Every day brings a new story about Republicans in disarray, the “mirage” of the GOP’s reform and the impossibility of change. The reality is that Congress is on schedule, progress is underway, and the many potential problems are avoidable.

Behind the scenes, members and staff are being briefed on options and the House will release a consensus proposal after the Presidents Day recess. The details matter and are under discussion, but the outlines are emerging. Congress will use the reconciliation budget maneuver to bypass the Senate filibuster and pass a version of the 2015 repeal bill that President Obama vetoed. This time they’ll incorporate as many replacement components as the rules allow to bring more predictability to insurance markets.

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The combination of high-deductible insurance with Health Savings Accounts (HSAs) is central to a market-driven reform of U.S. health care. There is, however, a problem with existing HSA policy that must be fixed if HSAs are to reach their full potential in improving the efficiency of health care arrangements: As currently structured, HSAs are not built to provide easy access to care from well-organized systems of health care. Rather, HSA enrollees buy services on a fee-for-service basis, which is, in most cases, a much less efficient way of getting needed care. The rules governing HSAs should be modified to allow account holders to buy access to care from integrated care systems on a fixed-fee basis.

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The Trump administration proposed new rules on Wednesday to stabilize health insurance markets roiled by efforts to repeal the ACA, by big increases in premiums and by the exodus of major insurers. The move came a day after Humana announced that, starting next year, it would completely withdraw from the public marketplaces created under the ACA. The proposed rules, backed by insurance companies, would tighten certain enrollment procedures and cut the health law’s open enrollment period in half, in hopes that a smaller but healthier consumer base will put the marketplaces on sounder financial footing and attract more insurance companies in states with limited choices.

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Molina Healthcare’s stock tumbled after hours Wednesday after the health insurer posted a fourth-quarter loss that was attributed to parts of Obamacare — a big problem for one of the health insurers that has had success in the program.

However, the company didn’t lose money because it had sicker-than-expected enrollees. In fact, medical costs for its Obamacare enrollees were $120 million lower than Molina thought. Instead, Molina got slammed because it had healthier members and had to pay $325 million into an Obamacare program called risk adjustment, which pools money from insurers in a given state and redistributes it to those who had higher-cost enrollees.

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The new administration should issue two new rules for the 2018 enrollment season:

  1. It should let online brokers complete enrollments for people who qualify for subsidies. No need to redirect these applicants to HealthCare.gov.
  2. It should stop imposing user fees to prop up its unnecessary website and finance ad campaigns.

These two changes would set loose an army of insurance carriers, traditional brokers and private online exchanges, all competing to enroll people in subsidized coverage.

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House Republican leaders began laying out components of an Obamacare replacement bill at a closed-door meeting with members on Thursday, Feb. 16. Party leaders, including chairs of key committees, proposed age-based tax credits to replace Obamacare’s subsidies, new options for Medicaid, and scrapping taxes. They also floated ideas on how to pay for the replacement plan, such as capping the tax exclusion currently offered only to employer-sponsored health plans. House members received a policy brief that outlines where legislation is headed to help them prepare for next week’s town hall meetings in their districts.
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Just 8.8% of Americans lacked health insurance as of this past September, according to the latest numbers from the National Health Interview Survey conducted by the Centers for Disease Control and Prevention.

But more insured people are on the hook for sizable portions of their health care costs. More than 39% of Americans younger than 65 are enrolled in a plan with a high deductible — a big increase from 2010, when 25% of people were in a high-deductible policy. Popular Republican plans to replace Obamacare rely heavily on high deductibles and health savings accounts.

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House Republicans are weighing specific reforms to Medicaid that could be included in a reconciliation measure to overhaul the Affordable Care Act.

How to deal with the federal expansion of Medicaid under the ACA is one of the main unanswered questions as Congress works to overhaul Obamacare — one that has exposed divisions between the House’s most conservative members and GOP lawmakers from states that chose to expand the federal program for low-income Americans.

Rep. Brett Guthrie (R-Ky.), the vice chairman of the Energy and Commerce Health Subcommittee, said Tuesday that lawmakers are considering what types of reforms — specifically shifting to per capita allotments or allowing states to choose block grants — could be included in a House reconciliation bill to repeal the ACA.

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While Republicans continue to grapple with plans to repeal and replace Obamacare and stabilize health insurance rates, Humana is the first major insurer to say it is dropping out of the individual market for 2018.

“Based on our initial analysis of data associated with the company’s health-care exchange membership following the 2017 open enrollment period, we continue to see further signs of an unbalanced risk pool,” said Humana CEO Bruce Broussard, on a conference call with analysts Tuesday. “Therefore, the company has decided that it cannot continue to offer this coverage for 2018.”

In the wake of the news, President Donald Trump tweeted that the insurer’s decision was another example of the failure of the Affordable Care Act, and he reiterated his plan to “repeal, replace & save healthcare for ALL Americans.”

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Following an Obama administration order, the IRS had been set to require taxpayers to indicate on line 61 on their form 1040s whether they had maintained health coverage in 2016 or paid the penalty. The IRS would have rejected returns if taxpayers failed to report their coverage status. But the IRS announced this week it would not reject returns that failed to check the appropriate ObamaCare boxes—an early indication of the administration’s efforts to provide relief from ACA mandates.

Filling out this portion will be optional:

“This year, the IRS put in place system changes [initiated by the Obama administration] that would reject tax returns during processing in instances where the taxpayer didn’t provide…information [attesting that the taxpayer had health insurance].

“The recent executive order [issued on day one of the Trump administration] directed federal agencies to exercise authority and discretion available to them to reduce potential burden.‎ Consistent with that, the IRS has decided to make changes that would continue to allow electronic and paper returns to be accepted for processing in instances where a taxpayer doesn’t indicate their coverage status.”

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