Articles on the implementation of ObamaCare.

It takes a journalist to clear the fog about Republican health policy alternatives. (Yes, they do have alternative plans.) In his new book, Overcoming ObamaCare, Philip Klein, who is the commentary editor of the Washington Examiner, presents a timely and accessible review of the three primary approaches that Republican officials and policy analysts are offering.

Klein acknowledges that Republicans failed to implement serious health reforms when they had control of the White House and of Congress during the George W. Bush administration, and the nation paid dearly when Democrats jammed their still-unpopular health law through when they had control of both branches of government in 2010.

He implicitly warns that if Republicans don’t come up with an alternative to ObamaCare, we could be saddled with ObamaCare’s “government takeover of health care” for good.

“During their time in the wilderness [after HillaryCare], smart liberals took lessons from their Clinton era defeat and refined their health care strategy in preparation for their next opening,” he writes. The book makes it clear that now is the time for conservatives to get to work coalescing around a plan.

Overcoming ObamaCare is a solid primer on conservative policy alternatives – a very useful tool especially for the army of conservatives elected to office in November who are intent on repealing, and in some cases replacing, ObamaCare.

Klein is a good student of conservative health policy, acknowledging “there’s one prominent area in which the U.S. does not have anything approaching a functioning consumer market, and where instead, the consumer is completely left in the dark, given few choices, elbowed out of the decision-making process by large bureaucracies, and given very little incentive to seek out the best deal. Unfortunately, this area accounts for $2.9 trillion in spending, representing more than one-sixth of the U.S. economy. I am, of course, referring to health care.”

As a former journalist, I am biased toward his clear, straightforward approach and his birds-eye reporting of the policy debate as it has unfolded in the political and policy realms.

Klein compares and contrasts the various reform plans and explains the three schools of thought and the philosophies driving them:

Reform. The margins aren’t always as clear as the categories would imply, but he places me in the reform school, saying I favor “a step-by-step approach to undoing ObamaCare.”

I am as opposed as anyone to this law (co-authoring Why ObamaCare Is Wrong for America in 2011), but five years out, reality has taken over. So far, Congress has passed and the president has signed 17 major changes to the law, including repeal of the 1099 reporting provision for small business, the CLASS Act long-term care Ponzi scheme, and blocking funding for the financially-troubled non-profit co-op health plans. Many more are teed up.

Thousands of legislators, millions of companies and tens of millions of Americans have had to make changes in their health care arrangements to comply with federal law. That means our health sector has been changed irreversibly by ObamaCare. We can no longer go back to the system we had before the law passed any more than we can go back to the 1990s. Most of the policies that people had before don’t exist. Many of the doctors that were in the networks their health plans before have retired or have sold their practices to hospitals. Hospitals have merged, and all providers have built new business models to comply with the law. State approval of previous health insurance plans has expired, and the plans can no longer legally be sold because they don’t comply with ObamaCare.

Americans “don’t want a big gigantic replacement plan. That scares them,” he quotes me as saying.

Avik Roy of the Manhattan Institute agrees. “His overarching idea is for Republicans to perform what he’s referred to as a ‘jiu-jitsu’ maneuver. In short, he has proposed that Republicans reform Obamacare to make it more mar­ket friendly and then use that modified structure to achieve broader reforms to the nation’s older health care entitlements.” He provides a detailed explanation of the reform plan Avik has offered, “Transcending Obamacare.”

Replace. Jim Capretta of the Ethics and Public Policy Center and Yuval Levin, also of EPPC and editor of National Affairs, are quoted extensively here. “You’re going to have to do replace with repeal,” Ca­pretta says. “You can’t displace this incumbent program without a replace program, in my judgment.”

Jeff Anderson, executive director of the 2017 Project, says the law isn’t “remotely fixable.” Ditto, Budget Chairman Tom Price with his “Empowering Patients First Act.”

He also provides a Cliff’s Notes overview of one of the replace proposals that has received significant attention: The Coburn-Burr-Hatch proposal by the three leading U.S. Senators.

But even some in this “replace” school implicitly agree that reform must evolve from the changed landscape of ObamaCare.

Restart. Finally, he talks about the Restart school, starting with Louisiana Governor Bobby Jindal’s reform proposal and his criticisms of those who would propose “ObamaCare Lite.” Cato’s Michael Cannon also is in this school, with his “Large HSA” proposal.

Klein takes a deep dive in each of these chapters into the tax treatment of health insurance – which is at the heart of conservative health reform. Conservatives have long supported providing financial assistance to the uninsured, especially those who are not offered or cannot afford employer-based health insurance but who make too much to qualify for public programs, especially Medicaid.

But the debate continues on the right about how to structure those subsidies – through tax credits, refundable tax credit, or tax deductions — with many variations in different plans. Klein portrays the vigorous debate that takes place in the policy community including, for example, an intense discussion with Louisiana Gov. Bobby Jindal (a tax deduction supporter) and policy experts Klein attended in April of 2014.

Klein doesn’t take sides. But he acknowledges, in his conclusion, “Republican control of the Senate and a spirited GOP presidential nomination contest should provide a great opportunity to debate many of the ideas explored in this book.”

And then we warns: “Those who aren’t happy about the direction of American health care need to start the process of coalescing around an alternative approach. If they can do that, there’s a chance to overcome ObamaCare and move toward a health care system that puts the consumer first.”

One final plug: I am biased in thinking that we must move to a new system that puts consumers in charge of their health care decisions and that we must seize opportunities to begin that process. The pending Supreme Court decision in King v. Burwell provides opportunities to make such changes: If the High Court were to decide that the IRS acted illegally in providing subsidies through federal health care exchanges, Congress and 36 governors are highly unlikely to sit back and watch as five million people lose their health insurance coverage. Congress already is working on plans to use the possible opportunity of a win in the courts to give citizens new options that could lead to the transformative change that underpins each of the conservative philosophies.

The Galen Institute today released an updated version of its list of significant changes made to the Affordable Care Act by the Obama administration, the Congress, and the U.S. Supreme Court since the law was passed in March of 2010. Today’s list includes four additional changes made by the Obama administration, most of them contrary to statutory language. By our count, more than 46 significant changes have been made to the law: at least 28 that the administration has made unilaterally, 16 that Congress has passed and the president has signed, and 2 by the Supreme Court. Here are the latest additions:
•Bay State Bailout: More than 300,000 people in Massachusetts gained temporary Medicaid coverage in 2014 without any verification of their eligibility, with the Obama and Patrick administrations using a taxpayer-funded bailout to mask the failure of the commonwealth’s disastrously malfunctioning website. (January 2014)
•Failure to enforce abortion restrictions: A GAO report found that many exchange insurance plans don’t separate charges for abortion services as required by the ACA, showing that the administration is not enforcing the law. In 2014, abortions were being financed with taxpayer funds in more than 1,000 exchange plans. (Sept. 16, 2014)
•Risk Corridor coverage: The Obama administration plans to illegally distribute risk corridor payments to insurers, despite studies by both the Congressional Research Service and the GAO saying a congressional appropriation is required before federal agencies can make the payments. (Sept. 30, 2014)
•Transparency of coverage: CMS delays statutory requirements on insurance companies to disclose data on the number of people enrolled, disenrollment, number of claims denied, costs to consumers of certain services, etc. (Oct. 20, 2014)

By Tom Miller & Grace-Marie Turner
Tax subsidies are one of the mechanisms through which the Affordable Care Act expands access to health insurance. These subsidies are available only to those who purchase highly regulated policies through government-run exchanges, and are allocated on a monthly basis to insurance companies to offset the costs of premiums and sometimes out-of-pocket costs.

The law’s formula for determining the amount of these premium subsidies specifies that people are eligible for them if they are enrolled in qualified plans offered in “an Exchange established by the State under [section] 1311 of the Patient Protection and Affordable Care Act.” Only 13 states are operating such exchanges this year. The rest are relying on exchanges created by the federal government. But in 2012, the IRS wrote a rule that allows the subsidies to flow through the federal exchanges as well. About 6 million people were enrolled on the federally run exchanges after open enrollment closed for the 2014 plan year, about 85 percent of whom received the subsidies.

The Supreme Court has agreed to hear a case, King v. Burwell, challenging the IRS rule. Plaintiffs argue that the law clearly restricts the subsidies to state exchanges, that this gives states an incentive to create their own exchanges, and that administrative agencies like the IRS cannot alter legislation or spend taxpayer dollars without statutory authorization by Congress. Defendants say that “established by the State” is at worst a drafting error, not a reflection of legislators’ intent, and that Congress wanted subsidies to be available in all of the states.

Will Congress Act?
The Supreme Court justices will hear oral arguments in the case on March 4. If the justices decide that the IRS acted illegally, residents of as many as 37 states soon will become ineligible for the subsidies. As a result, most will begin to face the full cost of the unsubsidized premiums on their policies and will be more likely to drop their coverage.

Many court watchers believe the decision could hinge on whether Congress has a viable plan to provide for alternative, if not continued, coverage for these millions of people. As a result, efforts are underway to develop legislation to transition those on the federal exchanges — especially lower-income individuals — to other types of subsidized coverage. The legislation should not only take care of people who are at risk of losing their current coverage, but also take the opportunity to move our system toward a more competitive market, centered around individual choice.

The congressional proposals exist primarily in draft form so far. Most aim to hold people in federal exchanges harmless going forward, providing an extension of their current coverage through the end of the current plan year. Most also would give people a much greater range of health-insurance options, while removing federal regulations and mandates for individuals to purchase or for employers to offer policies.

There is general agreement that Congress will need to act to provide assistance to the roughly 5 million people who would lose their subsidies as a result of the court decision. There are two schools of thought about how to do this: either through new, less restrictive federal tax credits to individuals; or through allocations to the states to distribute through other mechanisms, such as those used for the Children’s Health Insurance Program.

The public-relations wars over the pending Supreme Court decision already have begun: Families USA is leading the effort on the left and will try to show how many people will be harmed if the subsidies are struck down. Supporters of free markets and limited government are mounting their own serious media-outreach effort to show the harm that this law is doing, emphasizing the soaring cost of health insurance, the threat of mandate penalties, the labor-market disincentives, the disruptions in previous coverage, and patients’ reduced access to their preferred medical providers. Critics of the IRS rule need to explain very clearly that Congress is ready and willing to act to take care of the people who will lose their coverage if the Supreme Court decides not to allow subsidies on the federal exchanges.

The Consequences of Doing Nothing
If the Supreme Court rules that the IRS acted illegally, the government’s authority to distribute tax subsidies through federal exchanges will end within a month, assuming no new action by Congress. These exchanges can continue to operate, but the expensive insurance sold there will be much less attractive to customers without tax subsidies. States that created their own exchanges will be able to continue to operate and distribute subsidies, and other states may consider qualifying as a state exchange after a King ruling.

In states that have not established their own exchanges, the federal government will effectively be unable to impose any employer-mandate penalties. That is because the penalties are triggered when someone without access to employer-based coverage receives subsidized coverage on an exchange.

The individual mandate will take a blow as well. The mandate does not apply if the lowest-priced coverage available costs more than 8 percent of one’s household income, and the lack of subsidies will drive up the net cost of coverage. So, individuals in states that don’t establish exchanges will face higher income thresholds before the mandate can apply to them.

There will be numerous indirect effects as well. With both the employer and individual mandates weakened, the ACA’s other insurance rules will be weakened too. In states that don’t run exchanges, employers won’t be penalized for offering non-qualified coverage, and fewer individuals will have to, or will want to, buy ACA-prescribed coverage.

Insurers on the federal exchanges, meanwhile, will have fewer enrollees, likely skewed toward higher-risk patients who lack other coverage options. Many insurers could drop out, and losses for those that remain will add to the claims against ACA’s “risk corridor” funds. This would accelerate pressure to resolve the issue of whether these payments are meant to be budget-neutral — that is, payments for losses can be no greater than payments collected from more profitable exchange insurers going forward..

Countermoves by state and federal officials wanting to keep ACA coverage afloat are likely to include changes to Medicaid coverage, with more states agreeing to the law’s Medicaid expansion and possibly seeking federal waivers to cover people above the current income ceiling (138 percent of the federal poverty level). Officials also may get clever with the definition of a state-established exchange, for example by renting the federal exchange website mechanisms, contracting out to piggyback on other state exchanges, revising federal regulations for what constitutes a section 1311 exchange, etc.

Members of Congress and state officials must not simply restore the current law’s many costs and regulatory burdens. Instead, they need to prepare now to take advantage of the opportunities that will be available to them to improve our health sector and the choices of coverage available to consumers if the Supreme Court rules against subsidies on federal exchanges.

Tom Miller is a resident fellow at the American Enterprise Institute. Grace-Marie Turner is president of the Galen Institute.

WHEN Karen Pineman of Manhattan received notice that her longtime health insurance policy didn’t comply with the Affordable Care Act’s requirements, she gamely set about shopping for a new policy through the public marketplace. After all, she’d supported President Obama and the act as a matter of principle.

Ms. Pineman, who is self-employed, accepted that she’d have to pay higher premiums for a plan with a narrower provider network and no out-of-network coverage. She accepted that she’d have to pay out of pocket to see her primary care physician, who didn’t participate. She even accepted having co-pays of nearly $1,800 to have a cast put on her ankle in an emergency room after she broke it while playing tennis.

Stunning figure comes from Congressional Budget Office report that revised cost estimates for the next 10 years
Government will spend $1.993 TRILLION over a decade and take in $643 BILLION in new taxes, penalties and fees related to Obamacare
The $1.35 trillion net cost will result in ‘between 24 million and 27 million’ fewer Americans being uninsured – a $50,000 price tag per person at best
The law will still leave ‘between 29 million and 31 million’ nonelderly Americans without medical insurance
Numbers assume Obamacare insurance exchange enrollment will double between now and 2025

“I’m sorry sir,” the polite customer-service agent said. “There’s nothing I can do. You’re either going to have to enroll in Medicaid or you’re going to have to pay the full health-insurance rate.”

“The rate you quoted earlier?” I asked. “That’s nearly 30 percent higher than my current insurance bill, I just can’t afford it.”

“You’ll have to pay the full rate, yes,” the agent replied.

“I don’t understand,” I explained. “I have plenty of money to pay you a reasonable rate, but I can’t afford to pay the same rate a millionaire would be asked to pay. Why can’t I just receive a partial subsidy? I’m willing to pay more than what Medicaid offers.”

“Sir, that’s just not how the system works.”

Right. That’s not how ObamaCare works; it doesn’t work at all.

WASHINGTON (AP) — A little-known side to the government’s health insurance website is prompting renewed concerns about privacy, just as the White House is calling for stronger cybersecurity protections for consumers.

It works like this: When you apply for coverage on, dozens of data companies may be able to tell that you are on the site. Some can even glean details such as your age, income, ZIP code, whether you smoke or if you are pregnant.

Posted By Richard Pollock
H&R Block, the nation’s largest retail tax preparation company warns that the newly released Obamacare tax code, officially called the Affordable Care Act, is likely to confuse millions of taxpayers who try to tackle their tax returns for 2014.

“Now that the Affordable Care Act has made health care a tax issue, no one can understand it,” H&R Block flatly tells taxpayers in a video that resides on its dedicated Obamacare web site.

After the lofty promises that led to passage of the Patient Protection and Affordable Care Act, young people are waking up to how much the law targets them with higher costs. Yes, those lucky enough to be covered on their parents’ health plans can postpone the consequences until they are 26. But for the rest, the situation is grim: Young people face disproportionately high costs to pay for coverage and a crushing burden of taxes that could impede their future prosperity.

By Ben Casselman

On Friday, I posted this chart, showing that nearly all the job growth since the recession ended has been in full-time jobs. Part-time employment is pretty much flat.

I wasn’t trying to make a political point, but many readers saw one anyway. Specifically, they saw it as a refutation of a frequent Republican talking point: that the Affordable Care Act, or “Obamacare,” is killing full-time jobs because it requires employers to offer health insurance to their full-time (but not their part-time) workers.