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The Lord giveth and the Lord taketh away, but for governments its not that easy. Once something is given say, health insurance coverage to 20 million Americans you take it away at your peril. This is true for any government benefit, but especially for health care. Theres a reason not one Western democracy with some system of national health care has ever abolished it.

The genius of the left is to keep enlarging the entitlement state by creating new giveaways that are politically impossible to repeal. For 20 years, Republicans railed against the New Deal. Yet, when they came back into office in 1953, Eisenhower didnt just keep Social Security, he expanded it.

People hated Obamacare for its highhandedness, incompetence and cost. At the same time, its crafters took great care to create new beneficiaries and new expectations. Which makes repeal very complicated.

The Congressional Budget Office projects that, under Paul Ryans Obamacare replacement bill, 24 million will lose insurance within 10 years, 14 million after the first year.

Granted, the number is highly suspect. CBO projects 18 million covered by the Obamacare exchanges in 2018. But the number today is about 10 million. That means the CBO estimate of those losing coverage is already about 8 million too high.

Nonetheless, there will be losers. And their stories will be plastered wall to wall across the media as sure as night follows day.

That scares GOP moderates. And yet the main resistance to Ryan comes from conservative members complaining that the bill is not ideologically pure enough. They mock it as Obamacare Lite.

For example, Ryan wants to ease the pain by phasing out Medicaid expansion through 2020. The conservative Republican Study Committee wants it done next year. This is crazy. For the sake of two years savings, why would you risk a political crash landing?

Moreover, the idea that you can eradicate Obamacare root and branch is fanciful. For all its catastrophic flaws, Obamacare changed expectations. Does any Republican propose returning to a time when you can be denied health insurance because of a pre-existing condition?

Its not just Donald Trump who ran on retaining this new, yes, entitlement. Everyone did. But its very problematic. If people know that they can sign up for insurance after they get sick, the very idea of insurance is undermined. People wont sign up when healthy and the insurance companies will go broke.

So what do you do? Obamacare imposed a monetary fine if you didnt sign up, for which the Ryan bill substitutes another mechanism, less heavy-handed but still government-mandated.

The purists who insist upon entirely escaping the heavy hand of government are dreaming. The best you can hope for is to make it less intrusive and more rational, as in the Ryan plans block-granting Medicaid.

Or instituting a more realistic age-rating system. Sixty-year-olds use six times as much health care as 20-year-olds, yet Obamacare decreed, entirely arbitrarily, that the former could be charged insurance premiums no more than three times that of the latter. The GOP bill changes the ratio from 3-to-1 to 5-to-1.

Premiums better reflecting risk constitute a major restoration of rationality. (Its how life insurance works.) Under Obamacare, the young were unwilling to be swindled and refused to sign up. Without their support, the whole system is thus headed into a death spiral of looming insolvency.

Rationality, however, has a price. The CBO has already predicted a massive increase in premiums for 60-year-olds. Thats the headline.

There is no free lunch. GOP hard-liners must accept that Americans have become accustomed to some new health care benefits, just as moderates have to brace themselves for stories about the inevitable losers in any reform. Thats the political price for fulfilling the seven-year promise of repealing and replacing Obamacare.

Unless, of course, you go the full Machiavelli and throw it all back on the Democrats. How? Republicans could forget about meeting the arcane requirements of reconciliation legislation (which requires only 51 votes in the Senate) and send the Senate a replacement bill loaded up with everything conservative including, tort reform and insurance competition across state lines. That would require 60 Senate votes. Let the Democrats filibuster it to death and take the blame when repeal-and-replace fails, Obamacare carries on and then collapses.

Upside: You reap the backlash. Downside: You have to live with your conscience.

Charles Krauthammers email address is letters@charleskrauthammer.com.

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COMMENTARY: Republicans, the real world and repealing Obamacare - Las Vegas Review-Journal

WASHINGTON Republicans moved to require able-bodied, poor Americans to work to receive publicly funded health insurance through Medicaid on Thursday, advancing a long-held goal of conservative reformers.

These work requirements address a common concern of policymakers around public-assistance programs: that the poor will not look for work, because if they earned more, they might no longer be poor enough to qualify for help. Additionally, for Republicans and many Democrats, work requirements are a matter of fairness.

When Medicaid was created, it wasnt intended to become an entitlement for able-bodied adults, said Rep. Gary Palmer, R-Ala., introducing the proposal to include Medicaid work requirements in the Republicans health care bill.

Republicans on the House budget committee voted to include the proposal, a one-sentence motion that leaves the details of the plan for later in the legislative process. But like the Republicans health care bill itself, it has many hurdles left to clear to become law.

Many forms of public assistance, including food stamps, require recipients to work, look for work, volunteer or participate in vocational training. The work requirements vary by the program and traits of the recipients, such as their ages and whether they have children.

Yet when it comes to health insurance, such requirements would be nearly impossible to enforce, conservative and independent experts on the Medicaid program said Friday.

Its not entirely clear that this requirement makes a lot of sense, said Benjamin Sommers, a public-health expert at Harvard University.

The majority of adults receiving Medicaid already are working. Currently, about 78 percent of adults enrolled in Medicaid who are not elderly live in households with at least one person working, according to an analysis by the nonpartisan Kaiser Family Foundation. Those who are not working might have good reasons for doing so, said Diane Rowland, an executive vice president at the foundation.

Experts also questioned whether officials were really prepared to deny medical care to people who were seriously ill because they had not been working.

The proposal misses the point, said Robert Rector, an expert on welfare at the conservative Heritage Foundation, who dismissed the plan as largely a matter of press release, not policy substance.

Mr. Rector was skeptical that governors and other state officials would enforce the requirements strictly, if at all.

He pointed out that if a person wanted to avoid the requirement, she could simply not enroll in Medicaid unless she became ill, at which point she could go to a hospital or a clinic and enroll then.

Its very difficult to deny an individual medical services when theyre sick, he said. It seems reasonable to say, Well, if society is going to care for you, or assist you, you should do something back in return. The problem is its very difficult to do that with regard to medical care.

The analysis from the Kaiser Family Foundation, based on federal surveys, suggests that about 18 percent of adult Medicaid beneficiaries who are not working are in school. Another 28 percent report that they are taking care of members of their family, and 35 percent say that they are sick or disabled.

People who can work, try to work, the foundations Ms. Rowland said. Theyre working in gas stations and restaurants in places unless they live in San Francisco where they dont get health benefits.

The Republican recommendation is limited to able-bodied adults without children or other dependents.

Ms. Rowland pointed out, though, that states would presumably have the difficult task of determining who would be considered able-bodied and subject to the requirements, and who is too sick to work.

Nor is there evidence that Medicaid discourages beneficiaries from getting jobs.

Researchers had an opportunity to test this theory in Oregon, when the state expanded Medicaid to a larger group of residents using a lottery. The group that lost out in the lottery neither worked more nor earned more, the economists who studied the program found.

Other research has come to similar conclusions. A review published in 2012 concluded that Medicaid had essentially a zero effect on beneficiaries decisions about work. That could be because people who qualify for the program are poor enough that they need to work if they can, whether or not they have health insurance.

It is certainly possible that some recipients could be pushed to work, and that they might find private health insurance through their employer as a result.

Even so, Ms. Rowland argued that the program was unlikely to save much money from shifting those beneficiaries off the rolls. Those who are healthy enough to work likely cost Medicaid little, she said, while the program spends the bulk of its resources caring for people who will not be able to enter the labor force.

You probably are not going to do very much to change the cost of the program, Ms. Rowland said. Its not healthy people who are on Medicaid who cost money.

Michael Strain, an economist at the conservative American Enterprise Institute, agreed that the rule would be largely symbolic.

He called the idea of requiring work in general reasonable and sound, but added: If it were a firm requirement, and that meant that somebody who got hit by a bus showed up at a hospital and they werent treated, that seems like bad policy to me.

President Donald Trumps views on the question are unknown, but in the past, he has made expansive and inclusive promises about coverage for the poor.

Were going to have insurance for everybody, Mr. Trump told The Washington Post in January. There was a philosophy in some circles that if you cant pay for it, you dont get it. Thats not going to happen with us.

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Republicans threaten to deny poor people medical care if they aren't ... - Pittsburgh Post-Gazette

WASHINGTON U.S. House Republicans are working on changes to their healthcare overhaul bill that would implement a work requirement for the Medicaid program for the poor, as well as boost tax credits for older, lower income people, U.S. House Speaker Paul Ryan said on Sunday.

"We think we should be offering more assistance than the bill currently does," for lower-income people age 50 to 64, Ryan said of the tax credits for health insurance that are proposed in the legislation.

Speaking on the "Fox News Sunday" television program, Ryan also said Republicans are working on changes that would allow federal block grants to states for Medicaid. Lawmakers plan to have the healthcare legislation on the House floor this Thursday, Ryan said.

(Reporting by Susan Cornwell; Editing by Jeffrey Benkoe)

DUBLIN President Donald Trump may begin his overhaul of the U.S. tax code as early as late spring, White House spokesman Sean Spicer has told Ireland's Sunday Independent newspaper.

WASHINGTON When President Donald Trump's U.S. Supreme Court nominee Neil Gorsuch is sworn in for his Senate confirmation hearing on Monday, Democrats will make the case that he is a pro-business, social conservative insufficiently independent of the president.

NEW YORK Meals on Wheels America, the umbrella organization for 5,000 providers of home-delivered meals for seniors, said on Saturday that online donations have surged since the White House released a proposed budget that could lead to a big drop in its funding.

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US Republicans working on Medicaid, tax credit changes: Ryan - Reuters

Amid loud boos during a town hall in Cedar Rapids, Iowa on March 17, Sen. Joni Ernst (R-Iowa) said that Education Secretary Betsy DeVos was "carefully vetted" and that Congress will hold her accountable. (Facebookl/GazetteOnline)

Sen. Joni Ernst sat on the stage at Coe College in Cedar Rapids, Iowa, nothing but a table and a few bottles of water between her and an auditorium-full of constituent angst.

The chilliest response came after a question about Betsy DeVos, who was confirmed as education secretary in a historic tiebreaking vote by Vice President Mike Pence. In the vote, two Republicans voted with the 48 Democrats, saying they didnt think DeVos was qualified for the job.

Ernst, who voted for DeVos, said the Michigan billionaire was carefully vetted. She supports all types of education. I support all types of education.

The answer wasnt fully out of her mouth before it met with a loud chorus of boos.

Ernst was the latest Republican legislator verbally pummeled by the people she represents during a home-state town hall.

The town halls filled with angry constituents parallel the tea party movement that grew in prominence after Barack Obamas election as president in 2008.As The Washington Posts Dan Zak and Terence Samuel wrote last month, Republicans hosting town halls are enduring protests, sharp rebukes and emotional questions about what [questioners] see as a sharp turn in governance as well as the House and Senates willingness to check the White House.

That about sums up Ernsts experience Friday night, as hundreds endured a brisk Iowa night to ask their elected senator a question or upbraid her about various topics, including DeVos.

DeVos has drawn sharp criticism in the few weeks shes been education secretary.

As The Posts Valerie Strauss wrote, within a few weeks of being confirmed, DeVos had already insulted middle school teachers, made confusing statements about Common Core state standards and made clear that her top priority is alternatives to public schools.

Last month, she stirred up more controversy when she issued a statement saying historically black colleges and universities were pioneers of school choice not a reaction to racist policies that prevented blacks from going to college.

DeVoss qualifications for the job were openly mocked on a Saturday Night Live skit mostly remembered for Melissa McCarthys portrayal of White House press secretary Sean Spicer. In the skit, Spicer calls DeVos (played by Kate McKinnon) to the stage to field a complicated question about education standards:

I dont know anything about school, but I do think there should be a school. Probably Jesus school. And I do think it should have walls and roof and gun for potential grizzly, before she was pushed off the stage.

Onstage Friday, Ernst, the first female veteran to serve in the U.S. Senate, was laughed at and booed for saying that climate change was natural and for her statements on health care.

She did receive a favorable response after a man expressed his disappointment that Trump didnt release his taxes, according to Des Moines CBS-affiliate KCCI.

[Republican town halls are getting very, very nasty]

I will tell you, I agree that I think he should release his taxes, she told the man.

Trump became the first modern-era presidential candidate to not release his tax returns.NBCs Rachel Maddow reported on Trumps tax returns earlier this week, reviving calls for the president to release the documents.

When Ernst said she agreed with those calls, for a moment, a hostile crowd turned warm, according to Politico.

She got a standing ovation.

At a town hall in Des Moines on March 17, Sen. Joni Ernst (R-Iowa) was met by jeers and boos when she declined to say whether Rep. Steve King (R-Iowa) should resign following a controversial tweet that has been criticized as racist. (Twitter/Iowa Starting Line)

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A Republican senator defended Betsy DeVos at a town hall. Boos ... - Washington Post

The Daily Banter

Trump Is Scaring Republicans Straight (Temporarily) The Daily Banter The sight of Republicans running for the hills to avoid being seen as agreeing with Trump began in earnest after their Orange King tweeted that President Obama had tapped the phones in Trump Tower. Nebraska Senator Ben Sasse quickly called for Trump ... and more »

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Trump Is Scaring Republicans Straight (Temporarily) - The Daily Banter