Four ways to improve upon the Affordable Care Act

In a grand effort to snatch defeat from the jaws of victory, U.S. Congressional Republicans have failed in their attempt to repeal the Affordable Care Act (ACA). With the understanding that the ACA will remain the law of the land, what can Congress do to modify the law while retaining benefits the public uniformly agrees upon?

The ACA itself is a fusion of conservative and liberal ideals: its insurance market reforms borrowed the best ideas from conservative think tanks while its Medicaid expansion leans heavily upon liberal values of government-secured health coverage. The ACA’s legacy rests in its dramatic reduction in the United States’ uninsured rate.

The failure of the American Health Care Act (AHCA) makes this point abundantly clear: Americans will not tolerate their families, friends, and neighbors losing coverage.

There are four areas in which moderate Republicans and Democrats might find agreement and enough votes to pass the House, the Senate, and earn the president’s signature – reducing the burden of taxes and mandates, fixing the Medicaid gap, correcting the family glitch, and cutting costs by adding additional coverage options.

Reducing the burden of taxes and mandates

Republicans remain intent on repealing much of the ACA’s taxes and mandates. However, The individual mandate is untouchable both due to valid policy reasons and the fact that Democrats will not allow it to disappear. But the employer mandate is up for negotiation. If the employer mandate were repealed, coverage losses would be no more than half a million people with most being able to obtain insurance in some other fashion than from their job.

The budgetary losses would only be about $4 billion per year. On the contrary, the potential jobs lost to the employer mandate – by businesses not expanding their hiring above the mandate threshold – amount to approximately 700,000 Americans, outweighing those who would have lost coverage. The math makes sense. The employer mandate should go.

Many in Congress want to get rid of the medical device tax. This minor tax actually harms patients – to whom the costs are passed on – and not the device manufacturers. Thus removing it from the ACA should not face significant opposition.

Similarly, taxes on the pharmaceutical industry and health insurance providers, which were symbolic victories for the drafters of the ACA, merely shift the burden of these costs from corporations onto the American people who will ultimately pay more for drugs and health insurance.

Repealing these three taxes would cost $19 billion per year, but would provide relief to the people who actually face the cost of those taxes – patients in our healthcare system.

Bridging the Medicaid gap

Nearly three million uninsured Americans could be covered today if their states would simply allow Medicaid expansion. Kicking people off the Medicaid rolls, as the AHCA would have done, is not in the political calculus of moderate lawmakers.

But why stop at giving states money to fund health care for the poor when the federal government can cut out the middleman and directly support American families?  The next iteration of health reform should bypass recalcitrant states and allow Medicaid eligible populations to buy 100 percent subsidized coverage in the marketplaces.

Fixing the family glitch

The family glitch deserves to be fixed. By altering the calculus determining affordability of family coverage, significant relief can be obtained for American families by allowing either the entire family to enter the ACA marketplaces or by having the worker take employer coverage and letting dependents use Marketplace subsidies. Although fixing the family glitch would not dramatically increase health care coverage, allowing employees with unaffordable offers of family health insurance coverage access to marketplace subsidies would provide over $1000 of tax relief to millions of working American families.

Cutting insurance costs with catastrophic coverage

Lastly, the cost of coverage does need to decrease. There should be a serious debate over essential health benefits, not necessarily the 10 categories of benefits, but rather how deep into each category coverage needs to delve.

The option for catastrophic coverage should be made available to all Americans, not just those who are under 30 or those with a hardship exemption. In fact, the current administration could immediately make this a reality for Americans. Congress could then pass legislation increasing the maximum annual contribution limits for health savings accounts up to the level of the 2017 out-of-pocket maximum limit of $7,150.  At present, current health savings account contribution limits are less than half of this level.

Fanatical moderation

The time for fanatical moderation is now. Policymakers on both sides of the aisle should agree that eliminating some of the ACA’s taxes, repealing the employer mandate, fixing the family glitch, bridging the Medicaid gap, and pushing for coverage capable of protecting Americans from catastrophe are excellent policy choices.

In the wake of the AHCA’s failure, and with Obamacare yet again declared the “law of the land,” the time has come to admit that the ACA isn’t a disaster, but failing to improve upon it would be.

-By Dr. Cedric Dark, assistant professor of emergency medicine at Baylor College of Medicine

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