Any legislation that clears Congress under the repeal and replace banner needs to do four things:

  • It needs to rescue millions of people in ACA exchange plans now who are at risk of losing their coverage because of ObamaCare’s multiple failures.
  • It must provide states more flexibility in managing their Medicaid programs so they can better serve their neediest citizens.
  • It needs to provide a system of subsidies for people who need help in purchasing coverage but who aren’t offered health insurance at work and who are not eligible for public programs, especially Medicaid or Medicare.
  • And it needs to return more authority to the states to oversee their health insurance markets, but with new flexibility and resources.

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Health care legislating ain’t pretty. In many cases, it’s downright coyote ugly. Particularly in the absence of a coherent and consistent majority in favor of substantially revising the status quo. Hence, today’s Senate Republican leadership “discussion draft” bill.

To be fair, leaders can’t go where they don’t have enough followers. So a good bit of today’s exaggerated reactions on the Right involves failure to come to terms with the divergence between past feel-better rhetoric and today’s grimmer political realities. There are neither enough votes nor popular support to repeal Obamacare simplistically, or engineer a softer landing toward substantial reform of the ACA — let alone offer a long-term path toward market-based health policy in practice. A long parade of mistakes in politics and policy were made AFTER March 2010 that helped deliver us to today’s limited set of legislative options.

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Senate Republicans plan to vote before the July 4 recess on their legislation to repeal and replace ObamaCare.

Senate Majority Leader Mitch McConnell (R-Ky.) has little margin for error, as he can afford just two defections from his conference with all Democrats expected to oppose the bill. Vice President Mike Pence could then be called in to break the tie.

Here’s a look at where McConnell’s conference stands on the legislation, which was unveiled on Thursday.

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The House-passed bill left large numbers of Americans uninsured, in part because very low-income households could not afford to enroll in private coverage even with the House’s tax credits. Medicaid is the nation’s safety net insurance program. In practical terms, there is no real alternative to Medicaid for a person below the poverty line. Under the approach recommended here, federal Medicaid funding would be dispensed to the states to strengthen the safety net for the poor, even as there would be less support for expanding the program to persons with higher incomes.

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Enough insurers are planning to sell coverage on the Affordable Care Act’s insurance exchanges next year to keep them working — if only barely — in most parts of the country.

Competition in many markets has dwindled to one insurer — or none in some cases — and another round of steep price hikes is expected to squeeze consumers who don’t receive big income-based tax credits to help pay their bill.

“What we’re seeing is a deterioration in these markets, but the markets haven’t imploded, they haven’t gone into a rapid downward decline,” said Dan Mendelson, president of the consulting firm Avalere.

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Highlighting the continued uncertainty around the Affordable Care Act marketplaces, insurers announced major changes to their offerings for next year, including pullbacks that potentially leave more counties without exchange plans.

Anthem Inc. said it will exit the marketplaces in Wisconsin and Indiana next year, while nonprofit MDwise said it too would leave the Indiana exchange. Those moves may leave four Indiana counties at risk of having no exchange insurers in 2018, according to the Kaiser Family Foundation, though its researchers cautioned the outlook remains unclear. An estimated 44 counties in Ohio, Washington and Missouri will likely face a similar situation.

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Republicans are facing a critical test of Senate unity in the Trump era as leaders prepare to unveil a healthcare bill that they have grappled over in secrecy to reconcile the conflicting demands of party factions.

President Donald Trump’s policy ambitions depend on Republicans’ ability to bridge deep internal divisions, and after false starts on healthcare in the House of Representatives earlier this year the drama now moves to the Senate.

Mitch McConnell, the Senate majority leader, has promised to release a draft healthcare bill on Thursday, incorporating substantial revisions to a measure that passed the House in May. But whether it will secure enough votes to pass the Senate remains in doubt.

Healthcare reform has become a quagmire for Mr Trump, who campaigned on a pledge to repeal his predecessor’s Obamacare reforms. But he has seen efforts falter as his party disagrees on who should get health insurance and how it will be paid.

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