Millions of emergency room patients could face financial ruin — even if they deliberately seek care at hospitals covered by their insurers.

That’s the disturbing finding of a new study published in the New England Journal of Medicine. Conducted by two Yale professors, the study shows that 1 in 5 ER visits involve doctors who are not in the same insurance network as their hospitals. The patients treated by those out-of-network physicians are forced to pay for a portion of their care out-of-pocket. The average out-of-network ER charge is $600.

A bill that size spells disaster for many patients. About half of Americans wouldn’t be able to cover a surprise $400 bill without selling something or borrowing money.

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U.S. health insurers signaled Tuesday that they’re willing to give up a cornerstone provision of Obamacare that requires all Americans to have insurance, replacing it with a different set of incentives less loathed by Republicans who have promised to repeal the law.

Known as the “individual mandate,” the rule was a major priority for the insurance industry when the Affordable Care Act was legislated, and also became a focal point of opposition for Republicans. In a position paper released Tuesday — the first since President-elect Donald Trump’s victory — health insurers laid out changes they’d be willing to accept.

“Replacing the individual mandate with strong, effective incentives, such as late enrollment penalties and waiting periods, can help expand coverage and lower costs for everyone,” AHIP said.

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An Obamacare repeal resolution will be the first item the Senate votes on next year, Majority Leader Mitch McConnell said Tuesday, underscoring the GOP’s commitment to repealing the law even as its replacement plan remains unclear.

McConnell told reporters that repealing Obamacare would be “the first item up in the new year,” and the Kentucky Republican that he would like to “get Democratic cooperation” during the difficult process of replacing “a very, very controversial law.”

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A big question facing Republicans next year is how to pass a national healthcare reform law without taking a beating on Election Day.

Obamacare has been implemented, and 20 million Americans have health insurance through the law. That means Republicans have to figure out how they will keep their promise to repeal Obamacare without angering the people who already receive coverage from the law.

It’s a critical question for the GOP, as a matter of policy and politics, and they know from beating Democrats across the country how an unpopular healthcare bill can poison a lawmaker’s re-election chances.

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The GOP isn’t killing Obamacare. The program is already dead.

Andy Slavitt will step down as the government official overseeing Obamacare on January 20. He should be charged with leaving the scene of an accident. Obamacare’s individual markets are a twisted wreckage. Insurers are fleeing them, consumers are shunning them, and Democrats are looking for someone to blame.

In addition to devolving regulatory authority to the states, federal policymakers should consider providing them with resources to reform markets and subsidize coverage. Instead of writing suffocating rules and enlisting the Internal Revenue Service to distribute subsidies and exact penalties, the federal government should set states free to innovate and hold them accountable for results.

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The worm is about to turn in health policy and politics when Republicans shift from throwing stones to owning the problems of the health system and the Affordable Care Act or its replacement, as President Barack Obama and Democrats have for the past eight years. It’s hard to predict how events will play out, but it’s likely that grand plans to repeal and replace Obamacare, convert Medicaid to a “block grant” program, and transform Medicare into a premium support program could be whittled down or delayed as details of such sweeping changes, and their consequences, become part of the debate.

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Incoming Health and Human Services Secretary Tom Price is now assisted, instead of annoyed, by the big, executive powers granted by Obamacare.

As Price takes the helm at HHS, he will succeed Obama appointees he had sharply criticized for taking wide latitude in implementing the Affordable Care Act.

Now that the tables have turned, and Republicans hold the White House, Price will have the ability to reverse, rewrite or do away with dozens of rules and guidance spelling out exactly how individuals, businesses, health providers, insurers and states should comply with the healthcare law’s many requirements.

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Republicans are pitching Obamacare “repeal and delay”—the idea of quickly repealing the ACA, but leaving it in place for three years as they craft a replacement. But one key health care expert threw cold water on that idea. Robert Laszewski, president of Health Policy and Strategy Associates, warned the strategy could send the market into “death throes.”  He argues that to stabilize the insurance market and ensure that health insurers don’t flee is for the federal government to guarantee to cover their losses. But the politics of that aren’t easy because it would mean funding the three R’s— (risk adjustment, reinsurance, and risk corridors, all programs that subsidize insurance carriers that have significant losses.)

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Congressional Republicans are setting up their own, self-imposed deadline to make good on their vow to replace the Affordable Care Act. With buy-in from Donald Trump’s transition team, GOP leaders on both sides of the Capitol are coalescing around a plan to vote to repeal the law in early 2017 — but delay the effective date for that repeal for as long as three years.

“We’re talking about a three-year transition now that we actually have a president who’s likely to sign the repeal into the law. People are being, understandably cautious, to make sure nobody’s dropped through the cracks,” said Senate Majority Whip John Cornyn (R-Texas).

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