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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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Congressional Budget Office analysis that shows 14 million more people uninsured in 2018 under the Republican House health care plan, this increases to 24 million by 2026.

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This report in the WSJ by Peterson and Hackman shows how the American Health Care Act proposed by Speaker Paul Ryan provides less financial support and allows premiums to go higher for seniors approaching retirement in the 50-64 year age group. Premiums are allowed to go up 5 times that of premiums of young people in the Ryan House  plan compared to 3 times in the Affordable Care Act. Subsidies in the form of tax incentives provide $2000 to younger people going up by age not income to $4000 in the Ryan House plan. By contrast someone 60 years old making $20,000 a year can get Affordable Care Act credit of $9874, and making $40,000 a credit of $6752, according to analysis by Kaiser Family Foundation. The Ryan plan makes health care costs lower for young people in an effort to bring more young people who use less services into the system to support its overall financial condition. Another feature of the Ryan Plan is that it allows only for CPI index +1% even if health care costs are rising faster. Deep cuts to Medicaid affect lower income seniors on Medicare. As a result the AARP organization representing seniors has come out in opposition to the Ryan bill. The GOP plan wants to reduce premium costs yet in the process it makes vulnerable seniors with lower incomes pay more, which is likely to hurt Republicans who won by winning a large part of the senior vote. ...

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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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The Congressional Budget Office analysis of the Republican House health Care bill shows 24 million Americans would lose health insurance over 10 years. In terms of budget savings the bill saves $337 billion over 10 years. The increase in uninsured comes from the roll back of expansion of Medicaid under the House plan, the reduction of tax credits, plus the removing of income based credits replacing it with tax credits based on age. President Trump is promoting the bill saying it will reduce the premiums that have gone up since Affordable Care Act was passed and increase competition. House Speaker Ryan in promoting his plan says he is not in "some coverage beauty contest." The House Plan says Ryan, does not mandate that all be covered, but simply says coverage is in a free market giving people the option to buy insurance that they want, so that the numbers of insured would not be as many as under a mandate.

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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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Senators Mike Lee of Utah and Jerry Moran of Kansas declare their opposition to the Republican Health Care bill proposed by Senator McConnell. This decision by the two senators makes it impossible to begin debate on the bill. Earlier two other senators, Susan Collins of Maine and Rand Paul of Kentucky announced their opposition. This means the Republican health care bill has no chance in the Senate even after changes to the bill passed by the House of Representatives. Republicans have a thin majority in the Senate make it difficult to pass legislation. Collins met with residents in Maine and Moran with people in his home state of Kansas, and both senators heard a lot about the negative effects of the Republican bill on people in their state. The bill is seen as hurting people in rural areas, elderly, and not likely to do enough to bring down premiums. Its plan to slash Medicaid spending has drawn strong opposition from all Democrats.

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House Democrats in the U.S. see the Republican health care plan making the same mistakes in 2017 that the Democrats made in 2008. With the passage of the bill in the House of Representatives with a vote margin on May 4, 2017, rushed through in the way the Obama bill was also rushed through, the nation remains as divided as ever on the issue of health care. The Republicans favoring limiting subsidies and cutting Medicaid, and using some of the savings for a tax cut. The Democrats favoring mandated coverage for all and large subsidies to reduce the number of uninsured Americans, with expansion of Medicaid for very low incomes. Democrats in the House say the Republican House bill will result in Republicans losing seats in the House in midterm elections.

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In this insightful essay Peggy Noonan, former spokesperson for president Reagan, says that Republicans like Speaker Ryan with the Republican Health Care bill are making the same error made by president Obama.. Noonan says she had suggested a different way for president Obama to show compassion for the uninsured- first wait till the 2008 financial crisis was tackled, tackled waste and fraud in Medicare first, then look at the option of expanding Medicare to help the uninsured, and not the approach taken of swiftly focussing on the Affordable Care Act early in the first term disregarding Republican objections. She says Republicans are making the same mistake now by ignoring the impact the bill would have on Trump's base of working class Americans who may be affected by the bill's provisions not taking into account incomes in offering incentives or subsidies. Noonan says Trump did get one thing right in calling it a "carnage" for the worsening opioid epidemic in America which has hit rural areas and parts of the midwest hard. Noonan says Eberstadt has correctly documented the collapse in working class Americans wages and standard of living, and Caldwell the opioid epidemic at another level to their health. She also supports journalist Carlson who questioned Speaker Paul Ryan's judgement about eliminating the tax on wealthy investors in new legislation in a Fox News interview, as she says responding to the sense of America at the moment means listening to the sense of being left out of ordinary Americans, who have done not as well as the wealthy who have benefitted from a surging stock market.  ...

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Shear of the NYT says president Trump is taking risks of losing support from low income people who supported him in the presidential election by making aggressive cuts in programs that help low income people. In his first budget plan deep cuts to social programs and increase of 10% in defense spending of $54 billion is planned. The new health care plan of the Republicans House and Speaker Ryan is seen by the Congressional Budget Office as increasing uninsured people by 14 million. Trump has left Social Security intact, but he sees other cuts as cuts to the "administrative state' and overreach on entitlements. The budget plan is titled "America First," and shrinks foreign aid, cuts state department budget by about a third, and cuts funding to PBS, other agencies, and cuts social program spending.

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NYT reports show the Republican health care bill AHCA 33 votes short of passing the House and likely to fail. Conservative Republicans were looking to whittle down the safety net in the Affordable Care Act, and moderate Republicans could not stomach the whittled down bill removing guarantees of essential benefits for instance. The basic problem- no real consensus among Americans about providing health care to all Americans, and no real solutions possible as long as there is acceptance of disproportionately high levels of medical care costs for treating each disease in the U.S. compared to Europe and other countries.

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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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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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The Republican House health care bill AHCA  keeps some some of the more popular parts of the Affordable Care Act such as not taking pre-existing conditions to deny insurance, keeping children covered on parents insurance till age 26, and increase contributions to Health Savings accounts. It is different in that the expansion of Medicaid at 138% of poverty rate threshold is rolled back. Age is used for tax credits instead of income, hitting those approaching Medicare age harder. The maximum charged to older people is now set at  5 times compared to 3 times what young have to pay. In general the Republican bill is seen as targeting the elderly to keep premiums down. The elderly on low incomes are hit hardest. Fox News O'Reilly Show showed the host questioning House Republicans, citing the CBO estimates that elderly on low incomes may have to pay as much as $14,000 a year for insurance making it basically unaffordable, and 52 million Americans would be affected adversely. Large companies are no longer required to offer mandatory health insurance under the new bill. Conservatives from Freedom Caucus wanted to see the essential areas of benefits covered by the law limited to fewer than the ten areas in the Affordable Care Act. The ACHA Republican bill leaves to states to determine what are required essential benefits. At one point maternity benefits were to be dropped but this was changed to let states decide. As a result the bill is 33 votes short of the number needed for passing the house in March 2017.   Neither the Democrats Affordable Care Act or the Republican House bill of Speaker Ryan do much to tackle the real problem- the absolute amount and increases for health care dollars for treating each disease in the U.S. compared to European and other countries. As a result health care has become more of a partisan struggle between the two parties than a real effort by all to overcome the problems that have to be tackled. Republicans want to see premiums drop and keep the burden on the deficit down- but with the level of U.S. health care costs disproportionately high compared to Europe and the rest of the world the arithmetic is tough and ends up leaving out vulnerable groups such as the elderly on low incomes, thus making the whole proposition prone to fail. For the same reason the Democrats failed to keep premiums down with a wider safety net leading to calls for repeal of their version.   ...

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This Economist magazine editorial says the Republican plan for health care with its roll back of Medicaid expansion by limiting funding to states after 2020, and by scaling back subsidies especially for older Americans and not basing them on income levels, is likely to have its own problems just as the Affordable Care Act. One concern is that keeping healthy people in the market with a mandate that everyone have insurance is present but in a milder form with premiums going up by 30% in one year if they change their mind. There is concern that this may not work among insurers leading to an increase in premiums, pricing people out of the market in "a death spiral." This could lead to more people being priced out of the market as premiums rise. About 12 million people were added to Medicaid by increasing eligibility level to $16400, or 138% of poverty line- this reduced the uninsured from 16% in 2010 to 8.8% today. The Economist concludes that the Republican health care bill has its own problems, and that this bill does not clear up the problems in Obamacare by substituting Ryancare as the Republican bill is called. Peggy Noonan writing in the WSJ says this may have negative consequences for the new Republican base shift to populist support. Critics on the right like Rand Paul see even the reduced subsidies as an entitlement program, yet the Republicans can only change parts of the Affordable Care Act as they need 60 votes in the Senate where they only have a small majority.   ...

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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 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.