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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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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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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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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.

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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 Congressional Budget Office analysis of the Republican healthcare plan advocated by Mr. McConnell, Senate Majority leader, is that it would add 22 million uninsured if implemented. That plan ran into opposition from Republican Senators Collins, Capito, Murkowski, Paul, and Moran, and lacked enough support in the Senate. All Democrats opposed it and with the thin majority Republicans were divided. By taking away some benefits given under the existing Affordable Care Act the plan hurt the elderly and low income people, making some Republicans listen to their constituents in home districts and not the Republican leadership. The NYT profiled two in particular who astonishingly in a sign of today's strange politics were the only ones publicly holding townhall type meetings to hear the views of people in their voting districts- Susan Collins of Maine and Jerry Moran of Kansas. Both senators were listening to rural communities and Moran stated his opposition with the words- "I am a product of rural Kansas." With it the nation takes a breather and the message goes out that it is best to listen first and then to seek middle ground, not do what both parties Democrats and Republicans did in 2009 and 2017- rush serious legislation through without support across party lines and without serious discussion.   ...

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This is an exceptionally humorous operating room story of Dr. Trump and Dr. McConnell by Kristof of the NYT. Sometimes humor tells the story- and Kristof does this using a story of a surgeon president Trump in the operating Room trying to address the concerns of the patient Janet, as he keeps telling her she needs a new heart with great benefits, great benefits, before she implodes or goes down failing. Flat out take the old heart out even if a replacement hasn't been found, believe me great benefits the surgeon tells her, just that the patient just isn't getting convinced as its happening to her. The analogy is with replacing a health care plan, not just the Obama plan, any plan without something to take its place. For a few days before this article by Kristof, the Republican effort to repeal the Affordable Care Act without having a replacement was presented as a good idea. Janet is like the three Republican women- Collins of Maine, Capito of West Virginia, and Murkowski of Alaska who wanted to keep the heart they had till a replacement was found, against the surgeon Trump's advice. In a way it is about politicians in the last decade who never had any discussions as they rushed through with their own agendas, as the Republican and Democratic health care plans were rushed through Congress with relatively little participation and debate to hear all viewpoints. ...

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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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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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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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The U.S. Senate passes a motion that allows the chamber to proceed with a debate on a health care bill. The motion passed 51-50 with Vice President Mike Pence casting the deciding vote. Republican Senators Collins and Murkowski voted against the motion. This report in the WSJ says this sets in motion a process in which debate will take place and amendments will be made. It is not clear what shape the bill will take. Under the process used only a simple majority is needed in the Senate, yet this allows for many amendments to be made.  Only hours after this motion passed by one vote, a bill replacing major parts of the Affordable Care Act failed to pass 57 votes against and 43 in favor. Senator John McCain who arrived in Washington from Arizona following brain tumor surgery, delivered strong criticism of the way the Republican healthcare bill was rushed through allowing very little debate. Experts have commented on the way the bill was rushed through with a thin majority for passage, with very little debate, first by Democrats in 2009 and now in the House by Republicans. With the same pattern now followed in the Senate by Mitch McConnell, the Republican leader in the Senate. A backup bill would remove just the individual and employer mandates and a tax on medical devices- the elements Republicans agree on, if no majority can be put together for the healthcare bill. ...

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The distrust in negotiations between Republicans Boehner, Ryan, Cantor and Democrats Reid, Obama, and Pelosi, during the weeks in October 2013 preceding the reopening of U.S. government after the shutdown. Republicans call attention to the rising deficit from $4.9 trillion in 1993 compared to $16.7 trillion in 2013, triple the increase in the deficit in just one decade compared to the five decades prior to this period. Democrats say sharp spending cuts would hurt economic growth and the unemployed.