Repairing Obamacare

February 10, 2015; NPR, “Shots”

Although poor John Boehner has to lead his Republican colleagues through the monotonous mechanics of voting to repeal the Affordable Care Act whenever there is a lull in the House of Representatives, Speaker Boehner and his colleagues know that they have nothing to offer to replace the ACA. In fact, they know that to repeal and undo the program of national health insurance would be catastrophic for Americans. Aside from the indefatigable ideological positioning of some extreme wingnuts, the Republican establishment deep down doesn’t really want to scrap Obamacare.

Writing for Kaiser Health News, Julie Rovner suggests that this might be the time to fix the problems in the Affordable Care Act rather than imagining the entire program ought to be tossed away. NPQ has suggested the same many times, noting that legislation is typically reopened for technical corrections after it is passed by Congress and signed by the president. In the case of the ACA, however, the political posturing and polarization have been so extreme that such logical, normal actions such as technical corrections were not possible to contemplate. But whatever their frustrations with the national health insurance program, by most indications Americans actually favor fixing rather than repealing the Affordable Care Act.

If a sudden infusion of reason were to overcome congressional Republicans, what might be the agenda of fixes that our nation’s leaders might be well advised to pursue? A panel at the National Health Policy Conference earlier this week generated a list of potential ideas for improving the statute.

  • Jon Kingsdale, who led the first health exchange in Massachusetts prior to the ACA, said, “We took the most complex health care system on God’s green earth, and made it 10 times more complex.” Simplifying the “impossible job” of implementing the ACA would be high on his and probably most people’s agendas.
  • Judith Solomon of the Center for Budget and Policy Priorities suggested that there should be a modification in the way income eligibility is determined. Currently, taxpayers and the IRS have to rely on tax returns that are more than a year old—obviously, with tax data that is two years old—to predict their income eligibility for ACA subsidies. For determining income eligibility, something more robust and reliable is needed. Solomon also called for a “hardship exemption for people expected to pay back tax credits…because they underestimated their incomes,” or if not a specific hardship exemption, some sort of sliding scale so that moderate income taxpayers aren’t whacked with enormous tax bills.
  • Joseph Anton of the conservative American Enterprise Institute suggested a resolution to the problem of paying back tax credits—just get rid of the individual mandate entirely and replace it with a formula for requiring uninsured individuals to pay more for health coverage.
  • Georgetown University’s Sabrina Corlette recommended getting rid of the provision that permits insurers to charge higher premiums to tobacco users. “It prices out of coverage low- and moderate-income people who could most benefit,” she said. “And there’s no evidence that it encourages people to quit.”

The report seemed a little dispirited as the panelists acknowledged that Republicans were unlikely to be hit by that bolt of rationality necessary to repair rather than repeal the Affordable Care Act. Ultimately, however, the truly vital fix is at the state level. Until all states expand Medicaid eligibility to include the near-poor as well as the poor, millions of Americans will be left in a coverage gap between incomes too high for subsidies on the exchanges but too low to afford some insurance premiums and copays.—Rick Cohen