Hundreds of insurers selling health plans in Affordable Care Act marketplaces are being paid less than 2 percent of nearly $6 billion the government owes them for covering customers last year with unexpectedly high medical expenses.

The $96 million that insurers will get is just one-fourth of the sum that provoked an industry outcry a year ago, when federal health officials announced that they had enough money to pay health plans only 12.6 percent of what the law entitles them to receive.

This time, the Obama administration made no public announcement.

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The head of America’s Health Insurance Plans, the national trade association representing health insurers, lists three key priorities for reform:

1. Commit to policies that support continuous coverage for everyone—those who utilize insurance to obtain quality care and those who are healthy but have insurance to protect them in case they get sick. Both types of consumers must be insured for coverage to remain affordable.

2. Commit to market stability in 2017 and 2019 by funding temporary, transitional funding programs at least through January 1, 2019.

3. Reduce health costs for millions of Americans by eliminating the health-insurance tax on insurers, which is passed along to employers and consumers in the form of higher premium costs.

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Millions of emergency room patients could face financial ruin — even if they deliberately seek care at hospitals covered by their insurers.

That’s the disturbing finding of a new study published in the New England Journal of Medicine. Conducted by two Yale professors, the study shows that 1 in 5 ER visits involve doctors who are not in the same insurance network as their hospitals. The patients treated by those out-of-network physicians are forced to pay for a portion of their care out-of-pocket. The average out-of-network ER charge is $600.

A bill that size spells disaster for many patients. About half of Americans wouldn’t be able to cover a surprise $400 bill without selling something or borrowing money.

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U.S. health insurers signaled Tuesday that they’re willing to give up a cornerstone provision of Obamacare that requires all Americans to have insurance, replacing it with a different set of incentives less loathed by Republicans who have promised to repeal the law.

Known as the “individual mandate,” the rule was a major priority for the insurance industry when the Affordable Care Act was legislated, and also became a focal point of opposition for Republicans. In a position paper released Tuesday — the first since President-elect Donald Trump’s victory — health insurers laid out changes they’d be willing to accept.

“Replacing the individual mandate with strong, effective incentives, such as late enrollment penalties and waiting periods, can help expand coverage and lower costs for everyone,” AHIP said.

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The new direction of American health care should be fully consumer driven, empowering individuals to be the surveyors and purchasers of their care. If President-elect Trump and Rep. Tom Price, Trump’s HHS pick, want to make the most of this short window, they should keep four central reforms in mind: 1) Provide a path to catastrophic health insurance for all Americans. 2) Accommodate people with pre-existing health conditions. 3) Allow broad access to health-savings accounts. 4) Deregulate the market for medical services.

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President-elect Donald Trump has selected Rep. Tom Price (R-GA), a leading critic of the Affordable Care Act, to head the Department of Health and Human Services. If confirmed by the Senate, he would play a central role repealing and replacing the ACA. Price, an orthopedic surgeon, has for years been refining his own detailed plan for health reform, the Empowering Patients First Act. It would repeal the law, but, among many other changes, would provide support for those not eligible for employer-based coverage or public programs through age-adjusted refundable tax credits. (Price also played a key role this year in developing the House Better Way proposal unveiled by Speaker Paul Ryan in June that takes the legislative process a step further.)

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The main objective of the Affordable Care Act (ACA) was to increase enrollment in health insurance among those who were previously uninsured. Official estimates from the Census Bureau have consistently overstated the number of people who are uninsured. A major factor in the overestimate is the undercount of people in Medicaid. Also, millions of Americans have been officially uninsured despite their eligibility for public insurance or employer coverage. With the passage of the ACA, fewer than 10 percent of the remaining uninsured do not have a realistic path to securing health insurance. The future of the ACA is now uncertain, but any future policy changes will likely need to provide a sure path to insurance coverage for all Americans as well.

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In 2008, the year that Barack Obama was elected as president, the combined annual profits of America’s ten largest health insurance companies were $8 billion. Under Obamacare, the ten largest health insurers’ annual profits have risen to $15 billion. This is another fine example of the natural alliance between Big Government and Big Business, which flourishes at the expense of Main Street Americans.

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President Obama and Hillary Clinton love to talk about the “20 million people” who’ve allegedly been added to the health insurance rolls under Obamacare. But in truth, a lower percentage of Americans have private health insurance now than in 2007, even though Obamacare is the law. This is according to the federal government’s own figures. According to the Centers for Disease Control and Prevention, 67% of those living in the United States had private health insurance in 2007. Now, as of 2015, only 66% have private health insurance.

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Some health insurers say they’re paying too much to rival Blue Cross Blue Shield plans under a key pillar of the federal health law designed to compensate insurers that take on sicker and more expensive patients.

The critics’ chief complaint is that the Affordable Care Act’s risk-adjustment program unfairly rewards health plans — including Blue Shield of California — that have excess administrative costs and higher premiums. That comes at the expense of more efficient, lower-priced plans in the individual market, they say.

The Obama administration is considering changes to how these dollars are allocated in the state and federal exchanges, but critics say the proposed modifications don’t go far enough.

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