The Affordable Care Act (ACA) has always needed fixing. Now that the Congress has tried and failed to repeal and replace it, the time for repair seems at hand. Long term, a fair and sustainable approach to covering the uninsured and constraining our extraordinary health care costs will require bipartisan support. The question is whether the current Congress and administration — perhaps after a period of rest and reflection — can return to consider a modest set of fixes that will preserve the gains achieved under the ACA, and lay the groundwork for progress.
If we can create the political and mental space for such a bipartisan effort, we should turn to the strategies that Timothy Jost outlined earlier this month in a Commonwealth Fund To the Point. The immediate concern is stabilizing marketplaces to ensure that the 17 million to 18 million people getting coverage through the individual market will be able to successfully reenroll during this fall’s open enrollment period. Three key proposals for Congress to consider include:
- Cost-sharing reductions. Congress needs to set up permanent appropriation to pay insurers for the cost sharing reductions they are required to offer lower-income enrollees in the marketplaces. The uncertainty about these payments has led some insurers to propose higher premiums for 2018 than they would have otherwise. Because the cost of these payments is already included in the federal budget baseline, such an appropriation would not have budget consequences.
- Bare counties. Congress should ensure that all Americans who buy coverage in the individual market have a health plan to enroll in. There are currently about 40 counties in Indiana, Ohio, and Nevada where no insurer is planning to offer health plans in the individual market in 2018. One option is to require the largest private health insurers participating in the Federal Employees Health Benefit Program to offer at least one silver plan in the marketplaces in these counties as a condition of participation in the program. Another option is to allow people in states that have expanded Medicaid eligibility to buy into Medicaid. All three of the states with bare counties are expansion states.
- Reinsurance. Appropriating $10 billion to $15 billion for reinsurance — a provision of the Senate’s repeal-and-replace bill — would help insurers selling in the individual markets by partially reimbursing them for unexpectedly high enrollee costs. Reinsurance would help stabilize markets across the country and likely lead to lower premium increases for the next few years. The Trump administration recently approved a reinsurance plan requested by Alaska.
Our elected officials now understand how fraught and complex health care issues are. They are fraught and complex, in part, because they matter. Even when they don’t involve life and death — which they frequently do — health care debates stir our deepest hopes and fears for ourselves and those we hold dear. That is why the Commonwealth Fund will continue to support necessary improvements in our health care system by informing policymakers and the public about the objective consequences of the health care options they face.