The MacArthur amendment focuses on an idea that’s core to Republicans’ DNA: federalism.  That’s a positive step forward.  But what still seems to be lacking is a strategic roadmap for what Congress and the Administration should be trying to achieve.  By laying out this roadmap, the Administration can bridge the gap between Republican moderates and conservatives, and possibly open up a much-needed dialogue with centrist Democrats.

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The Trump administration appears to have scrapped one of the key tools the Obama administration used to encourage states to expand Medicaid under the Affordable Care Act.

The shift involves funding that the federal government provides to help hospitals defray the cost of caring for low-income people who are uninsured. Under a deal with Florida, the federal government has tentatively agreed to provide additional money for the state’s “low-income pool,” in a reversal of the previous administration’s policy.

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Congressional Republicans have called for restructuring Medicaid, reviving a debate that has largely remained dormant for two decades. During the mid-1990s, Congress and President Clinton advanced competing Medicaid reform proposals. Republicans urged that the federal government issue Medicaid block grants to states. The White House and congressional Democrats proposed instead to place per capita limits on federal Medicaid payments to states. The most salient difference between these approaches is that per capita allotments retain the individual entitlement to Medicaid while block grants generally do not. Today, Republicans who once resisted Medicaid per capita allotments support them, and Democrats who backed such allotments oppose them. Given this legislative history, policymakers seeking common ground might look to Medicaid per capita allotments as a point of departure.

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As congressional Republicans’ efforts to repeal and replace the Affordable Care Act remain in limbo, the Trump administration and some states are taking steps to help insurers cover the cost of their sickest patients, a move that industry analysts say is critical to keeping premiums affordable for plans sold on the law’s online marketplaces in 2018.

This fix is a well-known insurance industry practice called reinsurance. Claims above a certain amount would be paid by the government, reducing insurers’ financial exposure and allowing them to set lower premiums.

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It looks like House Republicans have been trying over the past few days to coalesce around a revised version of the AHCA. One key revision has involved a more assertive temporary federal reinsurance scheme to quickly lower premiums and stabilize the transition period to a new system. But maybe the most significant, and least familiar, new proposal has involved allowing states to obtain waivers from some Title I regulations in Obamacare.   The devil will be in the details, and they will matter enormously here, but the general concept of returning regulatory power to the states through waivers that are connected to the bill’s spending measures is an interesting way to deal with the constraints Republicans confront and could have real promise.

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Now that House Republicans have squandered their shot at reordering Medicaid, governors who want conservative changes in the health program for ­low-income Americans must get special permission from the Trump administration.

Near the front of the line is Wisconsin Gov. Scott Walker, a Republican who not only supports work requirements and premium payments but also a new additional condition: to make applicants undergo a drug test if they’re suspected of substance abuse.

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The Trump administration, working with governors and state legislatures, could make dramatic state by state changes to Medicaid and the ACA marketplaces using two types of state innovation waivers. Section 1332 of the ACA, which went into effect on Jan. 1, 2017, lets states waive several key provisions of the ACA, including the individual mandate, the employer mandate, the premium tax credit, cost-sharing subsidies, and essential health benefits for ACA marketplace plans. In short, Section 1332 (ACA) waivers let states operate their health care systems as if major parts of the ACA do not exist. Additionally, Section 1115 (Medicaid) waivers give states the opportunity to waive federal Medicaid law. The changes made possible by Section 1115 waivers aren’t as dramatic as those contained in the AHCA—for example, states can’t use these waivers to fully restructure Medicaid under block grants or per capita caps, nor can the federal government use them to take away federal reimbursements for Medicaid expansion—but they are still significant.

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With the passage of the ACA, Congress promised Americans that they would be able to keep the plans and doctors they like while paying less for health insurance and healthcare overall. Seven years later, many Americans have fewer choices when it comes to health decisions and are paying more for care and insurance. The State Policy Network has compiled stories from around the country that highlight state and local challenges and represent the need for a state-based approach that unleashes innovation in health care based upon the needs of citizens.

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Obamacare has already failed, and it failed because the government violated several basic economic and free-market principles, resulting in devastating outcomes for those seeking coverage, people already covered, and taxpayers.

Under Obamacare, our most vulnerable citizens in Pennsylvania are paying more for health insurance with fewer choices. According to the Kaiser Family Foundation, individual premiums increased by more than 50% in Philadelphia this year. Deductibles for a family plan now exceed $6,000, and the choices continue to shrink.

Pennsylvania’s health care delivery system should encourage participation in the health-insurance market rather than mandating it as Obamacare did, offer the option of using open network, lower-cost, catastrophic plans supported by health savings accounts, and place much greater emphasis on prevention and addressing the causes of poor health.

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As high health costs persist, insurance affordability remains a challenge for many employers and individuals. However, allowing insurers to sell coverage across state lines could result in unintended consequences such as market segmentation that could threaten the viability of insurers licensed in states with strict benefit coverage, issue, or rating rules. The ability for high-risk individuals to obtain coverage could be compromised as a result. If rules governing insurance are consistent across the states, as they are under the ACA, market segmentation could be minimized. However, potential premium savings would also be minimal, as premiums would continue to reflect local health care costs, regardless of location of the insurer.

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