Tierney Sneed

Tierney Sneed is a reporter for Talking Points Memo. She previously worked for U.S. News and World Report. She grew up in Florida and attended Georgetown University.

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Legislation to dismantle the Affordable Care Act was unveiled Monday evening, in a bill submitted to the House Energy and Commerce Committee. Republicans were scrambling through the weekend to make last-minute changes to the bill and comes after multiple debates over the approach the GOP should take in repealing Obamacare bogged down the effort. The bill include some replacement elements, but would also dramatically pull back assistance the federal government offers to help people obtain insurance coverage.

The legislation would transform Medicaid into a block grant with a per capita cap, meaning states would received a fixed amount of funding per enrollee to the program. The expanded Medicaid program some states opted into under the ACA would be allowed to continue until 2020, at which point expansion states would freeze their enrollments.

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Four Republicans senators hailing from states that have expanded Medicaid under the Affordable Care Act fired a shot across the bow -- in the form of a letter to Senate Majority Leader Mitch McConnell (R-KY) -- against the changes to the program that were included in draft House Obamacare repeal legislation.

"While we support efforts to repeal and replace the Affordable Care Act and make structural reforms to the Medicaid program, we are concerned that the February 10th draft proposal from the House of Representatives does not provide stability and certainty for individuals and families in Medicaid expansion programs or the necessary flexibility for states," the letter, signed by Sens. Rob Portman (R-OH), Shelley Moore Capito (R-WV), Cory Gardner (R-CO) and Lisa Murkowski (R-AK), said.

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The Congressional Budget Office said Friday that its projections for the federal government's spending on the Affordable Care Act's coverage provisions in 2019 are now a third lower than what they were when the law was passed in 2010.

CBO Director Keith Hall said in written responses to questions posed by the House Budget Committee that the CBO expects the federal government to spend $148 billion in 2019 on the law's coverage provisions, down from the $214 billion estimated when the law was passed.

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Outside groups backed by the Koch brothers, as well as other conservative organizations, are amping up their campaigns to pressure Republicans into repealing the Affordable Care Act, the New York Times reported Sunday.

The groups are embracing digital advertising, rallies and other tactics to urge GOP lawmakers to make good on their campaign promises to dismantle Obamacare. The ramp-up comes as congressional leadership's repeal proposals -- which they are expected to unveil in legislation this week -- have been met by resistance from conservative and moderate Republicans alike.

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The closer that Republicans get to settling on a Obamacare repeal plan, the uglier the intra-party fighting gets, with the latest round being over the types of tax credits lawmakers offer as an alternative to the Affordable Care Act.

The details are wonky, but reveal the deep differences in philosophies regarding health care reform that are currently roiling the GOP caucus. Just as troubling for Republican leadership in Congress is that a not-insignificant smattering of GOP lawmakers are vowing to vote against an Obamacare repeal bill that also offers the type of tax credits to which they object. The infighting was exacerbated by a leaked GOP plan that included a controversial form of the credits.

Here are 5 points on what the disagreement is over and why it has gotten so heated.

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In a topsy-turvy twist to the Obamacare repeal saga, Sen. Rand Paul (R-KY) set out Thursday in search of the House GOP's Obamacare repeal bill supposedly kept under lock and key in a secure basement room in the Capitol complex. With reporters tweeting his odyssey, Paul brought unwelcome attention on the House GOP's odd tactics for avoiding political fallout from the bill that is number one legislative priority for Republicans.

Before embarking on his "National Treasure" quest in the bowels of a House office building, Paul blasted the move to allow only Republicans members and staff of a House committee to review the current draft Obamacare repeal legislation, and to prohibit making copies of the bill.

"I am very upset that they’ve made the Obamacare proposal classified," said Paul, who has been critical of the direction House leadership is said be moving with the repeal. It was reported Wednesday that the bill would be available Thursday for Energy and Commerce Republicans to read, but under conditions akin to a secret intelligence meeting.

"We’re going to be trying to get a look at the Obamacare proposal, but I think the reason that they're keeping it in secret is that it’s Obamacare-lite " Paul told reporters on Capitol Hill. "Conservatives, I can tell you, on both sides of the ... House and the Senate, are very unhappy that they're now making the Obamacare proposal classified. It's under lock and key and we’re not allowed to have a copy of it. I think that’s crazy."

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Republicans on a House committee with jurisdiction over the Obamacare repeal legislation will be viewing the current version of the bill in secret in a basement room of a office building adjoining the Capitol Thursday, the Washington Examiner, Bloomberg and other outlets reported. GOP members and staff of the Energy and Commerce Committee will only be able to look at the legislation and will be prohibited from making copies, Bloomberg reported.

The opaque process comes after a leak of a draft version of the legislation last week sent the House Republican conference into disarray over disagreements about the draft provisions. Energy and Commerce Committee Chair Greg Walden (R-OR) (pictured) told Politico that members were viewing an "initial staff draft," but declined to go into any more detail about the next steps.

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An analysis by the Kaiser Family Foundation published Wednesday of a GOP proposal to rework the Affordable Care Acts subsidies into tax credits available to everyone illustrates how the plan, which was leaked last week, would represent a major loss for lower-income people and older Americans. Those higher on the income scale stand to gain under such a plan.

Republican leadership is considering offering refundable tax credits that start at $2,000 annual for individuals under 30 and raise with age, up to $4,000 for those over 60. Unlike the ACA's tax credits, they do not adjust with income, meaning a wealthy person would be getting the same break as a low income American. Obamacare's tax credits end for people making 400 percent of the federal poverty line.

The rate at which the Republican tax credits grow by age is slower that those offered under Obamacare, meaning older people will be bearing a greater burden of their premiums under the GOP plan. Currently, under the ACA, older people can face premiums three times higher than younger people, and Republicans' credits only double in size for those at the oldest end. GOP lawmakers have also proposed expanding the ratio for premiums for young and old people to one to five, which could further exacerbate the hit older people would take under the Republican plan.

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A leaked draft of legislation that represents the closest that congressional Republicans have come to signaling their way forward on repealing the Affordable Care Act is already up in flames, in part due to a revolt from the caucus’ hard right wing over a proposal that has been a mainstay of GOP health plans in recent years.

The objection by conservative members and outside groups to the draft proposal – and especially its inclusion of tax credits for Americans to use on individual insurance – shows how far GOP lawmakers still have to go in resolving the differences within their party over basic health policy questions.

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President Donald Trump in his address Tuesday to a joint session of Congress gave GOP congressional leadership a vague but important assist in getting their caucus on board with their Obamacare repeal plan.

Without going into much detail, Trump name-checked the major elements of a replacement package that has been floated by Republican leaders and was leaked in a draft legislation last week. Perhaps, most importantly, he called for tax credits for individuals to buy insurance -- which GOP hardliners have been vocally resisting -- as well as less controversial elements of the package, like expanded health savings accounts and allowing insurers to sell across state lines.

"We should help Americans purchase their own coverage, through the use of tax credits and expanded Health Savings Accounts –- but it must be the plan they want, not the plan forced on them by the Government," Trump said, according to his prepared remarks.

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