OPINION: Suggested fixes to the ACA By Hermann Vogelstein

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Thursday, Senate Majority Leader Mitch McConnell released the newest version of the Affordable Care Act repeal plan, called the “Better Care Reconciliation Act,” which, if passed, would reportedly leave millions without health coverage.

According to the New York Times, the bill would make deep cuts to Medicaid while allowing states to drop ACA-required benefits such as maternity care and mental health treatment. Additionally, the NYT reported that corporations and the richest families in the country would benefit by the nearly $1 trillion in tax cuts imposed by the new bill.

While many would agree that the Affordable Care Act isn’t perfect, millions have benefitted from having health insurance coverage. In a statement today, former President Barack Obama condemned the senate bill: “We didn’t fight for the Affordable Care Act for more than a year in the public square for any personal or political gain—we fought for it because we knew it would save lives, prevent financial misery, and ultimately set this country we love on a better, healthier course.” [Full statement: here]

Hermann Vogelstein, a member of Action Together Rochester’s Public Health Committee, weighed in on changes that could be made to the existing Affordable Care Act instead of an all out repeal:

1) Fix the so-called “family glitch.” Currently, family members of employees with coverage available from their employers are not allowed to receive subsidies on plans bought through the marketplace if the premium of the employer’s plan for the employee alone is deemed affordable, even if covering the entire family under the plan would be unaffordable. If the premium for the entire family under an employer-sponsored plan is unaffordable, an employee’s dependents should be eligible for subsidies if they buy coverage on the marketplace.

2) A public option should be added in every state. This would create more choices and competition, thus exerting downward pressure on premiums. It would also solve the problem of some states having only one insurer on their health insurance marketplace or none at all in some counties.

3) A way should be found to motivate all states to implement the Medicaid expansion. (Perhaps the number of years that the Federal government pays 100 percent of the cost could be extended).

4) It might also be advisable to consider increasing subsidies to those who are currently struggling to pay their premiums and out-of-pocket costs. Perhaps, the income limit for eligibility for the premium tax credit should be raised so as to provide relief from premium increases to those just above the cut off.

5) In those states that have not expanded Medicaid, the minimum income amount for eligibility for subsidies should be lowered or eliminated, so that those who need help the most don’t fall through the cracks.

6) Restore the funding that has been cut or never fully funded for certain elements of the ACA that were designed to stabilize the health insurance market. This includes reinsurance and the supplementation of the “risk corridor,” which funnels money from the government to insurance plans that have experienced losses because they ended up with an excessively high percentage of very sick patients in their insurance pool. This should obviate the need for insurers to increase premiums more than necessary in order to guard against being stuck with a losing pool of subscribers. It would also likely make them more willing to take the risk of participating in the individual market on the healthcare exchanges.

7) Extend funding for certain aspects of the ACA that are set to expire this year or next.

8) Reverse Trump’s executive orders relaxing enforcement of the penalty for failing to obtain insurance coverage, and consider increasing the penalty so as to reduce the temptation for healthy people to forgo health insurance.

9) Make care coordination a billable service for primary care physicians in order to help shift the emphasis in our health care system from expensive procedures and surgeries to preventive care.

10) Address the high cost of pharmaceuticals by increased regulation, by empowering the Center for Medicare and Medicaid Services to negotiate prices with drug companies, by allowing more medications to be imported, by creating transparency in drug pricing, by providing for easier drug comparisons, and by implementing value-based pricing of medications, taking into account their effectiveness.

11) Write into law the low-income cost-sharing subsidies for out-of-pocket costs (currently the subject of litigation), which allow those who qualify to have lower deductibles, out-of-pocket maximums, and co-pays if they buy a Silver plan.

12) States could offer preferential treatment to companies bidding on lucrative Medicaid contracts if they commit to selling plans on the ACA marketplaces (Nevada is already doing this; NY is considering allowing only companies that offer plans on its marketplace to bid on Medicaid contracts). 

Hermann Vogelstein is a member of the ATR Public Health Committee. 

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