Key Proposals to Strengthen the Affordable Care Act

By Timothy Stoltzfus Jost and Harold Pollack
The Century Foundation, December 15, 2015

The ACA undertook from the beginning an ambitious reform agenda, but some of its approaches have turned out to be ineffective, poorly targeted, or not ambitious enough to address deeply rooted problems.

Many of the remaining challenges in health care reform reflect the inherent complexities and path-dependency of the American system and were beyond the reach of any politically feasible reform. Perhaps the most serious problem — which this report will address repeatedly — is the inadequacy of the ACA’s subsidies and regulatory structures to address the problems of low-income Americans, for whom merely meeting the costs of day-to-day essentials is a continuing challenge, and for whom even modest monthly insurance premiums and cost-sharing are often serious barriers to health coverage and care.

This report identifies problems and suggests potential solutions. Some solutions would require federal legislation. Others could be implemented by the administration, state law, or by private parties.

In all, we propose nineteen steps that could help fix recognized flaws in the ACA as well as build on its accomplishments. Taken together, these proposals would further improve the access and affordability of health care under the ACA, create more robust provider networks, enhance competition among insurers, improve the consumer experience, and strengthen the Medicaid program. We understand that in the current political climate, improvements to the ACA that require congressional action are unlikely.

1. Expanding Access to Health Coverage for Moderate-Income Americans

*  Fix the Family Glitch.

*  Reduce Complexity in the Tax Credit Program.

*  Increase Credits for Moderate- and Middle-Income Families.

2. Making Health Care Affordable

*  Reduce Cost-sharing and Out-of-Pocket Limits and Improve Minimum Employer Coverage Requirements.

*  Increase Use of Health Savings Accounts for Moderate-Income Americans.

*  Allow Use of Health Reimbursement Accounts to Purchase Health Insurance.

*  Incorporate Value-based Insurance Design to Support Coverage for High-Value Services.

*  Improve State Regulation of Network and Formulary Adequacy.

*  Improve Protection from Balance Billing.

3. Improving the Consumer Marketplace Experience

*  Actively Guide Consumers in Coverage Selection.

*  Improve Network and Formulary Transparency.

*  Standardize Insurance Products.

4. Improving Medicaid for Low-Income Americans

*  Have the Federal Government Permanently Assume the Entire Cost of the Medicaid Expansion Population.

*  Constrain 1115 Waivers.

*  Eliminate Medicaid Estate Recoveries from the Expansion Population.

*  Improve Medicaid Payment Rates.

*  Ensure a Judicially Enforceable Right to Adequate Access to Medicaid Providers and to Adequate Medicaid Payment Rates.

*  Reconsider a “Public Option” Early Medicare Coverage within Health Insurance Marketplaces.

*  Raise or Eliminate Medicaid and Supplemental Security Income Asset Limits for People Living with Disabilities.

From the Conclusion

This report offers a number of proposals for building on the ACA, to make health coverage and health care even more affordable, accessible, and understandable for Americans. We understand that in the current political climate, improvements to the ACA that require congressional action are unlikely. Yet an administration committed to improving access could take some of the actions we recommend without new legislation, while other proposals could be implemented by the states, marketplace, or simply by insurers.

Congress is divided on what to do about our expensive but highly dysfunctional health care system. Congressional opponents of the Affordable Care Act (ACA) today will vote for the 62nd time to repeal the Act without offering any replacement, and President Obama will veto the legislation. In contrast, supporters of health care reform would like to improve the system so that it works better for everyone.There are two approaches to improving the system: either build on ACA and the existing financing system, or replace it with a single payer system. Today’s report is by two highly respected professors who are personally dedicated to health care justice – Timothy Stoltzfus Jost and Harold Pollack – and they would build on ACA. Thus today’s report represents the best of the “repair and improve” approach.

Take a close look at the nineteen recommendations by these two revered individuals who really care about our health care system, and then think about what impact these recommendations would have. Most of the them would hardly qualify as tweaks, though several of them would certainly be beneficial if we were to support the perpetuation of the current system. But what they do not do is to provide a new financing infrastructure that we would need to improve efficiency, equity, universality, access, quality, comprehensiveness, affordability, portability, and to reduce the administrative burden through public administration – features of a single payer national health program.

We can be thankful that we have individuals like Timothy Jost and Harold Pollack who have dedicated themselves to improve what we have. Until we can enact a single payer system, we need their efforts to continue. Yet they concede that “improvements to the ACA that require congressional action are unlikely.” That is the same reason given for not advocating for a single payer system – it supposedly is not politically feasible. But you don’t compromise policy for politics. You change politics so that you can achieve optimal policy.

Unfortunately Harold Pollack has a problem with PNHP. He has written, “I happen to dislike PNHP leaders’ unhelpful stance in the current debate,” and “I wish the group would talk and act rather differently in this debate,” and “Indeed its leaders denigrate important provisions of ACA that expand access for 32 million people and protect millions against catastrophic financial risks.” In fact, we have supported the beneficial gains of ACA as important transitional improvements until we can move the political process to achieve single payer. This matters because this abrasiveness has reduced the framing to incremental changes or nothing, when the framing should be incremental changes or single payer.

From the list in this report, the proposed incremental changes are far too feeble when compared to the need. I feel certain that Timothy Jost would be on board if there were a politically feasible path to single payer. I just wish Harold Pollack would join us as well.