Since passing the House Budget using a legislative tactic they’ve previously described as “unconstitutional,” Republicans have begun their appropriations process by marking up legislation that would cut millions from federal safety net programs and middle class health care benefits in order to finance their $3 trillion giveaway to corporations and the richest Americans.

Under the Republican-approved budget, for instance, the House Ways & Means committee is instructed to reduce the deficit by $53 billion between 2013 and 2022 and members are not wasting any time going after the benefits that lower and middle class Americans rely on and block granting social programs to the states. First on the chopping block: are health care subsidies for middle class families earning up to $90,000 a year who will purchase insurance in the state-based exchanges, child care and related assistance for 4.4 million children, Meals On Wheels and other home-based services for nearly 1.7 million older Americans, and transportation services for almost 1 million disabled individuals.

During this morning’s hearing, Rep. Xavier Becerra (D-CA) pressed the Joint Committee on Taxation on the consequences of the GOP’s health subsidy proposal — which would require families to pay back the government if their incomes fluctuate and dissuade people from claiming credits in the first place. Under current law, the premium support is paid out as an advance refundable amount to insurance companies based on an estimate of annual income (the assistance is available, on a sliding scale, to families of four making up to $90,000 a year). Should a family’s income change during the year, it will have to pay the government back a specific dollar amount come tax season. Congress has increased the amount since the law passed and under the current Republican proposal, “an individual would be liable for the full amount of the overpayment.”

The JCT found that the tax increase would lead 350,000 people to lose coverage and, as the National Women’s Law Center explained in a letter to Becerra, it would “especially hurt women”:

BECERRA: The letter from the National Women’s Law Center points out that eliminating this provision, which is called the safe harbor provision, would especially hurt women… A 2008 study by the Congressional Budget Office found that women experience more large changes in earnings from year to year than men. This suggests that women are more likely to have a difference in estimate actual income during the year and therefore more likely to repay a portion of the tax credit during the reconciliation. Eliminating the safe harbor by removing the repayment cap will leave women who enrolled in coverage but had an income change mid-year…vulnerable to an unaffordable tax bill. As a result hundreds of thousands of women will refuse coverage for fear of the repayment penalty.

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Republicans have also proposed repealing the health care law in its entirety, which would result in 30 million Americans becoming uninsured.

The Obama administration has released a new report tracking the progress of states in building the health care exchanges that are part of the Affordable Care Act. Twenty-eight states and the District of Columbia “are on their way toward establishing their own Affordable Insurance Exchange,” the report notes and have received three rounds of grants from the federal government to set-up the new regulated marketplaces where small businesses and individuals will be able to compare and shop for comprehensive insurance beginning in 2014. States that fail to build their own exchanges will have to turn over their markets to the federal government.

The theoretical concept of encouraging insurers to compete on a level playing field within a new regulated market was originally developed by the Heritage Foundation in the 1990s and later embraced in Mitt Romney’s Massachusetts health care reform law. As the administration’s report notes, it’s also gaining momentum in some right-leaning states, many of which are also suing over the constitutionality of the Affordable Care Act:

– Nevada: The Silver State Health Insurance Exchange was authorized through bipartisan legislation passed unanimously by both chambers of the Nevada Legislature and signed into law by Governor Brian Sandoval (R) on June 16, 2011. [...] Its seven-member board was appointed on September 23, 2011 and met for the first time on October 26, 2011.

– Alabama: Governor Robert Bentley (R), a physician, issued an Executive Order that created the Alabama Health Insurance Exchange Study Commission on June 2, 2011. [...] Alabama received an Exchange establishment grant of $8.6 million on November 29 from HHS. The State also is participating in a technical assistance program run by the Robert Wood Johnson Foundation. The legislature, which meets in February, is expected to take up legislation to establish an Exchange.

– Mississippi: The State created a Mississippi Health Insurance Exchange Study Commission in 2010, and used its $1 million planning grant to fund research and outreach. On April 26, 2011, then-Governor Haley Barbour (R) signed a law that allowed the Study Commission to continue its work through 2011. [...] After legislation authorizing an Exchange failed to pass, the State determined in October 2011 that the previously authorized non-profit high-risk pool association could broaden its mission to run the State’s Exchange.

– Michigan: On September 14, 2011, Governor Rick Snyder (R) announced his intent to create a State-based Exchange called MIHealth Marketplace. [...] The Senate passed bi-partisan exchange legislation in November, however the House failed to act. On November 29, the State was awarded $9.8 million to establish its Exchange and is seeking the legislature’s authority to spend the funds

— Pennsylvania: On November 23, 2011, Governor Tom Corbett (R) announced his commitment to establishing a State-based Exchange. [...] Pennsylvania used the majority of its Exchange planning grant to award a contract to a consulting firm to conduct extensive background research. This resulted in a comprehensive analysis of Exchange governance models, business operations, structure, plan management and financial management.

Federal regulators have also been eager to allow states additional flexibility in forming the exchanges. States can choose to share responsibilities with the federal government and use their establishment grants “to test their systems for their Exchanges that start later than 2014.”

The New York state Senate is dragging its feet in implementing the Affordable Care Act’s state exchange, but a new survey from HealthPass finds that New York’s small businesses strongly support the measure and say they may be “more likely to offer health insurance if such a health insurance exchange were available”:

The survey found that more than eight in ten (84%) respondents describe health insurance exchanges as a “good idea” after reading a description of the proposed New York State SHOP (small business) Exchange. Additionally, more than three-fourths of respondents (76%) would consider using such a health insurance exchange when enrolling their employees in a health benefits program. Even more striking, among businesses that do not currently provide health insurance to their employees, 60% said they would be more likely to offer coverage if an exchange was available.

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Interestingly, despite increasing health care costs, small businesses say they would consider providing health insurance in the future, with 75 percent of respondents agreeing “that offering health care benefits helps them attract and retain quality employees.”

The Department of Health and Human Services estimates that 29 states “are making significant progress in creating Affordable Insurance Exchanges.”

Virginia Gov. Bob McDonnell (R) is a strong opponent of President Obama’s Affordable Care Act, claiming that the “unconstitutional” law is full of “unfunded mandates” that could “overwhelm our health care system.” But a new report from a 24-member advisory council he appointed in 2010 finds that health reform would cut the number of uninsured Virginians in half and significantly reduce state expenditures on uncompensated care.

The council, which is tasked with developing recommendations for implementing the ACA in Virginia and advising the General Assembly on how to establish an exchange, is urging the state to create a quasi-government Health Benefit Exchange with a governing board, “so that Virginia policy makers will have maximum freedom to shape health insurance markets and health reform in Virginia.” As a result:

[R]oughly half of the uninsured in Virginia will gain coverage, a little more than 520,000 people, and that 420,000 of them will gain Medicaid coverage. A little over 100,000 Virginians would gain private coverage, and more than 60 percent of them will be in group as opposed to non-group markets…[A]lmost 400,000 of those who gain coverage are in households with incomes less than two times the federal poverty level, though 70,000 of the formerly uninsured earn more than three times poverty today.

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According to modeling conducted for the council by the Urban Institute, uncompensated “care for the uninsured (and therefore implicit expense now borne by providers and public plus private payers) is expected to fall by over $800 million, the uninsured and demand for safety net care will not disappear from Virginia, though the scale of it should decline by roughly half.” The group also estimated that approximately 150,000 Virginians will receive federal subsidies to help them afford health insurance coverage.

McDonnell has forwarded the council’s report to the General Assembly, which must begin “planning the exchanges by 2013 so they can be operational in 2014.”