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Sen. Rand Paul, R-Ky., walks to a room on Capitol Hill in Washington, Thursday, March 2, where he charges House Republicans are keeping their Obamacare repeal and replace legislation under lock and key. J. Scott Applewhite / AP

"Obamacare is dishonest in that it says, 'Yeah, we can expand it, but it won't cost anything,'" Sen. Rand Paul (R-KY), an early critic of the GOP bill, told NBC News. "Our country has a $20 trillion debt. It's a huge burden that I think threatens the country from within."

More moderate Republicans, however, are worried about reducing funding or changing the program too rapidly.

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There are some complaints on the House side as well. "I remain concerned about the impact of the Medicaid changes on vulnerable populations, as well as the overall effect of the bill on access to affordable care," Rep. Charlie Dent (R-PA), who represents a swing district, told NBC News in a statement.

While few members have declared their outright opposition to the bill, there's no obvious way to satisfy one side's concern without further alienating the other. That could make for a difficult negotiation as the party struggles with additional divisions over issues like tax credits for private insurance and whether to defund Planned Parenthood.

Some 32 states, including the District of Columbia, have accepted the ACA's increase in federal aid and many of the expansion states have Republican governors and state legislatures. Powerful advocacy groups representing doctors (

The controversy boils down to simple math. Under the House bill, states would have to make major cuts and raise taxes or simply drop coverage and benefits for the groups covered under the ACA. The Center on Budget and Policy priorities estimates that the House GOP plan would

This helps explain why Republican governors have been some of

As Kasich and other Republicans have mentioned, there are specific concerns tied to the opioid epidemic governors are confronting around the country and that President Donald Trump referenced often on the campaign trail. Medicaid pays for rehab and mental health treatment for many victims of drug abuse. In addition to removing millions from the program by undoing the expansion, some policy experts warn that the House's fixed per-capita formula would make it harder for states to respond to unexpected crises like drug outbreaks that raise the average cost of treating individual patients.

Caving in to the demands of moderate Republicans becomes even more complicated for another reason: The 19 states that have so far declined to participate in the Medicaid expansion.

These states paid a considerable price for their decision to stand with conservative activists demanding they hold the line against Obamacare with a future repeal bill in mind. A gap in the law created by the Supreme Court's Medicaid ruling left many poorer residents with incomes too high to qualify for Medicaid but too not high enough to qualify for subsidies to buy private insurance. The ACA also cut funding to hospitals for uninsured patients that the Medicaid expansion was supposed to make up.

The House bill makes some money available to non-expansion states elsewhere to try and address these fairness concerns, but any moves to bring more moderate senators into the fold in the expansion states could upset this balance.

"If a state expanded their Medicaid they should not somehow get a benefit from having done so versus a state that did what I thought was responsible at great political cost," Sen. Marco Rubio (R-FL), whose governor turned down the expansion, told NBC News.

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Why Medicaid Is So Hard for Republicans - NBCNews.com

Republicans are in a box. A yuge, terrific box of their own making, rhetorically crafted over the course of seven long years, but a box nonetheless. Its walls are equal parts procedural, political, and perceptual. Think of the GOP as Indiana Jones, sandbag in hand, trying to make off with the Democrats Golden Idol. Except that the idol swap is more like a bad game of Jenga, they lack the votes to start from scratch, and the electoral (if not actuarial) boulder is gaining on them either way.

Mixed metaphors aside, Ramesh Ponnuru is right when he points out that the harsh judgment on the American Health Care Act has been rendered without acknowledging the parameters within which Republicans are forced to work. Only so much can be done while maintaining the senatorial privilege of budget reconciliation, and even within those narrow confines you still have to account for ideological tensions both within and between the respective congressional chambers. So before delving into the bill itself, lets stipulate that this isnt anyones ideal. If mutual ambivalence is the hallmark of a good compromise, this bill is a doozy.

That said, I dont recall any asterisks in the mountains of campaign literature promising to repeal and replace. There was no fine print about the filibuster in the TV ads, no disclaimers about the Byrd Rule in the radio spots. Fairly or unfairly, Republicans are being graded on a curve of their own making even if that means campaigns floated political checks the conference cant legislatively cash.

But lets get back to the AHCA. By now the bill has been picked apart by the Left and the Right. We know what it is and what it isnt. So the operative question is binary and twofold: First, is this the best reform Republicans can achieve within the constraints of what can be signed into law? And second, is it better than doing nothing?

Substantively speaking, I yield to thoughtful conservative health-reform voices, such as Avik Roy and Philip Klein. There are certainly elements to like in the plan, but it does seem to arbitrarily pick and choose which of the underlying regulatory rails can be touched. As for what can plausibly be passed, the repeal bill vetoed by President Obama in early 2016 is almost certainly off the table now that Republicans are playing with live ammunition. And even if clean repeal was a default option, it would leave any parallel replacement bill subject to an inevitable Democratic filibuster. Suffice it to say that any legislative sausage with a path to the presidents desk wont be particularly pretty.

Assessing the second question is more complicated. Leaving aside the indignity of belly-flopping on the partys most visible priority in the first 100 days, failure to pass a repeal measure would imperil the rest of the GOPs legislative agenda. Beyond delivering on an explicit campaign promise, the most important aspect of ACA repeal is its role as a stalking horse for tax reform. Obamacare taxes represent half a trillion dollars in federal revenue over the ten-year budgetary window. Which is to say that a post-ACA baseline is imperative to lowering tax rates anywhere near the levels envisioned by President Trump and congressional Republicans. Indeed, the House tax-reform blueprint assumes these levies have been repealed in order for the internal arithmetic to work. And given the ongoing heartburn over border adjustability and changes to treatment of corporate interest expenses (both trillion-dollar line items in their own right), failure to eliminate the ACAs taxes would likely deal a crippling blow to any permanent, substantial reforms to the code.

On the other hand, the political Pottery Barn rule is in full effect as Democrats learned all too well, if you break it, you buy it. If Republicans truly believe Obamacare is in a death spiral and will collapse under its own weight, they had better be confident that nibbling around the edges of the law will be enough to stabilize the system. Otherwise this will be at best a pyrrhic victory, absolving Democrats and leaving Republicans exposed to whatever fallout is yet to come. And regardless of the macro effects, Democrats will be armed with countless heartbreaking anecdotes buttressed by ugly CBO coverage projections. If youre going to be blamed for disrupting a massive economic sector, youd better make sure its your best shot.

At the end of the day, Republicans have a fateful choice: pass this bill largely as is, pass it in a significantly modified form, or pass nothing at all. Unless the reforms can stand on their own merits, the GOP runs the risk of swallowing the spider to catch the Obamacare fly. And thats a perilous move no matter how many seats they owe to the fly-swatter.

Liam Donovan is a former GOP staffer who works in government relations in Washington, D.C.

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In Replacing Obamacare, Republicans Face the Pottery Barn Rule - National Review

CBO Director Keith Hall participates in a media briefing January 24, 2017.

Republicans have very good reason to fear what the Congressional Budget Office is probably going to say about Trumpcare:every analysis by independent health and economic think tanks has shown it's going to take insurance away from millions and cost the treasury bigly. Because they know from experience that the CBO chief they hand picked,Keith Hall, seems to actually stick to his extremely conservative bonafidesespecially when it comes down to matters relating to the deficit. And even though they've done everything to cook the books in their favor, Hall won't play along.

He was appointed to head CBO as Republicans in Congress revised rules for how the office would assess the impacts of legislation a switch to whats known as dynamic scoring, which lets CBO incorporate broader economic effects of proposed policy changes. Yet Halls use of that technique hasnt always resulted in estimates that help the GOP agenda. []

And in one highly significant report in Decemberwhich set up the possible upcoming clash with the Republican Congress Halls CBO said it wouldnt count skimpy health plans as coverage in its scores. In other words, people with limited health care benefits that are unlikely to protect them against expensive or catastrophic medical events won't meet the CBO standards for health coverage.

That means the CBO score of a Republican plan is almost certain to be less favorable than that of Obamacare.

Hence the determined effort by Republicans to discredit the CBO's eventual report before it hits the ground, which should be sometime next week. But the whole sorry mess proves again how remarkable it is that Paul Ryanwunderkind wonk and intellectual light of the GOPcan't even get his numbers to work out when he's set everything up in his favor.

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Republicans' hand-picked CBO chief is likely to trash Trumpcare - Daily Kos

Since President Trumps inauguration, Republicans have triggered a steady churn of outrage from the left over perceived gaffes, errors and omissions.

Some of it has been rightly deserved (see: erroneous Trump tweet on Gitmo prisoners). Some of the desk-thumping, however, has more than a hint of hypocrisy -- as that outrage machine was largely silent when similar comments were made by the Obama administration.

Here are just a few examples of statements met with thunderous criticism when uttered by Republicans, yet crickets when made by Democrats:

Carson vs. Obama

HUD Secretary Ben Carson, speaking to department employees earlier this week, sparked outrage when he referred to slaves as immigrants.

"That's what America is about, a land of dreams and opportunity," Carson said. "There were other immigrants who came here in the bottom of slave ships, worked even longer, even harder for less. But they too had a dream that one day their sons, daughters, grandsons, granddaughters, great-grandsons, great-granddaughters, might pursue prosperity and happiness in this land."

The NAACP and Chelsea Clinton were both among those offended by Carsons comparison. Actor Samuel L. Jackson tore into Carson in an R-rated tweet.

The problem was, then-President Barack Obama made a similar comparison before.

"It wasn't always easy for new immigrants. Certainly, it wasn't easy for those of African heritage who had not come here voluntarily and yet in their own way were immigrants themselves," he said at a 2015 naturalization ceremony.

The Federalistwent so far as to dig up 11 times Obama had referred to slaves as immigrants, and noted there was barely a peep of outrage each time. What changed?

Lay off the iPhones

Twitter was apoplectic when Rep. Jason Chaffetz, R-Utah, recently said Americans may have to choose between buying a new iPhone and health insurance.

"Well, we're getting rid of the individual mandate. We're getting rid of those things that people said that they don't want. ... Americans have choices, and they've got to make a choice," he said on CNN. "So rather than getting that new iPhone that they just love and want to go spend hundreds of dollars on that, maybe they should invest in their own health care.

Chaffetz was accused of everything from being OK with poor people dying to reviving the poverty is a choice argument."

Yet the criticism glossed over similar remarks made by Obama in 2014.

Asked in a Spanish-language town hall about those who said they cant afford premiums, Obama speculated about someone making $40,000-$50,000 a year, who thinks an insurance option that costs $300 a month is too much.

I guess what I would say is if you looked at that persons budget and you looked at their cable bill, their telephone cell phone bill, other things that theyre spending on, it may turn out that they just havent prioritized health care because right now everybody is healthy," he said.

Shame-rock

Some were put out after the Trump team recently put out green versions of his famous Make America Great Again hats, branded with a four-leaf clover. While said clover is considered a symbol of good luck, some Irish news outlets and others on Twitter grumbled that the three-leaf clover was more appropriate.

The shamrock is a three-leaf sprig of clover and is associated with St Patrick's Day, The Irish Independent complained. The four-leaf clover is a plant, that's rarer in abundance. It's also a sugary, oat piece that's usually found in a box of Lucky Charms cereal.

Yet Obama did something similar in 2012 when his campaign produced an OBama shirt with a four-leaf clover. While the error was noted, it produced little outrage, and even some apologists.

I think thats creative license, Kevin ONeill, a professor of Irish History at Boston College, told The New York Times. If you can add an apostrophe, why not a leaf.

Omission Outrage

A Trump White House statement on International Holocaust Remembrance Day provoked condemnation when it left out any reference to Jewish people the main target of Hitlers genocidal atrocities.

It is with a heavy heart and somber mind that we remember and honor the victims, survivors, heroes of the Holocaust. It is impossible to fully fathom the depravity and horror inflicted on innocent people by Nazi terror, the statement said.

A number of Jewish groups were critical of the omission. But former Democratic vice presidential candidate Tim Kaine, D-Va., went further by comparing the statement to Holocaust denial.

President Obama, President Bush always talked about the Holocaust in connection with the slaughter of Jews. The final solution was about the slaughter of Jews. We have to remember this. This is what Holocaust denial is, he said.

White House Press Secretary Sean Spicer blasted the controversy as nitpicking. He said: "To suggest that remembering the Holocaust and acknowledging all of the people -- Jewish, gypsies, priests, disabled, gays and lesbians -- it is pathetic that people are picking on a statement."

But Kaines comments in particular were striking considering his former running mate former Secretary of State Hillary Clinton released a statement in 2013 that also did not mention the Jewish people.

The statement said: "Each year, we gather together to commemorate the victims of one of the worst tragedies in human history. Indeed, almost 70 years after the end of World War II, we continue to honor those lives that were brutally taken during the Holocaust by the Nazis. This machinery of systematic extermination also took the lives of Roma, gays, persons with disabilities, and others deemed inferior or undesirable by the Nazis."

The statement did condemn Holocaust denial, while also mentioning other genocides, including in Cambodia, Srebrenica, Rwanda and Darfur.

Adam Shaw is a Politics Reporter and occasional Opinion writer for FoxNews.com. He can be reached here or on Twitter: @AdamShawNY.

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Four times Republicans faced outrage for things Dems did first - Fox News

A

little-noticed bill moving through Congress would allow companiesto require employees to undergo genetic testing or risk paying a penalty of thousands of dollars, and would let employerssee that genetic and other health information.

Giving employers such power is now prohibited by legislation including the 2008 genetic privacy and nondiscrimination law known as GINA. The new bill gets around that landmark law by stating explicitly that GINA and other protections do not apply when genetic tests are part of a workplace wellness program.

The bill, HR 1313, was approved by a House committee on Wednesday, with all 22 Republicans supporting it and all 17 Democrats opposed. It has been overshadowed by the debate over the House GOP proposalto repeal and replace the Affordable Care Act, but the genetic testing bill isexpected to be folded into a second ACA-related measure containing a grab-bag of provisions that do not affect federal spending, as the main bill does.

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What this bill would do is completely take away the protections of existinglaws, said Jennifer Mathis, director of policy and legal advocacy at the Bazelon Center for Mental Health Law, a civil rights group. In particular, privacy and other protections for genetic and health information in GINA and the 1990 Americans with Disabilities Act would be pretty much eviscerated, she said.

Employers say they need the changes because those two landmark laws are not aligned in a consistent manner with laws about workplace wellness programs, as an employer group said in congressional testimony last week.

Employers got virtually everything they wanted for their workplace wellness programs during the Obama administration. The ACA allowed them to charge employees 30 percent, and possibly 50 percent, more for health insurance if they declined to participate in the voluntary programs, which typically include cholesterol and other screenings; health questionnaires that ask about personal habits, including plans to get pregnant; and sometimes weight loss and smoking cessation classes. And in rules that Obamas Equal Employment Opportunity Commission issued last year, a workplace wellness program counts as voluntary even if workers have to pay thousands of dollars more in premiums and deductibles if they dont participate.

Despite those wins, the business community chafed at what it saw as the last obstacles to unfettered implementation of wellness programs: the genetic information and the disabilities laws. Both measures, according to congressional testimony last week by the American Benefits Council, put at risk the availability and effectiveness of workplace wellness programs, depriving employees of benefits like improved health and productivity. The council represents Fortune 500 companies and other large employers that provide employee benefits. It did not immediately respond to questions about how lack of access to genetic information hampers wellness programs.

Rigorous studies by researchers not tied to the $8 billion wellness industry have shown that the programs improve employee health little if at all. An industry group recently concluded that they save so little on medical costs that, on average, the programs lose money. But employers continue to embrace them, partly as a way to shift more health care costs to workers, including by penalizing them financially.

Do workplace wellness programs improve employees health?

The 2008 genetic law prohibits a group health plan the kind employers have from asking, let alone requiring, someone to undergo a genetic test. It also prohibits that specifically for underwriting purposes, which is where wellness programs come in. Underwriting purposes includes basing insurance deductibles, rebates, rewards, or other financial incentives on completing a health risk assessment or health screenings. In addition, anygenetic information canbe provided to the employer only in a de-identified, aggregated form, rather than in a way that reveals which individual has which genetic profile.

There is a big exception, however: As long as employers makeproviding genetic information voluntary, theycan ask employees for it. Under the House bill, none of the protections for health and genetic information provided by GINA or the disabilities lawwould apply to workplace wellness programs as long as they complied with the ACAs very limited requirements for the programs. As a result, employers could demand that employees undergo genetic testing and health screenings.

While the information returned to employers would not include workers names, its not difficult, especially in a small company, to match a genetic profile with the individual.

That would undermine fundamentally the privacy provisions of those laws, said Nancy Cox, president of the American Society of Human Genetics, in a letter to the House Committee on Education and the Workforce the day before it approved the bill. It would allow employers to ask employees invasive questions about genetic tests they and their families have undergone and to impose stiff financial penalties on employees who choose to keep such information private, thus empowering employers to coerce their employees into providing their genetic information.

If an employer has a wellness program but does not sponsor health insurance, rather than increasing insurance premiums, the employer could dock the paychecks of workers who dont participate.

The privacy concerns also arise from how workplace wellness programs work. Employers, especially large ones, generally hire outside companies to run them. These companies are largely unregulated, and they are allowed to see genetic test results with employee names.

They sometimes sell the health information they collect from employees. As a result, employees get unexpected pitches for everything from weight-loss programs to running shoes, thanks to countless strangers poring over their health and genetic information.

Sharon Begley can be reached at sharon.begley@statnews.com Follow Sharon on Twitter @sxbegle

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House Republicans would let employers demand workers' genetic test results - STAT