealed, according to a recent study. The guarantee of coverage has already become a rallying cry for people who want to keep the law.

The issue “is the third rail” for the Republicans, said Michael Turpin, a longtime health industry executive.

Before the law, a fairly typical life event — like a divorce or the loss of a job — and a relatively minor medical condition could upend a person’s health coverage options. Stories of sick people unable to get coverage when they needed it most were legion.

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“What about the 20 million people who got coverage?”

Republicans are naturally concerned. Liberals have weaponized this number to stop repeal of the ACA. But should 20 million people keep a bad law on the books? To answer this question, Congress must ask two different questions.

First, is the number real? In March 2016, the Department of Health and Human Services (HHS) estimated that 20 million uninsured adults gained coverage under the ACA: 17.7 million non-elderly adults (ages 18 to 64) since October 2013, and 2.3 million young adults (ages 19-25) between 2010 and 2013.

The estimates are based on data from the National Health Interview Survey and the Gallup-Healthways Well-Being Index. The estimates are “adjusted to account for changes in general economic conditions (via employment status), geographic location, demographics and other secular trends.” Thus, the 20 million is an estimate, not a rock-solid fact.

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While the average estimate shows nearly 21 million people have benefitted from Obamacare, it’s important to note that some people currently enrolled in Medicaid could have enrolled in Exchange coverage with nearly full subsidization had their state not expanded Medicaid, and would likely be eligible for whatever new subsidy structure might replace the current system. Regarding those in the Individual Market, not all of these individuals are receiving subsidies and would therefore not be financially impacted by the repeal. Making reasonable assumptions and accounting for those who lost insurance because of the ACA, and setting aside any assistance that would be provided by ACA replacement policies, the number of people who, on net, are potentially at risk of being negatively impacted is likely closer to 13-14 million.

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Beginning in January, the Republican-controlled Congress, working with the incoming Trump administration, will have the opportunity to roll back the Affordable Care Act and replace it with a plan that is less driven by federal control and regulation. The starting point for this effort ought to be that everyone in the United States should have health insurance, protecting them against major medical expenses. To do so, the GOP should:

  • Grandfather Coverage Provided by the ACA
  • Accept and Clarify Medicaid’s Role as the Safety Net Health Insurance Program
  • Impose Cost-Discipline and Generate Revenue with an Upper Limit on the Tax Preference for Employer-Paid Premiums
  • Build an Effective Auto-Enrollment Program to Achieve Higher Levels of Coverage

Health and Human Services Secretary-nominee Tom Price has a radical idea: Let Medicaid recipients choose their own health insurance plan just as millions of Americans do every year.

Both House Speaker Paul Ryan and Price want to replace Obamacare subsidies with refundable tax credits—which would essentially function like a federal subsidy—for people who do not have access to employer-provided health insurance, Medicare, Medicaid or VA coverage.

But under legislation introduced by Price in 2015 (see section 102), a person in a government-run program such as Medicaid could opt out and take the tax credit instead.

That’s exactly the right thing to do.

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House Republicans, responding to criticism that repealing the Affordable Care Act would leave millions without health insurance, said on Thursday that their goal in replacing President Obama’s health law was to guarantee “universal access” to health care and coverage, not necessarily to ensure that everyone actually has insurance.

“Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” a House leadership aide told journalists on the condition of anonymity at a health care briefing organized by Republican leaders.

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