Filling the need for trusted information on national health issues…

How the Republican Health Agenda Could Play Out

In this Wall Street Journal Think Tank column Drew Altman discusses how Republicans will assume ownership of health care’s policy and political problems as they assume control, and how that may affect their plans for the Affordable Care Act, Medicaid and Medicare.

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The Bigger Story, and Agenda, Behind GOP Changes to Obamacare, Medicare and Medicaid

This column was published as a Wall Street Journal Think Tank column on November 21, 2016. Early media coverage of the Republican health-care agenda has concentrated on plans to repeal and then replace the Affordable Care Act. The larger story is GOP preparations for a health policy trifecta: to fundamentally change the…

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Why the Key Indicators to Watch on Health-Care Marketplaces Come in 2017

In this Wall Street Journal Think Tank column, Drew Altman discusses why the real moment of truth in assessing the stability of the Affordable Care Act’s health care Marketplaces may come next spring.

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The Affordable Care Act’s Little-Noticed Success: Cutting the Uninsured Rate

This column was published as a Wall Street Journal Think Tank column on October 12, 2016. U.S. Uninsured Rate is At An All-Time Low, But The Public Doesn’t Know It Donald Trump derided the Affordable Care Act in the second presidential debate as a “total disaster.” One inarguable success…

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How Americans Feel About Immigration and Muslims in a Time of Donald Trump

In this Wall Street Journal Think Tank column, Drew Altman uses findings from a new KFF/CNN survey of working-class white Americans and from Pew Research to examine xenophobia in America in a time of Trump.

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The Missing Debate Over Rising Health-Care Deductibles

In this Wall Street Journal Think Tank column, Drew Altman discusses what may be the most important change in the American health system—hint it’s not the Affordable Care Act—which has occurred without much discussion.

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                    [post_content] => This was published as a Wall Street Journal Think Tank column on December 2, 2016.

The worm is about to turn in health policy and politics when Republicans shift from throwing stones to owning the problems of the health system and the Affordable Care Act or its replacement, as President Barack Obama and Democrats have for the past eight years. It’s hard to predict how events will play out, but it’s likely that grand plans to repeal and replace Obamacare, convert Medicaid to a “block grant” program, and transform Medicare into a premium support program could be whittled down or delayed as details of such sweeping changes, and their consequences, become part of the debate.

Republicans and the president-elect are on the hook for election promises to repeal the ACA or major parts of the law. If the GOP repeals the ACA but delays a replacement plan until after the 2018 midterms, the degree of political fallout is likely to depend a great deal on what happens in the non-group insurance market. (This includes people who buy their own coverage on the ACA exchanges and outside of them, all of whom are subject to the same premium increases.) If Republicans cannot make deals with insurers to keep the non-group market functioning for the roughly 19 million people who rely on it, and the market becomes unstable or collapses, public reaction could affect the entire GOP health-care agenda. The chances of this happening stand to grow if Republicans move quickly to eliminate major provisions of Obamacare that directly affect marketplace stability, such as the individual mandate. The budget reconciliation process–which can be used to address revenue and spending measures that have been scored by the Congressional Budget Office–is the fastest and most likely route to such changes.

The big Republican “reform” idea most likely to be delayed until after 2018 is fundamentally altering Medicare by converting it to a premium-support, voucher-like program. That could be delayed or tabled altogether; Medicare has long been the “third rail” of health-care issues and is the health issue with the greatest potential to influence elections. Advocates of premium support want savings from capping federal contributions to Medicare beneficiaries, but they are likely to be wary of the political fallout if it becomes clear that benefits for future beneficiaries will be eroded if fixed payments don’t keep up with the rising cost of medical care. Phasing in a plan so that it affects only future beneficiaries may soften the impact but is not likely to be enough to side step a political problem over Medicare in 2018, which might prompt some efforts to defer action.

Action on Medicaid is the toughest element of the Republican health-policy trifecta to predict. Republicans may face resistance from states over cuts in federal Medicaid funding that are integral to their block-grant plans, as well as resistance from Democrats in Congress. More red states (16) have expanded their Medicaid programs than have blue states (14) at this point, giving these Republican-led states a stake in what happens with the ACA and Medicaid. Many states might see incentives to make their own deals with the new administration through waivers. Republicans might back off broad legislation to convert Medicaid to some form of block-grant program and turn, instead, to a state-waiver program administered by the Department of Health and Human Services. A broader waiver initiative would allow the administration to achieve policy goals state by state but would not accomplish the permanent transformation of Medicaid or across-the-board federal savings a federal block grant could. A lot will depend on details of Medicaid proposals that are not yet known, particularly the details of how a per-capita cap on federal Medicaid spending might work and how many states find it attractive.

It’s not clear how much political strife Republicans will be willing to accept in a health-care debate. One factor that could embolden them: The number of GOP Senate seats at risk in 2018 is not significant. Already, however, there is talk of Senate Republicans signaling reluctance.

Another unknown is how President-elect Donald Trump will react when debate is joined over detailed legislative proposals and the politics of fundamentally changing the ACA, Medicaid, and Medicare become more real. Will he want to invest a large share of his early political capital in a series of divisive national debates on health care, as President Obama did? Or will he prioritize other issues? The merits of Republican health-care plans aside–they obviously have detractors on the left and advocates on the right–history shows that the burden is always on those who want to make big changes in the health system and its major programs, and that doing so often carries a political price.
                    [post_title] => How the Republican Health Agenda Could Play Out
                    [post_excerpt] => In this Wall Street Journal Think Tank column Drew Altman discusses how Republicans will assume ownership of health care’s policy and political problems as they assume control, and how that may affect their plans for the Affordable Care Act, Medicaid and Medicare.


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                    [post_content] => This column was published as a Wall Street Journal Think Tank column on November 21, 2016.

Early media coverage of the Republican health-care agenda has concentrated on plans to repeal and then replace the Affordable Care Act. The larger story is GOP preparations for a health policy trifecta: to fundamentally change the ACA, Medicaid and Medicare–all three of health care’s major programs–and in the process, fundamentally alter the direction of the federal role in health and core elements of the social contract.

The expected proposals seek to end federal entitlement spending in health as it has been known by capping federal financial exposure through fixed-dollar insurance tax credits, Medicaid block grants, and voucher-like supports for Medicare premiums. Legislative details haven’t been released yet, but Republican plans are likely to shift costs to individuals and states as well as reduce consumer protections–and result in a significant increase in the number of uninsured. Conservatives who have long favored these changes view them positively; they want to reduce government regulation and federal spending, give consumers more choices in the marketplace, drive down costs by promoting high-deductible insurance coverage, and give states greater flexibility to tailor health programs to their own preferences and needs.

Whatever the pros and cons, these would amount to the biggest changes in the direction of federal health programs since the passage of Medicaid and Medicare.

Each proposal to change these programs contains potential trap-door issues. Would protections for people with pre-existing conditions be eroded in Republican ACA replacement plans, and to what extent? Would states lose money in a Medicaid block grant, and with what consequences? Would the ACA marketplaces break down in confusion if there is an interregnum between repealing and replacing the ACA? How would Medicare premium supports be indexed, and would future Medicare beneficiaries be able to afford the care they need once it is phased in? These are just a few of the subjects to be examined closely.

The media, whose credibility Donald Trump undermined in the presidential campaign, will be challenged to explain the stakes involved in such sweeping changes. It will be all the more difficult to inform a meaningful national discussion if a Republican Congress moves quickly, attaches many changes to budget reconciliation bills, and limits political accountability by deferring implementation of an ACA repeal plan until after the 2018 elections and/or a Medicare premium support plan until 2024. Mr. Trump’s reaction to media coverage on these issues and polling about these changes, particularly on popular programs such as Medicare and Medicaid, is an important unknown.

Among the critical things to be reported: comparisons of forthcoming plans with current law in ways that show how they would affect people and who the winners and losers will be. It should not be surprising if Republican plans do not achieve the same things Medicare, Medicaid, and the ACA do today because Republicans are pursuing different objectives.

During the 2012 presidential campaign, in an admirable act of political honesty, Sen. Orrin Hatch said that “conservatives cannot allow themselves to be browbeaten for failing to provide the same coverage numbers as Obamacare. … [W]e cannot succumb to the pressure to argue on the left’s terms.” An important point in the coming health policy debate is to clarify objectives in repealing and replacing the ACA and in fundamentally changing Medicaid and Medicare. The deeper issue is not about whether one is for the Republican health-care trifecta or opposes it but understanding that Republicans are not setting out to replace the ACA with something that does the same job “better” or to “reform” Medicaid and Medicare to make the current programs work better. The word “reform” has become a loaded term; it means different things to liberals and conservatives and would probably be inappropriate to most news coverage in this debate. The challenge is to clarify how conservative policy goals differ from liberal policy goals, to describe how Republicans would change the federal role in health, and to explain what the changes would mean for Americans.

News cycles are often driven by juicy stories focusing on the most controversial policy changes and the partisan politics they stoke. So among the media’s toughest challenges may be treating the proposed changes to Medicare, Medicaid, and the ACA not only as many separate stories and incremental updates but as one larger story, and to lay out the consequences–potentially good and bad–of such significant change in the federal role in health so people can make informed judgments about it.
                    [post_title] => The Bigger Story, and Agenda, Behind GOP Changes to Obamacare, Medicare and Medicaid
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                    [post_content] => This column was published as a Wall Street Journal Think Tank column on October 26, 2016.

The announcement and subsequent flurry of news reports about big premium increases and fewer plan choices in 2017 for the HealthCare.gov marketplace plans was expected. So was the response. President Barack Obama said last week that problems in the marketplaces are “growing pains.” Critics on the right have said the ACA is in a “death spiral.” There is a lot to say about this year’s premium increases and no lack of people saying things.

What has not been said, however, is that the key moment for the marketplaces is not the start of this open-enrollment season on Nov. 1 or this round of premium increases but next spring and summer, when state regulators begin to see proposed premiums for next year’s open-enrollment season and we learn whether the marketplaces have stabilized.

Benchmark premium increases in the ACA marketplaces have varied widely; for example, there was a 145% increase in Phoenix and a 4% decrease in Indianapolis. In such disparate states as California and Florida the marketplaces are generally working well, but in many marketplaces premiums will rise sharply in 2017. Most of the 10.5 million marketplace enrollees receive premium subsidies and are shielded from the increases. But about 1.5 million of them and consumers who buy their own insurance outside the marketplaces–estimated to be about 7 million Americans–bear the full brunt of the increases.

Many state regulators who permitted large premium increases for next year did so primarily to enable premiums to catch up to the risk profile of the populations enrolling in plans, which is sicker than the typical pool. The regulators’ hope is that those increases, coupled with stable or modestly increasing enrollment, would solidify the marketplaces and return premium increases to much more moderate levels moving forward. Insurers submit proposed rates in the spring; this will be the initial signal of whether the marketplaces are stabilizing. Quarterly earnings reports to shareholders from the major insurance companies active in the marketplaces may also signal whether they are seeing rates come into alignment with their costs as well as their level of interest in participating in the marketplaces moving forward.

It’s a fair bet that the picture will improve, but it’s hard to predict to what extent, and there is likely to be continued variation in premium increases and plan choice around the country; the ACA is, in effect, 50 different ACAs. The health-care agenda is broader than the ACA, but the next president (of either party) and Congress will be watching these developments closely. A Clinton administration would prepare administrative and legislative actions. If the marketplaces continue to have problems, the administration and Congress would face decisions about which ACA marketplace “fixes” to propose and how to move them through Congress without unwanted compromises in health or other areas, or getting bogged down in a partisan fight about the ACA.
                    [post_title] => Why the Key Indicators to Watch on Health-Care Marketplaces Come in 2017
                    [post_excerpt] => In this Wall Street Journal Think Tank column, Drew Altman discusses why the real moment of truth in assessing the stability of the Affordable Care Act's health care Marketplaces may come next spring.
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                    [post_content] => This column was published as a Wall Street Journal Think Tank column on October 12, 2016.

[caption id="attachment_200333" align="aligncenter" width="735"]U.S. Uninsured Rate is At An All-Time Low, But The Public Doesn’t Know It U.S. Uninsured Rate is At An All-Time Low, But The Public Doesn’t Know It[/caption]

Donald Trump derided the Affordable Care Act in the second presidential debate as a “total disaster.” One inarguable success of the 2010 health-care law has been to drive the rate of uninsured Americans to a historic low. That sizeable shift makes it significant that a plurality of the public thinks the uninsured rate is unchanged and that the number of people who know the uninsured rate is at its low point is nearly the same as the number of people who mistakenly think the rate is at an all-time high.
To be specific: The uninsured rate for non-elderly Americans has fallen from about 16.6% in 2013 to 10% in the first quarter of 2016, and  8.6% taking into account seniors who have near universal coverage. Why don’t more people know this? It’s not that the news media have failed to cover the story. There have been regular news reports about government and private surveys showing progress on this issue because of the ACA. One factor affecting perceptions could be that a large number of Americans remain uninsured and the public may see these uninsured people among their family and friends or in their community as often or more often than they see the newly insured. Slightly less than 29 million Americans remain uninsured; just under half of those people are eligible for health coverage through the ACA. There have been many reports the past couple of months about problems in some of the ACA marketplaces, where premiums have risen sharply in some areas of the country (if far more slowly, on average, than Mr. Trump asserted in Sunday’s debate). It’s possible that negative reports focused on the marketplaces have colored perceptions of progress in other areas, including on the uninsured rate.  A contributing factor could be media coverage of the 19 states that have not expanded their Medicaid programs under the ACA. Slightly less than 3 million people fall in the coverage gap as a result of these state decisions and remain uninsured. This has been a hot issue, but people may assume the problem is larger than it actually is. Vox’s Sarah Kliff wrote recently about the news media’s tendency to cover problems and suggested that a media “negativity bias” might play a role in limited awareness of the decline in the uninsured. It could also be that categories experts refer to–uninsured, insured, under-insured–aren’t as meaningful for non-experts. People who are uninsured and people who have insurance both struggle to pay medical bills. Categorizing insurance status for statistical purposes may be more meaningful to experts who can recite study after study about how much insurance matters than it is to consumers struggling with medical bills even if they have coverage. It’s notable that one factor that usually explains most everything about the ACA, partisanship, does not seem to apply as well here. More Democrats (38%) know the uninsured rate is at an all-time low than Republicans (17%), but the share of Republicans who think the rate is at an all-time high (20%) is similar to the share of Democrats who think that (17%). Without knowledge of the facts people are more susceptible to spin and misrepresentation. The Affordable Care Act has covered about 20 million previously uninsured Americans but has little chance of improved standing with the public unless its most important achievement is better known. For various reasons–they’ve reported on this trend before, the decline itself is not new information–journalists, researchers and elected officials may tire of repeating numbers of the uninsured. And the data may not be new research or a fresh sound bite. But if informing the public on big issues under debate is a goal, new ways may need to be found to get the facts out again and again.
[post_title] => The Affordable Care Act’s Little-Noticed Success: Cutting the Uninsured Rate [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-affordable-care-acts-little-noticed-success-cutting-the-uninsured-rate [to_ping] => [pinged] => [post_modified] => 2016-10-12 10:40:50 [post_modified_gmt] => 2016-10-12 14:40:50 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=200307 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 199173 [post_author] => 36621681 [post_date] => 2016-09-30 13:09:54 [post_date_gmt] => 2016-09-30 17:09:54 [post_content] => This column was published as a Wall Street Journal Think Tank column on September 28, 2016. How the public responds to Donald Trump’s rhetoric about immigrants and Muslims may tell us as much about ourselves as it tells us about Mr. Trump’s candidacy. His rhetoric has not created a groundswell of anti-immigrant sentiment in the U.S., new polling suggests; rather, Mr. Trump has tapped into a reservoir of anti-immigrant feelings among a minority of Americans–some, but not all, working-class whites–that already existed and that also has been stronger at times in the past. The polling, conducted by the Kaiser Family Foundation in conjunction with CNN, found that Mr. Trump’s rhetoric about immigrants has not been as great a priority for his supporters as many might have thought and that while Americans are worried about terrorism, those fears have not translated into broader anti-Muslim sentiments. In short, the U.S. as a whole may be less xenophobic than many fear. [caption id="attachment_199464" align="aligncenter" width="735"]Americans’ General Views of Immigrants Have Remained Stable Over the Past Two Years Americans’ General Views of Immigrants Have Remained Stable Over the Past Two Years[/caption] As the chart above shows, the Kaiser/CNN polling found that 57% of Americans agree with the statement that immigrants “strengthen our country because of their hard work and talents.” Pew Research Center found the same share in its own 2014 polling, conducted more than a year before Donald Trump launched a presidential campaign with immigration as its central issue. By contrast, the recent Kaiser/CNN poll found that 31% agree that “immigrants are a burden on our country because they take our jobs, housing and health care.” Pew’s number in 2014 was very similar: 35%. These views have become more positive over the past decade; in 2005, Pew found the public evenly divided between those who said that immigrants were a burden (44%) and that they strengthen the country (45%). Views were even more negative in 1994, when 63% saw immigrants as a burden and 31% called them a strength. Working-class whites are the group most likely to see immigrants as a burden: 47% said so in the Kaiser/CNN poll conducted in August and early September. (The Kaiser Family Foundation regularly polls with media organizations on social issues, including immigration, race, and feminism.) The 2014 Pew poll found a nearly identical share: 48%. In the Kaiser/CNN poll, working-class Hispanics (74%) and white college graduates (67%) were much more likely to say that immigrants strengthen our country; 57% of working-class blacks said the same thing. For all the media attention they have received, Mr. Trump’s immigration positions do not appear to be a leading factor for large numbers of his supporters. The latest Pew election poll included an open-ended question asking respondents to list the main reason they would vote for him in November; 8% of voters who support Mr. Trump named immigration. When given a list of issues from which to choose the reasons they support Mr. Trump, immigration came in fourth, and his views on terrorism ranked No. 1. Working-class whites are not a monolithic group when it comes to views on immigration or anything else we polled about. Generally, rural and evangelical working-class whites hold more negative views toward immigrants on a range of questions. And while most are Trump voters, 29% of this group said they would consider voting for Hillary Clinton. The results were a reminder that broad-brush characterizations of this group often fail to reflect its nuances. [caption id="attachment_199466" align="aligncenter" width="735"]Americans’ Views of Recent Immigrants From Muslim Countries Americans’ Views of Recent Immigrants From Muslim Countries[/caption] There is no prior-year comparison for sentiments about Muslim immigrants, but views in the Kaiser/CNN poll were mixed. As the chart just above shows, fully 71% of the public agree that people who came here in the past 10 years from Muslim countries “are basically good, honest people.” Within that share, 63% of working-class whites agreed with that. Most Americans do not think Muslim immigrants add to crime or take jobs away from Americans. But respondents do have terrorism as a top concern, and 51% say that Muslim immigrants “increase the risk of terrorist attacks” (43% say they do not). As on virtually every immigration question, white working-class Americans stand out: 63% say immigrants from Muslim countries increase the risk of terrorist attacks. A lot has been said about Donald Trump’s rhetoric and its potential effect on sentiments toward immigrants and Muslims in this country. Our polling suggests that most Americans have not embraced a new anti-immigrant fervor. It is worth noting that Americans distinguish their views about Muslims who come to the U.S., which are largely positive, from their concerns about terrorism. That suggests that greater efforts to tell the positive stories about Muslim-Americans could counterbalance fears about terrorism and lead to a more thoughtful public discussion. [post_title] => How Americans Feel About Immigration and Muslims in a Time of Donald Trump [post_excerpt] => In this Wall Street Journal Think Tank column, Drew Altman uses findings from a new KFF/CNN survey of working-class white Americans and from Pew Research to examine xenophobia in America in a time of Trump. 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In this Wall Street Journal Think Tank column, Drew Altman discusses what may be the most important change in the American health system—hint it’s not the Affordable Care Act—which has occurred without much discussion.
[post_title] => The Missing Debate Over Rising Health-Care Deductibles [post_excerpt] => In this Wall Street Journal Think Tank column, Drew Altman discusses what may be the most important change in the American health system—hint it’s not the Affordable Care Act—which has occurred without much discussion. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-missing-debate-over-rising-health-care-deductibles [to_ping] => [pinged] => [post_modified] => 2016-09-18 12:43:44 [post_modified_gmt] => 2016-09-18 16:43:44 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=197869 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 203871 [post_author] => 36621681 [post_date] => 2016-12-02 13:07:45 [post_date_gmt] => 2016-12-02 18:07:45 [post_content] => This was published as a Wall Street Journal Think Tank column on December 2, 2016. The worm is about to turn in health policy and politics when Republicans shift from throwing stones to owning the problems of the health system and the Affordable Care Act or its replacement, as President Barack Obama and Democrats have for the past eight years. It’s hard to predict how events will play out, but it’s likely that grand plans to repeal and replace Obamacare, convert Medicaid to a “block grant” program, and transform Medicare into a premium support program could be whittled down or delayed as details of such sweeping changes, and their consequences, become part of the debate. Republicans and the president-elect are on the hook for election promises to repeal the ACA or major parts of the law. If the GOP repeals the ACA but delays a replacement plan until after the 2018 midterms, the degree of political fallout is likely to depend a great deal on what happens in the non-group insurance market. (This includes people who buy their own coverage on the ACA exchanges and outside of them, all of whom are subject to the same premium increases.) If Republicans cannot make deals with insurers to keep the non-group market functioning for the roughly 19 million people who rely on it, and the market becomes unstable or collapses, public reaction could affect the entire GOP health-care agenda. The chances of this happening stand to grow if Republicans move quickly to eliminate major provisions of Obamacare that directly affect marketplace stability, such as the individual mandate. The budget reconciliation process–which can be used to address revenue and spending measures that have been scored by the Congressional Budget Office–is the fastest and most likely route to such changes. The big Republican “reform” idea most likely to be delayed until after 2018 is fundamentally altering Medicare by converting it to a premium-support, voucher-like program. That could be delayed or tabled altogether; Medicare has long been the “third rail” of health-care issues and is the health issue with the greatest potential to influence elections. Advocates of premium support want savings from capping federal contributions to Medicare beneficiaries, but they are likely to be wary of the political fallout if it becomes clear that benefits for future beneficiaries will be eroded if fixed payments don’t keep up with the rising cost of medical care. Phasing in a plan so that it affects only future beneficiaries may soften the impact but is not likely to be enough to side step a political problem over Medicare in 2018, which might prompt some efforts to defer action. Action on Medicaid is the toughest element of the Republican health-policy trifecta to predict. Republicans may face resistance from states over cuts in federal Medicaid funding that are integral to their block-grant plans, as well as resistance from Democrats in Congress. More red states (16) have expanded their Medicaid programs than have blue states (14) at this point, giving these Republican-led states a stake in what happens with the ACA and Medicaid. Many states might see incentives to make their own deals with the new administration through waivers. Republicans might back off broad legislation to convert Medicaid to some form of block-grant program and turn, instead, to a state-waiver program administered by the Department of Health and Human Services. A broader waiver initiative would allow the administration to achieve policy goals state by state but would not accomplish the permanent transformation of Medicaid or across-the-board federal savings a federal block grant could. A lot will depend on details of Medicaid proposals that are not yet known, particularly the details of how a per-capita cap on federal Medicaid spending might work and how many states find it attractive. It’s not clear how much political strife Republicans will be willing to accept in a health-care debate. One factor that could embolden them: The number of GOP Senate seats at risk in 2018 is not significant. Already, however, there is talk of Senate Republicans signaling reluctance. Another unknown is how President-elect Donald Trump will react when debate is joined over detailed legislative proposals and the politics of fundamentally changing the ACA, Medicaid, and Medicare become more real. Will he want to invest a large share of his early political capital in a series of divisive national debates on health care, as President Obama did? Or will he prioritize other issues? The merits of Republican health-care plans aside–they obviously have detractors on the left and advocates on the right–history shows that the burden is always on those who want to make big changes in the health system and its major programs, and that doing so often carries a political price. [post_title] => How the Republican Health Agenda Could Play Out [post_excerpt] => In this Wall Street Journal Think Tank column Drew Altman discusses how Republicans will assume ownership of health care’s policy and political problems as they assume control, and how that may affect their plans for the Affordable Care Act, Medicaid and Medicare. 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