Ever since the Affordable Care Act’s insurance marketplaces opened for business in 2014, the Obama administration has worked hard to get Americans to sign up. Yet officials now are telling some older people that they might have too much insurance and should cancel their marketplace policies.

Each month, the Centers for Medicare and Medicaid Services is sending emails to about 15,000 people with subsidized marketplace coverage. The message arrives a few weeks before their 65th birthday, which is when most become eligible for Medicare.

The CMS says some Medicare beneficiaries are receiving tax credits to purchase insurance through the Affordable Care Act marketplace. The agency is warning them to cancel their exchange coverage immediately and pay back the credit they’ve received.

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Former Obama administration official Donald Berwick once called the Center for Medicare and Medicaid Innovation (CMMI) “the jewel in the crown of health-care reform.” The metaphor is apt: CMMI, more than any other aspect of Obamacare, is an imperial enterprise.

Congress established CMMI in the Obamacare statute with the goal of finding ways to reduce federal spending on medical care without diminishing its quality. That, of course, is the responsibility of Congress, which created the Medicare program and which alone bears responsibility for making legislative changes to it.

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Our constitutional system was carefully designed to prevent any one branch from seizing too much control over the entire government. Only Congress can write legislation; only the President can execute the laws; only the courts can judge whether the laws are constitutional.

This balance of powers, however, does not maintain itself. It is a dynamic equilibrium requiring each branch of government to protect and fully exercise its rightful authorities. When one branch encroaches on another, that balance is endangered — and so are the freedoms the separation of powers were intended to protect.

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When Aetna decided last week to drop 70% of its health plans in the Affordable Care Act markets, CEO Mark Bertolini publicly blamed the exits on the poor risk pool, as well as “the current inadequate risk-adjustment mechanism.”

The federal government’s decision to block Aetna’s acquisition of Humana also factored heavily into Aetna’s exchange exodus, as Bertolini warned in a July letter that was obtained by the Huffington Post.


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The insurance marketplaces created under the Affordable Care Act face some similar challenges that public insurance programs have faced as they’ve gotten off the ground.

Steps that were taken to stabilize Medicare Advantage and Medicare Part D could be a starting point to stabilize the ACA insurance exchanges, a policy brief released Tuesday by the Robert Wood Johnson Foundation suggests.

The report comes a day after Aetna announced it would not offer policies in most exchange markets in 2017 where it has offered plans this year, becoming the latest major insurer to do so. Scrutiny has increased around the exchanges since major insurers including UnitedHealth and Humana have announced they would pull back from from the exchanges for 2017.

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For six years, it has been abundantly clear that Americans want Obamacare to be repealed—but only if a well-conceived conservative alternative is positioned to take its place. That’s why the recent release of the House GOP health care plan is a big deal. The new plan would of course repeal Obamacare. But it would also fix what the federal government had already broken even before the law was passed and made things so much worse.

The proposal pairs an Obamacare alternative with Medicaid reforms and the crucial Medicare reforms (amounting to a kind of “Medicare Advantage Plus”) that Speaker Paul Ryan and House Republicans have long championed. As Ryan put it after the proposal’s release, “The way I see it, if we don’t like the direction the country is going in—and we do not—then we have an obligation to offer an alternative….And that’s what this is.” He called the plan not merely “a difference is policy” but “a difference in philosophy.”

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Today, after years of hearings and speeches and debates, the Paul Ryan-led House of Representatives has done something it has not done before: it has released a comprehensive, 37-page proposal to reform nearly every federal health care program, including Medicare, Medicaid, and Obamacare. No proposal is perfect—and we’ll get to the Ryan plan’s imperfections—but, all in all, we would have a far better health care system with the Ryan plan than we do today.

The first thing to know about the Ryan-led plan — part of a group of proposals called “A Better Way” — is that it’s not a bill written in legislative language. Nor is it a plan that has been endorsed by every House Republican.

Instead, it’s a 37-page white paper which describes, in a fair amount of detail, a kind of “conversation starter” that House GOP leadership hopes to have with its rank-and-file members, and with the public, in order to consolidate support around a more market-based approach to health reform.

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House Speaker Paul Ryan’s policy plan for health care, as expected, leans heavily on market forces, more so than the current system created by Obamacare. The proposal contains a host of previously proposed Republican ideas on health care, many of which are designed to drive people to private insurance markets.

Importantly for conservatives, as part of a full repeal of the Affordable Care Act, the current law’s mandates for individuals and insurers would disappear under the GOP plan. It would overhaul Medicare by transitioning to a premium support system under which beneficiaries would receive a set amount to pay for coverage. The plan also would alter Medicaid by implementing either per capita caps or block grants, based on a state’s preference.

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Policymakers are keeping their eyes on the 2016 Social Security and Medicare trustees’ report to see if the White House will stand by its projection that Medicare will be solvent until 2030. The Congressional Budget Office estimates funds (PDF) for the program will dry up in 2026.

Also of interest is whether the trustees will call for the creation of an Independent Payment Advisory Board called for in the Affordable Care Act to reign in Medicare costs if they grew faster than a set rate. But the board, called the death panel by ACA opponents, has not yet been created. There hasn’t been the need, and some say, the willingness to expend the political capital.

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