Republicans have their best opportunity in a generation to enact a reform plan for health care that moves decisively toward a market-based approach, with far less reliance on federal regulation and control. A reform plan of this kind would represent a dramatic break from decades of policymaking and would be a major component of an effort to rein in the sprawling federal welfare state.

To succeed in this effort, however, House and Senate Republicans, as well as the incoming Trump administration, must dispense with wishful thinking. There is no plan for replacing the Affordable Care Act (ACA) that is without political controversy. Whatever they do will involve trade-offs, and in some cases they will be attacked by their political opponents for doing what is necessary but perhaps unpopular.
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House Speaker Paul Ryan said Thursday Republicans plan to repeal President Barack Obama’s health care law at the same time they approve a GOP replacement plan.

“We want to do this at the same time, and in some cases in the same bill,” Ryan said during a town hall in Washington sponsored by CNN and moderated by Jake Tapper. “So we want to advance repealing this law with its replacement at the same time.” Ryan said Republicans are moving “as quickly as they can” to repeal and replace the Affordable Care Act, but said he doesn’t yet have a date, and it will take “a little bit of time” to do so.
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Congress has begun the work of replacing the Affordable Care Act, and that means lawmakers will soon face the thorny dilemma that confronts every effort to overhaul health insurance: Sick people are expensive to cover, and someone has to pay.

The 2010 health law, also known as Obamacare, forced insurers to sell coverage to anyone, at the same price, regardless of their risk of incurring big claims.

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The American health care system is not like a normal market. When you make most health care decisions, you don’t get much information on comparative cost and quality; the personal bill you get is only vaguely related to the services; the expense is often determined by how many procedures are done, not whether the problem is fixed. Republicans are going to try to introduce more normal market incentives into the process. They will likely rely on refundable tax credits and health savings accounts to ensure that everybody can afford to shop for their own insurance and care.

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The House voted Friday on the measure that passed the Senate, part of a process that will make it easier for a subsequent Obamacare repeal bill to advance through the Senate with a simple majority vote and without the threat of a Democratic filibuster. The budget resolution is a crucial first step for Republicans controlling Congress to keep their longstanding promise to repeal the law, which is saddled with problems such as rapidly rising premiums.

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A growing number of Republicans are balking at the prospect of repealing the ACA so quickly without a firm plan to replace it. Now with the Senate on a path to eliminate the ACA, some Republicans are worried about the political fallout and uncertainty of starting to roll back the law without knowing how the process will end. Conversations with Republican senators and a review of their statements show that nearly a dozen have publicly expressed some level of concern about repealing the law without a replacement. “There are a lot of people that have concerns about doing a repeal with no replacement or at least some guidance on replacement,” said Sen. Bob Corker (R-TN) who has co-sponsored language to delay the nonbinding deadline for repeal legislation until March 3. “The train leaving the station this week is not a big event, it’s when the train pulls back into the station that’s the big event,” Corker explained.

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Industries that were integral to the creation of the ACA are keeping their voices down as Republicans quickly dismantle it. The speed of Republican efforts to repeal the ACA has stunned health industry lobbyists, leaving representatives of insurance companies, hospitals, doctors and pharmaceutical makers struggling for a response to a legislative quick strike that would upend much of the American health care system. Given that repeal is forthcoming, the health care industry is staying relatively silent on the binary question of repeal, but is expected to get more heavily involved on the nature and details of replace.

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While the budget passed early this morning won’t be signed into law, it must be approved by both chambers for committees to begin drafting reconciliation legislation. Reconciliation is one of the most powerful weapons in the majority’s procedural arsenal. Under reconciliation, bills are protected from the 60-vote filibuster so they can be passed through the Senate and House by a simple majority. Democrats used it to finish passing the ACA seven years ago, and now Republicans intend to return the favor to dismantle the law. There’s a hitch, though: Under budget reconciliation, only provisions that affect federal spending or taxes can be targeted. That means Republicans cannot completely eliminate or replace the law in one fell swoop. The final call on what can or cannot be addressed in a reconciliation bill will be made by the Senate parliamentarian. The GOP did a dry-run in the last Congress, passing a reconciliation bill that killed key parts of the ACA, including the individual mandate, insurance subsidies for consumers and the Medicaid expansion. President Obama vetoed the legislation, but that won’t be an issue this time around with Trump in the White House.

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The House Freedom Caucus decided Wednesday afternoon not to take an official position on the House budget, freeing up their members to vote however they want on a resolution crucial to repealing Obamacare, according to a source familiar with their deliberations.

The budget is largely a procedural measure, but sets up a framework to repeal the health care law while avoiding a Senate filibuster. Conservatives in the Freedom Caucus have been pressing leadership to detail how they plan to replace the law before agreeing to go ahead with the budget vote.

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The U.S. public has been split in their views on the Affordable Care Act since the law was enacted in 2010, but what about those Americans who actually buy their health insurance through the federal program’s marketplaces?

Although most Obamacare participants give high marks to their health coverage, a growing segment of ACA exchange users has expressed frustration with rising costs and what they see as a shortage of plan options. According to the Henry J. Kaiser Family Foundation, the share of Obamacare enrollees who are dissatisfied with their plans rose from 14 percent in 2014 to 29 percent in 2016.

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