Donald Trump’s ascension to the White House puts President Barack Obama’s Affordable Care Act  in grave peril.

Ever since the law passed in 2010, Republicans have campaigned on a pledge to repeal Obama’s signature domestic policy achievement. Trump’s victory, with continued GOP control of Congress, gives them their first opportunity to do so.

Trump and congressional Republicans have set sky-high expectations for repealing Obamacare; he’s promised to scrap it “very very quickly.” And they have a road map to repeal significant parts of the law, even with a narrow Senate majority.

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We are nearing the grand finale of our long and disheartening election opera, one we dare not ignore because the outcomes matter so much. While the election results will not be determined by public reactions to the Affordable Care Act, the ACA’s fate will be mightily determined by Tuesday’s outcomes. What have we learned about our collective health future over the past 18 months and what might this mean for our health system’s future?

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In this space nine months ago, I proposed 5 questions every presidential candidate should answer on health care. Well, the delivery date for Election 2016 arrives tomorrow, and the questions remain “Asked and Not Answered.” There never was much of an effort by the two leading nominees, Hillary Clinton and Donald Trump, to respond directly, but one still might infer some rough parameters from their various omissions, evasions, and obfuscations. Given the lack of attention to health policy, let alone health policy details, by Trump, we will also assess the outline of House Republicans proposals for health reform embodied in the “A Better Way” documents released last June.

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ObamaCare’s political disciples are dismissive of the tales of woe that ObamaCare has left in its wake, pointing instead to statistics on the reduced rate of uninsured.

Whatever egalitarian ethos that the law’s architects anxiously claim that ObamaCare still achieves, it certainly doesn’t justify the pain that the scheme is causing middle class and families. There’s a very narrow band of Americans who qualify for the law’s special “cost sharing subsidies” who can find ObamaCare plans affordable. Many who fall outside this slim income range are being hammered.

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Speaker Paul Ryan (R-Wis.) on Wednesday embraced Donald Trump’s call for a special session of Congress to repeal ObamaCare.

Ryan, who has at times had a tense relationship with Trump, the Republican presidential nominee, also said repeal of ObamaCare is a reason why Trump should be president.

“Imagine if we had a Republican president,” Ryan told radio host Hugh Hewitt. “This is what Donald Trump is talking about — a special session. We’ve already proven this year with a Republican House and a Republican Senate we can have that special session, and we can repeal, and we can replace ObamaCare.”

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This may seem like same-old, same-old at this point. After all, lots of health insurers are threatening to leave the exchanges. You could be forgiven for yawning at the news that yet another company might pull back.

But in fact, this is huge news, because Anthem runs the Blue Cross/Blue Shield organizations in 14 states. And though Anthem doesn’t appear to be the sole company offering exchange coverage in any of those states, the Blues are generally the backbone of the exchanges. Where others have quailed, the Blues have by and large stuck with Obamacare. If they pull out, then it’s likely that we’ll see more counties, and possibly entire states, with no Obamacare policies on offer.

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While Obamacare has brought health insurance to millions of people in the U.S., some in the program are finding that the medical care they need is too expensive to actually use.

Michelle Harris, a 61-year-old retired waitress in northwest Montana, has arthritis in both shoulders. She gets a tax subsidy to help buy coverage under Obamacare, though she still pays $338 a month for the BlueCross BlueShield plan. Yet with its $4,500 deductible, she says she’s doing everything she can to avoid seeing a doctor. Instead, she uses ibuprofen and cold-packs.

“It hurts, but we don’t have that kind of money,” Harris said in an interview. “So I deal with it.”

Open enrollment for the insurance exchanges created by the Affordable Care Act kicks off Tuesday, and there’s a good chance consumers logging on to compare plans will face some sticker shock.

Monthly insurance premiums for popular plans on HealthCare.gov are rising by 25 percent on average next year, according to government data. But the increases will be more dramatic in certain parts of the country, especially for consumers not receiving subsidies, the numbers show.

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The fourth open enrollment for health coverage under the Affordable Care Act opened Tuesday, a critical 90 days that the Obama administration hopes will boost participation and stabilize markets roiled by premium increases and insurer withdrawals.

HealthCare.gov and state equivalents began taking applications Tuesday morning from people signing up for individual health coverage and learning about their eligibility for subsidies. This year is especially critical because consumers so far have been sicker and older than expected, which has led to higher-than-anticipated costs.

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As premiums for Affordable Care Act (ACA) insurance plans skyrocketacross the country, the Department of Health and Human Services (HHS) appears to be spinning the bad news by noting that 2017 premiums are about what the Congressional Budget Office (CBO) expected they would be when the law passed in early 2010. However, CBO’s November 2009 estimate of future premiums involved significant and generally unforeseeable errors in key underlying assumptions having nothing to do with the ACA. A valid understanding of the ACA’s effect on insurance premiums would need to account for these errors.

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