Republicans have long talk about replacing Obamacare, but no bill yet

http://www.cnn.com/2017/02/16/politics/republicans-obamacare-no-bill/index.html

Washington (CNN)Congressional Republicans insist they are moving forward on their campaign pledge to repeal and replace Obamacare, but internal divisions over key components mean they will head home for a week-long recess with few details on how they will overhaul the nation’s health care system.

Republicans huddled in the basement of the Capitol for a closed-door meeting Thursday to hear presentations from the two committee leaders leading the effort — Oregon Rep. Greg Walden and Texas Rep. Kevin Brady — who outlined plans to set up tax credits and restructuring how states will administer Medicaid programs that provide coverage for millions.
Members coming out of the meeting continued to stress they were unified on their goal and campaign promise to do away with the Affordable Care Act, but no draft language was was handed out. Most members described a more robust discussion of the House GOP’s “Better Way” health care proposal that they campaigned on in 2016.
“This is a complex issue, one of the members said ‘hey you’ve got to keep this simple.’ You can’t keep this simple. When you are talking about health care and rolling back 2,600 pages of the Affordable Care Act this is going to take some complexity,” Republican Rep. Mark Walker, the head of a group of fiscal conservatives, said after the meeting.
Many conservatives, despite the lack of details, said they are confident that there will be a vote in the first quarter of the year — a goal that House Speaker Paul Ryan has set.
But other members said their new target for moving legislation from committees to the House floor was sometime in mid-April.
In recent weeks, town halls in member’s districts have erupted with angry pushback from voters who are uneasy about the Republicans’ plans to transform the health care system.
At Thursday’s meeting, there was a PowerPoint presentation and members were supposed to get paper versions to bring home, but they weren’t ready in time for the meeting. Instead leaders promised to give each member packets with information so they will be armed with some more answers for voters.
A PowerPoint distributed after the meeting included quotes from Americans who had been negatively affected by the Affordable Care Act and included maps of just how much premiums had gone up in individual states and how few options there were in some places. The slide show included a briefing of the three-part plan to give regulatory relief through administrative action, repeal and replace using reconciliation and then move forward with additional legislation.
Michigan Rep. Bill Huizenga told reporters he wasn’t worried they still hasn’t seen a bill from leaders yet, noting that the Democrats’ efforts to design Obamacare took 14 months.
“We knew we haven’t gotten into this overnight,” Huizenga said. “We are not going to get out of it overnight.”
The official cost estimate of the GOP proposal is still a work in progress by the Congressional Budget Office. Members are awaiting the results.
“If it comes back and it’s out of the roof then it might take some more time to figure out how to pay for this,” Walker admitted.
Missouri GOP Rep. Ann Wagner downplayed the fact that leaders didn’t unveil actual legislation, telling reporters “I think we’ve got the outline of things that will be a part of a bill and part of a reconciliation package going along. We have had this in place for some time, and now we’re getting down to some of the very specifics.”

Trump’s man aims to reassure GOP

Newly installed Health and Human Services Secretary Tom Price, who recently resigned his House seat, attended the meeting and pledged “the president is all-in on this.”
But GOP leaders are concerned that the window for action is tight and they are scrambling to corral members around a proposal. The more time they take the more that counter-pressures from the right and left — to speed up or slow down the process — are making their job more difficult. They are using a budget procedure known as reconciliation to repeal major planks of the law and begin the process of replacing it. This process allows them to pass the measure with a simple majority in the Senate. But they want to use a similar strategy for tax reform so they are mindful of the need to get bill moving soon so they can tackle other issues this spring.
Price discussed the need to stick with the timeline the leaders set out. “Let’s not miss this opportunity. Let’s go shoulder to shoulder, arm to arm,” he said.
But multiple members from across the ideological spectrum stressed that a lot of decisions still hadn’t been made on key issues.
“So there’s obviously unanswered questions and — no shocker here — we have differences of opinion even within our conference,” Huizenga told reporters.

Future of Obamacare taxes, Medicaid programs

Committee leaders walked through several policy issues they are working through such as how to design tax credits for those who will be shopping for health care in the new system and how to address how money will flow to states that administer the Medicaid program.
They went over plans for creating high-risk pools and proposals for incentives for broader use of health savings accounts. In the PowerPoint sent out after the meeting, there was a promise to “deliver relief from the Obamacare taxes,” “eliminate the individual and employer mandate penalties,” and “repeal Obamacare spending for the Medicaid expansion and the new open-ended subsidies.”
But in some areas, there was no clear consensus. For example, the details on how states would handle the Medicaid program are still being worked out. Republicans from Medicaid expansion states have been fighting to keep their expansion money and ensure voters back home who were covered under the program could remain on it, but Medicaid has long been a top target for fiscal conservatives looking to make cuts in the budget. There is wide consensus that states need more flexibility in handling their federal Medicaid dollars, but there still are not clear details on whether that flexibility will come through block grants or per capita allotments is still up in the air.
Ways and Means Committee Chairman Brady told reporters that the discussion was also ongoing as to what to do with Obamacare taxes. Conservatives have said the taxes need to be repealed immediately, but others have been arguing that Republicans will need to keep the taxes in place in the short term to fund their own Obamacare replacement.
Rep. Pete Sessions of Texas told reporters that he had no actual budget numbers of how each program- from tax credits to health savings accounts- would be funded, a key factor in whether or not Republicans will be able to rally around the plan.
“They did not overlay the money and that is the big question,” Sessions said. “You cannot pass policy, you have to pass money. It’s about money.”
So far, a leading member of the conservative House Freedom Caucus didn’t sound impressed with what he heard from his leadership.
“So far it just sounds like Obamacare light,” said Idaho Republican Rep. Raul Labrador.
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On eve of possible repeal, the good, bad and ugly of Obamacare

The much-maligned Affordable Care Act may well be headed for the public policy scrap heap if the Trump administration has its way.

But the controversial law — funded by a prodigious river of at least $6.7 billion in tax money — has already fundamentally changed the health care industry. It gave free or subsidized health care coverage to nearly a half-million Oregonians. It also drove insurance companies out of business, led to painful insurance rate hikes, generated windfall profits for hospitals and undoubtedly saved lives.

Now, it’s all at risk. The entire country can only wait and watch to see what the Trump administration does

While the debate gears up in Congress, here’s a look at the profound changes wrought by the legislation. The Affordable Care Act in Oregon, by the numbers:

438,000

The first and most concrete impact of the Affordable Care Act was a vast expansion of Medicaid, the 52-year-old federal program that provides free health care to the poor.

Nearly a million Oregonians were enrolled in Medicaid in 2016, compared with just over 600,000 in the pre-Obamacare era.

The ranks of the uninsured plummeted from 16 to 5 percent, or about 280,000 Oregonians.

The new law liberalized qualifying standards to 133 percent of the federal poverty line. That’s not much money — $16,394 in annual salary for an individual.

State planners were stunned as the number of eligible Oregonians easily surpassed initial projections of 250,000 and eventually topped out at 438,000. In many Oregon counties, particularly the rural ones, a third of the population qualified.

So what will the Republicans do? Will they kill off the Medicaid expansion along with the rest of the Affordable Care Act?

No way, says Lynne Saxton, director of the Oregon Health Authority. Oregon just signed a waiver extension with the U.S. Centers for Medicare and Medicaid that should lock in the expansion for five years, she said. In exchange, Oregon agreed to continue to restrict the annual rate increase of delivering health care to 3.4 percent.

Saxton said Oregon provides Congress an example of health care reform that has worked.

“We’ve been developing a highly effective new model here with fiscal discipline,” Saxton said.

My crystal ball is, I think they’ll keep the expanded Medicaid population,” said Dr. Bruce Goldberg, an administrator at Oregon Health & Science University and a former state health official. “I hope they don’t want to see millions of people losing coverage. But they’ll decrease the funding or more subtly decrease funding by ignoring inflation. They’ll give states more ability to cut coverage. I think that’ll be really hard for sick people.”

$6.4 billion

Increasing the Medicaid rolls by nearly 60 percent in Oregon didn’t come cheap. The annual bill approached $1 billion in 2014 and surpassed $2.6 billion in 2015 and 2016.

Even before the Affordable Care Act was thrown into flux by the Republicans’ triumph in November, the Medicaid expansion faced significant budget issues. After paying the full freight for the first three years, the feds now expect states to begin contributing. For Oregon, that comes to $350 million over the next two years. With the state facing a sizable budget gap, it remains to be seen how it will come up with money.

Gov. Kate Brown said Friday that health care is “too important to be treated as a political football.” Her proposed $20.8 billion budget contains $55 million to further expand insurance coverage.

155,000

Donald Trump’s vow to repeal the Affordable Care Act was political red meat to his conservative base. But during the presidential transition, Americans flocked in record numbers to get health insurance through the new markets created by the legislation.

In Oregon, 155,000 people signed up in 2017, an all-time high. That’s more than double the 68,308 who signed up in the program’s first year of 2014.

This year, as the Jan. 31 enrollment deadline approached, state officials were inundated with thousands of last-minute applicants. When the Trump administration cut off federal money for customer outreach, Oregon kicked in $110,000 to do its own advertising.

“We got 8,000 new people in the last two weeks,” said Patrick Allen, director of the Oregon Department of Consumer and Business Affairs.The bottom line is, we know the system is going to change. But in these times, it’s a good idea to have health insurance.”

Of course, there was an element of coercion here. The Affordable Care Act threatened to levy financial penalties against Americans who didn’t sign up for health insurance — as much as $695 per person, $2,085 per family.

In 2015 alone, 7.5 million paid about $1.5 billion in tax penalties.

While Trump and Congress may save some significant parts of the Affordable Care Act, they almost certainly will eliminate the requirement to buy insurance, industry sources agreed.

“The individual mandate is dead on arrival,” Goldberg said.

But insurance executives and academics questioned whether the system would work without such a requirement. Dave Underriner, regional chief executive officer of Providence Health & Services, said there needs to be some mechanism to motivate people to sign up and stay insured. “Right now, it’s the mandate,” he said.

Nick Bagley, a University of Michigan Law School professor who tracks health policy, said Republicans have been slow to come up with an alternative to Obamacare because they can’t figure out how to make a system work without the individual mandate.

“It takes a carrot and stick for the market to work,” Bagley said. “And the Republicans hate the the stick. They really are stuck.”

74 percent

To many Americans who didn’t qualify for Medicaid, the Affordable Care Act has felt like a lie.

Insurers struggling to make money in the new market have repeatedly socked their customers with double-digit rate increases. People caught between premiums they can’t afford and tax penalties if they don’t buy insurance were understandably resentful.

Oregonians participating in the new individual market saw their rates climb an average of 27 percent in 2016. That’s on the heels of an average 23 percent jump in the prior year.

Some Oregonians got hit much harder. Jon and Mary Gill, 55-year-old Hermiston residents who own and operate a pool and spa store, got word last fall that their insurance rates would increase 74 percent.

Nevertheless, Moda Health, their Portland-based insurance company, raised their rates from $846 to $1,472 a month. “That’s more than double what we pay on our mortgage,” Mary Gill said.

The Gills say they have no significant health issues. Neither had any surgeries or major medical procedures in 2016. They don’t even take any prescription drugs.

For good measure, Moda also upped their deductible to $7,150 each a year.

Mary Gill said she appealed to Moda and the Oregon Health Division but got no satisfaction.

“It’s just hard to swallow when you pay and pay, but then you have to really have to think twice before you go out and get treatment.”

Moda declined comment.

Allen, the top state regulator overseeing the insurance industry, conceded the new individual market has been a difficult place for some consumers.”The population really dissatisfied with the act are the healthier folks who used to be able to get insurance at a price that reflected their good health,” he said. “Now, they are bearing much of the cost of insuring the rest of the folks who couldn’t get health insurance at any price because they were sick and needed to use it.”

$264.4 million

There’s a reason insurers have gotten aggressive on rates; it was either that or go out of business, they argued.

The Affordable Care Act has been a bloodbath for many insurers, particularly those who aggressively pursued customers in the markets newly created by the act. Companies like Moda badly misjudged the new markets and significantly underpriced premiums.

Though it seems obvious now, some companies failed to take into account that many of their new customers had been shut out of the health insurance market because of pre-existing conditions. The Affordable Care Act mandated that insurers accept those customers. When they finally did get coverage, they tended to be heavy users of health care, which took a toll on some insurers’ bottom lines.

Oregon insurers have cumulatively lost $264.4 million since 2014.

Moda, Oregon’s second largest health insurer, suffered a near-death experience. It lost $49.5 million in 2015 and an additional $33.4 million through the first three quarters of 2016. Regulators forced the Portland company into “supervision” — meaning all business decisions had to be cleared by the state — early last year, citing its sustained losses and depleted capital reserves.

Moda escaped the clutches of regulators only after its parent company raised $115 million in fresh capital by selling assets and by borrowing.

At least Moda survived; other companies had to pull out of the state. Two insurance co-ops created by the Affordable Care Act failed altogether, in part because promised federal financial assistance failed to materialize.

In all, about 58,000 Oregonians were forced to find other insurance as their existing coverage disappeared.

42,438

The Affordable Care Act let loose a torrent of tax dollars so large that some are predicting a sudden repeal and cutoff of that money could shock the economy into a recession.

In a just-issued report, the Economic Policy Institute predicts Oregon could lose 42,438 jobs if Obamacare is eliminated. The economic hit would be twofold, said Josh Bivens, a co-author of the report. The nearly half-million Oregonians suddenly without free or subsidized coverage would see their buying power vastly reduced. Plus, hospitals and health systems would suffer a serious blow.

Dr. Joe Robertson, president of OHSU, agreed and went a step further. The Affordable Care Act “has been one of the major factors that helped pull this company out of the last Great Recession,” he said. “That fact has been almost completely overlooked.”

OHSU has for years been a state economic powerhouse. But it and just about every large hospital in the state have enjoyed unprecedented boom times as the newly insured powered a rush of new patients and charity care plummeted.

Employment at OHSU has jumped from about 12,000 before Obamacare to around 16,000 today. But Robertson has opted to slow the hiring spree given the uncertainties in Washington.

Bivens said Oregon may be exceptionally vulnerable to an Affordable Care Act recession because it receives an oversized share of the federal booty.

“One thing that really stuck out as I looked at the numbers is that Oregon gets a ton of federal money,” Bivens said. “It gets a billion dollars more a year than Pennsylvania, which is three times larger. Oregon definitely looks like one of the big losers here.”

— Jeff Manning

502-294-7606, jmanning@oregonian.com

NIGGERHEAD OBAMA WASTES LITTLE TIME IN CONDEMNING REPUBLICANS FOR ‘REPEAL AND REPLACE’ ON OBAMACARE

http://www.newsweek.com/obama-wastes-little-time-condemning-republicans-repeal-and-replace-obamacare-549289

 

Repealing Obamacare without a replacement is “reckless” and “irresponsible,” and would leave the country “with more uninsured and uncompensated care than when we started,” writes former President Barack Obama.

In the commentary published Jan. 26 in the New England Journal of Medicine, one week after the inauguration of Donald Trump, Obama makes good on the pledge in his farewell news conference to speak out “where I think our core values may be at stake.

“What the past 8 years have taught us is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people,” Obama writes. “That is why Republicans’ plan to repeal the ACA with no plan to replace and improve it is so reckless.”

He acknowledged that the law needs fixing. In particular, he writes that the “ongoing challenges” include lack of choice in some health insurance markets, high premiums and high drug costs. And he suggests some remedies: “For example, allowing Medicare to negotiate drug prices could both reduce seniors’ spending and give private payers greater leverage,” he writes.

He sharply criticizes Republican plans to repeal now and replace later. “They have yet to introduce that “replacement bill,” hold a hearing on it, or produce a cost analysis — let alone engage in the more than a year of public debate that preceded passage of the ACA….This approach of ‘repeal first and replace later’ is, simply put, irresponsible — and could slowly bleed the health care system that all of us depend on.”

Given the Republicans’ failure to craft a replacement plan, “there might never be a second vote on a plan to replace the ACA if it is repealed,” he writes, harming tens of millions of Americans, he writes.

Policymakers should abide by the physicians’ oath, he concludes: “First, do no harm.

Secret recording reveals GOP is freaking out about repealing and replacing Obamacare

A secret recording obtained by the Washington Post reveals the GOP is freaking out about its Obamacare repeal. Republicans have spent the last years boasting of repealing former President Barack Obama’s Affordable Care Act, and with Donald Trump now in the White House, that goal seemed promising for Republicans — except they haven’t decided on a replacement.

The recording of a closed-door meeting on Thursday revealed GOP lawmakers’ concern about moving forward with a quick repeal. “We’d better be sure that we’re prepared to live with the market we’ve created [with repeal],” said California Rep. Tom McClintock. “That’s going to be called Trumpcare. Republicans will own that lock, stock and barrel, and we’ll be judged in the election less than two years away.”

While Trump insisted along the campaign trail that he would both repeal and replace the healthcare plan, the GOP has yet to craft a single plan that could effectively replace the ACA. Earlier this month, the then-president-elect promised to replace Obamacare “very quickly or simultaneously, very shortly thereafter.”

There appears to be no consensus on a replacement plan, as of Trump’s Thursday visit to Philadelphia for the GOP’s three-day retreat. “We don’t want to set arbitrary deadlines on things,” said House Speaker Paul Ryan, according to Kaiser Health News. “We want to move quickly, but we want to get things right.”

Oregon Rep. Greg Walden, Chairman of the House Energy and Commerce Committee, added that “There’s no single fix. There’s no single plan” with which to replace Obamacare.

A Congressional Budget Office analysis published earlier this month found that a total repeal of the Affordable Care Act could be a disaster for millions of Americans, especially without a serious replacement plan in the works.

The report found that with the repeal, nearly 18 million people could be at risk of losing their insurance within a year, noting also that individual insurance premiums would skyrocket.

Similarly, the CBO reported that if there was no replacement plan to follow the Obamacare repeal, the number of uninsured Americans could jump to 32 million people by the year 2026.

The urgency to craft a replacement plan is not lost on all Republicans. Maine Sen. Susan Collins said earlier this week, “If we do not start putting specific legislation on the table that can be debated, refined, amended and enacted, then we will fail the American people.”

“We have to take care of the American people immediately, so we can’t wait,” President Trump told the Congressional members at the retreat. There appears to be no path forward at this time, even though Republicans have several plans in the works. They just haven’t agreed on one.

“We’re telling those people that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them,” New Jersey Rep. Tom MacArthur said of those covered by state and federal programs, as well as those covered under Medicaid.

Full text: Trump’s executive order on Obamacare

THE WHITE HOUSE
Office of the Press Secretary
For Immediate Release January 20, 2017
EXECUTIVE ORDER
– – – – – – –
MINIMIZING THE ECONOMIC BURDEN OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT PENDING REPEAL
By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows:
Section 1. It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act (Public Law 111-148), as amended (the “Act”). In the meantime, pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market.
Sec. 2. To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.
Sec. 3. To the maximum extent permitted by law, the Secretary and the heads of all other executive departments and agencies with authorities and responsibilities under the Act, shall exercise all authority and discretion available to them to provide greater flexibility to States and cooperate with them in implementing healthcare programs.
Sec. 4. To the maximum extent permitted by law, the head of each department or agency with responsibilities relating to healthcare or health insurance shall encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.
Sec. 5. To the extent that carrying out the directives in this order would require revision of regulations issued through notice-and-comment rulemaking, the heads of agencies shall comply with the Administrative Procedure Act and other
2
applicable statutes in considering or promulgating such regulatory revisions.
Sec. 6. (a) Nothing in this order shall be construed to impair or otherwise affect:
(i) the authority granted by law to an executive department or agency, or the head thereof; or
(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.
(b) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.
(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.
DONALD J. TRUMP
THE WHITE HOUSE,
January 20, 2017.

Trump signs executive order that could effectively gut Affordable Care Act’s individual mandate

President Trump signed an executive order late Friday giving federal agencies broad powers to unwind regulations created under the Affordable Care Act, which might include enforcement of the penalty for people who fail to carry the health insurance that the law requires of most Americans.

The executive order, signed in the Oval Office as one of the new president’s first actions, directs agencies to grant relief to all constituencies affected by the sprawling 2010 health-care law: consumers, insurers, hospitals, doctors, pharmaceutical companies, states and others. It does not describe specific federal rules to be softened or lifted, but it appears to give room for agencies to eliminate an array of ACA taxes and requirements.

However, some of these are embedded in the law, so it is unclear what latitude the executive branch will have.

Though the new administration’s specific intentions are not yet clear, the order’s breadth and early timing carry symbolic value for a president who made repealing the ACA — his predecessor’s signature domestic achievement — a leading campaign promise.

Additionally, the order’s language about easing economic and regulatory burdens aligns with long-standing Republican orthodoxy that the government exerts too heavy a hand on the U.S. health-care system.

Two Americans: One saved by Obamacare, the other left behind

 

As Republicans in Congress gear up to repeal the Affordable Care Act, two Pennsylvanians reflect on their different experiences under Obamacare. (Alice Li/The Washington Post)

“Potentially the biggest effect of this order could be widespread waivers from the individual mandate, which would likely create chaos in the individual insurance market,” said Larry Levitt, senior vice president at the Kaiser Family Foundation. In addition, he said, the order suggests that insurers may have new flexibility on the benefits they must provide.

“This doesn’t grant any new powers to federal agencies, but it sends a clear signal that they should use whatever authority they have to scale back regulations and penalties. The Trump administration is looking to unwind the ACA, not necessarily waiting for Congress,” Levitt said.

The order, several paragraphs long, does not identify which of the many federal rules that exist under the ACA the new administration intends to rewrite or eliminate. In general, federal rules cannot be undone with a pen stroke but require a new ­rulemaking process to replace or delete them.

But in giving agencies permission to “waive, defer, grant ­exemptions from or delay” ACA rules, the order appears to create room for the Department of Health and Human Services to narrow or gut a set of medical benefits that the ACA compels insurers to include in health plans that they sell to individuals and small businesses.

The order does not mention Medicaid, but it says one of its goals is to “provide greater flexibility to States,” raising the question of whether the Trump HHS might try to loosen rules for states that have expanded the program for lower-income Americans, as the law allows.

The order directs all federal agencies “to minimize the unwarranted economic and regulatory burdens” of the ACA — the first step of Trump’s central campaign promise to repeal and replace former president Barack Obama’s health-care plan.

Trump’s action drew swift protests from ACA proponents who have coalesced to try to preserve the law. “While President Trump may have promised a smooth transition” from the current law to a replacement, said Leslie Dach, director of the fledging Protect Our Care Coalition, “the executive order does the opposite, threatening disruption for health providers and patients.”

Also late Friday, Reince Priebus, Trump’s chief of staff, issued an executive memorandum ordering a freeze on regulations for all government agencies.

The memo could freeze several new Energy Department efficiency standards, such as those affecting portable air conditioners, commercial boilers and uninterruptable power supplies, which were issued Dec. 28 but not yet published in the Federal Register. The regulations were part of the Obama administration’s broader effort to cut greenhouse-gas emissions linked to climate change.

The move echoes a missive that then-White House Chief of Staff Rahm Emanuel sent the heads of every federal agency on Jan. 20, 2009, asking them to freeze any rules that had not yet been published in the Federal Register, and to consider a 60-day extension of the effective date of rules that had not yet gone into effect.

Also Friday, Trump signed the official paperwork installing Defense Secretary James Mattis and Homeland Security Secretary John F. Kelly, two of his Cabinet picks the Senate voted to confirm earlier in the day.

Trump’s health-care order came at the end of what had otherwise been a largely ceremonial day. The White House did not immediately return requests for comment.

During his campaign and afterward, Trump pledged that fundamental changes to the health-care system would be a first priority. In a speech outside Philadelphia six days before the November election, Trump vowed to abolish the ACA before he was sworn in. “Have to do it,” he said. “I will ask Congress to convene a special session so we can repeal and replace.”

Last week, both chambers of Congress approved a budget resolution that was the first legislative step toward repealing the 2010 law, which was the centerpiece of the Obama administration’s health policies. But health care was not among a half-dozen issue areas listed on the new ­WhiteHouse.gov website that debuted shortly after noon on Friday.

Earlier Friday, in the Capitol, the new president took several more perfunctory executive actions shortly after he was sworn in at noon, the most notable being to overturn a recent mortgage-fee ­reduction — geared at helping first-time and low-income home buyers — that Obama announced last week and that called for the Federal Housing Administration to cut its annual borrowing fee by a quarter of a percentage point.

Trump also signed a waiver for Mattis to lead the Defense Department, despite his having been retired from military service for only three years. Without the waiver, federal law would have prohibited Mattis from serving as defense secretary until he had been retired from the military for at least seven years.

And just moments after Trump took the oath of office, he began implementing his general vision, transforming the official White House website with a new set of policy pledges that offered the broad contours of the Trump administration’s top priorities. They included fierce support for law enforcement and gun owners’ rights to defend themselves. There were also some notable absences, such as the omission of a policy page on climate change.

The issues page of Trump’s White House offered no new plans or policies but rather a rehash of many of his most prominent campaign promises — a signal to the nation that Trump, more pragmatic than ideological, plans to implement at least the key guideposts of his campaign vision.

The policies laid out on the website included plans to both withdraw from and renegotiate major trade deals, grow the nation’s military and increase cybersecurity capabilities, build a wall at the nation’s southern border and deport undocumented immigrants who have committed violent crimes.

“Our job is not to make life more comfortable for the rioter, the looter, or the violent disrupter,” read the law-and-order section, which calls for “more law enforcement” and “more effective policing.” “Our job is to make life more comfortable for parents who want their kids to be able to walk the streets safely. Or the senior citizen waiting for a bus. Or the young child walking home from school.”

[Donald Trump is sworn in as president, vows to end ‘American carnage’

The climate change Web page that existed under Obama was not replaced on the Trump site, with scant mention of climate change under the new president’s energy plan. Also gone or not immediately replaced were Web pages the previous administration had devoted to the rights of lesbian, gay, bisexual and transgender individuals; people with disabilities; and civil rights more generally.

Trump’s entire campaign was largely a repudiation of Obama, and a new Republican administration is unlikely to have the same set of issues and priorities as an outgoing Democratic one. But the missing issue pages were particularly alarming to Democrats and activists, especially after a vitriolic campaign in which Trump drew criticism for seeming to mock a disabled reporter and being insensitive to the needs and rights of minority communities.

[Trump is right. He didn’t create the country’s divisions. But will he heal them?

On energy, Trump vowed to eliminate “harmful and unnecessary policies” such as the Climate Action Plan and the Waters of the United States rule. The first represents a variety of efforts Obama had pursued to reduce U.S. ­greenhouse-gas emissions while the second is a rule issued by the Environmental Protection Agency to protect not only the largest waterways but also smaller tributaries that others believe should fall under the jurisdiction of states rather than the federal government.

The initial Trump website also did not devote a separate section to immigration, another central tenet of his candidacy, though it mentioned immigration under the law enforcement section. Despite rumors within the immigration advocacy community that one of Trump’s initial executive actions could be to revoke Obama’s protections for “dreamers” — undocumented immigrants brought to the country as young children — his website so far focused only on big-picture enforcement and security goals.

“He is dedicated to enforcing our border laws, ending sanctuary cities, and stemming the tide of lawlessness associated with illegal immigration,” read part of the immigration section.

The new administration’s language echoed Trump’s tough rhetoric on the campaign trail, including his promises to strengthen
the law enforcement community, crack down on what he views as a broad range of trade violations and potentially forge alliances with countries long considered dangerous rivals, such as Russia.

“Finally, in pursuing a foreign policy based on American interests, we will embrace diplomacy,” read part of Trump’s policy vision. “The world must know that we do not go abroad in search of enemies, that we are always happy when old enemies become friends, and when old friends become allies.”

 

Melania Trump, the first lady, also received a biographical overhaul. Her web page featured a black and white glamour shot of her, and touted her jewelry line and modeling career, describing the many high fashion photographers with whom she has worked and the glossy magazines for which she has posed (Vogue and the Sports Illustrated swimsuit edition, among others).

[Donald Trump’s full inauguration speech transcript, annotated

The first lady’s biography also correctly stated that she began college at the University of Ljubljana in Slovenia, her home country, but never graduated — a fact that was misstated during the campaign.

Only at the very end of her page did Melania offer a glimpse of the sort of first lady she might be: “Mrs. Trump cares deeply about issues impacting women and children,” read the biography, “and she has focused her platform as First Lady on the problem of cyber bullying among our youth.”

DONALD TRUMP, TOM PRICE AND THE DESTRUCTION OF OBAMACARE

Republicans have begun the process for repealing the Affordable Care Act, the healthcare law better known as Obamacare. But they don’t even need to follow through with their repeal to destroy the measure’s signature healthcare marketplace. Once he’s confirmed, Donald Trump’s nominee for Health Secretary, Congressman Tom Price, could unravel the marketplace, himself, with no help from Congress.

Related: U.S. House Takes First Steps Towards Obamacare Repeal with No Replacement Ready

It’s just one of many levers Price, who begins his confirmation hearings before the Senate today, can pull to dismantle Obamacare once he’s installed as head of the Department of Health and Human Services (HHS). And the ramifications could be widespread, from collapsing the individual insurance market to eliminating no-cost birth control.

Price’s power stems from the fact that the Affordable Care Act is “sprinkled with directions … that the secretary shall do this or that,” says former George W. Bush Health Secretary Mike Leavitt. “You just can’t legislate in that much detail” he explains, so lawmakers left it up to the HHS and other executive branch regulators to hash out the details. But any rules that the past two health secretaries have implemented can just as easily be undone by the incoming secretary. In fact, that’s an integral part of the GOP’s plan. In his weekly press briefing last week, House Speaker Paul Ryan promised a “step-by-step process” to undo Obamacare. “Some of these steps will be taken by Congress. Some of these steps will be taken by the incoming Trump administration, and after he is confirmed, HHS Secretary Tom Price,” Ryan said.

11_29_tomprice_01Chairman of the House Budget Committee Tom Price announces the House Budget during a press conference on Capitol Hill in Washington on March 17, 2015.JOSHUA ROBERTS/REUTERS

Two areas of the law, in particular, look ripe for a reversal by executive action. One is the individual mandate, which requires Americans to purchase insurance if they’re not already covered by their employer. It’s been an unpopular provision, which Republicans intend to do away with in their still-to-be-determined replacement plan. But in the meantime, Price could essentially gut the measure on his own.

As Health and Human Services Secretary, Price has broad authority to grant what are known as “hardship waivers,” which he could use to lift the mandate for large swathes of people, says Larry Levitt, a senior vice president at the research group the Kaiser Family Foundation. That, Levitt says, could “ effectively blow up the individual market,” by allowing healthy people to leave in droves, leaving mostly poor and sick people in the insurance pool. To cover those costs, insurers would have to raise premiums, creating the sort of “death spiral” Obamacare critics keep warning about.

117_Price ConfirmationU.S. Senator Chuck Grassley (R-IA) welcomes Representative Tom Price (R-GA), President-elect Donald Trump’s nominee to be secretary of health and human services, in Grassley’s office on Capitol Hill in Washington, U.S. December 8, 2016. Price’s Senate confirmation hearings begin Wednesday.JONATHAN ERNST/REUTERS

House Republicans are eyeing Price’s ability to expand the hardship exemption. But Leavitt, the former health secretary, argues it would be better if Congress eliminated the individual mandate through legislation, rather than leaving it up to the executive branch. Doing so would allow Republicans to better mitigate the fallout, rather that let the marketplace collapse with no replacement or transition period.

But there are plenty of other changes to the law Price can make that would avoid a collapse of insurance markets, while still scoring points with the repeal now crowd. In particular, Republicans are looking for Price to reign in some of the law’s benefits requirements that insurers find onerous. “That’s a place where Tom Price is going to make a huge difference for America as it relates to their ability to buy more tailor-made insurance,” GOP Senator Bob Corker told reporters at a breakfast earlier this month. But any move to curb benefits Americans are now getting for free will no doubt prove controversial—particularly birth control.

Under Obamacare, all health plans offered on the healthcare exchange or private market had to include a set of ten so-called “essential benefits,” including maternity care, hospitalization and prescription drugs. But the law left the details for what those benefits should include up to HHS. Now, under Price, “t hey could give states much more latitude in determining the details,” says Levitt of the Kaiser Family Foundation, making the requirements far less stringent. Similarly, Obamacare mandates  almost all health plans—including those provided by employers—to cover preventative benefits with no out-of-pocket costs. Among them: contraception.

Republicans have long fought the contraception requirements in the healthcare law on religious grounds, and Price would have plenty of conservative allies if he sought to rein in or altogether erase it. But he could also face a backlash from American women. Studies have found nearly 90 percent of women of childbearing age use some form of birth control, which depending on the method, can be expensive—hundreds of dollars a year for birth control pills and up to $1,000 for an intrauterine device, according to estimates from Planned Parenthood. Levitt says the preventative benefit requirements is one of the broadest mandated by Obamacare—only so-called “grandfathered plans,” which were purchased before the Affordable Care Act was passed in 2010, are exempt. So “if the contraceptive benefit was scaled back or eliminated that would effect a very large number of women,” he says.

Price’s ability to undo chunks of Obamacare is only the start in terms of his power over health laws. In the same way a Democratic Congress left it to Obama’s Health Department to write up the Affordable Care Act’s fine print, any replacement plan Republicans come up with will give Price and his officials the lead role in drafting and implement the details of the law. As former Secretary Leavitt observes, “ The details really make a difference.”

Abortion rate declines to historic low, with Obamacare a likely contributor, study says

The U.S. abortion rate has hit its lowest point since the procedure became legal nationwide in 1973, according to a new study.

The researchers estimated that there were 926,200 abortions in 2014, or 14.6 abortions for every 1,000 women of reproductive age. That was down 14% from three years earlier.

“We saw declines in abortion in almost every single state,” said Jenna Jerman, a public health researcher at the Guttmacher Institute, a reproductive rights think tank in New York, and a coauthor of the study, which was published Tuesday in the journal Perspectives on Sexual and Reproductive Health.

Though the study did not look at the reasons for the decline, the authors and other experts suggested that improved access to contraception played the biggest role by preventing unintended pregnancies.

“We don’t think it’s because people are having less sex,” said Dr. Diane Horvath-Cosper, an obstetrician with the New York-based group Physicians for Reproductive Health who was not involved in the study. “It’s because people are protecting from pregnancy better than they used to.”

Research has shown a large increase in the use of IUDs and implants that release hormones — highly effective, long-acting methods that in recent years have become more affordable and been deemed safe for use in adolescent women.

Under the 2010 Affordable Care Act, which President-elect Donald Trump and the Republican leadership in Congress have vowed to eliminate and replace, insurers are required to cover a wide variety of contraceptive methods without charging a copayment or coinsurance.

The U.S. abortion rate peaked at 29 out of every 1,000 women of reproductive age in 1979, six years after the landmark Roe vs. Wade Supreme Court ruling established a woman’s right to abortion. Since 1982, it has steadily declined.

The Guttmacher Institute is considered an authority on the abortion rate, having tracked it since 1973 by conducting a census every few years of all known abortion providers. Its counts do not include abortions that were carried out outside of medical settings.

The new study is based on data the institute collected on abortions performed in 2013 and 2014. The rates fell in 44 states, with the sharpest declines in the West and the South, which both saw a 16% drop compared with 2011. The rates rose in six states: Arkansas, Kansas, Michigan, Mississippi, North Carolina and Vermont.

It is unclear to what degree recent restrictions on abortions contributed to the decline, experts said. From 2011 through 2015, 31 states passed 288 laws that required counseling or a waiting period, imposed regulations on abortion providers or targeted funding for family planning, among other measures. The new study found that 90% of U.S. counties had no clinics that provided abortions.

Jerman noted that the majority of the decline in abortions occurred in states that did not have major new abortion restrictions.

But Dr. Daniel Grossman, an obstetrician at UC San Francisco and director of the research group Advancing New Standards in Reproductive Health, said that his research in Texas showed a clear connection between restrictive laws and declining abortion rates.

In 2013, the state passed HB 2, which made it harder for doctors to prescribe abortion-inducing medications, required abortion providers to have admitting privileges at a local hospital, banned abortions after 20 weeks of pregnancy and required all abortions to take place in hospital-like facilities known as ambulatory surgical centers. Almost overnight, more than half of the state’s 41 clinics shut down.

“In Texas I don’t think that the decline in abortion has been related to improvements in contraceptive use,” Grossman said. “I think it has more to do with barriers to accessing contraception.”

Grossman and his colleagues evaluated the results of HB 2 and found that while the total number of abortions in Texas fell, the number performed during the second trimester rose. That suggested to the researchers that women were struggling to find abortion providers, resulting in delays and procedures that are riskier and more expensive.

Grossman contrasted Texas to California, which has long sought to make family planning available to all patients, with a program to provide free services for low-income women without access to Medicaid.

“There really has been a good family planning safety net here in California,” he said.

He and other experts worried that abortions would rise if Congress, in its effort to repeal the Affordable Care Act, does not preserve mandated insurance coverage for birth control.

“We would be taking a lot of steps back [in women’s health] if the ACA went away,” said Horvath-Cosper, who has provided abortions for more than a decade.

She lamented that eliminating the law could also take away access to maternity care, breastfeeding classes, preventive screenings and prenatal care.

“If we’re going to tell people you can’t have an abortion … then where’s the coverage and support for people who parent?” she said.

OBAMACARE REPEAL EFFORT SENDS JITTERS THROUGH JEWISH SERVICE GROUPS (GOOD!!!!)

 

NEW YORK — Before the Affordable Care Act was passed in 2010, Jewish Family Service of Metro Detroit organized local doctors to provide free care to Jews who lacked health insurance.

The Detroit agency closed the doctors’ program after enactment of the health care law, also known as Obamacare, and instead worked to enroll people in health insurance, either through Medicaid or the state insurance exchange. The organization, which focuses on providing mental health care and financial aid to disadvantaged Jewish families, has enrolled some 10,000 people in health insurance through the ACA.

US House votes to begin repealing Obamacare

But now that Obamacare could be repealed, the Detroit agency may have to organize doctors once again. Its CEO, Perry Ohren, expects more families to seek emergency financial aid if they lose coverage.

“People will be hurting and they will have more expenses,” Ohren said. “We have an inverse relationship to the economy. When things go south, our business goes up.”

As Congress moves to repeal and possibly replace the health care law, the more than 100 Jewish Family Service agencies across the country are grappling with the question of what will happen once it’s gone. Even as some JFS executives are lobbying Congress to maintain some of the law’s protections, others are planning for a future where philanthropy and state government will have to fill in where Obamacare once was.

Early Thursday morning, Republicans in Congress voted on a budget measure that will move the repeal process forward. It remains unclear what will replace the it, as well as when that replacement would be passed. At a Jan. 11 news conference, President-elect Donald Trump spoke of a plan to repeal and replace the ACA, but offered no details.

JFS agencies also receive Medicare and Medicaid reimbursements for the counseling services they provide. According to the Jewish Federations of North America, whose local affiliates provide subsidies to JFS agencies, Jewish communal agencies receive a total of $6 billion a year from Medicaid, which was expanded under the ACA, as well as $1.5 billion a year from Medicare, whose coverage for seniors was also expanded.

“People are sort of on edge, because there are a lot of unknowns,” said Reuben Rotman, executive director of JFS of MetroWest New Jersey. “We feel it too, and this is all happening very, very, very quickly, so our options for how we can allay that uncertainty are really — we don’t even know yet what the true story is.”

Even under the existing law, some individuals have had to rely on community support to pay high premiums or get special treatments. Sheryl Grossman, 41, has Bloom syndrome, a genetic disorder that makes her more likely to develop cancer. Grossman has already had cancer nine times, and relies on the support of her community in Baltimore to pay for medicine and doctor’s visits.

She currently has health insurance through a former employer that will last until August. If Obamacare is repealed by the time she needs to purchase new coverage, she expects an individual plan to be too expensive for her, even with friends’ help. If she is without a plan, she’ll be forced to move into an assisted living home.

“If I have to go out and try to get an individual health insurance policy, I won’t be able to get it because I have a genetic condition that predisposes me to cancer,” she said. “People who have pre-existing conditions, a lot of us are facing worse health, if not death.”

Repeal would also affect those with disabilities who rely on the law’s protections. Jessica Belasco, a rabbinical student at the Conservative Jewish Theological Seminary who has a congenital muscle disorder, wants to do work with Jews with disabilities once she graduates, and expected to rely on Obamacare for insurance while she launches her efforts.

“What I have to offer in the Jewish world is something based on entrepreneurship, and I now do not feel free to do that,” she said. “I certainly want to see an outcry in the Jewish world about this.”

JFNA is coordinating Jewish leaders nationwide to lobby congressmen to maintain the law’s protections, which include preventing those with pre-existing conditions from being denied health insurance, assuring that women don’t have to pay higher rates than men and banning caps on lifetime coverage.

A new organization that combines existing umbrella groups for the JFS agencies, the Network of Jewish Human Service Agencies, will also advocate a replacement that maintains care for disadvantaged Americans. Rotman has been named its inaugural CEO.

William Daroff, director of JFNA’s Washington office, recognizes that some sort of repeal will likely happen. Despite the extreme partisanship that has characterized the health care debate, he hopes JFNA can get behind a replacement law members of both parties can support.

JFNA is troubled by proposals that “convert these programs into programs that are not as helpful to the vulnerable populations that depend upon them,” he said. “So we’re working with everyone to ensure that we find pragmatic, bipartisan, common-senses solutions to these seemingly intractable problems.”

Daroff said repeal could happen within a matter of months, and noted that Trump favors passing a replacement law immediately. But no one can say for certain what the future will hold.

“You can’t dismantle a system where millions of people have coverage in 10 seconds,” said Rotman. “Everyone is trying to stay on top of the news.”

Senate Takes Major Step Toward Repealing Health Care Law (GOOD!!!!)

WASHINGTON — Senate Republicans took their first major step toward repealing the Affordable Care Act on Thursday, approving a budget blueprint that would allow them to gut the health care law without the threat of a Democratic filibuster.

The vote was 51 to 48. During the roll call, Democrats staged a highly unusual protest on the Senate floor to express their dismay and anger at the prospect that millions of Americans could lose health insurance coverage.

One by one, Democrats rose to voice their objections. Senator Maria Cantwell of Washington said that Republicans were “stealing health care from Americans.” Senator Ron Wyden of Oregon said he was voting no “because health care should not just be for the healthy and wealthy.”

The presiding officer, Senator Cory Gardner, Republican of Colorado, repeatedly banged his gavel and said the Democrats were out of order because “debate is not allowed during a vote.”

The final vote, which ended just before 1:30 a.m., followed a marathon session in which senators took back-to-back roll call votes on numerous amendments, an arduous exercise known as a vote-a-rama.

The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama’s signature domestic policy achievement — a goal they believe can now be accomplished after Mr. Trump’s election.

The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.

Republicans say the 2016 elections gave them a mandate to roll back the health care law. “The Obamacare bridge is collapsing, and we’re sending in a rescue team,” said Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee. “Then we’ll build new bridges to better health care, and finally, when these new bridges are finished, we’ll close the old bridge.”

Republican leaders say they will work closely with Mr. Trump developing legislation to repeal and replace the health care law, but it is unclear exactly how his team will participate in that effort.

On Wednesday, Mr. Trump said he would offer his own plan to repeal and replace the law “essentially simultaneously.” He said he would put forth the plan as soon as his nominee for secretary of health and human services, Representative Tom Price, Republican of Georgia, is confirmed.

The Affordable Care Act has become ingrained in the American health care system, and unwinding it will be a formidable challenge for Republicans. More than 20 million people have gained coverage under the law, though premiums have risen sharply in many states and some insurers have fled the law’s health exchanges.

The budget blueprint instructs House and Senate committees to come up with repeal legislation by Jan. 27.

Senator Bob Corker, Republican of Tennessee, and four other Republicans had sought to extend that deadline by five weeks, to March 3. But late Wednesday night, Mr. Corker withdrew an amendment that would have changed the date.

“We understand that everyone here understands the importance of doing it right,” he said. He described the Jan. 27 date in the budget blueprint as a placeholder.

Senator Rob Portman of Ohio, another Republican who sought to delay the deadline, said: “This date is not a date that is set in stone. In fact, it is the earliest we could do it. But it could take longer, and we believe that it might.”

The House was planning to take up the budget blueprint once the Senate approved it, though some House Republicans have expressed discomfort with voting on the blueprint this week because of lingering questions over how and when the health care law would be replaced.

A vote on the measure in the House could come on Friday.

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes.

In the parlance of Capitol Hill, many of the Democrats’ proposals were “messaging amendments,” intended to put Republicans on record as opposing popular provisions of the Affordable Care Act. The budget blueprint is for the guidance of Congress; it is not presented to the president for a signature or veto and does not become law.

As the Senate plowed through its work on Wednesday, Republicans explained why they were determined to dismantle the health care law, and they tried to assuage concerns about the future of coverage for millions of Americans.

“This is our opportunity to keep our campaign promise,” said Senator Roger Wicker, Republican of Mississippi. “This is our opportunity to help the president-elect and the vice president-elect keep their campaign promises and show to the American people that elections have consequences.”

Senator Johnny Isakson, Republican of Georgia, said that while working to repeal the health care law, “we must also talk about what we replace it with, because repealing it without a replacement is an unacceptable solution.”

Republicans do not have an agreement even among themselves on the content of legislation to replace the Affordable Care Act, the timetable for votes on such legislation or its effective date.

Senator Susan Collins, Republican of Maine, said on Wednesday that she agreed with Mr. Trump that Congress should repeal the health law and adopt a replacement plan at about the same time.

“But I don’t see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month,” she said. “I just don’t see that as being feasible.” (Ms. Collins also supported pushing back the deadline to come up with repeal legislation.)

As Republicans pursue repealing the law, Democrats contend that Republicans are trying to rip insurance away from millions of Americans with no idea of what to do next.

The Senate Democratic leader, Chuck Schumer of New York, called the Republicans’ repeal plan “irresponsible and rushed” and urged them to halt their push to unravel the law.

“Don’t put chaos in place of affordable care,” he said.