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President-elect Donald Trumps return to the White House could embolden Republicans who want to weaken or repeal the Affordable Care Act, but implementing such sweeping changes would still require overcoming procedural and political hurdles.

This story also ran on NPR. It can be republished for free.

Trump, long an ACA opponent, expressed interest during the campaign in retooling the health law. In addition, some high-ranking Republican lawmakers who will now have control over both the House and the Senate have said revamping the landmark 2010 legislation known as Obamacare would be a priority. They say the law is too expensive and represents government overreach.

The governing trifecta sets the stage for potentially seismic changes that could curtail the laws Medicaid expansion, raise the uninsured rate, weaken patient protections, and increase premium costs for millions of people.

The Republican plans they dont say they are going to repeal the ACA, but their collection of policies could amount to the same thing or worse, said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a research and policy institute. It could happen through legislation and regulation. Were on alert for anything and everything. It could take many forms.

Congressional Republicans have held dozens of votes over the years to try to repeal the law. They were unable to get it done in 2017 after Trump became president, even though they held both chambers and the White House, in large part because some GOP lawmakers wouldnt support legislation they said would cause such a marked increase in the uninsured rate.

Similar opposition to revamping the law could emerge again, especially because polls show the ACAs protections are popular.

While neither Trump nor his GOP allies have elaborated on what they would change, House Speaker Mike Johnson said last month that the ACA needs massive reform and would be on the partys agenda should Trump win. Email Sign-Up

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Congress could theoretically change the ACA without a single Democratic vote, using a process known as “reconciliation.” The narrow margins by which Republicans control the House and Senate mean just a handful of “no” votes could sink that effort, though.

Many of the more ambitious goals would require Congress. Some conservatives have called for changing the funding formula for Medicaid, a federal-state government health insurance program for low-income and disabled people. The idea would be to use budget reconciliation to gain lawmakers approval to reduce the share paid by the federal government for the expansion population. The group that would be most affected is made up largely of higher-income adults and adults who dont have children rather than traditional Medicaid beneficiaries such as pregnant women, children, and people with disabilities.

A conservative idea that would let individuals use ACA subsidies for plans on the exchange that dont comply with the health law would likely require Congress. That could cause healthier people to use the subsidies to buy cheaper and skimpier plans, raising premiums for older and sicker consumers who need more comprehensive coverage.

Its similar to an ACA repeal plan, said Cynthia Cox, a vice president and the director of the Affordable Care Act program at KFF, a health information nonprofit that includes KFF Health News. Its repeal with a different name.

Congress would likely be needed to enact a proposal to shift a portion of consumers ACA subsidies to health savings accounts to pay for eligible medical expenses.

Trump could also opt to bypass Congress. He did so during his previous tenure, when the Department of Health and Human Services invited states to apply for waivers to change the way their Medicaid programs were paid for capping federal funds in exchange for more state flexibility in running the program. Waivers have been popular among both blue and red states for making other changes to Medicaid.

Trump will do whatever he thinks he can get away with, said Chris Edelson, an assistant professor of government at American University. If he wants to do something, hell just do it.

Republicans have another option to weaken the ACA: They can simply do nothing. Temporary, enhanced subsidies that reduce premium costs and contributed to the nations lowest uninsured rate on record are set to expire at the end of next year without congressional action. Premiums would then double or more, on average, for subsidized consumers in 12 states who enrolled using the federal ACA exchange, according to data from KFF.

That would mean fewer people could afford coverage on the ACA exchanges. And while the number of people covered by employer plans would likely increase, an additional 1.7 million uninsured individuals are projected each year from 2024 to 2033, according to federal estimates.

Many of the states that would be most affected, including Texas and Florida, are represented by Republicans in Congress, which could give some lawmakers pause about letting the subsidies lapse.

The Trump administration could opt to stop defending the law against suits seeking to topple parts of it. One of the most notable cases challenges the ACA requirement that insurers cover some preventive services, such as cancer screenings and alcohol use counseling, at no cost. About 150 million people now benefit from the coverage requirement.

If the Department of Justice were to withdraw its petition after Trump takes office, the plaintiffs would not have to observe the coverage requirement which could inspire similar challenges, with broader implications. A recent Supreme Court ruling left the door open to legal challenges by other employers and insurers seeking the same relief, said Zachary Baron, a director of Georgetown Universitys Center for Health Policy and the Law.

In the meantime, Trump could initiate changes from his first day in the Oval Office through executive orders, which are directives that have the force of law.

The early executive orders will give us a sense of policies that the administration plans to pursue, said Allison Orris, a senior fellow at the Center on Budget and Policy Priorities. Early signaling through executive orders will send a message about what guidance, regulations, and policy could follow.

In fact, Trump relied heavily on these orders during his previous term: An October 2017 order directed federal agencies to begin modifying the ACA and ultimately increased consumer access to health plans that didnt comply with the law. He could issue similar orders early on in his new term, using them to start the process of compelling changes to the law, such as stepped-up oversight of potential fraud.

The administration could early on take other steps that work against the ACA, such as curtailing federal funding for outreach and help signing up for ACA plans. Both actions depressed enrollment during the previous Trump administration.

Trump could also use regulations to implement other conservative proposals, such as increasing access to health insurance plans that dont comply with ACA consumer protections.

The Biden administration walked back Trumps efforts to expand what are often known as short-term health plans, disparaging the plans as junk insurance because they may not cover certain benefits and can deny coverage to those with a preexisting health condition.

The Trump administration is expected to use regulation to reverse Bidens reversal, allowing consumers to keep and renew the plans for much longer.

But drafting regulations has become far more complicated following a Supreme Court ruling saying federal courts no longer have to defer to federal agencies facing a legal challenge to their authority. In its wake, any rules from a Trump-era HHS could draw more efforts to block them in the courts.

Some people with ACA plans say theyre concerned. Dylan Reed, a 43-year-old small-buiness owner from Loveland, Colorado, remembers the days before the ACA and doesnt want to go back to a time when insurance was hard to get and afford.

In addition to attention-deficit/hyperactivity disorder and anxiety, he has scleroderma, an autoimmune disease associated with joint pain and numbness in the extremities. Even with his ACA plan, he estimates, he pays about $1,000 a month for medications alone.

He worries that without the protections of the ACA it will be hard to find coverage with his preexisting conditions.

It’s definitely a terrifying thought, Reed said. I would probably survive. I would just be in a lot of pain. Stephanie Armour: sarmour@kff.org, @StephArmour1

Sam Whitehead: swhitehead@kff.org

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Microsoft unveils new voice-activated AI assistant for doctors

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Microsoft unveils new voice-activated AI assistant for doctors

Microsoft is giving its health-care artificial intelligence tools a makeover. 

The company on Monday unveiled a new voice-activated AI assistant that combines capabilities from its dictation solution, Dragon Medical One, and ambient listening solution, DAX Copilot, into one tool.

“Dragon Copilot” will be able to help doctors quickly pull information from medical sources and automatically draft clinical notes, referral letters, post-visit summaries and more, according to the company. It’s Microsoft’s latest effort to help health-care workers cut down their daunting clerical workloads, which are a major source of burnout in the industry.

Clinicians spend nearly 28 hours a week on administrative tasks like documentation, for instance, according to an October study from Google Cloud.

“Through this technology, clinicians will have the ability to focus on the patient rather than the computer, and this is going to lead to better outcomes and ultimately better health care for all,” Dr. David Rhew, global chief medical officer at Microsoft, said Thursday in a briefing with reporters.

Microsoft acquired Nuance Communications, the company behind Dragon Medical One and DAX Copilot, for about $16 billion in 2021. As a result, Microsoft has become a major player in the fiercely competitive AI scribing market, which has exploded in popularity as health systems have been looking for tools to help address burnout. 

AI scribes like DAX Copilot allow doctors to draft clinical notes in real time as they consensually record their visits with patients. DAX Copilot has been used in more than 3 million patient visits across 600 health-care organizations in the last month, Microsoft said.   

Other companies like Abridge, which has raised more than $460 million according to PitchBook, and Suki, which has raised nearly $170 million, have developed similar scribing tools. Microsoft’s updated interface could help it stand out from its competitors. 

Dragon Copilot is accessible through a mobile app, browser or desktop, and it integrates directly with several different electronic health records, the company said. 

Clinicians will still be able to draft clinical notes with the assistant like they could with DAX Copilot, but they’ll be able to use natural language to edit their documentation and prompt it further, Kenn Harper, general manager of Dragon products at Microsoft, told reporters on the call.

For instance, a doctor could ask questions like, “Was the patient experiencing ear pain?” or “Can you add the ICD-10 codes to the assessment and plan?” Physicians can also ask broader treatment-related queries such as, “Should this patient be screened for lung cancer?” and get an answer with links to resources like the Centers for Disease Control and Prevention. 

WellSpan Health, which treats patients across 250 locations and nine hospitals throughout central Pennsylvania and northern Maryland, has been testing out Dragon Copilot with a group of clinicians in recent months. 

One of those clinicians is Dr. David Gasperack, chief medical officer of primary care services at WellSpan. It’s still early days, but Gasperack told CNBC the assistant is easy to use and has been more accurate than Microsoft’s existing offerings. 

“We’ve been asked more and more over time to do more administrative tasks that pull us away from the patient relationship and medical decision making,” Gasperack said. “This allows us to get back to that so we can focus on the patient, truly think about what’s needed.”

Microsoft declined to share the cost of Dragon Copilot but said the pricing structure is “competitive.” It will be easy for existing customers to upgrade to the new offering, the company added.   

Dragon Copilot will be generally available in the U.S. and Canada starting in May, Microsoft said. The roll out will expand to the U.K., the Netherlands, France and Germany in the months following.

“Our goal remains to restore the joy of practicing medicine for clinicians and provide a better experience for patients globally,” Rhew said.

Watch: What it’s like to have a doctor visit with AI

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The crypto law alphabet soup of the UAE

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The crypto law alphabet soup of the UAE

Navigating the UAE’s crypto ecosystem means decoding a maze of acronyms — SCA, VARA, DMCC, ADGM and more.

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Who’s in, who’s out? The ‘coalition of the willing’ that could secure peace in Ukraine

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Who's in, who's out? The 'coalition of the willing' that could secure peace in Ukraine

A “coalition of the willing” could provide boots on the ground in Ukraine in the event of a ceasefire. 

The phrase was a central theme of Sir Keir Starmer’s speech after European leaders gathered in London for crucial talks about Ukraine’s future.

Led by the UK and France, the initiative could see troops from a number of European and NATO countries deployed to Ukraine as peacekeepers in order to deter Vladimir Putin from rearming and attacking again in the future.

Follow latest: Russia not ready to negotiate, Zelenskyy says

Sir Keir said Europe “must do the heavy lifting” on defence and indicated several countries had expressed interest in being part of the coalition.

So who’s in, who’s out – and what’s behind these latest buzzwords?

Ukraine's President Volodymyr Zelensky, Prime Minister Sir Keir Starmer and France's President Emmanuel Macron hold a meeting during a Leaders' Summit on the situation in Ukraine at Lancaster House, London. Picture date: Sunday March 2, 2025.
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The UK, France and Ukraine are leading on developing a peace deal. Pic: PA

What is a coalition of the willing?

The prime minister has said the UK, France and Ukraine will work together on a peace deal that could be presented to the US.

The countries committed to working together on this deal would form a “coalition of the willing”.

Countries in the coalition could end up sending soldiers to act as peacekeepers in Ukraine in the event of a ceasefire.

Military analyst Michael Clarke said: “It has to be a coalition of the willing because you have at least two NATO members – Slovakia and Hungary – who are vetoing anything that Putin would not like… it’s the same with the EU.”

This approach would allow NATO members to act in a group but not under the NATO umbrella, avoiding vetoes from member states who don’t approve or don’t wish to be involved.

Sir Keir’s choice of the term “coalition of the willing” is also interesting. It’s perhaps intended to remind an American audience of a previous use of the same phrase: when the UK, Poland and other countries joined the US invasion of Iraq.

Russia has so far rejected the idea of any NATO or European peacekeeping force in Ukraine.

Map of military personnel by country, based on NATO estimates.
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Map of military personnel by country, based on NATO estimates.

Who’s in?

Sir Keir is being “quite coy about who the willing are”, Prof Clarke said.

The initiative is being led by the UK and France, so it seems a safe bet that both countries would be involved in the coalition.

Both have powerful militaries and the two nations are also the only countries in Europe with nuclear weapons.

“The important thing is that Britain and France are going to lead it because they are the two most important military powers in Europe,” Prof Clarke told Sky News.

It is notable that France’s President Emmanuel Macron originally raised the possibility of French troops in Ukraine last year, when he refused to rule it out.

A F-16 aircraft releases flares during the "Noble Sword-14" NATO international tactical exercise at the land forces training centre in Oleszno, near Drawsko Pomorskie, northwest Poland September 9, 2014. About 1,700 soldiers from Croatia, Estonia, France, the Netherlands, Lithuania, Germany, Norway, Poland, Slovakia, Slovenia, the U.S., Turkey, Hungary, Britain and Italy are participating in the three-week exercise. REUTERS/Kacper Pempel (POLAND  - Tags: POLITICS MILITARY)
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An F-16 aircraft releases flares during a NATO exercise over Poland. Pic: Reuters

The Baltic states – Estonia, Lithuania and Latvia – are also likely to be involved, along with Finland, Prof Clarke says. All four countries are in NATO and share borders with Russia.

Italy could be involved too, Prof Clarke said, though Prime Minister Giorgia Meloni has clashed with Mr Macron over the idea last week.

Not in Europe but a NATO member, Canada seems another potential contributor to the coalition of the willing.

Prime Minister Justin Trudeau, when asked about a potential deployment of troops as part of a peacekeeping force, said yesterday: “Canada has looked at the ways it can best help and as I’ve said a few days ago, everything’s on the table.”

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The Ukraine summit: How the day unfolded

Who’s out?

Prof Clarke said Poland, Spain and Germany are not expected to send troops as peacekeepers, for different reasons.

Poland has one of the strongest militaries in Europe and aims to spend 4.7% of its GDP on defence this year, well above the NATO target.

But it also has a long border with Ukraine and Belarus and is concerned about its own security.

Polish Prime Minister Donald Tusk last month said: “We do not plan to send Polish soldiers to the territory of Ukraine.”

“We will… give logistical and political support to the countries that will possibly want to provide such guarantees in the future, such physical guarantees.”

starmer X meloni
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Italy’s Giorgia Meloni has been critical of plans to send troops to Ukraine

Spain’s foreign minister Jose Manuel Albares said last month that it was “too early at the moment to talk about deploying troops in Ukraine”, in remarks quoted by AFP.

He added: “There is no peace at the moment, and the effort has to be to achieve it as soon as possible.”

Spain’s government has faced a number of crises at home and spends around 1.28% of GDP on defence, well below the NATO 2% target.

As the biggest economy in Europe, Germany is a crucial part of any united response to the Ukraine war.

But a new government has not yet been formed after last month’s elections.

Friedrich Merz, leader of the Christian Democratic Union (CDU) party, at a rally in Munich. Pic: Reuters
Image:
Incoming German Chancellor Friedrich Merz. Pic: Reuters

Outgoing Chancellor Olaf Scholz has previously ruled out sending German troops to Ukraine as peacekeepers.

While his government has provided substantial support to Ukraine since the full-scale invasion, he has been seen by some as hesitant – for example resisting calls to send the vaunted Taurus missiles to Kyiv.

Friedrich Merz, who is expected to replace him as chancellor once the new government is in place, has taken a harder line, including on pledging Taurus missiles, so it remains to be seen if his attitude on deploying troops will also deviate from his predecessor.

‘Coalition of the willing’ is a curious term to revive


Deborah Hayes

Deborah Haynes

Security and Defence Editor

@haynesdeborah

The use of the term “coalition of the willing” to describe the nations that agree to support an international force to help protect any ceasefire deal in Ukraine is interesting and notable.

It could perhaps be an attempt by Sir Keir Starmer to appeal to an American audience as this was the phrase the United States used for its “coalition of the willing” to invade Iraq more than two decades ago.

That intervention ended in disaster, triggering a bloody insurgency and locking the US and its allies into a costly war, despite the successful toppling of Saddam Hussein.

But reviving the words “coalition of the willing” will – if nothing else – remind Washington that London was its biggest and strongest backer when it turned to allies to back its 2003 invasion.

What about America?

The elephant in the room is the biggest contributor to NATO: the US.

For example, of the 5,015 fighter and fighter ground-attack aircraft in NATO, 2,951 of them are from the US, and a further 1,108 are US-made, according to the International Institute for Strategic Studies thinktank.

And America’s military is not just the largest in the world, but its ability to support troops in the field in terms of logistics is very hard to replace.

The coalition of the willing initiative seems designed to show President Donald Trump that Europe is serious about shouldering the defence burden and taking on more responsibility for the defence of Ukraine.

It should be pointed out that while the US is the single biggest donor to Kyiv, Europe as a whole has pledged more, according to the Kiel Institute for the World Economy thinktank.

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The hope seems to be that the coalition of the willing initiative would persuade the US as the world’s most powerful military to pledge support as a backstop, to underwrite the peace deal.

It’s unclear so far what Washington’s response will be, particularly after the fiery recent meeting between Mr Trump, vice president JD Vance and Mr Zelenskyy.

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