“Economist Larry Summers said Monday that roughly 10,000 more Americans will die each year if Republican tax-reform legislation passes and includes a repeal of the ObamaCare individual mandate.
“When people lose health insurance, they’re less likely to get preventive care, they’re more likely to defer health care they need, and ultimately they’re more likely to die.”
The Senate passed its tax-reform legislation early Saturday morning. The upper chamber’s bill includes a repeal of the individual mandate, while the House’s tax-reform bill does not.
Summers’s estimate is based on a Congressional Budget Office report that 13 million Americans would opt out of ObamaCare if the individual mandate is repealed.
Summers, who served as former President Clinton’s Treasury secretary and former President Obama’s National Economic Council director, said it’s hard to quantify the number of deaths precisely, but called an estimate that thousands will die because of the bill “very conservative.” (A)

“One clear effect of the GOP tax bill is the provision that medical groups object to most: the repeal of the individual mandate to buy health insurance.
Both the House and the Senate versions of the bill include a repeal of the mandate, which calls for a tax on people who don’t buy health coverage to help make up the cost of care for the uninsured.
While the mandate is unpopular among voters, it was a must-have for health insurance companies. They demanded such a mandate to even take part in the health insurance exchanges set up by the 2010 Affordable Care Act, and without it, many more can be expected to hike premiums or drop out altogether from the Obamacare markets, experts predict.
“If the requirement to carry adequate health insurance disappears, so will the health care coverage of many Americans,” American Heart Association CEO Nancy Brown said in a statement.
“As insurance rolls decrease, premiums will rise an average of 10 percent,” Brown said. “Paying more for health insurance will be a heavy weight to carry if you have a pre-existing condition like heart disease or stroke. We fervently believe this provision should be rejected and removed from the final legislation.”
The Congressional Budget Office (CBO) estimated that repealing the mandate would result in 13 million fewer people being covered by health insurance and would cause insurance companies to raise premiums by 10 percent a year.
“The repeal of the individual insurance mandate destabilizes an essential pillar of the ACA by removing incentives for young and healthy people to purchase insurance,” a coalition of health and consumer groups, including the American Diabetes Association, the American Cancer Society Cancer Action Network and the American Lung Association.” (B)

“Within a year or two of elimination of the mandate, the individual insurance market will resemble the failed pre-Obamacare days when pre-existing conditions and high premiums made access impossible. The difference is that the government will foot a large part of the cost through subsidies. Before the A.C.A., lower-income people who didn’t qualify for Medicaid were priced out of the individual market, but with subsidies, they can now purchase lower-cost plans. If the individual mandate is eliminated, it will be middle-income people without subsidies who lose access.
The continuing high enrollment this fall supports the idea that most people still see the subsidized insurance offerings on the exchanges as a good deal. As a result, the demand side of this unusual market will stay strong for the subsidized customers.
How will the insurance companies react? They will see high demand for subsidized insurance as a tempting market in spite of past and future chaos. The problem for them is that these customers are sicker and less predictable in their needs, which makes it difficult to set a price. This is precisely why the number of insurers this year has dropped so severely. But managing uncertainty is at the core of this business. Any risk is acceptable if the compensation is high enough….
However, the timing of a mandate repeal is central. Eliminating the individual mandate will make little difference to insurers in 2018 if the mandate expires in 2019. But Congress may decide to eliminate the individual mandate immediately. Then insurers, who priced their plans assuming continuation of the same historical enrollee pool, will lose their shirts as healthier enrollees drop out. Changing the rules halfway through the game is not something insurance company C.E.O.s. can anticipate, but it is their biggest challenge now….
Yet as long as the subsidies continue, health plans will offer their policies on the exchanges with very high premiums. While this may allow access for some who otherwise would be left out, the grand purpose of the A.C.A. — to allow affordable care for all — will slip away. Is this any way to do health policy?” (C)

“With one simple move, the tax reform bill passed by Senate Republicans Saturday could herald the beginning of the end of former President Barack Obama’s Affordable Care Act, better known as Obamacare.
The new bill repeals Obamacare’s key requirement that all Americans obtain health insurance. Policy experts say that removing the mandate will force insurance premiums to rise, as young and healthy Americans opt out, leaving millions of Americans without healthcare.”
“It’s going to take a bunch of healthy people out of the insurance market,” Craig Garthwaite , director of the healthcare program at Northwestern University’s Kellogg School of Management, told Reuters.
Obamacare “is going to collapse even more now,” he said.” (D)

“Members of a joint congressional committee will now meet to resolve those differences, conflicts that pit all sorts of special interests against one another. But Republicans are so eager to pass a tax bill — and claim a so-far elusive big win in President Donald Trump’s first year — that compromise is not expected to be too difficult.
Health care mandate: The Senate bill would repeal the requirement in the 2010 Affordable Care Act that most people pay a penalty if they don’t purchase health insurance.
The provision isn’t in the House bill, but is popular among House conservatives. Yet those same conservatives are opposed to health care provisions that would be considered as a result of including the repeal, which might be necessary to delivering critical votes in the Senate.
Sen. Susan Collins, R-Maine, said she expects legislation that would reinstate cost-sharing payments to insurance companies to pass before the tax bill is complete. The provision, authored by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would help lower health insurance premiums, she said.” (E)

“Sen. Susan Collins (R-Maine) has doubled the amount of money she’s requesting in her ObamaCare stabilization bill in exchange for her vote on the GOP’s tax-reform plan.
Collins, a key vote on tax reform, is pushing for the passage of two ObamaCare bills in an attempt to mitigate the effects of the tax bill’s repeal of the individual insurance mandate.
One of those bills — sponsored by her and Sen. Bill Nelson (D-Fla.) — would provide states with $10 billion over two years to establish high-risk pools or reinsurance programs to lower premiums.
That’s more than double the $4.5 billion originally requested in her bill, which she introduced in September.
Senate Majority Leader Mitch McConnell (R-Ky.) said he would support passage of both bills, which could be added to the end-of-year spending deal.” (F)

“In Maine, an estimated 50,000 fewer people could have health coverage by 2025. That’s because insurance rates would rise if, as expected, many healthy young people exercised their option to go without insurance — leaving the pool of insured people older and sicker. And as those rates rise, even more people would be priced out, including some who qualify for subsidies. The budget office estimates that average premiums in the individual market would rise about 10 percent a year for the next decade as a result of repeal. That would be on top of unrelated premium increases….
In 2017, some 79,400 Mainers were covered by individual plans purchased on the state’s insurance marketplace. That an Affordable Care Act provision that allows consumers to make apples-to-apples comparisons between available plans. The majority of the plans purchased in Maine qualified for a premium subsidy, available to enrollees who earn up to 400 percent of the federal poverty limit. That’s about $48,424 for an individual and $98,400 for a family of four. The subsidy takes the form of a tax credit.
In 2015, the most recent year for which information is available, 38,560 taxpayers in Maine qualified for that credit, at a total subsidy value of $184.3 million, according to the Internal Revenue Service. Of those taxpayers, 15,460 had household incomes of between $10,000 to $25,000. Another 13,340 had household incomes between $25,000 to $50,000.
Collins, who earlier this year helped defeat efforts to end the Affordable Care Act, initially said that repealing the individual mandate would destabilize health insurance markets. But in the days leading up to the vote, Collins said she was reassured by Trump’s assertion that other steps will be taken to offset any negative impacts of repeal.” (G)

“But one expert says such efforts are inadequate. Aviva Aron-Dine, senior fellow and senior counselor at the Center on Budget and Policy Priorities, warns that temporary underfunded reinsurance programs are not enough to reverse the impact of the individual mandate’s repeal.
“As a result, it will not meaningfully reduce the risk that insurers will leave the market. Even a much larger reinsurance program would leave insurers in doubt about how to price their insurance products for the state of the overall risk pool: what they should assume, for example, about how many people will leave the market, how much healthier this group is than average, and how quickly the full effects of mandate repeal would be felt,” Aron-Dine wrote.” (H)

CMS Chief Seema Verma:
“Well, first start by saying, I’m not sure that the individual mandate has really been effective. If we look at what’s gone on since Obamacare was implemented, we’ve seen rates go up by over 100%. In some areas of the country, it’s over 200%. While prices have gone up, if we look at the types of plans that are being offered, in many states, right now we have eight states that have only one insurance company. That means that people may not have the choice of doctor. One third of our folks that are using the exchanges will only have one insurer, so our choices are going down.
We’re also hearing from people that the plans that are being offered in and of themselves are high deductible plans or they’re narrow networks. Folks are looking at this and saying, “It’s very expensive, there’s a high deductible, and I don’t want this. I would rather pay the penalty.” If we look at the number of people that are paying the penalty, it’s over seven million people. Out of that seven million, 5.2 million are earning less than $50,000 a year. This is really a tax on low income people, low income people that may not be able to afford coverage and then on top of it they’re paying a penalty. That’s one area of the law, I don’t think that, that in and of itself, is going to address the underlying issues.
From our standpoint, we’re trying to do what we can, making things more flexible, more market friendly, and trying to create more choices, but ultimately, there’s only so much we can do. We need a Congressional, a comprehensive Congressional solution, that’s not only going to provide flexibility for states and empower states, but it’s going to address the underlying reasons of why costs are going up so much.” (I)

“Republicans are also facing the possibility that the $1 trillion tax bill will trigger deep, automatic cuts to Medicare next year unless Congress stops it from happening.
Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) that the cuts required by the “pay-as-you-go” or “pay-go” budgetary rule won’t happen.
Collins was a key holdout, and she said the personal promise from McConnell helped win her support for the legislation.
McConnell on Friday issued a joint statement with Speaker Paul Ryan (R-Wis.) saying the pay-go cuts won’t happen.
“Congress has readily available methods to waive this law, which has never been enforced since its enactment. There is no reason to believe that Congress would not act again to prevent a sequester, and we will work to ensure these spending cuts are prevented,” McConnell and Ryan said.
Lawmakers have voted numerous times in the past to waive the rule, but they need the support of Democrats, who have so far been reluctant to offer it.” (J)

“Speaker Paul Ryan’s (R-Wis.) office told a meeting of congressional leadership offices on Monday that the Speaker is not part of a deal to get ObamaCare fixes passed before the end of the year, according to a source familiar with the meeting.
Senate Majority Leader Mitch McConnell (R-Ky.) made a commitment to Sen. Susan Collins (R-Maine) that he would support passage of two bipartisan ObamaCare bills before the end of the year, a promise that helped win her vote for tax reform.
However, Ryan’s office told a meeting of staff from the four top congressional leadership offices on Monday that he has not made that same commitment, raising further questions about whether the ObamaCare bills, already opposed by House conservatives, can pass the House.
Ryan’s office did not go so far as to say it opposed the bipartisan bills, the source said, and it is still possible the measures could pass before the end of the year. The Senate is expected to add the measures to a government funding bill later this month, which would put pressure on the House to accept it or else risk a government shutdown.” (K)

“The top House tax writer said Tuesday that House and Senate Republicans will likely scrap Obamacare’s individual mandate in their final tax bill.
“Yeah, I believe we will,” House Ways and Means Committee Chairman Rep. Kevin Brady, R-Texas, said when asked if the joint plan would get rid of the provision requiring most Americans to have health insurance or pay a penalty.
Brady’s statement appears to resolve one of the key differences between the separate tax legislation passed by the House and Senate. The Senate bill would effectively repeal the mandate, while the House proposal would not.” (L)

“Republicans appear to be on the brink of striking down the Affordable Care Act’s health-insurance requirement, an ardently sought goal of the law’s opponents. But the fate of a bipartisan bill that centrist Republicans hoped would offset some of the fallout remains uncertain. Some key GOP centrists supported a Senate tax overhaul that repeals the requirement that most people have health insurance, a move experts say will likely drive up premiums, on the condition that it be swiftly accompanied by a bipartisan measure that aims to lower premiums.” (M)

“Repealing the individual mandate means fewer people will sign up for health insurance—13 million according to the Congressional Budget Office (CBO)—and the government will pay out less in premium support. The calculus is clear—tax cuts for the wealthiest Americans will be paid for by providing less support for working families to buy health insurance. Indirectly, however, people who need insurance the most—older, less healthy Americans—will subsidize tax cuts via higher premiums.
Without a mandate, the exchange population will trend older and sicker. Without a balanced risk pool, premiums will spike—at least 10% in most years according to the CBO. Importantly, the ACA’s subsidies will mitigate financial hardship for Americans making under 400% of the federal poverty level, about $98,400 for a family of four. But families above that threshold—who are by no means poor, but certainly not rich—will be thrown to the wolves. Although they will not necessarily be paying higher taxes to support corporate tax cuts, they will be stuck paying higher premiums as a result of the mandate repeal. In many cases, families will be priced out of the insurance market entirely—people can’t choose to buy what they can’t afford.
The GOP tax bill is a bomb lobbed in to the heart of the U.S. health care system. It willingly ignores the dynamics of insurance markets. Under the flag of free markets and consumer choice, the bill guts choice for millions of middle-class Americans to pay for regressive tax cuts.” (N)

“This week, Sen. Orrin Hatch (R-UT) helped push a tax bill through the Senate that will cost about $1 trillion. At the same time, he lamented the difficulties of finding the money to fund the Children’s Health Insurance Program (CHIP), which pays for health care for 9 million children and costs about $14 billion a year — a program Hatch helped create.
A Sunday-morning tweet from MSNBC’s Joe Scarborough quoting Hatch kicked off a dustup on Twitter over the Utah Republican’s take on CHIP. Funding for the program — which was created as a joint effort between Hatch and Democratic Sen. Edward Kennedy in 1997 — expired at the end of September; Congress has yet to reauthorize it. That puts health care for millions of American children at risk.
On Thursday evening, as the Senate debated the Republican tax plan, Sen. Sherrod Brown (D-OH) asked whether there’s “something we can do to get the children’s health insurance program done.”
Hatch’s response, in a nutshell: Yes, we’ll fund the program, but we’re really short on money.
“We’re going to do CHIP; there’s no question about it in my mind. And it’s got to be done the right way,” Hatch said. “But the reason CHIP’s having trouble is because we don’t have money anymore, and to just add more and more spending and more and more spending, and you can look at the rest of the bill for the more and more spending.”” (O)

(A) Economist Larry Summers: 10,000 people will die annually from GOP tax bill, by BRETT SAMUELS, http://thehill.com/policy/healthcare/363152-larry-summers-10000-people-will-die-annually-from-gop-tax-bill
(B) Repeal of health insurance mandate in GOP tax bill could have big effects, by MAGGIE FOX, https://www.nbcnews.com/health/health-care/repeal-health-insurance-mandate-gop-tax-bill-could-have-big-n826441
(C) How the G.O.P. Tax Bill Will Ruin Obamacare, by J. B. SILVERS, https://www.nytimes.com/2017/12/04/opinion/gop-tax-bill-obamacare.html
(D) HOW DONALD TRUMP SHOT DOWN OBAMACARE WITH THE SENATE TAX REFORM BILL, by TOM PORTER, http://www.newsweek.com/senate-tax-reform-bill-could-spell-beginning-end-obamacare-729328
(E) With Senate tax bill passed, deal-making with House to begin, by Ron Johnson, https://www.ohio.com/akron/news/breaking-news-news/with-senate-tax-bill-passed-deal-making-with-house-to-begin
(F) Collins doubles funding ask for ObamaCare bill, by JESSIE HELLMANN, http://thehill.com/policy/healthcare/363130-collins-doubles-funding-ask-for-obamacare-bill
(G) What repealing Obamacare mandate would mean for Maine, by Meg Haskell, https://bangordailynews.com/2017/12/02/health/what-repealing-obamacare-mandate-would-mean-for-maine/
(H) Senate passes tax bill that repeals individual mandate, by David Lim, https://www.healthcaredive.com/news/senate-passes-tax-bill-that-repeals-individual-mandate/512125/
(I) CMS Chief Seema Verma Speaks About Her Top Health Care Policy Priorities, by Avik Roy, https://www.forbes.com/sites/theapothecary/2017/12/05/cms-chief-seema-verma-speaks-about-her-top-health-care-policy-priorities/3/#6eda9c236100
(J) Tax bill could fuel push for Medicare, Social Security cuts, by NATHANIEL WEIXEL, http://thehill.com/policy/healthcare/362866-tax-bill-could-fuel-push-for-medicare-social-security-cuts/
(K) Ryan’s office warning he wasn’t part of deal on ObamaCare, by PETER SULLIVAN, http://thehill.com/policy/healthcare/363306-ryans-office-warning-he-wasnt-part-of-deal-on-obamacare-source
(L) Final GOP tax bill will likely scrap Obamacare individual mandate, top House tax writer Brady says, by Jacob Pramuk, https://www.cnbc.com/2017/12/05/kevin-brady-expects-tax-bill-to-repeal-obamacare-individual-mandate.html
(M) Support Wavers for Senate Bill to Shore Up Health-Insurance Markets, by Stephanie Armour and Kristina Peterson, https://www.wsj.com/articles/support-wavers-for-senate-bill-to-shore-up-health-insurance-markets-1512490052
(N) Obamacare Architect: How Is Trump Paying for Wealthy Tax Cuts? By Kicking People Off Their Health Insurance, by Ezekiel J. Emanuel and Aaron Glickman, http://fortune.com/2017/12/04/tax-reform-bill-2017-explained-obamacare-individual-mandate/
(O) GOP senator says it’s hard to fund $14 billion children’s health care program — then advocates for $1 trillion tax cut, by Emily Stewart, https://www.vox.com/2017/12/3/16730496/orrin-hatch-

… according to the Congressional Research Service. The final product is a “conference report,” which is passed by the majority of the members in the conference committee and then sent to the full House and Senate floors. Both the House and Senate have to pass the conference report outright for it to be sent to the president’s desk. (A)

“Because the Senate was rewriting its bill till the last minute, only the dealmakers themselves knew what the chamber voted on. There will, no doubt, be many unpleasant surprises as both houses work to pass final legislation for President Trump to sign.
The votes for the bill by Susan Collins of Maine and John McCain and Jeff Flake of Arizona were particularly disheartening. Ms. Collins, who helped sink an effort to effectively repeal the A.C.A. in September, blithely voted for a tax bill that will leave a gaping hole in that law by repealing its requirement that most people have insurance or pay a penalty. She traded away her vote for an inadequate deduction for property taxes and empty promises from Mr. Trump and the majority leader, Mitch McConnell, that they would help shore up the A.C.A., which they have repeatedly tried to sabotage.” (B)

“Left more uncertain is the trade-off Republican leaders made in order to secure support from all but one Senate Republican. Sen. Susan Collins, R-Maine, who voted against GOP efforts to repeal parts of Obamacare this summer, came onboard for the tax plan after promises from leadership that the Senate would bring a bipartisan bill to the floor known as Alexander-Murray. Collins also was able to secure a pledge to bring a two-year, $5 billion-a-year reinsurance fund to the floor, a bill she introduced with Sen. Bill Nelson, D-Fla.
“After securing significant changes, as well as commitments to pass legislation to help lower health insurance premiums, I will cast my vote in support of the Senate tax reform bill,” Collins tweeted Friday.
But Democrats have repeatedly said that passing both bills would not negate the side effects of repealing the mandate. Insurers have warned that without the individual mandate they are likely to raise premiums for the country’s estimated 16 million Obamacare customers, or withdraw from the exchanges where some of these customers can purchase plans that are subsidized by the federal government.
Sen. Patty Murray, D-Wash., who helped author the bill that carries her name and that of Sen. Lamar Alexander, R-Tenn., said that her deal with Alexander wasn’t designed to mitigate mandate repeal.
“Our bill was designed to shore up the existing healthcare system and deal with problems that President Trump and Republicans have already created — not solve the new problems in this awful Republican tax bill,” Murray said on the Senate floor Friday.
Alexander-Murray makes cost-sharing reduction payments to insurers for two years. In exchange, states get more latitude to waive Obamacare insurer regulations. The payments reimburse insurers for a requirement to lower copays and deductibles for low-income Obamacare customers.
Trump ended the payments starting on Oct. 18. In response, many Obamacare insurers raised premiums to offset the costly requirement for lowering out-of-pocket costs for low-income customers.
Murray said the reinsurance bill sponsored by Collins and Nelson won’t offer relief.
“This bill is good policy on its own — but won’t stop the premium increases, coverage losses, and chaos that the Republican tax bill will cause,” she said Friday.” (C)

“Another argument – that the repeal of the individual mandate wouldn’t be the same as throwing people who already have insurance off insurance – is entirely specious. The individual mandate repeal unwinds the exchanges, allowing young and healthy people to stay out of the risk pools, making coverage more expensive and even unaffordable for those who remain. Surely, Collins and Murkowski know this to be the case from the Obamacare repeal debate. Simply put, as the Center on Budget and Policy Priorities found, “Pairing mandate repeal with the Collins-Nelson bill, or a similar approach . . . would not change the fact that repealing the mandate would drive up uninsured rates. That would weaken access to care, health, and financial security for millions of people. It would also substantially raise uncompensated care costs, which would ultimately be borne by providers, other health-care consumers and taxpayers.”
None of this addresses the damage that the bill may do to Medicaid and Medicare. Because of the deficits it creates (an issue that has thrown the entire legislative process into confusion), there may be a $25 billion sequester in Medicaid and Medicare funding in 2018 alone under the so-called pay-as-you-go (PAYGO) rules. Collins has said she’d oppose that, but her colleagues do not show the same concern.” (D)

“But let’s be clear: Repealing the individual mandate would be a big deal. The mandate is a valuable device for stopping free riders. Obamacare mandated that insurance companies offer insurance to everybody who wants it, with only minimal price discrimination based on age and smoking status. But if a healthy person knows they can buy insurance whenever they want for a given price, they may well decide to only purchase it after they get sick and need coverage.
This would be a big problem for insurance markets, as the pool of covered beneficiaries would be an unhealthy and expensive group. That’s why, for example, the CBO forecasts that repealing the individual mandate would cause premiums in nongroup markets to rise significantly.
Additionally, the mandate provides a hard nudge to people on the fence about getting enrolled in health insurance, including those in nongroup markets but also those who have Medicaid or employer-sponsored insurance. The CBO estimates that of the 13 million people who would lose coverage if the mandate is repealed, seven million are dropping out of Medicaid and employer-sponsored plans. In short, the mandate is a very efficient tool for keeping premium increases in check and increasing enrollment in all types of coverage.
Finally, while the individual mandate repeal is the only plank of the tax bill that directly attacks the ACA, Republicans have made no secret of the fact that after this bill passes, they will point at the resulting deficits to justify cuts in Medicaid and Medicare. This is not idle speculation; the House and Senate passed a budget resolution last month with $1.8 trillion in cuts to both of these programs. The battle over health care won’t end with this tax bill—or anytime soon.” (E)

“High-ranking Republicans are hinting that, after their tax overhaul, the party intends to look at cutting spending on welfare, entitlement programs such as Social Security and Medicare, and other parts of the social safety net.
“House Speaker Paul D. Ryan (R-Wis.) said recently that he wants Republicans to focus in 2018 on reducing spending on government programs. Last month, President Trump said welfare reform will “take place right after taxes, very soon, very shortly after taxes.”
As Republicans advocate spending cuts, they have frequently cited a need to reduce the national deficit while growing the economy.
“You also have to bring spending under control. And not discretionary spending. That isn’t the driver of our debt. The driver of our debt is the structure of Social Security and Medicare for future beneficiaries,” Sen. Marco Rubio (R-Fla.) said this week.
While whipping votes for a GOP tax bill on Thursday, Senate Finance Committee Chairman Orrin G. Hatch (R-Utah) attacked “liberal programs” for the poor and said Congress needed to stop wasting Americans’ money.
“We’re spending ourselves into bankruptcy,” Hatch said. “Now, let’s just be honest about it: We’re in trouble. This country is in deep debt. You don’t help the poor by not solving the problems of debt, and you don’t help the poor by continually pushing more and more liberal programs through.”
The GOP tax bill currently under consideration in the Senate would increase the federal deficit by nearly $1.5 trillion over a decade, according to Congress’s official tax analysts and multiple other nonpartisan analysts. When economic growth the measure could create is included in the analysis, Congress’s official tax scorekeeper predicted the bill would add $1 trillion to the deficit over 10 years.
Trump has not clarified which specific programs would be affected by the proposed “welfare reform.”
During the presidential campaign, Trump vowed that there would be “no cuts” to Social Security, Medicare or Medicaid, although the president has reversed many of his economic campaign promises since taking office.” (F)

“In the hours before the Senate’s final vote on the tax overhaul package, McConnell and House Speaker Paul D. Ryan (R-Wis.) sought to tamp down fears of such cuts, issuing a joint statement in which they accused Democrats of “misleading claims” and promised to “work to ensure these spending cuts are prevented.”
The bill itself does not avert them, however. Separate action would be required later and — unlike the parliamentary maneuvers used to adopt the tax plan with only GOP votes — would require support from some Democrats. Republican leaders predict that Democrats would cooperate rather than bear blame for harming health-care funding.
The leaders’ joint statement has its skeptics. “We are aware they say they will waive the paygo, but we have little comfort that they can do this,” said Georges S. Benjamin, executive director of the American Public Health Association. “Why did they not write the bill to address this in the first place?”
The cuts, if they happen, would decrease federal spending on Medicare by 4 percent — amounting to about $25 billion next year, the Congressional Budget Office forecast. Because paygo rules do not allow Medicare benefits to be touched, the funding loss would be spread among payments to doctors, hospitals and others that provide care to the program’s 56 million older and disabled Americans.
Those rules focus only on the mandatory spending within the federal budget and would leave untouched some health-care programs that provide help to low-income Americans, such as Medicaid and the Children’s Health Insurance Program. But it could eliminate nearly $1 billion a year for a Prevention and Public Health Fund, created under the ACA, that now represents 12 percent of the Centers for Disease Control and Prevention’s budget.” (G)

“There are some timing issues that could impact this process. Collins told reporters Tuesday that if she is going to vote on the Senate’s tax bill, she wants to see two Obamacare stabilizations bills passed before the conference report comes out.” (A)

(A) Senate Republicans pass a tax bill giving corporations a massive tax cut and cutting health care. By Tara Golshan, https://www.vox.com/policy-and-politics/2017/12/2/16720052/senate-republicans-pass-tax-bill
(B) A Historic Tax Heist, https://www.nytimes.com/2017/12/02/opinion/editorials/a-historic-tax-heist.html?_r=0
(C) Republicans send Obamacare individual mandate repeal to conference, by Robert King and Kimberly Leonard, http://www.washingtonexaminer.com/republicans-send-obamacare-individual-mandate-repeal-to-conference/article/2642364
(D) Two senators’ inexplicable flip-flop on health care, by Jennifer Rubin, http://www.sfgate.com/opinion/article/Two-senators-inexplicable-flip-flop-on-health-12398430.php
(E) Commentary: The Hidden Victim of Trump’s Tax Plan: Your Health Insurance, by Josh Bivens, http://fortune.com/2017/12/01/trump-senate-tax-bill-vote-individual-mandate/
(F) GOP eyes post-tax-cut changes to welfare, Medicare and Social Security, by Jeff Stein, https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.7430216da035
(G) Senate’s huge tax bill would have potent ripple effects for health-care system, by Amy Goldstein, https://www.washingtonpost.com/national/health-science/senates-massive-tax-bill-would-have-potent-ripple-effects-for-health-care-system/2017/12/02/8e1701b2-d6c3-11e7-a986-d0a9770d9a3e_story.html?utm_term=.ab7093963f

…who rely on the federal government for their health insurance.
The bill reaches into every major American health care program: Medicaid, Medicare, and the Obamacare marketplaces.
These are expected outcomes based on two key policy changes in the bill. First, the bill repeals the individual mandate, a key piece of Obamacare that requires most Americans get covered. Economists expect its elimination to reduce enrollment in both the Affordable Care Act’s private marketplaces and Medicaid by millions. The money saved will be pumped into tax cuts for the very wealthy.
The bill also includes tax cuts so large that they would trigger across-the-board spending cuts — including billions for Medicare. The last time Medicare was hit with cuts like this, patients lost access to critical services like chemotherapy treatment.
This tax bill deserves a broader name. Its policies will cause millions of vulnerable Americans to lose coverage, disrupt care for the elderly, and potentially change the health care system in other ways we can’t fully predict.” (A)

“Health care became intimately mired in the tax reform debate as Senate Republicans heeded President Trump’s call to tack on a repeal of Obamacare’s individual mandate, one of the health law’s most unpopular measures, into their plan. The mandate requires all Americans to carry insurance (subsidized for the vast majority of people buying individual health insurance plans) or pay a tax penalty.
Trump and the Congressional GOP have long aimed to nix that requirement. But they’ve been unsuccessful to date in part because the CBO has projected that repealing the mandate would lead to millions of fewer insured Americans relative to current law while also hiking rates. And while experts may quibble over the precise magnitude of those effects, the CBO hasn’t equivocated about the overall trend.
“There’s a lot of uncertainty around how effective the mandate has been,” Larry Levitt, senior vice president at the independent health care think tank Kaiser Family Foundation (KFF), told Fortune in an interview. “But CBO has said the direction of the effect is clear. Repealing the mandate would increase premiums, would increase the number of people who are uninsured.”
Just how big of an effect would a mandate repeal have? According to CBO, 13 million fewer people would be insured in 2027 compared with current law while premiums would spike 10%. That’s because, without the policy “stick” of a mandate, healthier and wealthier people would likely drop out of Obamacare’s marketplaces, in turn making individual insurance risk pools more costly by disproportionately leaving them with sicker Americans.” (B)

“President Trump at a closed-door meeting with GOP senators on Tuesday said he would support two proposals meant to stabilize ObamaCare’s insurance markets in exchange for a repeal of the law’s individual mandate, several Republicans in attendance said.
The two bills would fund key ObamaCare insurer payments, and provide billions to help states create reinsurance programs for high-cost patients.
Passage of the measures could prove crucial to winning support for the Senate tax bill, which includes repeal of ObamaCare’s mandate, from Sen. Susan Collins (R-Maine)….
Collins left the meeting feeling she’d been reassured by Trump that he’d support both bills.
“[Trump] said that he understood the need to have something to offset the premium increases and appeared very open” to signing the two bills into law, she said.” (C)

“Sen. Susan Collins (R-Maine) said early Thursday that she expects legislation to lower health-care premiums to pass Congress before senators take a final vote on a $1.5 trillion tax-reform bill that would repeal the Affordable Care Act’s individual mandate….
To mitigate the impact, GOP leaders plan to pass legislation negotiated by Senate Health Committee Chairman Lamar Alexander (R-Tenn.) and Sen. Patty Murray (Wash.) that would reinstate cost-sharing reduction payments to insurance companies.
It will be paired with legislation sponsored by Collins and Sen. Bill Nelson (D-Fla.) that would set up health reinsurance programs for older and sicker individuals.
The measures are likely to be attached to a government stopgap funding bill, Collins said.
“I have met with the president of the United States about this and have gotten his endorsement, I’ve met with the Republican leadership and with the members of the Finance Committee,” she said. “They are most likely to be on the continuing resolution.”
“Assuming the tax bill passes the Senate, we then turn to the CR and those two bills will be put on the CR,” she said.
“While the tax bill is in conference, the CR will presumably become law and then the tax bill come back from conference,” she said. “So I’m going to know whether those provisions made it and that matters hugely to me.”” (D)

“Larry Levitt, an Obamacare expert with the Kaiser Family Foundation, told CNBC that “Alexander-Murray, as it’s currently drafted, wouldn’t really do anything to mitigate the effects of repealing the individual mandate.”
But funding reinsurance programs “could offset any premium increase” resulting from repeal, Levitt said.
Totally offsetting such price hikes from repeal would require some additional funding, and extending reinsurance beyond the two-year span outlined in Collins’ bill, he said.
However, “it wouldn’t do anything to deal with the fact that more people are likely to be uninsured” as a result of the mandate’s repeal, Levitt said.
If the mandate is repealed, the CBO estimates that 13 million more people would become uninsured by 2027 than are currently projected.
“Most of the losses [in insurance coverage] are due to the fact that people are not getting pushed into getting coverage,” Levitt said.
Sen. Patty Murray, D-Wash., who co-authored the Alexander-Murray bill, told The Washington Examiner, “I support reinsurance, but it won’t solve the problem they created,” referring to the mandate repeal.
“The bill we designed has not been written to block the premiums they’re creating,” Murray said.
Republican lawmakers as a group are less likely to be concerned with the increase in the number of uninsured people.
“The premium increases on middle-class consumers is probably the most troubling part of repealing the individual mandate, particularly for Republicans,” Levitt said.
Many middle-income Americans earn too much to qualify for Obamacare subsidies that lower monthly premiums. That means those people bear the full brunt of premium increases.” (E)

“The Senate Republican plan to use tax legislation to repeal the federal requirement that Americans have health coverage threatens to derail insurance markets in conservative, rural swaths of the country, according to a Los Angeles Times data analysis.
That could leave consumers in these regions — including most or all of Alaska, Iowa, Missouri, Nebraska, Nevada and Wyoming, as well as parts of many other states — with either no options for coverage or health plans that are prohibitively expensive.
There are 454 counties nationwide with only one health insurer on the marketplace in 2018 and where the cheapest plan available to a 40-year-old consumer costs at least $500 a month. Markets in these places risk collapsing if Congress scraps the individual insurance mandate.
“It’s very, very concerning to us,” said Denise Burke, healthcare analyst at the Department of Insurance in Wyoming, where the cheapest plan for a 40-year-old consumer in most of the state will cost $586 a month next year.
The precise nationwide impact of the Senate GOP tax plan, which would eliminate the Affordable Care Act’s unpopular mandate penalty, is unclear, as many forces affect how much insurance costs and where insurers sell plans.
But the legislation is widely expected to cause insurers to raise prices or exit markets out of fear that fewer healthy people will buy plans if there is no longer a penalty for going without coverage.
The risk is greatest in places where health insurance is already very expensive and where there are few insurers.” (F)

“But the argument that getting rid of the mandate will improve people’s well-being by allowing them to opt out of coverage without a penalty is weaker than it first sounds, as per this analysis by Aviva Aron-Dine. She draws heavily on the Congressional Budget Office’s estimate that repealing the mandate will lead to 13 million fewer people with coverage and a 10 percent increase in premium costs.
First, the mandate isn’t in the Affordable Care Act just for fun. Health coverage plans with cost controls typically have some version of a mandate to avoid “adverse selection,” wherein the people who buy health coverage tend to be those who need it the most, making it too expensive for others. This undermines health insurance markets, which work through the healthy subsidizing the sick. If that sounds unfair, consider that at some point, you could be either one of those people (i.e., healthy or sick), but you can’t know now which one you’ll be. That’s the problem insurance solves.
Aron-Dine argues that because of this dynamic, “some of the coverage losses from repealing the mandate would not be ‘voluntary’ in any sense.” Instead, they’d be a function of higher premiums due to healthier people leaving the risk pool.
Next, consider that according to the CBO, about half of those budget savings come from fewer people on Medicaid. What’s up with that? After all, Medicaid recipients don’t pay premiums, so why would repealing the mandate affect them either way?
It’s because, as Aron-Dine notes, “the mandate also serves a critical outreach function, leading uninsured people who are unaware of their eligibility for marketplace subsidies or Medicaid to explore their available options and then enroll.” The CBO estimates that this ultimately will lead to 5 million fewer people with Medicaid coverage.
Then there’s the risk that people who don’t get coverage pose to themselves and, through negative spillovers, to the rest of us. Those who decide to forgo coverage are making a bet that they won’t get sick. But some will lose that bet, and when they do, these patients will receive “uncompensated care” because hospitals must treat the sick regardless of their insurance status. And you know who pays for such care, right? The rest of us.” (G)

“Throughout this decadelong healthcare debate, the organization I lead, the National Coalition on Health Care, has urged Congress to pursue bipartisan solutions in healthcare. We have called for reforms that improve our health system and reduce costs through evidence-based policy—but instead, Congress is pursuing across-the-board cuts hidden in a tax bill.
In the individual market today, bipartisan solutions would mean continuing cost-sharing reduction payments and stabilizing premiums—without pushing millions off health coverage. Instead, the Senate tax bill’s repeal of the individual mandate would increase the number of uninsured by 13 million and increase premiums in the nongroup market by about 10%, according to the Joint Committee on Taxation and the Congressional Budget Office.
In Medicaid today, bipartisan solutions would mean fostering state innovation, not shifting the cost burden onto states, beneficiaries or providers. States are already making efforts to transform their care delivery systems by helping beneficiaries remain independent in their homes and integrating care for lower income seniors and disabled individuals enrolled in both Medicare and Medicaid. Targeted federal policy has the ability to improve and expand upon these initiatives. Unfortunately, in this bill much of the savings attributed to the individual mandate repeal would come from a substantial reduction in federal support for state Medicaid programs. An analysis of the mandate repeal published recently by the CBO projected those Medicaid cuts would total $179 billion over 10 years.
In Medicare today, bipartisan solutions would mean improving the quality of care and reducing costs while avoiding indiscriminate cuts that harm beneficiaries. The Senate-passed CHRONIC Care Act is one example of such an effort, providing vital flexibilities to enable providers and health plans to deploy high-tech telehealth and high-touch personal support to improve care for the chronically ill.” (H)

“While the ACA is not perfect, it has provided an important pathway for moving from peril to progress in strengthening America’s health care system. It is important to remember that in 2008, prior to the ACA’s enactment, 82 percent of Americans wanted an overhaul of the U.S. health care system at a time when over 47 million people — or 18 percent of the U.S. population — lacked health insurance. The historic passage of the ACA signed into law by President Obama in 2010 represents the most significant and comprehensive health care legislation since the establishment of Medicare and Medicaid in 1965 and it has transformed the U.S. healthcare system. Through its reforms, the legislation has enabled 20.4 million people to gain insurance coverage by 2016. Medicaid expansion itself covered 11 million people, including nearly two million Americans in rural areas. Furthermore, the ACA’s coverage mandates protect the nearly 129 million Americans with pre-existing conditions — or one in two people — from being charged discriminatorily higher premiums or denied coverage. The ACA’s provisions also put into place payment reforms that incentivized quality care over quantity of medical services provided and fueled a prevention revolution through the provision of preventive services at no cost to consumers in their insurance plans, the establishment of a Prevention and Public Health Fund to support community prevention programs, and the creation of a National Prevention Strategy with the participation many governmental departments and numerous stakeholders.
This is not the time to sabotage the ACA legislation but rather the very moment to strengthen it. Since the establishment of the Affordable Care Act in 2010, much progress has been made to advance America’s health care system in communities, states and nationally. The significant achievements made since the law’s enactment highlight the importance of working together to safeguard, improve, and expand on the ACA’s progress to improve the health of all Americans now and in the years ahead.” (I)

“Gov.-elect Phil Murphy said Wednesday he plans to examine New York Gov. Andrew Cuomo’s efforts to preserve health insurance coverage for residents of his state as a model for New Jersey if parts of the Affordable Care Act are repealed under a new Republican tax bill in Congress….
In June, Cuomo issued emergency regulations requiring any private insurer to guarantee the 10 “essential health benefits” offered under Obamacare, and blocking any insurer that withdraws from New York’s health insurance exchange from participating in Medicaid or its children’s health plan.
But Murphy was adamant that his first priority should be to pressure Congress to preserve the individual mandate to buy health insurance that serves as the Affordable Care Act’s linchpin.
“Make no mistake,” said the governor-elect. “There’s almost nothing the state can do to replace the federal government.”
The current tax reform bill in the U.S. Senate also threatens to slash health insurance for the 900,000 New Jerseyans who’ve gained access to health care under Obamacare by scrapping the the individual mandate requiring people to buy health insurance through a Medicaid exchange or pay a penalty.” (J)

(A) Is it a tax bill or a health care bill?, by Sarah Kliff, VoxCare, November 30. 2017
(B) GOP Tax Plan Would Still Leave 13 Million Without Health Insurance, CBO Says, by Sy Mukherjee, http://fortune.com/2017/11/29/gop-tax-plan-obamacare-cbo/
(C) Trump backs bipartisan fixes to ObamaCare markets, by JESSIE HELLMANN, http://thehill.com/policy/healthcare/362168-trump-backs-bipartisan-fixes-to-obamacare-markets
(D) Collins: Health-care fix will pass before tax bill, by ALEXANDER BOLTON, http://thehill.com/homenews/senate/362537-collins-health-care-fix-will-pass-before-tax-bill
(E) Why a new GOP idea won’t solve biggest problem with repealing Obamacare’s mandate, by Dan Mangan, https://www.cnbc.com/2017/11/28/gop-idea-wont-solve-biggest-problem-with-repealing-obamacare-mandate.html
(F) Republicans’ latest plan to repeal Obamacare’s insurance requirement could wreak havoc in some very red states, by Noam N. Levey, http://www.latimes.com/politics/la-na-pol-insurance-mandate-repeal-20171127-story.html
(G) How the Republican tax cut plan goes after health care, by Jared Bernstein, https://www.washingtonpost.com/news/posteverything/wp/2017/11/27/how-the-republican-tax-cut-plan-goes-after-health-care/?utm_term=.23fcc55219d5
(H) Guest Commentary: Tax reform should mean improving the economy, but not at the expense of our healthcare system, by John Rother, http://www.modernhealthcare.com/article/20171129/NEWS/171129914
(I) Safeguarding America’s Health System from Sabotage, by Susan Blumenthal, M.D. and Alexis Boaz, https://www.huffingtonpost.com/entry/safeguarding-americas-health-system-from-sabotage_us_5a1ecf33e4b0e37da0447b66
(J) Murphy says he’d consider emergency action to save Obamacare for N.J., by By Claude Brodesser-Akner, http://www.nj.com/politics/index.ssf/2017/11/following_cuomo_murphy_will_consider_obamacare_exc.html#incart_river_home

For some middle-income families the increased premium from pulling the individual mandate is going to cancel out the tax cut they would get

Sunday Puzzle: “Which Health Plan Is Cheaper?
Doing a thorough comparison of health care plans is difficult.
But there is an imperfect, yet fairly, simple way to check whether a high-deductible plan might qualify for “no-brainer” status, meaning, it enables you to save on health care no matter how often you go to the doctor.
Here’s how to do it: https://www.nytimes.com/2017/11/04/business/which-health-plan-is-cheaper.html ”

“Democrats and other ACA advocates are arguing that eliminating the penalty would hurt lower-income Americans because fewer people would buy coverage overall – about 13 million fewer Americans over a decade, according to the Congressional Budget Office.
But that argument assumes that Obamacare plans aren’t attractive enough for people to keep buying them voluntarily. It seems unlikely that low-income Americans eligible for subsidies would drop their coverage without the mandate — because they’d still be able to access the same subsidies as before. The ACA is designed to make coverage affordable for people in the lower-income brackets by shielding them from the full cost of premiums.
But there is definitely a segment of the population that could suffer without the mandate. The people who are already bearing all the costs of Obamacare plans. These are the people who earn too much to qualify for a subsidy (that is, who earn at least 400 percent of the federal poverty level) and must therefore endure the full brunt of premium hikes.
In the absence of the mandate, some healthy people who don’t feel they need coverage would probably drop out of the market, resulting in higher premiums for everyone else. The CBO has said that average premiums in the individual market would increase by about 10 percent in most years, were the mandate struck from the books.
Collins expressed precisely this fear yesterday on CNN.
“The fact is that if you do pull this piece of the Affordable Care Act out, for some middle-income families, the increased premium is going to cancel out the tax cut they would get,” she said.” (A)

“In the Affordable Care Act and other subsequent reforms, Congress directed the Department of Health and Human Services to test new ways to pay for health care, challenging health care providers, hospitals, and private insurers to provide better care for less money. Under President Trump and former HHS Secretary Tom Price, that work slowed and, in some cases, stopped altogether. With Price out the door, the nominee to replace him, Alex Azar, should commit to righting the ship.
Congress passed payment reforms to test several simple but powerful notions: First, paying doctors and other health care providers for the quality of their care, not just the number of tests they order, ought to improve the health of their patients. Second, keeping patients out of hospitals and other institutions ought to lower costs. Third, preventive strategies should keep people healthier and lower costs. Finally, holding health systems accountable for quality and total cost of care ought to drive innovation.
Achieving those goals would make Americans healthier and help us save on the more than $3 trillion we spend on health care every year. We far outspend the most expensive, universal coverage health care systems in the world, and we aren’t getting better results. Our life expectancy is comparable to Chile and the Czech Republic. More than 250,000 Americans die due to medical errors every year.
Under Price’s leadership, HHS walked away from addressing these problems. He proposed canceling or shrinking Medicare programs to prompt innovation in joint replacements and cardiac care, which could lower costs across the health care system. In September, under Price’s instruction, Medicare chief Seema Verma signaled a “new direction” for the Center for Medicare and Medicaid Innovation, which Congress set up to test promising new ways to improve care and reduce system-wide costs. Instead of vigorously pursuing that mission, the Innovation Center is now looking for ways to loosen protections for Medicare patients, pushing payment systems that would allow unlimited charges for medical services, and even voucherizing the program for seniors. Apparently, the agency’s “new direction” is backwards….
Failing to align incentives in our health care system has real, lasting, life-or-death consequences. Azar needs to convince Congress that he will correct the course that Price set and renew HHS’s commitment to lowering health care costs and improving quality. The American people deserve better than the inefficient and costly system we have today.” (B)

“So the mandate’s repeal leads to a smaller, more expensive insurance market. The mandate is designed, after all, to bring healthier people into the market — without it, we would expect the remaining customers to be sicker and therefore cost more.
Alexander-Murray doesn’t really take any steps to address those problems. The stabilization bill is actually dealing with a whole different set of issues, brought on by Trump’s overt sabotage of the health care law….
Alexander-Murray is best thought of as an attempt to mitigate the damage that Trump has already done to Obamacare’s insurance markets. But repealing the mandate in the tax plan would erode the markets even further, and this other bill doesn’t have any provisions designed to address that new harm.
“The primary benefit of Alexander-Murray would be symbolic. It would be a sign that some bipartisan effort aimed at stabilizing the insurance market is possible, potentially boding well for future efforts,” Larry Levitt, senior vice president at the Kaiser Family Foundation, told me. “But, beyond the symbolism, it really wouldn’t do much to offset the effects of repealing the individual mandate, and could arguably even make things worse.”
That’s because most states and health insurers found a way to price their plans after the loss of cost-sharing reductions so that they actually yielded better deals for many Americans who buy insurance through Obamacare. If Alexander-Murray were passed, it would make those strategies unnecessary, eliminating these cheaper deals for people.
Then when you add in the repeal of the mandate, and the resulting rise in premiums, you have a market that might be even worse off than if Republicans had simply repealed the mandate and not passed Alexander-Murray.
The exact effects can be debated and might be simply unknowable. But what we can conclude, according to these experts, is that passing Alexander-Murray won’t be nearly enough to negate the consequences of repealing the mandate….
Senate Republicans are taking advantage of the superficial logic — repealing the mandate and Alexander-Murray both affect the insurance market, so it makes sense to tackle them at once — to paper over the fact that the tax bill and the stabilization bill are actually dealing with two totally different issues within the health care law.” (C)

“Moderate Republicans like Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska) have said passing Alexander-Murray could help ease their concerns about the destabilizing effects of repealing the mandate in tax reform.
However, Collins said Sunday she wants Alexander-Murray to pass before the tax bill does, which would likely not be the case if the bill waited until the end-of-the-year package.
Experts say that passing Alexander-Murray would not fully offset the effects of repealing the individual mandate, though, which the Congressional Budget Office estimates would increase premiums by 10 percent.” (D)

“Sen. Lisa Murkowski (R-Alaska) said she would support repealing the Affordable Care Act’s individual insurance mandate, giving a potential boost to the Republican effort to pass a massive tax cut package next week.
“I believe that the federal government should not force anyone to buy something they do not wish to buy, in order to avoid being taxed,” Murkowski wrote in an opinion piece published Tuesday by the Fairbanks Daily News-Miner.” (E)

“There are a variety of proposed alternatives to the ACA’s individual mandate to give people incentives to get and stay insured.
One way is to impose a penalty for people who wait to enroll in the form of higher premiums, similar to Medicare Part B. Following that model, the House GOP’s ACA repeal-and-replace bill this year proposed a one-time, 30% premium surcharge for people who enroll following a gap in coverage…
Another approach is to automatically enroll uninsured people in a health plan, giving them the option to drop out…
Other possibilities include requiring people who have not maintained continuous coverage to wait for a set period of time, say six months, before they can enroll in a plan. That was the approach proposed earlier this year in the Senate Republicans’ Better Care Reconciliation Act, which did not pass.
It’s widely agreed that the ACA’s individual mandate penalty—currently $695, or 2.5% of household income, whichever is greater—has not been as effective as hoped in prodding younger and healthier people to buy coverage. But it’s unclear whether any of the alternatives on their own would be as effective as the mandate without costing the federal government significantly more money.
A recent analysis by Wakely Consulting Group found problems with each of the alternative approaches. Several of those models, including late-enrollment penalties and enrollment waiting periods, could actually worsen the risk pool by giving healthier people incentives to put off buying insurance.
Auto-enrollment could boost enrollment among younger people, but it would be logistically difficult to implement because there’s no existing database of those who currently are uninsured…”(F)

“Despite the efforts of President Trump and many congressional Republications to repeal and replace the ACA in 2017, it is still the law of the land. Therefore, marketplace plans are again being offered for 2018.
However, the Trump administration did make some changes that could make it more difficult for consumers to sign up for healthcare coverage or deter them from doing so. This could result in fewer Americans being insured.
Here’s a look at seven specific steps the administration has taken.
1. Shortening the enrollment period.
2. Making changes to qualifying events.
3. Decreasing the amount spent on advertising ACA plans.
4. Decreasing the number of navigators.
5. Planning more maintenance outages on the exchanges.
6. Collecting unpaid premiums.
7. Canceling a subsidy to insurers that lowers consumer costs.” (G)

“Not-for-profit executives are concerned the Senate bill would hurt hospital capital financing by prohibiting advance re-funding of prior tax-exempt bond issues, which made up about 25% of the municipal tax-exempt bond market in 2017. The House GOP tax bill passed earlier this month goes further, eliminating all tax-exempt municipal bond financing starting next year. That’s projected to save the government nearly $40 billion….
Beyond that, healthcare industry groups fear that the Senate bill’s repeal of the Affordable Care Act’s individual mandate would sharply increase the number of uninsured patients. And they foresee Congress later pushing for big Medicare and Medicaid cuts to reduce the $1.5 trillion bump to the deficit that would result from passage of the tax-cut bill.” (H)

“The White House is trying kill Obamacare. Americans are throwing it a lifeline.
Despite the Trump Administration’s promises to “repeal and replace” the Affordable Care Act, enrollment for health insurance under the program is quite healthy with less than a month to go in the current sign-up period, according to the Centers for Medicare & Medicaid Services, a federal agency.
“In week three of Open Enrollment for 2018, 798,829 people selected plans using the HealthCare.gov platform,” the agency reported.
That brings the total number of enrollees in this period to 2.3 million, which is almost 900,000 people — or 64 percent — more than the number of customers who signed up during the first four weeks of enrollment in 2016, according to CNBC.
The figures included more than 566,000 new consumers and 1.7 million renewals, with total Healthcare.gov users exceeding 8.1 million.” (I)

“In a health care system teeming with fine print, here’s an oddity that middle-class people who buy insurance on their own, rather than through an employer, need to know: You might want to take a pay cut next year.
Consider the situation of a 63-year-old married couple with a projected household income of $70,000 next year. The lowest-cost health plan they can buy in Milwaukee County will cost them $24,034.80.
If that couple’s income falls to $60,000, however, the same health plan would cost them $24.
That’s not a typo. It’s the total premium for the year.
The difference: At $60,000, they’ll qualify for a federal subsidy. At $70,000, they won’t.
“The disparity between the cost of health insurance for people eligible for the subsidy and middle-class people who are not is huge,” said Larry Levitt, a policy expert at the Kaiser Family Foundation.” (J)

“Why have Republican leaders set their sights on health care again? They have a serious accounting problem on their hands. Congressional leaders and the Trump administration want to give corporations and wealthy families a giant tax cut, but they have committed to not adding more than (a whopping) $1.5 trillion to the federal deficit over the next decade. So they’re trying to increase revenue by raising taxes on many middle-class families and would compound that harm by cutting spending on things like health care, all in service of further enriching the wealthiest Americans through a plan they’re selling as a break for the middle class. We’d say you can’t make this stuff up, but it turns out they can.” (K)

(A) The Health 202: Republicans are right. The individual mandate is a tax on the poor., by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/11/20/the-health-202-republicans-are-right-the-individual-mandate-is-a-tax-on-the-poor/5a0f2dc030fb045a2e003215/?utm_term=.de5336388219
(B) Alex Azar must commit to ‘righting the ship’ for health care payments, By SHELDON WHITEHOUSE, https://www.statnews.com/2017/11/20/alex-azar-health-care-payments/
(C) The cockamamie health care scheme Senate Republicans are using to pass their tax bill, https://www.vox.com/policy-and-politics/2017/11/21/16679274/senate-republican-tax-plan-alexander-murray
(D) GOP senator: ObamaCare fix could be in funding bill, by BY PETER SULLIVAN, http://thehill.com/policy/healthcare/361218-alexander-bipartisan-obamacare-fix-could-be-in-funding-bill
(E) Republican Sen. Lisa Murkowski announces support for repealing individual mandate, a potential boost to tax overhaul, by Damian Paletta, https://www.washingtonpost.com/news/business/wp/2017/11/21/republican-sen-lisa-murkowski-announces-support-for-repealing-individual-mandate-a-potential-boost-to-tax-overhaul/?utm_term=.1d2a1d95ca98
(F) While axing the ACA mandate, why not replace it with a different coverage incentive?, by Harris Meyer, http://www.modernhealthcare.com/article/20171120/BLOG/171129994
(G) Open enrollment: 7 ways Trump’s actions could impact uninsured rate, by Karen Appold, http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/open-enrollment-7-ways-trump-s-actions-could-impact-uninsured-rate
(H) Looming Senate tax bill vote making healthcare leaders uneasy, by Harris Meyer, http://www.modernhealthcare.com/article/20171121/NEWS/171129971
(I) AMERICANS SIGN UP FOR OBAMACARE IN DROVES AS TRUMP TRIES TO KILL OBAMA LEGACY, by CELESTE KATZ, http://www.newsweek.com/obamacare-affordable-care-act-open-enrollment-repeal-replace-721850
(J) Making an extra $10 could cost you $24,000 more for health insurance, by Guy Boulton, https://www.jsonline.com/story/money/business/health-care/2017/11/24/few-dollars-can-determthe-same-health-plan-can-cost-middle-class-couple-24-034-year-24-year-cost-sam/893295001/
(K) When a Tax Cut Costs Millions Their Medical Coverage, https://www.nytimes.com/2017/11/24/opinion/republican-taxes-healthcare.html?_r=0

“HEALTH CARE: The Senate plan calls for eliminating the individual mandate in the Affordable Care Act (”Obamacare”). This will gut the ACA just as much as outright repealing it as the Senate tried earlier in the year, and failed. Eliminating this mandate will cause 13+ million taxpayers, many of them Trump supporters, to lose their health insurance. The savings of some $338 billion by doing this will be used to pay for the tax plan and those wealthy Americans that will see their taxes go down. ..
MEDICARE and MEDICAID: Here is one that has not received much attention, but all those 65 and older that are on Medicare, take note: as a result of what the Republicans wish to force down voters’ throats, $25 billion will be slashed from Medicare. This is due to a 2010 law, called PAYGO (”pay-as-you-go) that requires ensuring any new legislation enacted during a term of Congress does not collectively increase estimated deficits. If there is an increase in the deficit (again, the tax plan will increase the deficit by $1.5 trillion) OMB (Office of Management and Budget) is required to order a sequestration to eliminate the overage. Medicare would not be immune from this. ..Medicaid subsidies would also get axed by $179 billion…(A)

“Senate Republicans’ proposed tax reform bill would increase Obamacare prices by an average of almost $2,000 per family in 2019, according to an analysis released Thursday.
And the tax bill would lead to 1.8 million more people lacking health insurance in California than currently, another 1 million people becoming uninsured in Texas, and more than 800,000 newly uninsured in New York and Florida each, the report said.
Cumulatively, 13 million more people nationally would become uninsured.” (B)

“ “I believe in the Affordable Care Act; it worked for me under the Obama administration,” said Sara Stovall, 40, who does customer-support work for a small software company. “But it’s not working as it was supposed to. It’s being sabotaged, and I feel like a pawn.”
Ms. Stovall said she might try to reduce her hours and income, so her family could qualify for subsidies on offer to poorer families to help pay for premiums.” (C)

“For those who are over the age of 64 or who live with the challenges of disability, this tax bill does not carry benefits. Instead it leads to a path towards poverty, unemployment, and potentially tragic loss of life.
The most significant proposal is the elimination of the medical tax deduction, as it will have immediate and devastating impact on the 8.8 million Americans who have claimed the benefit to help offset medical expenses, includes those dealing with the devastating consequences of medical crisis or disabilities.
Of those who claimed the deduction in 2015, nearly half earned less than $50,000 and almost 70 percent earned less than 75,000 annually, according to AARP…
In short, the medical expenses deduction has saved American families and lives by easing the financial burden on struggling individuals and families, and these middle class communities will feel the impact if it is discontinued….” (D)

“Were the ACA’s insurance mandate repealed absent a new policy to compel the purchase of coverage, the CBO projects that premiums would rise 10 percent for people who buy insurance on their own and more than 13 million Americans would lose or drop their coverage.
But a reduction in the number of people with insurance also translates to less taxpayer money spent to provide subsidies for premiums under the ACA. Ending the requirement as of 2019 would save the government an estimated $318 billion, helping to offset the cost of lowering the corporate tax rate….
The White House argues that the ACA’s insurance mandate isn’t popular and disproportionately affects low- and middle-income Americans who are forced to buy insurance that may be more expensive than they can afford.
“The President’s priorities for tax reform have been clear from the beginning: make our businesses globally competitive, and deliver tax cuts to the middle class,” White House spokesman Raj Shah said in a statement. “He is glad to see the Senate is considering including the repeal of the onerous mandates of Obamacare in its tax reform legislation and hopes that those savings will be used to further reduce the burden it has placed on middle-class families.”…
Insurers, hospital groups and disability advocates have spoken out forcefully against the health-care proposals in the bill. Hospitals and insurance groups wrote a letter to congressional leaders on Tuesday warning of dire health-care outcomes if the tax measure becomes law.
“Repealing the individual mandate without a workable alternative will reduce enrollment, further destabilizing an already fragile individual and small group health insurance market on which more than 10 million Americans rely,” said the letter, signed by six health-care groups, including the American Hospital Association and America’s Health Insurance Plans.” (E)

“A group of Republican senators met with President Trump at the White House on Thursday to push him to support a bipartisan ObamaCare fix, according to a Senate GOP aide….
Collins and another moderate, Sen. Lisa Murkowski (R-Alaska), have indicated that passing Alexander-Murray would help ease their concerns about the spike in premiums from repealing the mandate.
Getting Trump’s support for that measure would help ease its passage, especially through the House, where many Republicans are opposed to it as a bailout of insurance companies….
A major obstacle for the idea of pairing Alexander-Murray with repealing the mandate in tax reform, though, is that Democrats have rejected that trade. Senate Democratic Leader Charles Schumer (N.Y.) said this week that Democrats would block the Alexander-Murray bill if the GOP goes forward with repealing the mandate.
Several experts also say that Alexander-Murray, which is aimed at stabilizing markets by continuing key payments for insurers, would not cancel out the destabilizing effects of repealing the mandate, which could lead to a lack of healthy people signing up and a rise in premiums.
The Congressional Budget Office has found that repealing the mandate would increase premiums by 10 percent, but that markets would continue to be stable in almost all areas of the country. “ (F)

Alaska Republican Sen. Lisa Murkowski suggested Thursday that her vote on the current version of the Senate GOP tax overhaul is contingent on the passing of a separate bill to stabilize the individual health insurance market.
The tax legislation now includes a section to repeal the individual mandate in the 2010 health care law — a provision that opens up more than $300 billion in revenue — but could also threaten the viability of the overall law….
Murkowski believes legislation from the Senate Health, Education, Labor and Pensions leaders, Chairman Lamar Alexander and ranking member Patty Murray, is necessary before the mandate — which supporters of the law say is a critical foundation for the current insurance markets — is repealed.
“I think that there is a path and I think the path is a reasonable path,” Murkowski said of her support for the measure. “If the Congress is going to move forward with repeal of the individual mandate, we absolutely must have the Alexander-Murray piece that is passed into law.”
Without such a measure — which would, among other things, appropriate money for so-called cost-sharing subsidies — Murkowski says middle-class Americans may not receive the kind of tax relief the GOP is aiming to provide.
“There is a path forward. It just means that some who have said some nasty things about CSRs are maybe just going to have to acknowledge that, well, this might be the way that you thread this needle,” she said. “If that tax cut is offset by higher premiums, you haven’t delivered benefit.”
The Congressional Budget Office has estimated that removing the mandate could lead to millions more uninsured individuals over the next ten years and could raise health care costs for some, particularly sicker Americans.
Twelve Republican senators — along with every Democratic member — have come out in support of the Alexander-Murray bill, enough for it to pass under the regular 60-vote threshold in the chamber.” (G)

“Maine Sen. Susan Collins wants the Senate to strike a provision in the tax reform bill that would repeal the individual mandate because she fears it will cause what amounts to a tax increase on some families.
Speaking on CNN’s “State of the Union,” Collins, a crucial Republican swing vote in the Senate, said the measure, which would essentially cripple the Affordable Care Act by removing one of its key pillars, should be removed from the Senate’s version of the bill.
“I don’t think that provision should be in the bill,” she said. “I think the Senate should follow the lead of the House and strike it.”…
Collins said the measure must be taken out of the bill because it will end up causing families who have healthcare through the Affordable Care Act to pay more for their insurance.
“The fact is that if you do pull this piece of the Affordable Care Act out, for some middle-income families, the increased premium is going to cancel out the tax cut that they would get,” she said.” (H)

“On Sunday, Mick Mulvaney, President Trump’s budget director, said on CNN’s “State of the Union” that the administration supports repealing the mandate. Most people who owe the penalty earn less than $100,000 a year, he said, arguing that “there’s actually a benefit to folks” if the mandate goes away. But he added, “If it becomes an impediment to getting the best tax bill we can, then we’re O.K. with taking it out.”” (I)

(A) The GOP Tax Plan-A Wolf In Sheep’s Clothing, by Miles J. Zaremski, https://www.huffingtonpost.com/entry/the-gop-tax-plan-a-wolf-in-sheeps-clothing_us_5a102167e4b023121e0e92f4
(B) GOP tax bill would spike Obamacare premiums nearly $2,000 for families, trigger Medicare cuts, by Dan Mangan, https://www.cnbc.com/2017/11/16/gop-tax-bill-would-spike-obamacare-premiums-nearly-2000-for-families.html
(C) Middle-Class Families Confront Soaring Health Insurance Costs, by ROBERT PEAR, https://www.nytimes.com/2017/11/16/us/politics/obamacare-premiums-middle-class.html?_r=0
(D) The GOP tax bill will be a health care burden on American families, by JANNI LEHRER-STEIN, http://thehill.com/opinion/healthcare/360801-the-gop-tax-bill-will-be-a-health-care-financial-burden-on-american
(E) 4 ways the Republican tax plan could change health care, by Dylan Scott, https://www.vox.com/health-care/2017/11/16/15643218/voxcare-tax-plan-health-care
(F) Trump met Senate Republicans on ObamaCare fix, by PETER SULLIVAN, http://thehill.com/policy/healthcare/360955-trump-met-senate-republicans-on-obamacare-fix
(G) Murkowski Suggests Tax Vote Depends on Stabilizing Individual Health Insurance Market, by Joe Williams, https://www.rollcall.com/news/politics/murkowski-alexander-murray-necessary
(H) Susan Collins wants repeal of Obamacare mandate out of Senate tax reform bill, by Kyle Feldscher, http://www.washingtonexaminer.com/susan-collins-wants-repeal-of-obamacare-mandate-out-of-senate-tax-reform-bill/article/2641179
(I) Will Cutting the Health Mandate Pay for Tax Cuts? Not Necessarily, by KATE ZERNIKE and ABBY GOODNOUGH, https://www.nytimes.com/2017/11/19/health/tax-plan-obamacare-mandate.html?_r=0

“The move to tuck the repeal of the so-called individual mandate into the tax overhaul is an attempt by Republicans to solve two problems: math and politics. Repealing the mandate, a longstanding Republican goal, would save hundreds of billions of dollars over the next decade. That would free up money that could be used to expand middle-class tax cuts or help pay for the overall cost of the bill, which can add no more than $1.5 trillion to the deficit over 10 years. It could also help secure the votes of the most conservative senators, enabling lawmakers to pass the bill along party lines.
If it becomes law, the repeal would save more than $300 billion over a decade but result in 13 million fewer Americans being covered by health insurance by the end of that period, according to the Congressional Budget Office. Republicans said on Tuesday that they would use the savings — which stem from reduced government spending to subsidize health coverage — to pay for an expansion of the middle-class tax cuts that lawmakers had proposed.
On Tuesday evening, the chairman of the Senate Finance Committee, Orrin G. Hatch, Republican of Utah, was expected to release an amendment that would add the repeal of the mandate to the Senate’s tax plan. On the House side, members of the Rules Committee met Tuesday evening, one day earlier than scheduled, to pave the way for a floor vote on Thursday. (A)

“Now it turns out that getting rid of the mandate could help Republicans as they tackle the difficult math of tax reform. According to a recent Congressional Budget Office estimate, eliminating the mandate could lower the deficit by $338 billion over a decade. A third of a trillion dollars can help pay for a lot of tax cuts. Which is why Senate Republicans, trying to find funding and keep their promise to dismantle Obamacare, are now vowing to add a mandate repeal to their tax bill. (B)

“President Donald Trump said Monday that he will nominate former pharmaceutical executive Alex Azar as secretary of the U.S. Health and Human Services Department….
Azar in February, during an interview on CNBC in February, said “The remarkable thing here is Obamacare is failing completely on its own terms.”
Speaking about what was then a prospective Republican Obamacare repeal-and-replacement bill, Azar said there was a consensus among Republicans and Democrats that the government should play a role in expanding insurance coverage and subsidizing its purchase by individuals. But he suggested that the way to do that was one other than Obamacare’s system.
And Azar was firm in his prediction that the GOP bill would become law within months.
“There will be a piece of legislation passes this year that is called ‘the repeal of Obamacare,’ ” Azar said. “I don’t know what’s going to be in the substance of it, but there will be a piece of legislation that says that.”
Azar was wrong about that. Republican leaders in Congress repeatedly fail to pass repeal-and-replace bills, despite controlling both the Senate and the House.
Azar has previously said he does not believe the expansion of Medicaid has been successful, saying he would have preferred to use government money through “private-sector vehicles” to deliver health care.” (C)

“Vice President Mike Pence is exerting growing influence over the American health care system, overseeing the appointments of more than a half-dozen allies and former aides to positions driving the White House’s health agenda.
On Monday, President Donald Trump nominated Alex Azar, a former Indianapolis-based drug executive and longtime Pence supporter as Health and Human Services secretary. If confirmed, Azar would join an Indiana brain trust that already includes Centers for Medicare & Medicaid Services Administrator Seema Verma and Surgeon General Jerome Adams. Two of Verma’s top deputies — Medicaid director Brian Neale and deputy chief of staff Brady Brookes — are former Pence hands as well, as is HHS’ top spokesman, Matt Lloyd.
Yet another Pence ally — Indiana state Sen. Jim Merritt — is in the running to be White House drug czar.
Pence’s sway with the policymakers controlling Obamacare, Medicare and Medicaid comes at a time when Trump and Congress continue to struggle with the repeal of the Affordable Care Act. But Pence and his cadre are driving a national agenda dominated by the kinds of conservative, anti-regulatory policies he embraced as Indiana governor.” (D)

“Azar has called Verma “one of the leaders in reinventing Medicaid.” He shares her view that the health care program for low-income Americans has to be put on a more “sustainable” financial footing, and states should be given more accountability and responsibility for running the joint federal/state program.
On the individual insurance market, the other major aspect of health care restructured by the Affordable Care Act, Azar has echoed the Trump administration’s view that the market is failing.
“Obamacare is going down right now,” Azar told Fox News in July. “It is an almost impossible market to do from an insurance perspective.””
He’s said the regulations need a “top-to-bottom comprehensive rewrite” to impose “as much free market, localized flexibility as humanly possible.” (E)

“There’s one set of eyes that President Trump’s appointees absolutely cannot ignore as they set about trying to reshape Obamacare and enact sweeping new changes to the government’s health-care programs.
They belong to Joe Grogan, director of health programs at the White House’s Office of Management and Budget.
You’ve probably never heard of Grogan — but you should know who he is. Grogan, perhaps more than any other member of Trump’s administration, holds the power to nix or give the nod to hundreds of regulations shaping how the federal government runs Medicare, Medicaid, the Affordable Care Act marketplaces, the FDA, the CDC and all the other sub-agencies contained within the sprawl of the Department of Health and Human Services.
Without Grogan’s assent, for example, the Centers for Medicare and Medicaid Services wouldn’t have been able to essentially wipe out steep and long-term drug discounts received by charity and rural hospitals. Last month’s rule change to the 340B program — viewed by many as rather gutsy on the part of CMS because it infuriated hospitals — had to get past Grogan’s desk at OMB, just like every other regulation change the administration wants to make.” (F)

“As Republican lawmakers worked on Monday toward a delicate compromise on a $1.5 trillion tax cut, President Trump threw himself back into the discussion, suggesting that Republicans could reduce taxes even further by repealing the Affordable Care Act’s mandate that most people have health insurance.
In recent weeks, Mr. Trump has called for including the repeal of the individual mandate in the tax bill. Doing so would save more than $300 billion over a decade and would allow Republicans to boast that they took a step forward in dismantling a law that continues to haunt them.” (G)

President Donald Trump remains intent on undoing the Obamacare individual mandate one way or another.
Encouraged by Trump, a group of congressional conservatives want to add repeal of the mandate to the GOP’s overhaul of the tax code. But other Republicans fear the toxic politics of Obamacare could jeopardize the tax fight, and so far have kept repeal language out of both Senate and House versions of the tax package.
That means it could be left to Trump to act unilaterally to neutralize what polls consistently show to be the most unpopular part of the Affordable Care Act.
Most legal observers believe the administration has the necessary authority to interpret the law and substantially weaken enforcement of the tax penalty levied on most Americans who fail to obtain coverage. The downside is that unraveling the mandate might ultimately make it harder for Republicans to follow through on their long-standing promise to repeal and replace Obamacare.
The White House has drafted an executive order to scrap the individual mandate, but is waiting to see if Congress opts to go first, multiple media outlets reported this week. House Ways and Means member Jim Renacci (R-Ohio) worked behind the scenes to add a repeal provision to tax legislation moving to the House floor, according to a source close to the talks.
The White House denies that any executive action is imminent.
“We are always looking for ways to provide relief from Obamacare,” said a spokesman in an email. “The longstanding issues with the mandate would be best resolved legislatively.” (H)

“After cutting funds for nonprofit groups that help people obtain health insurance under the Affordable Care Act, the Trump administration is encouraging the use of insurance agents and brokers who are often paid by insurers when they help people sign up.
The administration said in a recent bulletin that it was “increasing partnerships” with insurance agents and viewed them as “important stakeholders” in the federal marketplace, where consumers are now shopping for insurance. But some health policy experts warned that a shift from nonprofit groups, which are supposed to provide impartial information, to brokers and agents, who may receive commissions for the plans they recommend, carries risks for consumers.
“Insurance agents can educate consumers about the marketplace, and that is a good thing,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But I worry that they work on a commission and therefore have a financial incentive to steer consumers to particular products, which may or may not be in the consumer’s best interest.”” (I)

“Buried in almost every version of the Republican health care legislation this year was a little provision that would have enabled states to make a major change to their Medicaid programs, by requiring people to work if they’re going to get coverage. When those bills died, it appeared that Medicaid work requirements died with them.
But this week, Seema Verma, the head of the Centers for Medicaid & Medicare Services and a longtime supporter of work requirements, sent a strong message that work requirements are back on the table. In a speech to the country’s Medicaid directors, Verma lambasted the Obama administration’s approach to Medicaid, calling it a “tragic example of the soft bigotry of low expectations,” and argued that requiring Medicaid beneficiaries to work would improve the program.
The speech doesn’t result in any immediate policy changes, but CMS is reviewing at least seven waiver proposals from GOP-led states that would impose work requirements on their Medicaid populations. The details around each waiver vary and it’s unclear whether Verma, who helped design a work requirement policy in Indiana that was rejected by the Obama administration, will ask states to tweak their submissions or when she will approve the first waiver. But her speech this week was a clear sign that big changes are coming to Medicaid — even without any help from Congress.” (J)

“For years, red states have effectively been subsidizing part of health insurance for blue states.
By declining to expand their Medicaid programs as part of the Affordable Care Act, many of those states have passed up tens of billions of federal dollars they could have used to offer health coverage to more poor residents. That means that taxpayers in Texas are helping to fund treatment for patients with opioid addiction in Vermont, while Texans with opioid problems may have no such option.
If they did, they could collect billions of federal dollars to help them cover more low-income residents.
Now new estimates prepared by the consulting firm Avalere Health for The Upshot give a sense of just how much states are giving up. Texas could collect around $42 billion in Medicaid over a decade if it opted in, according to the Avalere analysis. Tennessee could pull in around 5 percent of its state budget next year. Altogether, Avalere estimates that the 18 states that have still not expanded Medicaid could give up more than $180 billion over the next 10 years.” (K)

(A) Senate Plans to End Obamacare Mandate in Revised Tax Proposal, by THOMAS KAPLAN and JIM TANKERSLEY, https://www.nytimes.com/2017/11/14/us/politics/tax-plan-senate-obamacare-individual-mandate-trump.html?_r=0
(B) Obamacare’s Insurance Mandate Is Unpopular. So Why Not Just Get Rid of It?, by Margot Sanger-Katz, https://www.nytimes.com/2017/11/14/upshot/obamacares-insurance-mandate-is-unpopular-so-why-not-just-get-rid-of-it.html
(C) Trump nominates former drug company executive Alex Azar as next Health and Human Services secretary, by Dan Mangan, https://www.cnbc.com/2017/11/13/trump-nominates-alex-azar-as-next-hhs-secretary.html
(D) Pence’s health care power play, by By ADAM CANCRYN, https://www.politico.com/story/2017/11/13/pence-health-care-azar-244859
(E) Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency, by Maureen Groppe, https://www.usatoday.com/story/news/2017/11/13/former-pharmaceutical-ceo-nominated-trump-head-department-health-and-human-services/858240001/
(F) The Health 202: The Trump appointee you’ve never heard of who’s reshaping health policy, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/11/13/the-health-202-the-trump-appointee-you-ve-never-heard-of-who-s-reshaping-health-policy/5a05e5fa30fb045a2e002f8e/?utm_term=.eabfd0d7cd19
(G) Trump Again Wades Into Tax Debate, Suggesting Repeal of Obamacare Mandate, by ALAN RAPPEPORT and THOMAS KAPLAN, https://www.nytimes.com/2017/11/13/us/politics/trump-taxes-obamacare-individual-mandate.html?_r=0
(H) Trump may use executive power to weaken Obamacare’s individual mandate, by Paul Demko, https://www.politico.com/story/2017/11/10/trump-executive-power-obamacare-mandate-244782
(I) Trump Administration Guiding Health Shoppers to Agents Paid by Insurers, by ROBERT PEAR, https://www.nytimes.com/2017/11/11/us/politics/obamacare-health-insurance-marketplace-agents.html?_r=0
(J) 5 things Trump did this week while you weren’t looking, by DANNY VINIK, https://www.politico.com/agenda/story/2017/11/10/trump-policy-immigration-cuba-regulation-000582
(K) What Red States Are Passing Up as Blue States Get Billions, by MARGOT SANGER-KATZ and KEVIN QUEALY, https://www.nytimes.com/2017/11/13/upshot/what-red-states-are-passing-up-as-blue-states-get-billions.html