The next great health care war is already starting. It’ll be about costs this time, not coverage, and Democrats are the ones firing the first shots — though neither party has a complete strategy just yet.

Why it matters: After a bruising, decade-long fight over the Affordable Care Act, plenty of candidates and lawmakers would love to keep their distance from the politics of health care. But the issue is so personal, and the system is so dysfunctional, that may be impossible.

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Consumers and insurers face new uncertainty with the Justice Department’s assertion this week that key provisions of the Affordable Care Act are invalid.

In a brief filed Thursday, the department asked a federal court to unwind the health law’s protections for individuals with existing medical conditions, such as diabetes or asthma. The law, known as Obamacare, prohibits insurers from refusing to sell coverage to people with pre-existing conditions or from charging them more than healthy consumers.

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House Democratic Leader Nancy Pelosi (Calif.) said Thursday that “Medicare for All” proposals should be “evaluated” if Democrats win back the House this year, adding “it’s all on the table.”

Pelosi has long backed a public option for health insurance, but has not supported going further — as many Democrats want — and setting up government-run, universal health insurance.

The Democratic leader did not explicitly endorse the idea of Medicare for All during a press conference Wednesday, but she also did not rule out the proposal.

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Federal officials will not block insurance companies from again using a workaround to cushion a steep rise in health premiums caused by President Donald Trump’s cancellation of a program established under the Affordable Care Act, Health and Human Services Secretary Alex Azar announced Wednesday.

The technique — called “silver loading” because it pushed price increases onto the silver-level plans in the ACA marketplaces — was used by many states for 2018 policies. But federal officials had hinted they might bar the practice next year.

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The Republican-led Michigan Legislature on Thursday gave final approval to a bill requiring able-bodied adults in the state’s Medicaid expansion program to meet work or job-related requirements, sending it to Gov. Rick Snyder for his expected signature.

Starting in 2020, adults age 18 to 62 would have to show workforce engagement averaging 80 hours a month — through work, school, job or vocational training, an internship, substance abuse treatment or community service. Michigan would first seek a federal waiver to implement such requirements that have been embraced by President Trump’s administration.

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Gov. Ralph Northam (D-VA) signed a bill into law Thursday that will allow more people to sign up for health care coverage paid for by the Medicaid program. This is projected to move 400,000 low-income residents onto the program. Lawmakers arrived at a compromise on Medicaid and on other parts of spending in part by setting a tax on hospitals. Under Obamacare, the federal government paid for all of the cost of Medicaid expansion in states beginning in 2014, but this support will fall to 90 percent of costs by 2020. In some states, that will mean billions of dollars in additional spending.

In a court case filed by Texas and 19 other states, the Justice Department said in a brief on Thursday that the requirement for people to have insurance — the individual mandate — was unconstitutional.

If that argument is accepted by the federal court, it could eviscerate major parts of the Affordable Care Act that remain in place.

A definitive court ruling could be months away and appeals of any decision could take many more months, during which the law is likely to stay in effect.

The downward spirals have begun. The combined Social Security trust funds—one for disability, one for retirement—as well as Medicare’s hospital-insurance trust fund, will begin eating into their reserves this year, according to reports released this week by the programs’ trustees. The trust funds for these safety-net programs are now projected to diminish until they are depleted. The Medicare hospital-insurance fund is projected to run dry in 2026. The bipartisan trustees have for several years been warning that Social Security and Medicare finances need fundamental repairs or people are going to get hurt.

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Senate Majority Leader Mitch McConnell’s move to scrap most of the chamber’s August recess promises to rob politically imperiled Democratic incumbents of campaigning time, but Minority Leader Chuck Schumer is embracing the change with a pitch for how to spend it: health care.

Schumer (D-N.Y.) plans to send McConnell (R-Ky.) a letter on Wednesday asking him to set aside August time for votes on five Democratic-backed proposals aimed at expanding and lowering the cost of health care, which he previewed Tuesday after the Kentucky Republican announced plans to ax three of the Senate’s four planned recess weeks during that month.

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Even health insurers that don’t expect many of their plan members to drop insurance coverage after the individual mandate penalty is zeroed out still may have to raise individual market premiums in 2019 as their payments from the ACA’s risk adjustment program change thanks to the mandate loss.

Buffalo, N.Y.-based insurer Independent Health doesn’t expect a large number of its 5,000 ACA exchange members to drop their coverage when the individual mandate penalty is effectively repealed starting in 2019. Its population skews older and sicker, and most members need their insurance coverage. Its average member is about 49 years old, and about half receive federal premium subsidies.

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