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Trump wants to ditch 'Obamacare' but keep the gains
[WASHINGTON] Health coverage for all: the promise of President-elect Donald Trump was also the vow of his predecessor Barack Obama, whose signature domestic achievement is now under serious threat of repeal.
Such is the paradox surrounding the first legislative push expected by the new Trump administration.
Since the 2010 passage of the Affordable Care Act, its defunding and eventual repeal have been a top priority for Republicans, who control both chambers of Congress and, beginning with Mr Trump's inauguration Friday, the White House.
In their view, Obamacare has marked a costly drift toward socialised, European-style medical care.
But the law has managed to add more than 20 million people onto the insurance rolls, lowering the percentage of Americans without coverage from 16 per cent in 2010 to 8.9 per cent last year.
Republicans, in their push to repeal and replace Obamacare, are insisting they will leave no one out in the cold.
Mr Trump, a billionaire real estate tycoon, has declared it inconceivable that poor Americans are locked out of health coverage due to financial constraints. It has been a constant of his controversial campaign.
"We'll do things - because there are people that can't afford it. And nobody is going to be dying on the streets with a President Trump," he told Fox News on Tuesday.
"We're going to have insurance for everybody," Mr Trump added in comments to the Washington Post at the weekend.
But in a health care system that relies almost entirely on the private sector, such a commitment would be tough to fulfill.
Only one third of the US population is covered by public insurance - either Medicare, for those over age 65, or Medicaid for the poorest Americans.
Half of all Americans are insured through their employers, according to the Kaiser Family Foundation, while about seven per cent are covered through the so-called individual market, which serves those who are self-employed or are employees without coverage through work.
Mr Obama's solution rested largely on the obligation that everyone be insured, and to provide federal subsidies to those who cannot afford coverage. Republicans deemed the first requirement too coercive, and the latter too costly.
Instead of universal coverage, which Republicans argue is not an inherent right for citizens, they have begun calling for universal "access".
"I look forward to making sure every single American has access to the highest quality care and coverage possible," congressman Tom Price, Mr Trump's pick for health secretary, told senators Wednesday at his confirmation hearing.
The Republican plan, as described by US House Speaker Paul Ryan, would abolish the individual mandate to purchase health insurance, offer new refundable tax credits for those purchasing insurance on the individual market, and create "high-risk pools" in each state for the millions of Americans with pre-existing conditions.
Mr Ryan argues that removing the sickest people from the commercial market and placing them in high-risk, tax-subsidised plans would reduce premiums overall and help stabilise the commercial market.
Republicans appear loath to tamper with one aspect of Obamacare that remains broadly popular: the right of children to remain on their parents' health plan until age 26.
But they are firm in their desire to fix what they declare is a broken system.
"We want more choices, lower prices, more competition, no monopolies," Mr Ryan told a town hall-style event last week.
Deep holes in the GOP plan remain, Democrats warn. Would maternity care still be covered, or treatment for drug addiction? Would insurance companies be allowed to reinstate caps on yearly or lifetime coverage costs, something Obamacare prohibits?
Perhaps the biggest mystery of all is when conservatives will implement their plan.
Republicans are pledging a repeal of Obamacare and rapid votes on a replacement bill in order to prevent gaps in coverage and reassure a restless insurance industry.
Mr Trump has said repeal and replace should occur "simultaneously", a stiff challenge given the complexity of America's vast health care system.
Some conservatives have even said they would refuse to vote in favour of repeal until the new replacement law was ready.
And while Republicans have promised that no one will lose their coverage, it remains unclear what provisions in their plan would guarantee such bold assurances.
Mr Trump has delegated the crafting of the new plan, flawed as it may still be, to lawmakers, while insisting on his ultimate goal: "health care that is far less expensive and far better".