During the legislative debate over the passage of President Obama’s healthcare law, supporters of the program were sensitive to any suggestion that it represented a government takeover of the healthcare system.

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Almost all of Obamacare’s landmark health insurance co-ops are in financial trouble.

The co-ops were invented by the health-care law — they’re private nonprofits that were awarded a total of $2.4 billion in loans from the federal government, in order to establish nonprofit competition to private health insurance companies.

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The federal government shelled out $2.4 billion in loans to a series of non-profit health plans under Obamacare, but now they’re struggling to stay alive.

The plans, dubbed CO-OPs (Consumer Operated and Oriented Plans) were intended to increase competition in the insurance market and serve as a check on private insurers by providing an alternative that wasn’t focused on profit. They were a compromise measure intended to satisfy liberals who wanted the law to set up a fully government-run health insurance option.

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Unless conservatives change their strategy soon, history is likely to record them as the unintended enablers of Obamacare’s expansion. Yet another key moment for a turn toward free-market reform is upon us. Will congressional Republicans again pursue a strategy that sounds serious but results in Obamacare’s unimpeded implementation? Or will they try to actually impede the law in real time and make clear to the American people which party is on their side as we approach 2016?

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The Centers for Medicare & Medicaid Services (CMS) has taken formal action in response to concerns about the finances of four of the new nonprofit, member-owned CO-OP health plans, according to the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG).

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Senate Majority Leader Mitch McConnell championed a renewed push to bypass a filibuster and repeal Obamacare with 51 votes on Tuesday, he announced in a joint statement with Utah Senator Mike Lee, one of the most conservative Republicans in the chamber.

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Fed up with the insurance industry, Democrats used the health care overhaul to create nonprofit co-ops that would compete with the corporations. Now a government audit finds co-ops are awash in red ink.

Only one out of 23 — the co-op in Maine — made money last year, said Thursday’s report from the Health and Human Services inspector general’s office. Thirteen lagged far behind their sign-up goals for 2014.

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As Medicare and Medicaid reach their 50th anniversary on Thursday, the two vast government programs that insure more than one-third of Americans are undergoing a transformation that none of their original architects foresaw: Private health insurance companies are playing a rapidly growing role in both.

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This Viewpoint discusses 4 key changes that could improve the Affordable Care Act and create broad support across the states.

The Affordable Care Act (ACA) is best seen as transitional legislation on the road to long-term structural reform of the US health care system. This is not so much because the ACA is politically controversial and there is bound to be pressure for changes, despite the US Supreme Court’s King v Burwell decision,1 but rather it is because the ACA’s design still lacks the consistent, strategic building blocks needed for a stable, long-term system redesign.

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Neither Republicans nor Democrats have spent much time, at least not in public, discussing changes to the Affordable Care Act (ACA) that could refine or improve the legislation. Republicans have mostly focused on strategies to repeal the ACA, which, even with their control of the House and Senate, appears highly unlikely because they could not muster the 67 votes needed to override a presidential veto. Democrats, while privately acknowledging there are changes that could improve the legislation, have publicly devoted most of their energies to defending the ACA.

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