I was finishing my breakfast Friday morning when my youngest daughter expressed her frustration with her up coming year in Pala Alto and some of the decisions that she has to make. She commented that she really didn’t want health care insurance and had reviewed with me the huge cost-$5,000. That is more than 15% of the salary that she would be getting. We had discussed the various plans including competitive premiums, deductibles, coverage, and exclusions.

She was frustrated and wanted to know why she just couldn’t purchase health care insurance. I had to point out to my very liberal, Anti-Trump daughter that this was not a choice. Why? Because her favorite president, former President Obama and the Democrats passed into law the Affordable Care Act which, by law requires everyone to purchase health care coverage, i.e. insurance.

I did explain the rationale for that requirement and that it was not such a bad idea. But having the healthy working youth pay for everyone else who doesn’t want to work or participate in their own health and well being is non-sustainable. Many young workers were, in fact, taking the tax penalty. However, over time as the penalty increases, this also becomes untenable along with the fact that they still also don’t have health care coverage.

So, the question still looms now and in the future, is “allowing” our healthy as well as unhealthy patients to choose not to have health care coverage a good idea? You think we live in a democracy and people should be able to choose not to purchase health care coverage if they don’t want to. But for obvious reasons when they need it and don’t have it, it becomes very expensive and the system now pays for it. Remember my comment last week that a person who shows up at an Emergency room with an injury or sickness that needs care, the ER can not turn the person away due to rules called EMTALA.

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.

So, this safety net already exists. But it is very expensive, often not paid for and puts a huge onus on hospitals and caregivers. Therefore, I understand the call for basic coverage for all. The question is if Congress is going to push for reduced taxes and Medicare and Social Security are in trouble financially, how do we pay for the universal/ Medicare for All, expanded Medicaid, or any of the various extrapolations of guaranteed coverage for all when a large population does have skin in the game and there are no penalties for not contributing to the funding of a universal system? We are looking at a socialized system, which is non-sustainable and we can’t keep expecting the youth to continue to fund those that can but refuse to work and abuse the system.

Now we learn that the GOP has a newer health care bill, the Better Affordable Care Bill, or what ever they call it this time. Who are the winners and who are the losers. Let us look again and compare.

Gisele Grayson, Alyson Hurt, and Alison Kodjak put together a few comparison charts, which help to get a true idea of the progress or lack of progress. The GOP’s latest proposal to repeal and replace the Affordable Care Act hews closely to the earlier bill that didn’t win enough support among lawmakers to bring to a vote.Perhaps the biggest change in the document released Thursday is that it leaves in place the Affordable Care Act taxes on wealthy individuals. It uses that money to reduce the number of people left without insurance coverage by the law’s changes. This latest version adds $70 billion to a fund for states — bringing the total to $132 billion — to help support coverage of low-income people.

It also would allow insurance companies to offer health plans without the consumer protections included in the Affordable Care Act, or Obamacare. That means insurers could sell stripped-down policies that cover fewer conditions and offer fewer benefits than currently allowed under the law.

Those plans would very likely be cheaper than the policies currently offered on the Obamacare exchanges. But for people who would like to purchase plans that cover the essential health benefits mandated by the Affordable Care Act, including mental health coverage, addiction treatment, maternity care and prescription drug coverage, costs could go way up. The word here is could! The states are already looking into inefficiency and fraud and how to cover those that need the safety net of Medicaid.

The nonpartisan Congressional Budget Office hasn’t yet analyzed the new bill. It weighed in on the earlier Senate bill, saying that proposal would result in 22 million fewer people having health coverage in the next 10 years, compared with under the Affordable Care Act. Of those, 15 million would lose Medicaid coverage. That version was projected to lower the deficit by billions over 10 years — but that may have changed as the latest version offers billions more for state grants and also doesn’t repeal as many of the Obamacare taxes.

Yet this new variant is the same as its predecessor when it comes to subsidies to help individuals pay for insurance. It would mostly reduce subsidies and cause out-of-pocket costs to rise, as the CBO said about the previous bill. It’s not yet clear how the state grants would alter that dynamic.

Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., aren’t on the list of likely “no” votes for the Republican health care bill, but that isn’t stopping them from offering up an alternative option.

As Senate Republicans were set to meet Thursday morning to learn about the newest version of their party’s bill to repeal and replace Obamacare, Graham and Cassidy went on CNN to float an entirely different approach.

The Graham-Cassidy amendment would keep most taxes from the Affordable Care Act in place and take the money raised and send it back to the states in the form of block grants. The states could then use it to create a state-specific system for providing health insurance.

“If you like Obamacare, you can reimpose the mandates at the state level. You can repair Obamacare if you think it needs to be repaired. You can replace it if you think it needs to be replaced,” Graham said on CNN. “It’ll be up to the governors. They’ve got a better handle on this than any bureaucrat in Washington.”

Graham said there will be a formula — not yet figured out — to decide how much money each state gets.

Many governors, including some Republicans, have expressed concerns about the Senate version of the health care plan. Ohio Gov. John Kasich, a Republican, said Friday that the draft bill “is still unacceptable.” He cited “deep” cuts to Medicaid and the lack of power it gives states to “innovate in order to cope with those reductions.”

Graham and Cassidy would get rid of the requirement that individuals must have insurance coverage and employers have to offer insurance to full-time employees. The repeal of the individual and employer mandates is a key Republican request. Legislation that doesn’t include it would have a hard time passing the Senate.

Cassidy’s office said that under the Graham-Cassidy plan, federal funding for Medicaid would “continue to grow in a sustainable manner, adjusted for inflation,” but they provided no details on how that would work.

The phase-out of Medicaid funding under the current bill is a critical issue for a handful of moderate lawmakers who are currently undecided on the bill. Thirty-two states, including Washington, D.C., expanded Medicaid under the Affordable Care Act, and lawmakers in both parties worry about what will happen to people enrolled in the program under the current bill.

Graham and Cassidy insist they aren’t trying to sink the GOP leadership’s health care bill — called the Better Care Reconciliation Act — and are hoping to offer their option as an amendment once the bill is brought to the Senate floor.

“We’re going to support Mitch’s effort with his new plan, but we want an alternative and we’re going to see which one can get 50 votes,” Graham said. “We’re not undercutting Mitch, he’s not undercutting us.”

But Graham is also putting the groundwork in place in case McConnell’s health bill fails — currently, it’s unclear whether it even has the 50 votes needed to be brought to the floor. Graham has reached out to at least one Democrat, moderate Sen. Joe Manchin of West Virginia, to see whether he’d be interested in talking.

Manchin spokesman Jonathan Kott said Manchin would talk about repairs to Obamacare, as long as Republicans stopped trying to repeal it.

On CNN Thursday, Graham told Democrats why he believed they should support the bill. “You’re gonna have to go to your governor in your state and say, ‘We don’t trust you with this money, we trust the bureaucrats more,'” Graham said. “That’s going to be hard politics if we keep the taxes in place for Democrats because they’ve gotta pick between a Washington bureaucrat and their own people in their state.”

“I think it’s provocative. What Lindsey has done a good job of doing is talking to governors about what they want, and it appears the answer is more money,” South Carolina Republican Sen. Tim Scott told USA TODAY. Scott said the proposal could be a way “to get governors satisfied.”

“I think it’s intriguing,” said Nevada Sen. Dean Heller. “I think we ought to take a closer look at it.” Heller’s announcement that he opposed the first Senate repeal bill was a key tipping point, and ultimately McConnell had to scrap a planned vote on the bill. Heller has not yet said whether he supports the new Republican bill.

Maureen Groppe, Eliza Collins and Deirdre Shesgreen stated that Senate Republicans hope their latest proposed bill to replace Obamacare will attract enough votes from the moderate and conservative wings of their party to pass next week.

But there are at least five hurdles that could derail efforts to reach consensus. They include:

1. The bill still makes major cuts to Medicaid

More than 14 million Americans gained eligibility for Medicaid through Obamacare, and they could lose that coverage under the Senate bill, which phases out federal funds by 2024 for expanded Medicaid coverage.

That’s a problem for some moderate Republicans, who worry that their most vulnerable constituents will be harmed. Sen. Susan Collins, R-Maine, cited those cuts in a tweet Thursday saying that she will vote against a procedural motion to bring the bill to the floor, known as a “motion to proceed.”

Still deep cuts to Medicaid in Senate bill. Will vote no on MTP. Ready to work w/ GOP & Dem colleagues to fix flaws in ACA.

Patients who rely on Medicaid to get treatment for opioid abuse also could lose that coverage, undermining efforts by moderate GOP Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia to boost federal support to fight the epidemic in their states. However, the bill does provide $45 billion in additional funding for opioid treatment, in an effort to lure Portman, Capito, and others.

2. It does not fully repeal Obamacare

Conservatives want a complete repeal of the Affordable Care Act, especially its taxes. This bill would not do that.

While it eliminates taxes on health insurance, prescription drugs, medical devices and high-cost employer-sponsored plans, the legislation leaves in place Obamacare taxes on wealthy Americans to help subsidize coverage for lower-income people.

Sen. Rand Paul, R-Ky., a conservative with a libertarian bent, said he cannot support a bill that leaves so much of Obamacare in place. His spokesman said the senator plans to vote against the motion to bring the GOP legislation to the Senate floor next week.

“I pledged to the voters to repeal Obamacare, I think it’s a disaster,” Paul said Thursday on Fox News. “But this bill doesn’t repeal it. It keeps about half of the Obamacare taxes, it keeps most of the Obamacare regulations, it keeps most of the Obamacare subsidies, and it creates a giant new insurance bailout Superfund of about $200 billion. This isn’t repealed by any means, shape or form.”

3. It still raises costs for older Americans

Groups representing older Americans — who traditionally vote in higher numbers — are blasting the bill for continuing to impose an “age tax” on Americans 55 to 64, who are still too young to benefit from Medicare.

“AARP reiterates our opposition to the Age Tax which would allow insurance companies to charge older Americans five times more than everyone else for the same coverage,” the organization said in a statement Thursday. The organization has 38 million members 50 and older.

Democrats signaled that they would hit Republicans hard during next year’s congressional elections if they vote for this provision.

“Premiums for so many people aged 55 to 64 will go way up,” said Minority Leader Chuck Schumer, D-N.Y., in a speech on the Senate floor Thursday. “Americans in their sixties could be paying tens of thousands of dollars more than they do today.”

4. It still defunds Planned Parenthood

The bill would block Planned Parenthood from receiving Medicaid funding for a year. Federal law already prohibits the organization from using federal funds to perform abortions, but the bill would also prevent the group from using Medicaid money to offer birth control services, treat sexually transmitted diseases, and provide other medical care.

Most Republicans support defunding Planned Parenthood, but two key moderates — Collins and Sen. Lisa Murkowski, R-Alaska — are strong supporters of the group and have consistently opposed efforts to defund it.

“I, for one, do not believe that Planned Parenthood has any place in our deliberations on the Affordable Care Act,” Murkowski said in an address to Alaska state lawmakers earlier this year. “Taxpayer dollars should not be used to pay for abortions, but I will not vote to deny Alaskans access to the health services that Planned Parenthood provides.”

5. Two GOP senators are offering a potentially attractive alternative

Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., offered an alternative Thursday that they said could attract more support than the bill introduced by GOP leaders.

Their plan would send the current federal funding for Obamacare, estimated at about $110 billion last year, to the states in the form of block grants that governors could use however they want. Graham said states could keep Obamacare in place or replace it with a new system.

“Instead of having a one-size-fits-all solution from Washington, we should return dollars back to the states to address each individual state’s health care needs,” Graham said.

Sen. Ron Johnson, R-Wis., who opposed an earlier version of the GOP health care bill and is undecided on the latest version, said the Graham-Cassidy alternative “actually has some appeal to me.”

Reviewing the tables that I included one wonders, does anybody except me see how this is progressing? The GOP revisionary bills are becoming more and more to parallel the Affordable Care Act/Obamacare as the Republican Senators with reasonable “brains” realize that there are some parts of the ACA that are “good” and important enough to get their new health care bill to have any chance of passing in the Senate. But, also there are some well thought out parts of the ACA that do make the delivery of health care better. I know, I shouldn’t have stated that I think parts of the ACA are good for patients, but there are good parts to this well-thought out bill. The problem, as I continue to stress is that it is not sustainable and that there are flaws that if our Congress were really concerned would work together to modify the ACA to make it work for all.

I will look more at many questions that you all may wonder about and I promise I will try to clear some of the murky waters that probably are confusing any ability to understand really what the new bills and all the revisions mean to all of us.