Trump Says He Got Rid of Obamacare. The I.R.S. Doesn’t Agree.

The I.R.S. has started sending penalty notices to businesses that failed to comply with the Affordable Care Act’s employer mandate, angering Republicans and business groups.

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Economic View: Back to the Health Policy Drawing Board

Congress’s repeal of the Obamacare mandate threatens the future of health care insurance, but there are attractive paths toward a single-payer system, a Cornell economist says.

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A Big Divergence Is Coming in Health Care Among States

As the Trump administration chips away at Obamacare, some states are building it back up.

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Health Law Repeal Could Cost 18 Million Their Insurance, Study Finds

Republicans cautioned that the report painted only part of the picture — the impact of a fast repeal without a Republican replacement. Senator Orrin G. Hatch, Republican of Utah and the chairman of the Finance Committee, said the numbers represented “a one-sided hypothetical scenario.”

“Today’s report shows only part of the equation — a repeal of Obamacare without any transitional policies or reforms to address costs and empower patients,” he said. “Republicans support repealing Obamacare and implementing step-by-step reforms so that Americans have access to affordable health care.”

Congress last week approved a budget that clears the way for speedy action to repeal the health care law. The votes were 51 to 48 in the Senate and 227 to 198 in the House.

But Republicans have yet to agree on a replacement bill, and existing Republican plans, like one drafted by Representative Tom Price of Georgia, who was selected as Mr. Trump’s secretary of health and human services, have yet to be scrutinized by the budget office. The office provides Congress with the official projections of legislative costs and impact that lawmakers use to formulate policy.

In 2026

59 million

Before A.C.A.

57 million

2 years later

54 million

After Medicaid expansion and marketplace subsidies go away.

1 year later

44 million

After penalties associated with the individual mandate go away, and some insurers leave the market.

Now

26 million

Here’s how much the number of uninsured could rise if major portions of the health law were repealed today, according to a new study.

In 2026

59 million

Before A.C.A.

57 million

2 years later

54 million

After Medicaid expansion and marketplace subsidies go away.

1 year later

44 million

After penalties associated with the individual mandate go away, and some insurers leave the market.

Now

26 million

Here’s how much the number of uninsured could rise if major portions of the health law were repealed today, according to a new study.

“No wonder President-elect Trump realizes that repeal without replace is the real disaster,” said Senator Chuck Schumer of New York, the Democratic leader. “No wonder he has admonished the Congress not to do plain repeal.”

Republicans now have two powerful reasons to “repeal and replace” together: They hope to protect about 20 million Americans who have gained coverage under the law. And they want a politically acceptable judgment from the Congressional Budget Office on the effects of their alternative.

Mr. Trump’s statement last week that a replacement plan should go hand in hand with repeal efforts had already ignited a sense of urgency among Republicans on Capitol Hill. Over the weekend Mr. Trump said he was close to completing a plan to replace the Affordable Care Act with the goal of “insurance for everybody,” but congressional aides said Tuesday that they had not seen an actual proposal.

Republican congressional leaders are trying to put together a plan that could pass muster with the Trump team and also win approval in the Senate under fast-track procedures that would neutralize the threat of a Democratic filibuster.

House Speaker Paul D. Ryan and Senator Mitch McConnell of Kentucky, the Republican leader, met last week with Mr. Price to hash out alternatives, and they have been in close contact with the relevant committee leaders and staff members to begin hammering out ideas that could come into relief at the end of the month, when Republicans have their annual policy retreat.

Stephen Miller, a former Senate press aide and the incoming senior White House adviser for policy, who has been particularly aggressive in presenting himself as the voice of Mr. Trump on all policy matters, has pushed the notion that a plan should move quickly and in tandem with a replacement measure, rather than in a series of smaller bills, congressional aides said.

The repeal legislation analyzed by the budget office would have eliminated tax penalties for people who go without insurance. It would also have eliminated spending for the expansion of Medicaid and subsidies that help lower-income people buy private insurance. But the bill preserved requirements for insurers to provide coverage, at standard rates, to any applicant, regardless of pre-existing medical conditions.

“Eliminating the mandate penalties and the subsidies while retaining the market reforms would destabilize the nongroup market, and the effect would worsen over time,” the budget office said.

The office said the estimated increase of 32 million people without coverage by 2026 resulted from three changes: About 23 million fewer people would have coverage in the individual insurance market. Roughly 19 million fewer people would have Medicaid coverage. And there would be an increase in the number of people with employment-based insurance that would partially offset those losses.

The estimates by the budget office are generally consistent with projections by the Obama administration and by insurance companies.

In its report, the budget office said that repealing selected parts of the health care law — as specified in the earlier Republican bill — would have adverse effects on insurance markets.

In the first full year after the enactment of such a bill, the office said, premiums would be 20 percent to 25 percent higher than under current law.

Repealing the penalties that enforce the “individual mandate” would “both reduce the number of people purchasing health insurance and change the mix of people with insurance,” as younger and healthier people with low health costs would be more likely to go without insurance, the budget office said.

The Republican bill would have eliminated the expansion of Medicaid eligibility and the subsidies for insurance purchased through Affordable Care Act marketplaces, after a transition period of about two years.

Those changes could have immediately increased the number of uninsured by 27 million, a number that would gradually increase to 32 million in 2026, the budget office said.

Without subsidies, the budget office said, enrollment in health plans would shrink, and the people who remained in the individual insurance market would be sicker, with higher average health costs. These trends, it said, would accelerate the exodus of insurers from the individual market and from the public marketplaces.

As a result, it said, about half of the nation’s population would be living in areas that had no insurer participating in the individual market in the first year after the repeal of marketplace subsidies took effect. And by 2026, it estimated, about three-quarters of the population would be living in such areas.

While writing the Affordable Care Act in 2009 and 2010, lawmakers continually consulted the Congressional Budget Office to understand the possible effects on spending, revenue and insurance coverage. The current director of the budget office, Keith Hall, who signed the report issued on Tuesday, was selected and appointed by Republican leaders of Congress in 2015.

The latest report was requested by Mr. Schumer and two other Democrats, Senators Ron Wyden of Oregon and Patty Murray of Washington.

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Fear Spurs Support for Health Law as Republicans Work to Repeal It

With their quick strike on the law in the first days of the new Congress, Republicans had hoped to begin the repeal process before a backlash could develop or opposition could be organized. But congressional Republicans are at risk of losing the message war, especially since they are fighting on two fronts.

On one side, the president-elect has repeatedly lobbed disruptive demands at them, such as his insistence that they prepare a replacement health bill almost immediately. To that, he added a new promise over the weekend: that the Republican version would provide “insurance for everybody.”

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Health care activists rallied on Friday near Trump Tower in Midtown Manhattan. Credit Drew Angerer/Getty Images

On the other front, Democratic lawmakers have taken to quoting grateful constituents to personalize what can be an arcane legislative fight: Bryce in Seattle; Randy in Rhinelander, Wis.; Nicole in Hockessin, Del.; and many more. The focus of public attention appears to be shifting from the well-documented defects of the health care law to the plaintive pleas of people terrified of losing insurance if the law is repealed.

“I want to thank President Obama from the bottom of my heart because I would be dead if it weren’t for him,” Jeff Jeans, a small-business man from Sedona, Ariz., who described himself as a lifelong Republican, told Speaker Paul D. Ryan on Thursday at a town-hall-style meeting televised on CNN.

Republicans acknowledge their constituents’ concerns, but they say supporters of the health law are manufacturing them. Representative Rob Woodall, Republican of Georgia, blamed Democrats for “amping up anxiety” with “fear mongering.”

“The anxiety is real,” Mr. Woodall said, “but it’s real based on the failures of the president’s health care law.”

Republicans will soon face a new challenge: maintaining anger at “Obamacare” without Mr. Obama in the White House to stir their passions.

Regardless of its provenance, the law’s support has until now received less attention. Appearing on the NBC News program “Meet the Press” five days after Mr. Obama signed the Affordable Care Act in 2010, Senator Chuck Schumer, Democrat of New York, predicted that as people learned about the law, “it’s going to become more and more popular.”

Around 20 million Americans have gained coverage through the Affordable Care Act’s online insurance marketplaces or through its expansion of Medicaid, and enrollment has continued to grow. About 11.5 million people have signed up for marketplace plans or had their coverage automatically renewed for this year, nearly 300,000 more than at this time last year, the Obama administration said this month.

But the popularity bounce never came. Public opinion remains deeply divided, with the law no more popular today than when it was passed. In December, according to a monthly tracking poll by the Kaiser Family Foundation, 46 percent of Americans had unfavorable views of the law, up from 40 percent in April 2010. The share with favorable views slipped to 43 percent, from 46 percent in April 2010.

“In the short term, the A.C.A. has been a political disaster for President Obama and the Democrats,” Dr. Ezekiel J. Emanuel, a health policy adviser in the Obama White House from 2009 to 2011, said in a 2014 book.

As Congress took a first step last week toward rolling back Mr. Obama’s signature domestic achievement, Mr. Trump celebrated. “The ‘Unaffordable’ Care Act will soon be history!” he said on Twitter.

Some Democrats distanced themselves from the Obama administration after HealthCare.gov crashed on its debut in 2013. More recently, with premiums soaring and insurers defecting from the Affordable Care Act marketplace in many states, Democrats were hard put to defend the law, which was passed without any Republican votes.

But as Mr. Trump and congressional Republicans race to repeal the law, Democrats are taking a more aggressive stance.

Senator Debbie Stabenow, Democrat of Michigan, told the story of Sonja L. Podjan, a 55-year-old blueberry farmer in Watervliet, Mich., who was in pain for several years until she got insurance under the Affordable Care Act, which covered the cost of surgery to repair a severe tear in the meniscus of her right knee.

In an interview, Ms. Podjan said she “started freaking out” after the election and sent an email to Ms. Stabenow. She said she was “flabbergasted” when she heard back from the senator’s office.

Ms. Podjan said that the premium for an insurance policy covering her and her husband was about $1,000 a month, but that they paid just $62 after receiving government subsidies provided under the law.

“I am scared to death we will lose our insurance, and what happens then?” said Ms. Podjan, who reported that she and her husband had medical expenses totaling $41,000 in the past two years.

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Demonstrators at a rally in support of the Affordable Care Act on Sunday in Denver. Credit Chris Schneider/Agence France-Presse — Getty Images

Senator Tom Udall, Democrat of New Mexico, told the story of a constituent, Kevin Kargacin, whose daughter Amber takes drugs costing more than $60,000 a year for multiple sclerosis. “Kevin is scared because the cost of treating Amber’s disease is so high,” Mr. Udall said.

In an interview, Mr. Kargacin said he wrote to Mr. Udall because “we are terrified that without the Affordable Care Act, Amber could be denied insurance or run into lifetime caps on expenditures for her treatment.”

Senator Amy Klobuchar, Democrat of Minnesota, said: “Many Minnesotans have contacted me in the last few months, frightened about the future of their health care coverage. I heard from a man in Orono. His wife was diagnosed with cancer this year. On top of everything his family is now dealing with, he is terrified that his family will lose coverage if there is a repeal.”

Whether such concerns reflect a change in public opinion is difficult to say. Over the past six years, Republicans have collected stories from hundreds of constituents complaining that their insurance policies were canceled, their premiums have shot up and their deductibles are so high that the insurance is nearly worthless.

“Scott from Hickory has had his health insurance canceled three times now, disrupting his continuity of care,” said Representative Virginia Foxx, Republican of North Carolina. “Patricia from Kernersville now has a whopping $6,550 deductible.”

Representative Pat Tiberi, Republican of Ohio, reported that a constituent named Kimberly had difficulty obtaining treatment for a brain tumor because, she said, “virtually no doctors take the marketplace insurance.”

The differing accounts are not necessarily in contradiction. Some people have benefited from the law while others have seen their coverage disrupted.

Republicans said the Obama administration had been slow to recognize and acknowledge problems with the Affordable Care Act. Administration officials said insurance rate increases of 25 percent or more were not a significant problem because low-income people could get subsidies to help defray the cost — even though millions of people buying insurance on their own do not receive subsidies.

The administration insisted that insurance markets were “stable and vibrant” even as large insurers pulled out of Affordable Care Act exchanges where they were losing hundreds of millions of dollars. In 2015, the administration said that “claims data show healthier consumers” in the exchanges, but some insurers disputed that assessment, saying they had not seen an influx of healthy people to help cover the costs of sick people.

Correction: January 16, 2017

Because of an editing error, an earlier version of this article misstated the day on which the town-hall-style meeting with Speaker Paul D. Ryan was held. It was Thursday, not Friday.

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On Washington: ‘Repeal and Replace’: Words Still Hanging Over G.O.P.’s Health Care Strategy

The uncertainty has reignited the fight to define the health insurance program in the public mind, with Republicans and Mr. Trump painting it as a disaster, and Democrats portraying it as a success that provides security to millions of Americans, many of them Trump voters. Democrats have latched on to their own catchphrase, warning that repealing the law will “Make America Sick Again” — a twist on the Trump campaign’s “Make America Great Again” theme.

Photo

The notecard on which Josh Holmes, then a top communications adviser to Mr. McConnell, first wrote the “repeal and replace” slogan for the Republican strategy in opposition to the Affordable Care Act.

Republicans have derided the Democratic message — personally developed by Senator Chuck Schumer of New York, the new Democratic leader — as trite and ineffective. But Democrats like it and believe that it goaded Mr. Trump into a more direct and complicating role in the Republican deliberations over how quickly to propose a replacement for the health care program.

They say Republicans are still relying on Mr. Holmes’s years-old brainchild because they are groping for a replacement with their new unified government days away. Democrats see the confusion as a victory in their push to thwart repeal or slow it down while wringing all the political advantage they can from the attempt.

After a series of late-night Senate budget votes that laid the procedural groundwork for repeal with no certainty on what was to follow, one Democrat delivered a new punch line.

“This is called repeal and run,” Senator Claire McCaskill, Democrat of Missouri, said on Twitter as the Senate was voting. “Chaos is coming.”

Mr. Trump’s involvement has muddled the issue further as he and Republican leaders in Congress have offered differing timetables for when a Republican alternative might be unveiled, underscoring again how difficult it can be to push through an agenda even for a party that controls all the levers of government.

The origin story of the “repeal and replace” mantra is also a reminder of how pivotal strategic messaging has been throughout the health care debate. It has produced some of the more memorable political lines in recent years, from “death panels” to “If you like your health plan, you can keep your health plan” to “Obamacare” itself. After Republicans began throwing that term around as a pejorative, Mr. Obama embraced it.

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Senator Chuck Schumer of New York, the Democratic leader, during a news conference this month in Washington on Republican attempts to repeal the health care law. Credit Zach Gibson/Agence France-Presse — Getty Images

Even before landing on “repeal and replace,” Republicans scorched Democrats with buzzy phrases. In his book “The Long Game,” Mr. McConnell recounted how he instructed his legislative experts to identify special provisions that had been added to the health bill to win over wavering Democrats.

His communications staff would then “brand” these legislative sweeteners with catchy but disparaging nicknames to build opposition and public distrust for the law. The result: the “Louisiana Purchase,” “Gator Aid” and the memorable “Cornhusker Kickback,” to tarnish provisions inserted to woo senators from Louisiana, Florida and Nebraska.

“In some ways, we were enjoying ourselves,” Mr. McConnell acknowledged in his book.

The same communication strategists who originated those terms were brainstorming on March 22, 2010, while Mr. Holmes jotted ideas on a notecard. When he hit on “repeal and replace,” the McConnell team decided it had what it needed. The big question was whether they could get lawmakers to embrace it. That answer would come quickly.

“I think the slogan will be ‘repeal and replace,’ ‘repeal and replace,’” Mr. McConnell told reporters the next day. “No one that I know in the Republican conference in the Senate believes that no action is appropriate.”

Mr. Holmes said a turning point came shortly after, when Representative Mike Pence of Indiana, who was then in charge of political messaging for House Republicans, and is now the vice president-elect, latched on to the phrase. That caused conservative resistance to the “replace” aspect of the debate to evaporate.

Mr. Holmes acknowledged that he had to create only the phrase, not the actual replacement.

“I don’t do policy,” he said with a laugh.

But Republican lawmakers and leaders of the new administration do have to do policy. And they may need to do it fast if they are going to assure Americans that they intend to fulfill their seven-year-old promise to not just repeal the law, but also replace it.

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Senate Takes Major Step Toward Repealing Health Care Law

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.”

Interactive Graphic

Peeling away pieces of the law could lead to market chaos.

OPEN Interactive Graphic

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.

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Health Insurers List Demands if Affordable Care Act Is Killed

Insurers could decide within a few months whether to pull out of the state marketplaces for 2018, a deadline they are pushing to have delayed.

The trade group, one of two major groups representing insurers, was a major force in the passage of the law in 2010 and is expected to be influential in its discussions with Republicans. While its clout has been reduced by the departure of large members like the UnitedHealth Group, the organization has a powerful voice in Congress.

The Blue Cross Blue Shield Association, the other major trade group, has not yet said what it needs from Republican lawmakers to continue operating in the market.

Ms. Tavenner, a former Medicare official in charge of overseeing the creation of the state marketplaces, brings deep knowledge of both the government’s and the industry’s roles in health care. She said her group had begun meeting with members of Congress and their staffs.

Hospital groups also held a news conference on Tuesday to warn of what they said would be the dire financial consequences of a repeal if the cuts to hospital funding that were part of the Affordable Care Act were not also restored.

Interactive Graphic

Peeling away pieces of the law could lead to market chaos.

OPEN Interactive Graphic

While insurers say they do not plan to fight the Republicans’ efforts to repeal the law, they are in no hurry to see it unwound. And Ms. Tavenner said the industry would support a delay so it could prepare for the changes. “We would love to see a three-year time frame, as long as possible,” she said.

The marketplaces, now three years old, have not become as robust as expected by many of the people behind the Affordable Care Act. Even President Obama, who pushed the law and the marketplaces through Congress, has suggested some improvements.

Some of the largest insurers, like UnitedHealth and Aetna, have stopped selling policies on some of the state marketplaces after losing hundreds of millions of dollars, and other insurers say they are still debating whether to stay in the market. Many have raised their premiums sharply.

Ms. Tavenner acknowledged that the current law “needed to be improved.” But she emphasized that there was widespread agreement among Republicans about the need for some the law’s provisions, including covering people with expensive medical conditions. President-elect Donald J. Trump has also signaled his support of this popular provision. “There are common starting platforms,” she said.

Ms. Tavenner did not give many details about her group’s positions, but she said its top priority was to stop the immediate threat of eliminating the subsidies for plans sold to low-income people. House Republicans have already sued to block these payments, and the lawsuit is now delayed. If the new administration chose not to defend the lawsuit, the money would disappear, and insurers would probably rush to the exits because fewer potential customers would be available.

Another of the industry’s concerns is ensuring that enough young and healthy people sign up to stabilize the market. Republicans have discussed eliminating one of the law’s main tools, the so-called individual mandate, a tax levied on those who do not enroll.

In talking with Congress, Ms. Tavenner said, her members are emphasizing the need for some alternative, especially after criticism by insurers that the penalty is not large enough to persuade enough people to enroll. “There’s not one magic solution,” she said. She pointed to some of the provisions in Medicare that encourage people to sign up before they become sick. And she discussed some options to ease how insurers price their policies to be able to offer plans that are less expensive to younger people.

She also argued that the insurers had no desire to return to the time before the law was passed, when people with pre-existing conditions were routinely denied coverage in the individual market.

Still, the industry seems willing to embrace some of the ideas being discussed by Republicans, including giving individuals more choices of plans and more accountability for the cost of their health care. Republicans also seem eager to put the states in charge of some of the details of how coverage in both the individual market and Medicaid will look. Ms. Tavenner said the industry had a long history of working with state insurance regulators.

Republicans are discussing other ways to stabilize the market, including the creation of high-risk pools, where people with expensive medical conditions might be covered, bringing down the coverage costs for everyone else. “We would hesitate to rush back to that,” Ms. Tavenner said. In the past, those programs, typically run by the states, have not been adequately funded, she noted.

The insurers are also beginning to discuss a potential overhaul of Medicare, pushed by the House speaker, Paul D. Ryan, who favors so-called premium support, or vouchers, as a way for people to find coverage. “We’re not big fans of that approach,” said Ms. Tavenner, although she said the industry would be open to discussing it.

Ms. Tavenner said the industry wanted to know more about what the Republicans were planning, including information on the fate of the Medicaid expansion under the law. “We still have more questions than answers,” she said. “We don’t want to disrupt individuals who are relying on our coverage,” she said.

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