On Donald Trump’s victory Republicans in Congress are primed for an ambitious agenda, and not a moment too soon. One immediate problem is ObamaCare’s expansion of Medicaid, which has seen enrollment at least twice as high as advertised.

Most of the insurance coverage gains from the law come from opening Medicaid eligibility beyond its original goal of helping the poor and disabled to include prime-age, able-bodied, childless adults. The Supreme Court made this expansion optional in 2012, and Governors claimed not joining would leave “free money” on the table because the feds would pick up 100% of the costs of new beneficiaries.

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Healthcare is the top issue Americans want Donald Trump to address during his first 100 days in the White House, according to a Reuters/Ipsos poll released on Thursday, an apparent rebuke of outgoing President Barack Obama’s signature reform, Obamacare.

Some 21 percent of Americans want Trump to focus on the healthcare system when he enters the White House on Jan. 20, according to the Nov. 9-14 poll, conducted in the week after the Republican won the U.S. presidential election.

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But it is absolutely possible to craft a health-reform agenda that conforms to Trump’s core policy principles: (1) repealing and replacing Obamacare; (2) near-universal coverage; (3) lower health insurance premiums. As a bonus, these goals can be achieved by a plan that reduces federal spending, cuts taxes, and improves health outcomes for the poor.

Few would have predicted that Donald Trump could be a more successful health reformer than Barack Obama. But if he can get over a few important hurdles, it could very well end up being true.

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The main objective of the Affordable Care Act (ACA) was to increase enrollment in health insurance among those who were previously uninsured. Official estimates from the Census Bureau have consistently overstated the number of people who are uninsured. A major factor in the overestimate is the undercount of people in Medicaid. Also, millions of Americans have been officially uninsured despite their eligibility for public insurance or employer coverage. With the passage of the ACA, fewer than 10 percent of the remaining uninsured do not have a realistic path to securing health insurance. The future of the ACA is now uncertain, but any future policy changes will likely need to provide a sure path to insurance coverage for all Americans as well.

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President-elect Trump has made waves by saying that though he plans to repeal Obamacare, he wants to keep the aspect of it that bans coverage for those with pre-existing conditions. But this is not possible without broader changes to the healthcare system.

The pre-existing condition ban is ultimately one of the primary drivers of the premium hikes we’re seeing within Obamacare. The reason is that with insurers forced to offer coverage to anybody who applies, they incur higher medical costs, and they thus require more signups from younger and healthier people — but those signups aren’t materializing in a large enough volume to offset costs.

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Republicans on Capitol Hill are growing confident that they can begin to repeal Obamacare once President-elect Donald Trump is sworn in, along with a pledge to replace it later.

“We have an Obamacare emergency right now,” said Sen. Lamar Alexander (R-Tenn.), the chairman of the Senate HELP Committee. “I think we could move forward in January on some aspects of repeal but we need to make sure that we are helping people and that we do no harm.”

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Congressional Republicans may be mulling a plan to repeal Obamacare before President-elect Trump takes office, a top GOP leader said Wednesday.

“Nothing has been decided but that is certainly one of the options,” Senate Majority Whip John Cornyn, R-Texas, told reporters after a closed-door GOP meeting on Wednesday.

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Steven Lopez has gone without health insurance for 15 years, and the Affordable Care Act hasn’t changed his mind. Once again this year he will forgo coverage, he said, even though it means another tax penalty.

Last tax season, the 51-year-old information technology professional and his family paid a mandatory penalty of nearly $1,000, he said. That’s because they found it preferable to the $400 to $500 monthly cost of an Obamacare health plan.

“I’m paying $6,000 to have the privilege of then paying another $5,000 [in deductibles],” said Lopez, who lives in Downey, a suburb of Los Angeles. “It’s baloney — not worth it.”

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According to a recent statistical analysis, medical care determines only about 11 percent of health—far less than individual behavior (38 percent), social circumstances (23 percent), and genetics and biology (21 percent). The preponderance of evidence demonstrates that much of what we spend on health care does not translate into better health outcomes and that collectively we don’t receive nearly enough benefit to justify the costs in higher taxes, higher premiums and lower wages.

As Congress and the incoming Trump administration consider how to replace the Affordable Care Act (ACA), they should focus on the drivers of excessive spending, the primary one of which is comprehensive health insurance. By doing so, President-elect Trump can best attempt to deliver on his promise of “great health care for much less money.”

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President Obama will be leaving office with the Affordable Care Act, his signature policy initiative, in deep peril.  An incoming Republican president and Congress, concerned with the cost of ACA exchange plans jumping by an average 25 percent next year and employee health care costs rising, have pledged to repeal the law.  For his part, the President sought to shift the blame for rising out-of-pocket cost from the ACA’s flaws to employers and insurers.  During a recent speech defending the law, he said the ACA has had no impact on the affordability of employer-provided health care benefits “except to make it a better value.”  As the President put it, “if your premium is going up, it’s not because of Obamacare.  It’s because of your employer or your insurer — even though sometimes they try to blame Obamacare for why the rates go up.  It’s not because of any policy of the Affordable Care Act that the rates are going up.”

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