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The Washington Post survey of 1200 readers on how the Republican healthcare plan of Speaker Ryan and the House of Representatives looks to them, how it affects them in their lives. Here Somasekhar of the Post gives the stories of 5 Americans. Some see the prospect of losing their insurance under the Republican plan even as they reach an older age, others a smaller segment says the Post, whose premiums jumped under the Affordable Care Act say they faced high premiums and high deductibles. The Post says the large majority of opinions have expressed anxiety over the proposed Republican Ryan House plan for healthcare. One of them is an uninsured poor farmer, Mr. Woosley,  income about $18000 who gained benefit from expanded Medicaid under the Affordable Care Act,  one Mr. Smith, 32 years, a personal injury attorney who faces paying $10,000 if he did not take insurance and $10,000 if he took insurance because of high premiums so a wash either way deciding to do without it, one a tech worker Mrs. Powers, 62 years, income $22,000 on year and $4000 the next, from middle class during the tech boom but facing fewer opportunities and uncertain income from part time work, hit by the deep recession facing fewer opportunities as she gets older and now the prospect of losing insurance without government subsidies, one who is from the middle class who sees little benefit from the Affordable Care Act and is forgoing insurance because of the high premiums yet faces a penalty for not being insured under the ACA, another Mr. Blanchard, 52 years, is from the middle class, a computer programmer who lost his job in downsizing, earns $100,000 as a consultant self-employed, pays $767 in premium a month and relies on the Affordable Care Act which helps him gain freedom from working at a company that could downsize,  another is a middle class programmer Mr Riffle,age 44, and his wife, who does not qualify for a subsidy with a $71,000 family salary from working 4 jobs between himself and his wife- this person finds it too expensive for his salary to buy insurance $900 a month and $14,000 deductible under the Affordable Care Act. His views are worth listening to as they go to the crux of the problem- he says he may not be any better with the Republican plan. He sees the real problem as the high cost of health care in the U.S. and the only way this can be fixed is for members of Congress to be asked to use the insurance exchanges they create. If this sample is representative it shows that there are real problems with both the Affordable Care Act and the Republican plan, that the high cost of health care the problem lurking behind every plan that does not squarely address this, and till that happens and members of Congress experience what ordinary people face, this problem can never by fully solved.   Woosley, Smith, Powers, Blanchard, Riffle, and their personal experience is at the crux of what is right and wrong  with the Affordable Care Act, and also with the new Republican plan of Speaker Ryan and the House of Representatives. For every Woosley, Powers and Blanchard who benefit, there is a Smith and a Riffle who are indifferent or are affected by the high cost under Affordable Care Act and the current system of medical care with its high cost. The Affordable Care Act does not  tackle high cost, for that to happen the culture in America that makes it possible and acceptable to charge high prices must change. Another problem apart from bringing health care costs is that any solution needs to have the whole country behind it. If the notion that all people are entitled to basic health care is to stand, the whole country needs to believe it as they do in countries like France, Britain, Germany and Japan. If this has to be made a workable proposition health care has to be offered at a price that makes this possible to achieve, and that idea also needs the deep and broad sense of support from the culture in America similar to that in these other countries. Until that happens politicians in America will get elected and turned out of office in turns on issues such as health care, based on which side they take and which problems they choose not to face squarely and responsibly. ...

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This article in the NYT provides a look at the features of the Republican House Health Care Plan- Both the Affordable Health Care Act and the House Plan provide incentives for buying insurance- the ACA bases these incentives on income levels whereas the House Plan does not provide additional help for low incomes or elderly. Incomes at $20,000 would see a loss greater than  $2000 under the House Plan and as many of the elderly poor living in high cost areas may not have the resources to make up for this loss of subisidies they may forgo buying insurance or have insurance coverage that protects only in a limited way. President Trump has given assurances that all will be covered. For people with incomes of $50,000 or $75000 the loss of $2000 subisidies would also have some impact. At larger incomes or the well to do the subsidies are not handed out under either plan. Under the ACA the emphasis was on income levels and high cost insurance areas the subsidies were greater, under the House Plan the subisidies would be higher for the elderly compared to the young but very low income levels are not given additional help.     ...

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What is behind Pew Research Report finding showing an unacceptable concentration of wealth that endangers democracy. Higher income groups making $244,000 a year in 2024 gained 19 percentage points of the total US Household Income moving from 29% in 1970 to 48% in 2024. About 50% of the nation's income going to 20% of its people and most of that to 2%-5% of the people of the US. The gains meant loss of 17 of these percentage points for middle income households making $106,000 a year that went from 62% in 1970 to 43% in 2024. Another 2 percentage points was suffered by vulnerable Lower Income groups making $35,000 a year who owned 10% of US wealth in 1970 went down to 8%.  The problems of divisiveness in the Nation come from three distinct areas. First money for state financed education for all being put into wars in the Middle East from Reagan through Obama and Trump and some wasted through capital misallocation to low priority investment by faulty capital market allocation. Second the high cost of pharmaceuticals and healthcare putting a heavy burden on low income and middle income households making $35,000 or 106,000 a year. Third the neglect of manufacturing that cutoff the opportunities for middle and lower income households and their one chance to move up the ladder. And the parallel shift of resources to technology and financial sectors that created opportunities for a smaller group of immigrant and higher middle income households with these skills.  These are the sources of America's distress and each problem is being attacked at its source by president Biden- exit from Afghanistan, canceling student loans that are egregious and prevent the investment in education America needs, large sustained investment in manufacturing and new supply chains, antitrust action on tech monopolistic behaviour, redrawing the shape of America's pharmaceutical sector to provide access to medicine to all parts of the population.    ...

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The Republican House Health Care pLan in 2017 relies on tax credits of between $2000 and $4000 based on age. Under the Affordable Health Care Act the elderly poor in high cost insurance areas received additional help. These people would lose over $2000 per person and may forgo full coverage or coverage entirely under the Republican House Health Care Plan. A report by Standard & Poor's estimates about 2 to 4 million people who are in 50's and 60's not yet qualifying for Medicare might lose their coverage they now have under ACA. The Republican plan also gives incentives through tax credits higher for older people, $4000 for a 60 year ol and $2000 for a 25 year old. Under the ACA the insurers are not allowed to charge more than three times what is charged for younger people, under the Republican plan this goes up to five times. 

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Gerald Seib of the WSJ points out that the winners in the passing of the Republican healthcare bill in the House by a 4 vote margin are Speaker Ryan who never wanted the job in the first place, and president Trump who showed he could cajole Republicans into getting it passed because he likes winning. Now comes the hard part says Seib, when it goes to the Senate- House conservatives are not going to be happy when they find major changes they dislike. If the bill clears the Senate in a modified version Republicans will now have to own any issues with healthcare, including says Seib things that may not work out for pre-existing conditions- or for groups that are disadvantaged, including older people.

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The major provisions of the Republican House healthcare bill that passed by a vote of 217-213 are- 1. To help people buy insurance coverage the bill offers $2000 to $4000 a year, upto $14,000 a year in credits based mainly on age, reducing them for families making $150,000, individuals making $75,000. 2.  Under the Affordable Care Act insurers cannot charge older Americans more than 3 times for same coverage they offer to younger people, the new bill makes this 5 times. This would increase premiums for older Americans and reduce it for younger Americans. This is the most controversial part of the bill. Older Americans supported the Republican party in the presidential election. 3. The new bill ends Medicaid as an open ended entitlement and places this on a budget with cuts of $880 billion over 10 years. 4. To mollify conservative Republicans a provision allows state to opt out some provisions of the ACA that requires minimum benefits such as maternity care and emergency services. It retains coverage for pre-existing conditions to mollify moderate Republicans. The bill provides states with $138 billion over 10 years to subsidize premiums, provide coverage for pre-existing conditions, mental healthcare and drug addiction. 5. The bill removes the taxes imposed under the Affordable Care Act (ACA) on high income people of about $300 billion over 10 years by repealing a payroll tax increase and tax on investment income. This bill and the ACA offer 2 competing visions on healthcare, both bills passed only by a margin of 4-5 votes in the House. The ACA overlooked the impact on premiums causing discontent among middle income Americans. The new bill lets premiums rise for older Americans in order to keep premiums down for other Americans. This shows the many tradeoffs involved and choices being made, and the lack of a consensus on the issue of healthcare in the U.S., becoming a highly politicized issue instead of the way it is treated in western Europe.     ...

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This NYT editorial points out that the cuts to Medicaid amount to taking out a fourth of its budget and are sure to hurt low income Americans. The cuts are about $880 billion over 10 years for Medicaid. The $300 billion less in subsidies over ten years is likely to hurt the elderly. It also points out that removing the individual mandate will make it harder to reduce premiums as fewer healthy adults offset the costs of sick patients.

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Experts say Chief Justice Roberts somehow found a path through in bridging the ideological divide and avoiding a show of partisanship in an election year. He somehow navigated and found a path through in his vote on the U.S. healthcare law letting it stand. Early on Roberts advocated "judicial modesty and humility" in jurisprudence. He compared the judge's role to that of an umpire in baseball during the 2005 confirmation hearings. The umpire would not pitch or bat, his job would be to call balls and strikes. It was seen as a determmined show of independence at a time when Justice Kennedy was seen as the swing vote. He has also earned political capital to be able to vote independently on other issues before the court instead of becoming embroiled in controversy about the role of the Court in overturning the work of Congress during the early part of the Obama administration.

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Under the Deferred Action for Childhood Arrivals (DACA) executive order of 2012, a group of immigrants brought to the country as children can have temporary status to stay and work in the U.S. In 2012 this was restricted to children brought in under the age of 16, with a maximum age of 30. The program was called "Dreamers." Under president Obama's executive order this will be changed to children brought in under the age of 18, with no maximum age. The number of immigrants goes up from 1.2 million in 2012 to 1.9 million with this particular change in 2014. A new group of parents of children who are citizens or legal residents residing in the U.S. for more than 5 years adds another 3.3 million to this number, with an additional 100,000 for parents of Dreamers. The total 1.9 million children and 3.4 million parents would be 5.3 million given new status to stay and work in the U.S. The 5.3 million will not be eligible for subsidies and for the Affordable Healthcare Act assistance. All will be required to pass security checks. This leaves about 6 million, including farm workers and other undocumented or illegal immigrants not touched by the new executive order. President Obama is expected to make the announcement of the executive order on Nov. 20, 2014, in Nevada, a state with a large Hispanic population. On the question of legal authority for the executive order, Prof. Stephen Yale-Loehr, an expert on immigration law at Cornell says the U.S. president does have broad authority to decide which group should get a reprieve from deportations. The decision to exclude benefits of government subsidies and subsidized healthcare was made to appeal to increased support of the American public for the executive order. ...

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Bob Kocher, special assistant to President Obama for healthcare policy in 2009-2010 describes how hospital mergers with the passage of the Obama Healthcare Law are not doing much to control health care costs in the U.S. This is contrary to what was expected during the policymaking in 2009. In 2015 there were 112 hospital mergers in the U.S.  He says smaller physician led health care organizations do better at taking steps to improve productivity, adopt technological improvements and control costs.

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U.S. Senator Ben Sasse suggests an alternative approach of simply repealing the Affordable Care Act called Obamacare and replacing it at a later date. This is endorsed by president Trump. This is the new Republican strategy in July 2017. Forty nine senators voted in favor of this repeal in 2015, when president Obama vetoed this legislation. Two more senators are expected to support repeal according to Ben Sasse.

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The U.S. House of Representatives votes to repeal and replace the Affordable care Act 217-213. Moderates were won over by an addition of $8 billion  to add coverage for a popular feature of the ACA that covered people for pre-existing conditions.  The bill that passed gives credits of $2000 to $4000 a year, depending mostly on age, upto $14,000 for a family. Credits are reduced for individuals making over $75,000 a year or families making over $150,000. There is no mandated insurance coverage. This trims the federal budget deficit, yet also is expected to keep 24 million more Americans without health coverage after 10 years. The bill now goes to the Senate where moderate Republicans are worried that this may increase premiums for older people, one of the drawbacks of the earlier version of the House Republican bill.

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A health care practitioner says the real problem is the high cost of medical care in the U.S. when compared to other countries. She points out that the Obama bill in 2008 did not take effective steps to bring down the cost of health care before enacting legislation to cover the uninsured, leading to higher premiums for the middle class. The link between healthcare and profits is seen as the main problem. 

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This story in the NYT describes how the flawed effort to pass the Republican healthcare bill or repeal the Affordable Care Act passed under president Obama failed after another effort. Many developments killed it. In the end the president lost interest, especially when he saw Republican Senator Rand Paul of Kentucky go on talk shows on the weekend before its collapse to complain about the bill. Senator Collins of Maine was exasperated by the way the bill was being rushed through Congress, and she voiced her strong opinions about this by talking to people back home in Maine and sharing her conversations with the media. The bill pushed by Senator McConnell, the Republican leader in the Senate, imposed annual caps on Medicaid spending. And did this without any discussion, shutting out committee debate, any public discussion, or formal drafting. Once this process was set in motion in this way the Republican Senators formed camps. Senator Grassley of Iowa and Jerry Moran of Kansas, normally conservative moved to the moderate side. Moran held a town hall meeting covered in the NYT, where older people voiced their concerns. Most of the patient advocacy groups, the hospital groups such as the American Hospital Association, and other medical groups also opposed it.  After Senator McCain of Arizona said he could not return following a surgery in Phoenix, Senators Lee and Moran announced their opposition. With this the bill's support crumbled including any effort to repeal the Affordable Care Act.  ...

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With the rushed approach adopted by the Trump administration not enough consideration was given to winning support in the House from 25 conservatives in the Freedom Caucus. Without their support the bill cannot be passed in the House of Representatives. The fight also includes one over what are essential health benefits including whether  maternity care would be included. As a result some moderate Republicans are also expressing opposition on the grounds that less people will be covered and fewer benefits will be provided under the Republican House plan called AHCA. President Trump has not involved himself in the details, and the bill comes very early in the first 100 days, leading to the perception that health care has become a partisan conflict without really grappling with the problems of high cost of health care and creating a solution that all can support. Democrats are seen as having made the same error early in Obama administration's first term. President Trump sees this as a much needed win with a drop in his approval ratings, making this even less of an effort to come out with a good plan.  ...

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The coverage of the Republican healthcare bill and how it affects the elderly, and people on Medicaid, people in rural areas, is likely to have changed public opinion in the U.S. about the necessity of ensuring all Americans have health coverage. The Pew survey cited here in this NYT report by Zernike and Goodnough was done in Jan 2017, and shows a shift. The shift would be much higher today after people look hard at the consequences of what were simply hypothetical positions or ideological positions taken without looking at consequences in daily living. On Medicaid that opinion by July 2017 compared to Jan 2017 has shifted 10 percentage points for Republicans to 53% who think Medicaid is important to them and their families, according to Kaiser research. There is stronger sentiment about people having benefits taken away.  [article-55059] The opinion has shifted to where people see that coverage is important and people should not have coverage denied or benefits taken away from them. Opinion remains strong in favor of changes to reduce the high premiums, but not to replace the existing health benefits and law with no law at all to replace it. That leaves 20 million more uninsured according to the Congressional Budget Office. Changes have to be constructive is the popular view today,  and this requires dialogue between Republicans and Democrats- which has not taken place. ...

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This editorial in the WSJ points out that U.S. president Obama made economic inequality "the defining challenge of our time" in his State of the Union address in 2013, yet the U.S. has seen widening economic and social disparities in his two terms- creating the situation where Bernie Sanders is now in a virtual tie in Iowa with Hillary Clinton. It says Hillary Clinton wins handily over Sanders on three of four issues of the most concern for Democratic caucus voters in pre-entrance polls, healthcare, terrorism, and on the important issue of jobs and economy by 51% to 42%. Where she falls behind is on the issue of income inequality, and by a very wide margin reflecting voter disillusionment with policies that resulted in marginalization of some workers through globalization and long term unemloyment, and reduced access to education with high tution costs- there Sanders wins by 61% to 34%. Federal Reserve policies that kept rates low near zero hurt middle class savers, working class savers, and benefitted disproportionately upper class investors in the stock market, widening the social and economic disparities....

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State based exchanges in New Mexico, Oregon and other states have experienced difficulties setting up and running the exchanges. Many states have turned to the federal government to operate the exchanges.