Insurers are generally confident they could manage the transition away from Obamacare and into a new replacement plan, according to a survey from the Urban Institute.

The group interviewed executives at 13 insurance companies participating in the individual market in 28 states to ask them how they would respond in various repeal scenarios proposed by the new administration. While all insurers said that uncertainty regarding the future of Obamacare is bad for business and for the stability of the individual market, they were confident they could manage policy changes. They also expressed optimism about a replacement plan that offered continuous coverage, which many Republican plans include.

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One of the stated aims of the Affordable Care Act was to increase competition among health insurance companies. That goal has not been realized, and by several different measures the ACA’s exchanges offer less competition and choice in 2017 than ever before. Now in the fourth year of operation, the exchanges continue to be far less competitive than the individual health insurance market was before the ACA’s implementation. Moreover, insurer participation in the law’s government-run exchanges has declined over the past two years and is now at the lowest level yet. This lack of insurer participation leaves exchange customers in 70 percent of U.S. counties with no insurer choice, or a choice between merely two insurers.

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President Donald Trump’s administration has promised to repeal and replace the Affordable Care Act and Congressman Darrell Issa is proposing a new health care plan to Congress.

In an interview Saturday, he told NBC 7 he calls his plan “The Access to Insurance for All Americans Act.”

The plan would give people access to the federal employee health benefit plan that government employees use. It calls for no mandates on businesses and individuals.

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Since its passage in 1965, Medicaid has expanded and contracted with the political tides. With concurrent Republican executive and legislative control in 2017, conservative policy makers have already declared their desire to repeal the Affordable Care Act (ACA) and its Medicaid expansion, which has been responsible for approximately 12 million of the 20 million individuals who became newly insured as a result of the ACA. But proposals for fundamental reform of Medicaid are even more far-reaching in terms of their consequences for the other 60 million low-income children, parents, the elderly, and individuals with disabilities who rely on the program. Understanding the rationale for and likely effects of these proposals is critical for physicians and patients alike.

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The strategy that Congress and the Trump administration will pursue to repeal and replace the Affordable Care Act continues to evolve. In early January, the favored strategy seemed to be to repeal as much as possible of the ACA through legislation, but to delay the repeal of key provisions, such as the premium tax credits and marketplaces, for two or more years and then begin work on a replacement. In mid-January, this seemed to be giving way to an approach, apparently favored by the Trump administration, under which replacement legislation would be adopted more or less simultaneously with repeal, although it was not clear how this could take place without cooperation from Democrats, which seemed unlikely.

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During the election campaign, Donald Trump promised to abolish Obamacare and replace it with better health reform that would not leave anyone behind. In order to understand what is implied by that promise, consider Figure I, which highlights three groups of people:

    • About 11 million people are getting insurance in the exchanges and many of them are unhappy. In the words of former president Bill Clinton, many are “paying twice as much for half the coverage” they were previously enjoying.
    • Another 11 million or so people are getting individual insurance outside the exchanges. These people have all the same problems as people in the exchanges. But, they receive no federal tax break for the purchase of insurance, even though a federal mandate requires them to buy it.
    • In addition, about 29 million people are uninsured and that number is unlikely to change very much going forward. Polls show that the most important reason why so many people are uninsured is cost.

One way to think about Donald Trump’s campaign promise is to see that he wants to make health insurance less expensive and better for the first two groups without leaving the third group permanently uninsured. And he wants to do it with money that is already in the system. In other words, without raising taxes.

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The pre-existing conditions issue played a central role in the design of the Affordable Care Act, and dealing with this issue appropriately in any ACA replacement plan will be instrumental to the achievement of stable and sustainable individual and small group health insurance markets.

House Speaker Paul Ryan and House Republicans’ June 2016 Better Way health care reform proposals, supported by Representative Tom Price, President-elect Trump’s nominee to head HHS, will surely influence the development of replacement legislation.  Consistent with the Better Way, there would appear to be fairly broad support among Congressional Republicans for a replacement plan that at a minimum (1) guarantees that people who maintain continuous coverage can do so at terms that do not reflect health status, (2) provides substantial incentives for people to purchase coverage before needing costly medical care, and (3) provides some form of safety net for those who fail to purchase and maintain coverage.

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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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The Republican congressional leadership has made a new timetable for gutting the Affordable Care Act, aiming to get legislation done by March or possibly April.

But that doesn’t give insurers much time to meet their first deadline for submitting plans for 2018 on the individual market, which includes the law’s exchanges.

A rule published four days before President Trump took office set the deadlines for insurers to sell health plans on the individual market, which is for people who don’t get insurance through their jobs. Democrats have charged that Republicans will throw the market into chaos by repealing the law without an alternative, with Republicans responding that the markets are already in turmoil.

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