One of the ill-fated bill’s greatest weaknesses was that it did not have a unifying purpose or goal. Was it about access or coverage? Cost or quality? Individual choice or collective responsibility? The answer was, effectively, a bit of each, due to congressional negotiations and the president’s pre-inauguration pronouncements. Canadian F.H. Buckley caused a maelstrom in conservative circles last week when he called on President Trump to advance a single-payer model for U.S. health care. The first step in any renewed effort to reform American health care is to define the objectives.

A second major health-insurer has decided to quit selling individual policies in Iowa, raising fears that tens of thousands of Iowans will have no options for coverage next year.

Aetna informed Iowa regulators Thursday that it had decided to stop selling such policies, which cover people who lack access to employer-provided coverage or government plans. The move would affect 36,205 customers, the company told regulators.

Aetna’s move takes effect in January. It came three days after Iowa’s dominant health-insurer, Wellmark Blue Cross & Blue Shield, announced that it would no longer sell individual health-insurance policies in Iowa.

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More insurance companies around the country are refusing to pay brokers commissions on higher-tier exchange plans or special enrollment sales as the companies face financial losses on the federal marketplace. “It’s the Wild West out here, and companies are doing what they can to survive,” says Ronnell Nolan, CEO of Health Agents for America, which represents independent insurance brokers. “They’re not paying commissions on platinum plans, and they are not paying them for special enrollment plans which cover some of the sickest patients.” An exodus of brokers from the federal marketplace could undermine enrollment efforts since brokers historically sign up at least 50% of exchange enrollees.

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The deal House Republicans reached on Thursday addresses a key problem with their alternative to the Affordable Care Act: steep premiums. The provision, which House Republicans decided to add to their Obamacare replacement bill before they face constituents during the Easter recess, would dole out $15 billion to states over about a decade to help insurers cover the sickest people in the health care system and reduce premiums for individual health plans.

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It looks like House Republicans have been trying over the past few days to coalesce around a revised version of the AHCA. One key revision has involved a more assertive temporary federal reinsurance scheme to quickly lower premiums and stabilize the transition period to a new system. But maybe the most significant, and least familiar, new proposal has involved allowing states to obtain waivers from some Title I regulations in Obamacare.   The devil will be in the details, and they will matter enormously here, but the general concept of returning regulatory power to the states through waivers that are connected to the bill’s spending measures is an interesting way to deal with the constraints Republicans confront and could have real promise.

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Health and Human Services Secretary Tom Price holds broad authority over administration of the Affordable Care Act, including the power to give additional flexibility to states and insurers under the law. Section 1332 of the ACA allows HHS to offer “state innovation waivers” for that allow states to waive some (but not all) of Obamacare’s insurance regulations in return for a block grant of ACA funding. States that want to keep the ACA status quo could do so, while Republican-led states could go in a different direction.

An approach that started with 1332 waivers and layered on additional legislative reforms would allow both the more conservative and moderate members of the GOP to declare victors, because the states themselves would be put back in charge of their own health insurance markets.

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The demise of the American Health Care Act (AHCA) was ultimately precipitated by factional opposition to different provisions of the bill. Moderate and conservative members of the Republican conference did not agree on much, except they shared an animus towards the ill-fated legislation.

The future of health-care reform is now highly uncertain. Forging a legislative consensus will continue to be a challenge due to the inherent trade-offs between broad-based coverage and personal freedom, to say nothing of competing views about the respective roles of the market and the state (including different levels of government).

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President Trump cannot repeal the ACA by executive order. The ACA is a statute, enacted by Congress, which under the Constitution only Congress can repeal or modify. Furthermore, the order does not itself change existing regulations. Rather, it provides instructions or guidelines as to how Trump wants responsible agencies to exercise their discretion in interpreting and applying statutory requirements. The order appropriately recognizes that the new priorities it outlines can be followed by administration officials only “to the maximum extent permitted by law.”

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Democrats, hoping to seize on momentum from the apparent collapse of the Republicans’ health bill, are grappling with a tough question—whether they can do anything to prevent the Trump administration from weakening the Affordable Care Act through administrative actions by the Department of Health and Human Services.

Democrats are trying to mobilize public support to block potential changes. Five Democrats on the Senate health committee sent a letter to President Donald Trump Monday calling on him not to undermine the health law.

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It is valuable to understand what would happen if AHCA in fact became law, and what could be done to improve it or a new reform proposal. The best place to start is with the cost estimate of the plan produced by the Congressional Budget Office (CBO). Some have criticized CBO for this estimate, arguing that it is a fundamentally inaccurate assessment. While some of CBO’s assumptions are indeed questionable, there is little doubt that the agency’s bottom line assessment is basically correct: The bill, as currently structured, would trigger a rise in premiums in the short-run, a sharp increase in the number of people without insurance over the next two years, and then also a steady increase in the number of uninsured Americans over the following eight years. Instead of trying to discredit this finding, the authors of the legislation would be better off fixing the bill. CBO’s estimate provides a roadmap for what needs to be done to improve the chances the bill will produce the results its authors intend.

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