Three years ago, health economists believed Obamacare’s soon-to-launch marketplaces would grow to replace much of America’s fractured, complex employer-based health insurance system.

Predictions for the employer-sponsored insurance system’s collapse ran rampant. The question around companies shifting workers to the new public marketplaces was often framed not as if but when. University of Pennsylvania’s Zeke Emanuel pegged it at 2025. MIT’s Jonathan Gruber estimated 2050.

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Recently, Avalere worked with the Council for Affordable Health Coverage to examine enrollment trends for the Affordable Care Act (ACA).

Avalere projects that 10.1 million individuals will be enrolled in an exchange plan by the end of 2016. To date, exchange enrollment has not reached original projection numbers. In March 2010, the Congressional Budget Office predicted enrollment figures for 2016 to be at 21 million. Their projections have decreased since then- in January 2016 it was 13 million and in March 2016, it was 12 million. The Obama administration projects 10 million in enrollment for 2016.

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They say you’re damned if you do and you’re damned if you don’t. So House Speaker Paul Ryan did, and got damned on both the left and right—and all but ignored by his own party’s presidential candidate—when he unveiled his caucus’s outline for a replacement of the Affordable Care Act.

Which raises the question: How serious can this ACA alternative be? Maybe not very. The centerpiece of Ryan’s proposal—tax credits for everyone who needs to purchase individual policies regardless of income—may not go far enough to prevent people from losing coverage while creating new spending that would benefit high-income earners who can already buy their own health insurance.

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Five Republican-led states and several provider groups are suing to block a new Obamacare rule that’s meant to prevent health care providers and insurers from discriminating against transgender patients.

The five states — Texas, Wisconsin, Kentucky, Nebraska and Kansas — and the provider groups argue that the nondiscrimination rule requires doctors to perform gender transition procedures even when they are against the doctor’s medical judgment.

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Health insurance startup Oscar Insurance Corp. will reevaluate its approach to Obamacare after suffering significant losses under the U.S. program and will pull out of two markets next year.

Oscar, which pitches itself as a tech-savvy alternative to traditional health insurers, plans to end sales of Affordable Care Act plans in Dallas, a market it entered this year, and New Jersey. It’s part of a more conservative approach by the New York-based company as it plans to introduce insurance products for businesses next year.

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Democratic presidential nominee Hillary Clinton wants to crack down on rising prescription drug costs. She has made it a pillar of her campaign, the stuff of TV ads and stump speeches. She also has ambitious plans for Alzheimer’s research and other medical science initiatives.

But, even if she wins the White House, Clinton might have to put all that on hold.

A series of setbacks to Obamacare in recent months has raised real questions about the viability of the Affordable Care Act, with three major insurers announcing that they will leave many of the law’s marketplaces next year and others requesting substantial premium increases.

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“If you like your doctor, you can keep your doctor” was President Barack Obama’s signature catchphrase he used to sell the Affordable Care Act to the American people. Now Obamacare’s flagship website, healthcare.gov, no longer even addresses the issue.

Ironically, the section in question was the first public (if indirect) admission by the Obama administration that the president’s promise was less than a “guarantee.” As THE WEEKLY STANDARD first reported in July 2013, the website told consumers that they “may be able to keep your current doctor,” in contrast to the president’s unequivocal statement: “Here is a guarantee that I’ve made. If you have insurance that you like, then you will be able to keep that insurance. If you’ve got a doctor that you like, you will be able to keep your doctor.”

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Long-time Obamacare advocate and Aetna chief executive Mark Bertolini created a political earthquake when he announced his company will drastically reduce its individual public exchange participation next year. Similar announcements by United Healthcare, Humana and even some Blues plans show that Obamacare is failing.

Those who designed this disastrous government intervention into the marketplace now want more disastrous government intervention. Their solution is more taxpayer money for subsidies to individuals and insurance companies and a “public option” government health plan.

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With the fourth open-enrollment period set to begin this fall for the marketplaces set up by the Affordable Care Act, it’s becoming clear that the market for health insurance has not evolved as expected, or hoped.

The market is smaller than projected. The people who have bought health plans overall are sicker than predicted. And health insurers have incurred larger losses than anticipated.

As a result, some large national insurance companies, including UnitedHealthcare, Humana and Aetna, plan to abandon markets across the country next year. And health insurers in Wisconsin are proposing the largest rate increases yet for health plans sold on the online marketplaces throughout the state.

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Increasingly, U.S. consumers may have fewer insurance options under Obamacare.

The latest evidence comes in a study from consulting firm Avalere Health, which examined areas, known as rating regions, that insurers use to set premiums and decide where to offer plans to individuals under the Affordable Care Act.

According to Avalere, 36 percent of the approximately 500 rating regions in the U.S. may have just one health insurer when the 2017 signup season starts on Nov. 1. Another 19 percent could have just two carriers. There was far more competition this year, with about two-thirds of rating areas having three or more health insurers vying for customers’ business, according to Avalere.

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